AeroContractors B735 near Lagos on Jun 5th 2015, loss of cabin pressure
Last Update: December 6, 2017 / 18:38:58 GMT/Zulu time
Incident Facts
Date of incident
Jun 5, 2015
Classification
Incident
Cause
Loss of cabin pressure
Airline
AeroContractors
Flight number
AJ-181
Departure
Lagos, Nigeria
Destination
Kaduna, Nigeria
Aircraft Registration
5N-BLE
Aircraft Type
Boeing 737-500
ICAO Type Designator
B735
The airline confirmed a depressurization of the cabin. As there are maintenance facilities in Abuja the aircraft was diverted to Abuja to fix the problem.
On Dec 6th 2017 Nigeria's AIB published their final report concluding the probable causes of the serious incident were:
The inadvertent failure to discover that the PRSOV was in the LOCKED CLOSED position after the engine change.
Contributory Factor
Failure to recognise that the number 2 bleed pressure was zero after engine start and subsequent failure to monitor the pressurisation system during climb.
The AIB analysed:
It is pertinent to note that 5N-BLE has a history of frequent engine changes.
On the 26th of May 2015, #2 engine with serial number 721707 was changed in Abuja due to a surge problem and replaced with engine, serial number 858904. The aircraft was then ferried to Lagos.
On 5th June, 2015; the day of the incident, #2 engine with serial number 858904 was changed due low time remaining and replaced with another engine, serial number 725373. According to evidence available to AIB, this incident occurred on the first commercial flight after this engine change.
The engine post-installation procedure requires that the PRSOV should have been checked after the engine change to confirm that it is in the OPEN position. The engine installation procedure as contained in the AMM Section 71]00]02 requires a series of post-installation tests to verify correct operation. One of these tests is the Pneumatic Leak Test (AMM Section 36-11-05-705-16). This test requires that the PRSOV be manually wrenched to the OPEN position. The PRSOV will remain open when there is pneumatic pressure upstream of the PRSOV.
There is no evidence to show that these procedures were followed by the maintenance engineers during the engine installation. Also, there was no evidence that a duplicate inspection was carried out to confirm that appropriate procedure had been followed during the engine installation. If these procedures had been followed, it would have been discovered that the PRSOV was still in the CLOSED and LOCKED position and this incident would not have occurred.
Therefore, this action contributed to the occurrence.
Incident Facts
Date of incident
Jun 5, 2015
Classification
Incident
Cause
Loss of cabin pressure
Airline
AeroContractors
Flight number
AJ-181
Departure
Lagos, Nigeria
Destination
Kaduna, Nigeria
Aircraft Registration
5N-BLE
Aircraft Type
Boeing 737-500
ICAO Type Designator
B735
This article is published under license from Avherald.com. © of text by Avherald.com.
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