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Lesson Plan
Supporting Materials
PowerPoint
Within the Supporting Materials section you will find the handouts and a detailed
report on the second incident. Also in this section are copies of pax letters, regarding
both incidents, which were sent to the airlines.
We would recommend that you allow 40 minutes to run this module in the classroom.
Objective:
To be covered as follows:
Distribute Handout 1 for first case study and ask delegates to highlight
communication and co-ordination errors
Facilitate and discuss scenario from a communication and co-ordination
perspective
Distribute Handout 2 for second case study and ask delegates to highlight how
this incident was handled differently, also from a communication and coordination perspective,
Facilitate and discuss scenario to highlight differences between both incidents.
KEYWORD
DETAIL
Case Study
Objectives
Objective:
To study two actual incidents from a communication and coordination perspective
Background
AIDS
Slide
Case Study
Slide
Objective
Task
Points for
discussion
Handout 1
Pax letter
The letter then goes on to discuss the lack of support the pax had at
OLY
High workload and stress of the crew are just some of the factors
here that contribute to the lack of information experienced by the
passengers.
Discussion
Slide
Question
Summary
Slide
Slide
Issue the handout sheet and again, working in groups of 3, ask the
class to compare the communication and co-ordination problems in
with
the first
Integrated this
Teamincident
Solutions
Limited
2006incident give 5 minutes to do this
Task
Special thanks to the pilot, who got us down safely & then for
talking to us individually during our time at Brest airport.
We hope it hasn't put the young cabin crew staff off flying again!
They were all fantastic & should be proud of the way they
conducted themselves.
Thanks also to the crew of the 757 who rescued us & brought us
home safely. They made us feel a lot more at ease than we ever
expected to be.
Instructor note: See report if more information required
SUPPORTING MATERIALS
Content:
Handout Decompression 1
Handout Decompression 2
Report Decompression 2
Pax Letters
Boeing 737-300
Occurrence Date :
August 2005
Flight Number :
ABC 123
Flight Routing :
Nature of flight :
Occupants :
Crew :
Location of incident : Approx 60 nautical miles to the east of Brest, France, at the
time of incident
Brief summary :
to rapid
Brest, France
Local time in Malaga and Brest is two hours ahead of GMT; local time at London Gatwick is one hour
ahead of GMT
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Control of the aircraft passed from Spanish to French Air Traffic Control 48 minutes
after departure and the aircraft was given a direct clearance to the navigational
beacon at Agen (AGN).
At 16.42 hrs, whilst the aircraft was approaching a position abeam the navigational
beacon at Monts dArree (ARE) [near the French town of Lorient], a BLEED TRIP OFF
caution light illuminated on the Automatic Centralised Warning System panel. The
flight crew conducted the checklist drill and requested initial descent clearance from
Air Traffic Control to descend to 25,000ft, which is in line with Boeings Standard
Operating Procedures [SOP] if the aircraft has partial failure of its pressurisation
system.
During this initial descent, the flight crew noted that the cabin altitude (the pressure
level in the cabin relative to the outside air) was rising rapidly. As the cabin altitude
rose above 10,000ft, the cabin altitude warning horn sounded on the flight deck and
both flight crew members placed on their own oxygen masks in accordance with the
airlines SOP. The depressurisation drill was followed, including an announcement
over the aircrafts Public Address system to alert the cabin crew members.
The flight crew requested clearance from ATC and then initiated an emergency
descent to 10,000ft.
The cabin altitude continued to rise; further attempts were
made by the crew to control the pressurisation by switching from automatic to
manual mode but these were unsuccessful.
As the cabin altitude rose through 14,000ft, the passenger oxygen masks deployed
automatically. In accordance with the pre-flight demonstration, passengers were
directed to pull the masks towards them to open the oxygen supply, place the mask
on and then breathe normally.
The cabin crew immediately commenced their
decompression drill, passing through the cabin from rear (where they were in the
galley at the time of the incident) to the front and once the decompression drill had
been conducted, assembled in the forward galley for a briefing from the SCCM and
checked the drills had been completed correctly through reference to the Cabin
Crew Safety Manual.
The flight management computer [FMC] indicated that the nearest available airfield
was at Brest and the crew requested clearance to land at Brest. The remainder of
the flight was uneventful and the aircraft landed at Brest at 17.14 hrs and engines
were shut down on the parking stand at 17.16 hrs.
Notification
The airlines 24-hour Operations Control Centre [OCC] was notified of the air diversion
by Air Traffic Control at 17.08 hrs and further confirmation was given at 17.15 hrs that
the aircraft had landed safely at Brest. This was confirmed by the Captain who used
a mobile telephone to contact the OCC at 17.25 hrs.
A plan was formulated to dispatch one of the airlines Boeing 757 aircraft from
London Gatwick to carry an engineering team out to Brest and then to fly all
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Crew details
The Aircraft Commander is a 52-year old male (Australian national) who holds a valid
UK Air Transport Pilots Licence [ATPL(A)]. He is an experienced 737 Captain who had
previously flown the type in Australia; joined the airline in April 2003, completed
training in May 2003 and was promoted to the role of Training Captain in October
2003.
The First Officer is a 38-year old male (UK national) who holds a valid UK Commercial
Pilots Licence [CPL].
He joined the airline in April 2005 and completed training in
May 2005.
Both pilots were licensed on 737-300 to -900 aircraft variants and held valid medical
certificates. The crew were properly licensed, trained and rested to undertake the
flight duty.
The four cabin crew members had all undergone initial training with the airline in April
2005 after joining the airline. The SCCM held appropriate previous flying experience
as Cabin Crew on a fixed-wing aircraft to operate in that capacity. All cabin crew
members were trained in accordance with the airlines approved training
programme, had undergone medical examinations and were rested to undertake
the flight duty.
All crew members were interviewed by the airlines flight crew and cabin crew
management teams following the incident.
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Flight crew members completed routine pre-flight walk-round checks of the aircraft
before both sectors with no defects or issues noted.
The aircraft was properly maintained in accordance with Boeing Maintenance
Planning Document and the airlines maintenance procedures, which are approved
by the UK Civil Aviation Authority.
Flight recorders
The aircrafts Cockpit Voice Recorder was retained by the French Department
General de lAviation Civile inspectors who visited the aircraft on arrival at Brest. The
Quick Access Recorder [QAR] data was removed from the aircraft by the airlines
engineers on the day after the incident and analysed.
The data is consistent with the account from the flight crew. The descent profile was
analysed and in the graph below, the blue line shows the profile of the aircraft. The
QAR indicates that the aircraft descended from its cruising altitude of 36,000ft to an
altitude of 10,500ft over a period of 6.5 minutes.
Fig 1 QAR data of descent profile between 16.42:00 hrs and 16.51:30 hrs
The average descent rate was 4,300ft per minute versus 2,000ft per minute in a
conventional descent. The maximum angle of descent recorded by the QAR was
4.922 and the maximum rate of descent reached at any point was 6,200ft per
minute.
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which uses outside air from the right-hand engine and compresses it in order to supply
the cabin air conditioning and pressurisation system whilst in flight. The structural
integrity of the aircrafts fuselage and all external doors and hatches was assessed
and found to be intact.
A low-level ferry flight (i.e. unpressurised) with a minimum safety crew aboard was
undertaken late on the evening to return the aircraft to London Gatwick; during this
sector, a pressurisation check was carried out during which the fault was repeated
and found to be consistent with the earlier crews accounts.
Engineering Analysis
The 737 has two independent bleed air systems one from each engine, feeding two
totally independent air-conditioning supply systems. Under normal circumstances
each air conditioning system is designed to maintain the cabin pressure with a high
level of extra capacity in reserve.
On investigation, the airlines engineers reset the right-hand bleed air system and
carried out a cabin pressurisation system check. This test revealed a broken clamp
round the Auxiliary Power Supply [APU] air duct sealing skirt, allowing air to leak out of
the cabin. This high leak rate explains why the flight crew were unable to maintain
the cabin altitude using only the left-hand air conditioning supply system as should
normally have been possible.
The automated safety alert systems functioned correctly in notifying the flight crew of
the bleed air valve failure and the rising cabin altitude.
The automated oxygen mask drop out system deployed correctly as designed. Each
set of four masks (left-hand side of the cabin) and three masks (right-hand side of the
cabin) is supplied by an individual oxygen generator and the passenger action of
pulling the mask towards themselves pulls the firing pin out of the oxygen generator
and thus commences a flow of oxygen.
Subsequent inspection of the oxygen
system indicated that all oxygen generators had fired correctly and produced
oxygen. A small number of oxygen generators (including those in the forward and
one aft toilet, which were not occupied at the time of the incident), were not used.
Passenger reports of a burning smell towards the rear of the aircraft prior to the
incident have been investigated. No evidence of fire or smoke has been found, but
the engineering investigation indicated some residue in the aircrafts centre rear
galley oven consistent with food debris from passenger meal service. None of the
cabin crew members recalled any such issue and all had been in the rear galley
around the time of the incident.
The individual oxygen generators above each seat row normally produce heat and a
light acrid haze when fired and it was concluded that the passenger reports of smoke
after the deployment of oxygen masks were consistent with the normal functioning of
the oxygen generators.
Repairs were effected to restore the integrity of the pressurisation system through
replacement of the air duct clamp and the aircraft was test flown two days leter with
a full pressurisation check undertaken. It was found to be functioning correctly in
both automatic and manual control modes.
Further work was undertaken to
replace the oxygen generators above each passenger seat, replace all oxygen
masks (standard procedure after use), re-stow oxygen masks and then conduct a
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final function check on the oxygen mask system. The next day a further test flight
was conducted before the aircraft was cleared to return to passenger service.
Incident history
No other comparable incidents of decompression have been recorded on the
airlines fleet of aircraft. The airline operates a total of five identical Boeing 737-300s
and two Boeing 737-700 aircraft and has undertaken over 21,000 sectors without any
event of this nature.
Follow up action
The aircraft manufacturer, Boeing Airplane Company, has been notified of the failure.
The airline has undertaken a full inspection of its aircraft fleet to ensure that no similar
defects exist. There is no requirement from Boeing or the UK Civil Aviation Authority to
replace the failed component on the aircraft as part of routine maintenance checks,
but the airline is formulating procedures to replace these during each annual
overhaul of the aircraft as a precautionary measure.
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Probably about 30 to 45 minutes into the flight we were told to fasten our seatbelts, put our
seat backs upright etc as we were about to experience some turbulence. On obeying these
instructions the plane seemed to almost hit a brick wall then drop.
Just at this point the O2 masks deployed and the a/c began a very steep descent. To be
perfectly honest, I, my wife and the rest of the pax thought we were going down permanently.
The steep descent seemed to go on for an age. The sight of a stewardess with a look of
sheer fear on her face and tears in her eyes did nothing to calm the mood on board. We
believed we were going to die!!
At no point during this steep descent did any crew member offer any support to us! It was
every man for himself! Eventually the plane levelled off but again no information was given to
pax until a very shaky captain/FO told us that we were diverting to Charles de Gaulle to find
out what the problem was. Then the next piece of information that was offered was that no
we are not diverting to CDG but we are diverting to OLY instead.
Why did this person not try to offer some explanation for what was happening? Even a
simple explanation like dont worry, the engines are fine, it just appears to be a problem with
the cabin pressure. No we were kept in the dark and made to suffer in silence. No
information. No information. No information.
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Dear sir/madam,
We were passengers on flight ABC123 which had to emergency land in France on Friday.
Whilst the experience was extremely distressing, we would like to thank the captain & crew
for their professionalism during the incident, when they were clearly distressed themselves.
Their support was exemplorary, particularly the way they managed to look after everybody
once we had landed.
Special thanks to the pilot, who got us down safely & then for talking to us individually during
our time at Brest airport.
We hope it hasn't put the young cabin crew staff off flying again! They were all fantastic &
should be proud of the way they conducted themselves.
Thanks also to the crew of the 757 who rescued us & brought us home safely. They made us
feel a lot more at ease than we ever expected to be.
Please keep us informed regarding the cause of the emergency & once again well done to all
concerned!
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