ASN Wikibase Occurrence # 314372
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Date: | Friday 7 September 2012 |
Time: | 07:43 LT |
Type: | Boeing 737-8AS (WL) |
Owner/operator: | Ryanair |
Registration: | EI-EKV |
MSN: | 38507/3211 |
Year of manufacture: | 2010 |
Fatalities: | Fatalities: 0 / Occupants: 166 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | near Madrid -
Spain
|
Phase: | En route |
Nature: | Passenger - Scheduled |
Departure airport: | Madrid-Barajas Adolfo Suárez Airport (MAD/LEMD) |
Destination airport: | Las Palmas-Airport de Gran Canaria (LPA/GCLP) |
Investigating agency: | CIAIAC |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:EI-EKV, a Boeing 737-800 operated by Ryanair en route to Las Palmas de Gran Canaria (Spain) with 166 persons onboard, made an emergency return to the Madrid-Barajas Airport (Spain), from which it had taken off, due to what the crew identified as a pressurization problem.
At 07:43 local time, climbing to FL220, without any contact between the cabin and cockpit, the purser contacted the cockpit and informed the captain that the cabin crew were feeling unwell. This confirmed his own feeling of being unwell. After the purser’s call, the captain decided to declare an emergency, stop the climb, start the CABIN ALTITUDE WARNING procedure, although no such warning was received, and return to the Madrid-Barajas Airport. As a consequence of the CABIN ALTITUDE WARNING procedure the outflow valve kept closed until the end of the flight, causing the subsequent overpressurization and depressurization of the cabin.
The investigation determined that the pressurization system on aircraft EI-EKV worked correctly during the incident flight. At the time of the incident, the cabin altitude was 3,774 ft.
The investigation could not determine the cause of the symptoms reported by several members of the crew. The hypotheses considered to possibly explain said symptoms were hypoxia by poisoning, motion sickness, suggestion among members of the crew or a combination of the last two.
The following factors contributed to the incident and to the handling of the emergency:
• the crew’s suspicion that the aircraft was malfunctioning, as evidenced by the constant problems since taking off, specifically the operation of the CABIN ALTITUDE WARNING, which had not worked prior to the flight, and
• the possible confusion in executing the CABIN ALTITUDE WARNING or Rapid Depressurization checklist due to:
– including an option between two choices as part of memory item 5,
– having a second option (item 6) on a different page, and
– completing the checklist and redirecting to another as part of the memory items.
Accident investigation:
|
| |
Investigating agency: | CIAIAC |
Report number: | IN-036/2012 |
Status: | Investigation completed |
Duration: | 2 years and 11 months |
Download report: | Final report |
|
Sources:
NTSB DCA12WA145
Revision history:
Date/time | Contributor | Updates |
02-Jun-2023 16:44 |
ASN Update Bot |
Added |
05-Jun-2023 14:32 |
harro |
Updated |
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