Crew illness and checklist confusion lead to emergency return of Ryanair Boeing 737

Casualties unknown • Aeropuerto de Madrid-Barajas (Madrid), ES

A Ryanair Boeing 737-800 returned to Madrid after the crew reported feeling unwell during a climb, following a series of technical warnings caused by improper maintenance.

What happened

On 7 September 2012, a Ryanair Boeing 737-800, registration EI-EKV, was climbing through FL220 en route from Madrid-Barajas to Las Palmas de Gran Canaria when the flight crew declared an emergency. During the climb, the purser notified the cockpit that the cabin crew were feeling unwell, a sensation the captain also began to experience.

Prior to the emergency, the aircraft had experienced several technical warnings. Shortly after takeoff, the MASTER CAUTION light activated multiple times, and the crew found they were unable to engage the autopilot. Following the report of crew illness, the captain stopped the climb, initiated the CABIN ALTITUDE WARNING procedure, and returned to Madrid. During the descent and subsequent taxiing, the cabin underwent significant pressure fluctuations, including an overpressurization and a rapid depressurization, which caused barotrauma and ear discomfort for several passengers and crew members.

The investigation

The CIAIAC investigation examined the aircraft's maintenance history, the flight data, and the crew's execution of emergency procedures. The investigation found that the aircraft had undergone unrecorded maintenance the previous night, which left a circuit breaker and a trim switch in incorrect positions. This led to the activation of the MASTER CAUTION and prevented the use of the autopilot.

Investigators also analyzed the symptoms reported by the crew. While the symptoms were consistent with hypoxia, the investigation could not definitively confirm the cause, considering hypotheses such as motion sickness, suggestion, or carbon monoxide poisoning. Furthermore, the investigation reviewed the effectiveness of the airline's emergency checklists during the event.

Probable cause

The investigation could not determine the exact cause of the crew's physical symptoms, though hypoxia, motion sickness, or suggestion were considered. The incident was exacerbated by the crew's suspicion of a malfunction due to previous technical warnings and potential confusion caused by ambiguities in the execution of the CABIN ALTITUDE WARNING and Rapid Depressurization checklists.

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Frequently asked questions

What happened in the 2012-09-07 Boeing 737-800 accident near Aeropuerto de Madrid-Barajas (Madrid), ES?

A Ryanair Boeing 737-800 returned to Madrid after the crew reported feeling unwell during a climb, following a series of technical warnings caused by improper maintenance.

What aircraft was involved and where did it happen?

The accident on 2012-09-07 involved a Boeing 737-800, registration EI-EKV, at Aeropuerto de Madrid-Barajas (Madrid), ES.

What was the probable cause of the accident?

The investigation could not determine the exact cause of the crew's physical symptoms, though hypoxia, motion sickness, or suggestion were considered. The incident was exacerbated by the crew's suspicion of a malfunction due to previous technical warnings and potential confusion caused by ambiguities in the execution…

Investigation report by the Spanish Civil Aviation Accident and Incident Investigation Commission (CIAIAC). Original record: https://www.transportes.gob.es/recursos_mfom/comodin/recursos/2012_036_in_eng.pdf. This page is a structured re-presentation; facts and quotes are in the Comision de Investigacion de Accidentes e Incidentes de Aviacion Civil (CIAIAC), Spain - Ministerio de Transportes y Movilidad Sostenible.

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