Safety issue

Safety issue description

The operator’s training system did not adequately cover the unique requirements of the CAB PR EXCESS CAB ALT alert procedure, increasing the risk of an incorrect or delayed application of the required procedure.
Issue number AO-2021-005-SI-02
Issue owner Qantas Airways Limited
Transport function Aviation: Air transport
Issue status Closed – Adequately addressed
Date issue released 21/03/2023
Issue status justification

The ATSB is satisfied that the proactive safety actions taken by Qantas provide a suitable training-based mitigation against the risk of an incorrect or delayed application of the CAB PR EXCESS CAB ALT alert procedure.

Safety action

Action type Proactive action
Action number AO-2021-005-PSA-62
Organisation Qantas Airways Limited
Action description

Qantas advised of the following changes implemented in response to the occurrence:

  • The commencement of a wide education process about the importance of crew donning oxygen masks in any potential hypoxia scenario.
  • Notification to all A330 flight crew about the circumstances of the QF583 incident, with emphasis on the need to immediately initiate an emergency descent in response to a CAB PR EXCESS CAB ALT alert.
  • For all recurrent training sessions and refamiliarisation paths, inclusion of specific discussion items and practical training scenario concerning the need for immediate oxygen mask use and the emergency descent procedure for the CAB PR EXCESS CAB ALT alert.
  • An update to the A330 training library to ensure that all material reflects the latest FCTM guidance.
  • All instructors notified of the changes to the FCTM, and the need to reinforce to flight crew the importance of oxygen use in any potential hypoxia scenario and of consulting FCOM if time permits after an ECAM is complete.
  • Modification to instructor notes for type rating and ground session instruction to clarify the expected crew actions in event of an CAB PR EXCESS CAB ALT alert.
  • Adjustment to all A330 training paths and relevant training simulator series to reflect the FCTM intent on emergency descents and the CAB PR EXCESS CAB ALT alert.
Action status Closed