Aviation safety investigations & reports

Pressurisation system event, Brisbane, VH-QOD

Investigation number:
200603726
Status: Completed
Investigation completed

Summary

Download Final Report
[Download  PDF: 205KB]
 

On 29 June 2006, Bombardier DHC-8-402 (Dash 8-400) was being operated on a scheduled passenger service from Brisbane to Mackay, Qld. As the aircraft passed through FL220, the cabin altitude warning light illuminated, accompanied by the associated aural warning.

Initial checks by the crew indicated that the cabin differential pressure and cabin air flow appeared to be normal. The aircraft's bleed air switches also appeared to the crew to be correctly selected to the ON position.

An attempt by the crew to manually confirm the position of the bleed air switches revealed that both switches were in the OFF position. The subsequent selection of the switches to the ON position extinguished the cabin altitude warning light and the associated indications, and the aircraft's pressurisation system commenced normal operation.

In response to this incident, the operator developed an amendment to the Flight Crew Operating Manual for application in the company's turboprop operation, including affecting the Dash 8-400 checklist. The amendments to the aircraft checklist included:

  • revised responses to the pressurisation-related checklist items
  • an additional Pressurisation checklist requirement to be conducted at Transition
  • the addition of the requirement for the tactile confirmation of some checklist responses, including when one pilot has responsibility for both the 'challenge' and 'response' actions.
Download Final Report
[Download  PDF: 205KB]
 
 
 
General details
Date: 29 June 2006   Investigation status: Completed  
Time: 1900 UTC    
Location   (show map): 56km N of Brisbane, Aerodrome    
State: Queensland   Occurrence type: Warning devices  
Release date: 02 April 2007   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Bombardier Inc  
Aircraft model DHC-8  
Aircraft registration VH-QOD  
Serial number 4123  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Brisbane, Qld  
Departure time 1835  
Destination Mackay, Qld  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL
Last update 18 April 2018