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Significant Factors


  1. Both bleed air switches were inadvertently selected to ENVIR OFF at about 10,000 ft in the climb.
  2. The cockpit warning system did not adequately alert the pilot to the cabin depressurisation.
  3. The oxygen mask deployment doors were incorrectly orientated during installation, so that the masks would not automatically deploy when required.
  4. Hypobaric training did not provide an effective defence to ensure that the pilot or passengers would identify the onset of hypoxia.
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