Star Cargo B733 near Port Elizabeth on May 4th 2018, loss of cabin pressure

Last Update: September 15, 2018 / 17:56:24 GMT/Zulu time

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Incident Facts

Date of incident
May 4, 2018

Classification
Incident

Flight number
JE-536

Aircraft Registration
ZS-VDP

Aircraft Type
Boeing 737-300

ICAO Type Designator
B733

A Star Air Cargo Boeing 737-300 on behalf of Mango Airlines, registration ZS-VDP performing flight JE-536 from Port Elizabeth to Johannesburg (South Africa) with 116 passengers and 8 crew, was climbing through FL230 out of Port Elizabeth when the crew noticed an anomaly with the cabin pressurization. While troubleshooting the problem the flight crew selected the cabin pressurization switch to the standby position, the outflow valve opened fully causing the loss of cabin pressure. The flight crew initiated a rapid descent to FL100 and returned to Port Elizabeth for a safe landing.

South Africa's CAA (SACAA) reported a cabin pressure controller was replaced. Two investigators were dispatched to investigate the occurrence.

On Sep 15th 2018 the SACAA released their final report concluding the probable causes of the incident were:

The primary cause of the loss of pressurisation control was due to a loss of the CPC’s ability to correctly modulate the outflow valve position.

The secondary cause of the pressurisation failure, which caused the high cabin pressure differential, was due to the failure of both pressure relief valves. Neither of these valves opened at 8,3 psi to ensure that the cabin differential did not exceed the amber band.

The SACAA reported the aircraft was climbing to its assigned enroute flight level out of Port Elizabeth when the crew noticed the cabin altitude remained at 230 feet (elevation of Port Elizabeth) with the rate of pressure change indication remaining at zero. The crew performed fault finding, as result they turned the rotary switch for the pressurization control from AUTO to STBY. The outflow valve moved to the full open position causing the cabin to depressurize while the aircraft was climbing through FL230. The passenger oxygen masks were released (6 passenger service units did not open). The crew initiated a rapid descent to FL100, requested to return to Port Elizabeth and landed safely back.

The SACAA reported that the cabin pressure controller was replaced, thereafter the function of the outflow valve and pressurization system was normal.

The SACAA analysed: "The investigation revealed that the Cabin Pressure Controller (CPC) had failed to modulate the outflow valve to maintain the correct pressure schedule and the failure of the safety valves to open and relief pressure at 8.3Psi differential."
Incident Facts

Date of incident
May 4, 2018

Classification
Incident

Flight number
JE-536

Aircraft Registration
ZS-VDP

Aircraft Type
Boeing 737-300

ICAO Type Designator
B733

This article is published under license from Avherald.com. © of text by Avherald.com.
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