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ASN Wikibase Occurrence # 207806
Last updated: 21 February 2020
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Date:03-MAR-2018
Time:18:28 UTC
Type:Silhouette image of generic B737 model; specific model in this crash may look slightly different
Boeing 737-75B (WL)
Owner/operator:Germania
Registration: D-AGEU
C/n / msn: 28104/39
Fatalities:Fatalities: 0 / Occupants: 128
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Canary airspace -   Spain
Phase: En route
Nature:International Scheduled Passenger
Departure airport:Puerto del Rosario Airport, Canary Isl./Fuerteventura Island (FUE)
Destination airport:Berlin Schönefeld Airport (SXF)
Investigating agency: CIAIAC
Narrative:
Germania flight ST1433 was en route at FL380 when the flight crew experienced intense pressure changes. After observing the Cabin Rate of Climb Indicator, they noticed that there was a problem with the pressurization of the cabin. Moments later, the visual and auditory cabin altitude warning activated. The crew put on oxygen masks.
The pilot monitoring noted that the FLT ALT and LAND ALT indicators showed dashes, so they concluded that a double failure of the cabin pressure controller had occurred.
Meanwhile, the altitude of the cabin reached 15,000 feet in an uncontrolled manner. The oxygen masks of the passengers were deployed automatically when the cabin altitude reached 14,000 feet.
The crew declared the emergency situation (MAYDAY) to the air traffic control service, communicating their intentions to carry out an emergency descent.
During the descent, the crew manually regained control of cabin pressurization, after which they decided to cancel the emergency declaration.
The crew decided to divert and land at the Malaga Airport, where they landed normally.

CAUSES:
The investigation was unable to realiably determine the cause of this incident.
1. According to the studies conducted during the investigation into this incident, it may have been caused by two possible faults.
Initially. the #2 cabin pressure controller (CPC2) commanded the outflow valve (OM to open completely. The upset that opened the OFV was caused by corrupted data in the CPC. The source of that corrupted data was either a SEU or the result of failing solder joints.
Later, due to the stiffness of the OFV, the # 1 cabin pressure controller (CPC1) was unable to return it to its closed position and thus stabilize the cabin pressure. This may have bee n a factor contributing to the severity of the depressurization. It was possible to identify what caused the stiffness of the OFV.
2. After the incident, suspecting that both cabin pressure controllers had failed simultaneously, they were replaced; however, various anomalies continued to occur involving the loss of cabin pressure.
3. The aircraft operator did not provide information on what caused the loss of cabin pressure after the cabin pressure controllers were replaced.
Moreover, it is not known if these subsequent incidents were analyzed in detail by the operator.

On 3 March 2018, before the incident, two other incidents involving cabin pressure were re ported. It is thought that the lack of a detailed analysis of these prior incidents by the operator's maintenance technicians could have been a contributing factor in this incident.

Sources:

http://www.fomento.gob.es/MFOM/LANG_CASTELLANO/ORGANOS_COLEGIADOS/CIAIAC/INVESTIGACION/2018/IN-008-2018.htm

Accident investigation:
cover
  
Investigating agency: CIAIAC
Status: Investigation completed
Duration: 1 year and 3 months
Download report: Final report


Images:

Photo of D-AGEU courtesy AirHistory.net


Kemble - Cotswold (EGBP / GBA)
2 January 2019; (c) Alastair T. Gardiner

Revision history:

Date/timeContributorUpdates
18-Mar-2018 10:23 harro Added
05-Jun-2019 10:24 harro Updated [Destination airport, Narrative, Accident report, ]
05-Jun-2019 10:25 harro Updated [Departure airport, Destination airport]

Corrections or additions? ... Edit this accident description