Garuda A332 enroute on Aug 22nd 2015, ice bomb injures flight attendant

Last Update: December 9, 2016 / 16:45:49 GMT/Zulu time

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Photo of Garuda Indonesia PK-GPO, Airbus A330-200 — Garuda Indonesia PK-GPO, Airbus A330-200 (Photo credit: Aero Icarus / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Aug 22, 2015

Classification
Accident

Airline
Garuda Indonesia

Flight number
GA-717

Departure
Melbourne, Australia

Destination
Jakarta, Indonesia

Aircraft Registration
PK-GPO

Aircraft Type
Airbus A330-200

ICAO Type Designator
A332

A Garuda Indonesia Airbus A330-200, registration PK-GPO performing flight GA-717 from Melbourne,VI (Australia) to Jakarta (Indonesia) with 187 passengers and 13 crew, was enroute at FL380 neer DEENO waypoint (S21.585 E131.215) about 3 hours into the flight when a refrigerator in the middle galley blew out causing a metal part to hit a flight attendant into the face. The aircraft continued to Jakarta where the aircraft landed safely about 4 hours later.

On Sep 8th 2015 the French BEA reported in their weekly bulletin, that the flight attendant received serious injuries when a wine chiller in the middle galley blew out, the occurrence was rated an accident and is being investigated by Indonesia's NTSC.

On Dec 8th 2016 the NTSB released their final report concluding the probable cause of the accident was:

The burst of the refrigeration door was a result of pressure build-up that exceeded the capacity of the safety relief valve due to dry ice being placed in the refrigeration unit compartment. The door burst resulted in serious injuries to the flight attendant.

The NTSC reported the aircraft was about 3 hours into the flight when a flight attendant put pieces of dry ice into an empty bottle of mineral water and put the bottle into the refrigerator unit in the middle galley. About 3 minutes later the unit door burst and was thrown into the face of the flight attendant. The flight attendant fell to the floor with a bleeding face and was assisted by a passenger and another flight attendent. Another flight attendant pulled the circuit breaker of the refrigerator. An announcement looking for medical staff on board revealed an internist doctor and a paramedics, who treated the injured flight attendant. The flight crew considered to divert to Darwin,NT (Australia), however, as the flight attendant could get stabilized and the bleeding was stopped decided to continue the flight to Jakarta with the option to divert to Denpasar should the condition of the flight attendant deteriorate again.

The NTSC reported that the unit could be operated in three different modes including wine chilling mode, the fridge was operated by the flight attendant in charge of the middle galley and only for chilling wines and champagne.

The flight attendant received serious injuries requiring cranial surgery and remained in hospital care for 18 days.

The NTSC analysed:

The only substance on board the aircraft that could initiate an increase in pressure was dry ice and it was established that it was inserted into the refrigeration unit prior to the failure.

In reference to the Material Safety Data Sheet (MSDS) of dry ice, it stated that dry ice starts to sublime at -78.5 ºC (-109.3 ºF) and if stored in confined gas tight container, it will build up to a pressure of 850 psig at 70º F.

The presence of dry ice in the refrigerator compartment at a temperature of 46° F, would therefore lead to dry ice sublimation, and a subsequent increase of the pressure in the refrigeration unit compartment.

A safety relief valve was fitted in the refrigeration unit door to relieve pressure differences between the inside of the compartment and external pressure. However, if the pressure build-up was too rapid, the safety relief valve would not have the capacity to relieve the pressure and a pressure build up would occur within the compartment to the point of failure of the compartment door. The investigation was unable to establish the peak pressure obtained within the compartment that leads to the door failure.

With respect to the captain's decision to continue the flight the NTSC analysed:

After the occurrence, a Flight Attendant informed the PIC that one of the FA’s had been injured. After first aid had been administered to the injured FA, at approximately 48 minutes after the occurrence, the PIC consulted with the doctor regarding the condition of the injured FA. The doctor stated that the injured FA condition was stable, the bleeding had stopped and that it was safe to continue the flight to Jakarta. Referring to the doctor’s statement, the PIC decided to continue the flight to Jakarta and the PIC requested the doctor to inform him of any significant changes.

Assuming that the aircraft was cruising with a ground speed of 550 knots, at the time the PIC consulted to the doctor, the aircraft was approximately 458 Nm from waypoint DEENO. The suitable airports near that position were Denpasar and Darwin. The distance from this point to Denpasar was approximately 740 Nm and approximately 440 Nm to Darwin. The flight time to Darwin would take approximately 50 minutes and to Denpasar would take approximately 80 minutes.

The PIC considered the possibility of diverting to Denpasar if the injured FA’s condition required further immediate medical assistance and had coordinated with the flight operation staff in Denpasar airport.

The PIC did not elect to divert to Darwin as he considered that the injured FA was stable and that a 30 minute difference would not significantly affect the injured FA’s condition. Diverting to Darwin would also likely increase the complexity of the continuation of the flight in relation with passenger handling, flight approval and refuelling as Garuda Indonesia did not have representative in Darwin. Other consideration was that the failure of the refrigeration unit did not relate to security issue.

After communicated with the Flight Operation Staff in Denpasar, the pilot received information from the doctor that the FA condition was stable, the bleeding had stopped and it was safe to continue the flight to Jakarta. The pilot decided to continue the flight to Jakarta.

The operator’s Basic Operation Manual (BOM) 5.2.1 Sickness and Accidents on Board point (5) Action To Be Taken When Flight Attendant Incapacitated, contained the procedure in the case a flight attendant becomes incapacitated and unable to perform their job. Practically all items described in the above mentioned manual were executed by the crew, except the item that was the PIC transmission of an urgency or emergency message.

By not communicating the urgency or emergency message as required by the BOM, the PIC reduced the possibility of utilising additional resources (in this case ATC) to assist make a decision to either divert or continue to Jakarta. In hindsight, the injuries sustained by the FA were more serious than initially indicated and required more immediate attention.