Aviation safety investigations & reports

Warning device event 46km W of Mackay Qld; Boeing Co 737-7Q8, VH-VBC

Investigation number:
200506298
Status: Completed
Investigation completed

Summary

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On 2 December 2005, a Boeing Company B737-7Q8 aircraft, registered VH-VBC, was being operated on a scheduled passenger flight from Townsville to Brisbane Qld. While the aircraft was passing flight level 370 on climb, the crew heard a 'bang', which was closely followed by the annunciation of a Window Overheat master caution. After becoming aware that the outer layer of the pilot in command's L1 window was cracked, the crew followed the checklist for window damage. As a result, at about 2106 Eastern Standard Time, a cabin altitude warning horn sounded. The sounding of the warning horn was the normal result of the crew's implementation of the checklist for window damage. However, the flight crew believed that the aircraft was depressurising as a result of the window damage and responded to the cabin altitude warning by carrying out an emergency descent from 33,000 ft to 10,000 ft.

During the descent, the crew closed the valve that controlled the outflow of air from the aircraft. However, the pressurisation system was functioning normally and closing the outflow valve caused the aircraft to exceed its cabin pressure limit, as a result of which the over-pressure safety relief valves opened. The flight crew realised that the aircraft was not depressurising, but pressurising, and opened the outflow valve. The combined action of the crew and the automatic opening of the safety relief valves reduced the cabin pressure at a rate greater than that which passengers normally experience. As a result, 11 passengers sustained minor injuries.

Following a company investigation, the operator retrained the flight crew involved in the incident, audited its check and training system and modified the simulator programme to include operational issues identified in this incident.

The aircraft manufacturer has modified the checklist for window damage to minimise the possibility of a cabin altitude warning occurring when the checklist is used.

The operator, in conjunction with the manufacturer, is still investigating the cause of the window breakages.

Download Final Report
[Download  PDF: 2.36MB]
 
 
 
General details
Date: 02 December 2005   Investigation status: Completed  
Time: 2057 EST    
Location   (show map): 46km W Mackay    
State: Queensland   Occurrence type: Windows  
Release date: 20 March 2007   Occurrence class: Technical  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: Minor  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737  
Aircraft registration VH-VBC  
Serial number 30638  
Type of operation Air Transport High Capacity  
Damage to aircraft Minor  
Departure point Townsville, QLD  
Departure time 2037 EST  
Destination Brisbane, QLD  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 3475.0 12908.0
Co-Pilot/1st Officer ATPL 2000.0 4000.0
Last update 16 February 2016