Improper Manual Pressure Control Leads to Serious Incident in Airbus A330

Casualties unknown • Zürich Flughafen (LSZH), inbound, ZH, CH

A failure in the automatic cabin pressure regulation of an Airbus A330 resulted in a serious incident during flight near Basel.

What happened

On 21 November 2014, an Airbus A3/330-343, registration HB-JHB, was operating in the airspace approximately 110 NM west-northwest of Basel when a serious incident occurred involving the aircraft's cabin pressurization. The aircraft experienced a failure in its automatic pressure regulation system due to a blocked outflow valve. In response to the developing situation, the flight crew initiated an emergency descent.

The investigation

The Swiss Transportation Safety Investigation Board (STSB) examined the technical and operational aspects of the event. The investigation focused on the mechanical failure of the outflow valve and the subsequent actions taken by the crew. Investigators reviewed the aircraft's electronic flight instrument system (EFIS) and the centralized fault display system to understand how the crew perceived the cabin altitude and differential pressure during the descent. The probe also looked into the cockpit's automated display logic and the crew's application of manual pressure control procedures.

Findings

Technical analysis revealed that a blocked outflow valve caused the automatic cabin pressure regulation to fail. A significant contributing factor was a system-related limitation where the cockpit displays for cabin altitude and differential pressure were automatically hidden when the cabin altitude dropped below -2,060 ft.

Regarding the crew's response, the investigation determined that the crew initiated an emergency descent intuitively without first performing a structured analysis of the situation. Furthermore, the procedures required for managing the cabin pressure via manual control were not fully implemented by the flight crew during the event.

Probable cause

The primary cause of the incident was the failure of automatic cabin pressure regulation due to a blocked outflow valve, compounded by the crew's decision to perform an emergency descent without a structured situational assessment and the incomplete application of manual pressure control procedures.

Frequently asked questions

What happened in the 2014-11-21 AIRBUS S.A.S. A330-343 accident near Zürich Flughafen (LSZH), inbound, ZH, CH?

A failure in the automatic cabin pressure regulation of an Airbus A330 resulted in a serious incident during flight near Basel.

What aircraft was involved and where did it happen?

The accident on 2014-11-21 involved a AIRBUS S.A.S. A330-343, registration HB-JHB, at Zürich Flughafen (LSZH), inbound, ZH, CH.

What was the probable cause of the accident?

The primary cause of the incident was the failure of automatic cabin pressure regulation due to a blocked outflow valve, compounded by the crew's decision to perform an emergency descent without a structured situational assessment and the incomplete application of manual pressure control procedures.

Investigation report by the Swiss Transportation Safety Investigation Board (STSB / SUST). Original record: https://www.sust.admin.ch/inhalte/AV-berichte/2269_e.pdf. This page is a structured re-presentation; facts and quotes are in the Swiss Transportation Safety Investigation Board (STSB), Switzerland.

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