What happened
On 22 August 2015, an Airbus 330-200, registration PK-GPO, was operating a scheduled service from Melbourne, Australia, to Jakarta, Indonesia. During the cruise phase of the flight, approximately three hours after departure, a flight attendant placed pieces of dry ice inside an empty plastic water bottle and stored it within the middle galley's refrigeration unit.
Roughly three minutes after the dry ice was placed in the unit, the refrigeration door failed catastrophically. The force of the failure propelled the door forward, striking a flight attendant in the face and causing serious injuries. The impact caused various galley items, including juices and milk, to scatter across the floor. Following the incident, the crew deactivated the unit's circuit breaker to prevent electrical issues, and medical assistance was provided by a doctor and a paramedic among the passengers.
The investigation
The investigation focused on the mechanical failure of the refrigeration unit and the subsequent decision-making process by the flight crew. Investigators examined the damage to the unit, noting significant bulging and deformation of the door. The analysis of the refrigeration system, a B/E Aerospace vapour cycle unit, revealed that the unit was surrounded by an oven and galley walls, which directed expanding gases toward the door.
Investigators also reviewed the pilot's decision to continue the flight to Jakarta rather than diverting to nearby airports like Darwin or Denpasar. While the pilot coordinated with ground staff in Denpasar and consulted with the onboard medical professional, the investigation noted that the pilot did not declare an urgency or emergency message to Air Traffic Services as required by the operator's manual.
Findings
- The primary cause of the door failure was rapid pressure build-up caused by the sublimation of dry ice within the enclosed compartment.
- The pressure generated by the sublimating dry ice exceeded the discharge capacity of the unit's safety relief valve.
- The structural configuration of the galley directed the accumulating gas pressure toward the door, which acted as the weakest point.
- The flight crew followed established procedures for medical stabilization, but the failure to communicate an emergency status to ATC limited the availability of external support during the event.
Safety action
Following the incident, PT. Garuda Indonesia issued safety notices to all cabin crew members. These instructions included the temporary deactivation of identical refrigeration units and a strict prohibition against storing dry ice within the refrigeration compartments.