Aviation safety investigations & reports

Depressurisation event 246 km south-west of Coolangatta, Queensland 17 November 2007 VH-VBC Boeing Company 737-7Q8

Investigation number:
AO-2007-062
Status: Completed
Investigation completed

Summary

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On 17 November 2007 a Boeing Company 737-7Q8 aircraft, registered VH-VBC, with two flight crew, four cabin crew and 145 passengers was being operated on a scheduled passenger service from Coolangatta, Queensland to Melbourne, Victoria. During the takeoff, the Master Caution system activated and the right BLEED TRIP OFF light illuminated. The pilot in command, who was the pilot flying, elected to continue the takeoff. Once airborne the Bleed Trip Off non-normal checklist was actioned. The right engine bleed could not be reset with the effect that, when above flight level (FL) 170 (17,000 ft above mean sea level), only the left engine bleed air was available for airconditioning and cabin pressurisation.

At FL318 during the climb, the flight crew observed the left PACK TRIP OFF light illuminate, followed by a rapid loss in cabin pressure and the cabin rate of climb indicator showing a rate of climb of about 2,000 ft/min. The crew fitted their emergency oxygen masks, commenced the Emergency Descent checklist and began a rapid descent to 10,000 ft. During the descent, the cabin altitude exceeded 14,000 ft, at which time the passenger oxygen masks deployed automatically. The aircraft was diverted to Brisbane for landing. There were no reported injuries to passengers or crew and no damage to the aircraft.

The investigation found that a combination of technical faults contributed to the loss of pressurisation and identified a number of other safety factors relating to operational procedures and cabin crew knowledge of the passenger oxygen system.

The operator conducted an internal investigation of the incident and carried out a number of safety actions as a result. Those actions included the enhancement of a number of the operator's manuals and the amendment of the operator's cabin safety recurrent training. In addition, the operator's passenger oxygen use in-cabin brief was enhanced to include advice that oxygen would flow to passengers' masks even if the associated bag was not inflated.

Download Final Report
[Download  PDF: 2.58MB]
 
 
 
General details
Date: 17 November 2007   Investigation status: Completed  
Time: 21:14 ESuT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 246 km south-west of Coolangatta    
State: New South Wales   Occurrence type: Air/pressurisation  
Release date: 29 April 2010   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

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 Nil  
Departure point Gold Coast, Qld.  
Destination Melbourne, Vic.  
Last update 14 November 2018