Serious incident Boeing 737-8AS (WL) EI-GJT,
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ASN Wikibase Occurrence # 230366
 
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Date:Tuesday 9 October 2018
Time:22:05 UTC
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8AS (WL)
Owner/operator:Ryanair
Registration: EI-GJT
MSN: 44837/6928
Year of manufacture:2018
Engine model:CFM56-7B26E
Fatalities:Fatalities: 0 / Occupants: 183
Aircraft damage: None
Category:Serious incident
Location:between Porto, Portugal and Edinburgh, U.K. -   Atlantic Ocean
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Porto-Francisco Sá Carneiro Airport (OPO/LPPR)
Destination airport:Edinburgh-Turnhouse Airport (EDI/EGPH)
Investigating agency: AAIB
Confidence Rating: Information verified through data from accident investigation authorities
Narrative:
Shortly after reaching cruise at FL360 the commander’s attitude indicator malfunctioned affecting numerous aircraft systems, and the aircraft climbed 600 ft. After a significant time delay an irs caution was displayed. The Quick Reference Handbook (QRH) was followed by the crew and the left Air Data Inertial Reference Unit (ADIRU) was put into ATT mode. The left Primary Flight Display (PFD) continued to display erroneous attitude information to the pilot, and other systems were also affected. The aircraft was flown manually to Edinburgh where it landed safely.

AAIB Conclusion:
On EI-GJT, the IRS of the left ADIRU suffered a fault which led to an erroneous calculation of position. This resulted in the display of faulty attitude information on the commander’s PFD, and the supply of erroneous information to several aircraft systems. The problems were contained through manual flight and the use of standby instrumentation. Although action could have been taken to restore reliable attitude information to the commander’s PFD, such action was not directed from within the QRH. The training given to the crews discouraged them from acting unless directed by the QRH, so this lack of relevant information in the QRH contributed to the situation.

Accident investigation:
cover
  
Investigating agency: AAIB
Report number: EW/C2018/10/01
Status: Investigation completed
Duration: 1 year
Download report: Final report

Sources:

AAIB

Revision history:

Date/timeContributorUpdates
02-Nov-2019 20:40 harro Added
02-Nov-2019 20:41 harro Updated [Time, Narrative]

Corrections or additions? ... Edit this accident description

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