ASN Wikibase Occurrence # 234164
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| Date: | Wednesday 18 March 2020 |
| Time: | 04:16 UTC |
| Type: |  Fokker 100 |
| Owner/operator: | Air Niugini |
| Registration: | P2-ANF |
| MSN: | 11351 |
| Year of manufacture: | 1992 |
| Fatalities: | Fatalities: 0 / Occupants: 48 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | about 70nm west of Madang -
 Papua New Guinea
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Wewak-Boram Airport (WWK/AYWK) |
| Port Moresby-Jacksons International Airport (POM/AYPY) | |
| Investigating agency: | AIC PNG |
| Confidence Rating: |  Accident investigation report completed and information captured |
A Fokker 100 aircraft, Air Niugini flight PX121, experienced a cabin depressurisation event during a scheduled IFR passenger flight from Boram Airport, Wewak, East Sepik Province to Jacksons International Airport, Port Moresby. The aircraft subsequently diverted and landed at Madang Airport. The Pilot in Command (PIC), during interview with investigators, stated that straight after take-off from Boram, the No.1 engine bleed fault activated on the overhead panel. They subsequently switched the bleed system off and back on again as required by the Fokker 100 Quick Reference Handbook (QRH) Bleed Fault procedure. The fault disappeared and the crew continued with the departure and commenced to climb to Flight Level (FL) 350. The PIC was the designated pilot flying while the copilot was the pilot monitoring.
As the aircraft passed FL 290, it entered cloud. The PIC subsequently activated the aircraft’s engine anti-icing4 system. About 3 to 4 seconds later, the No.1 engine bleed fault light illuminated on the overhead panel, followed another 3 seconds later by the No.2 engine bleed fault. The crew referred to the QRH ‘Double Bleed Fault’ checklist and started the actions. Both pilots donned their oxygen masks and switched off both engines bleed systems. The Master Caution (MC) alert activated 5 seconds after the bleed systems were switched off. The PIC levelled the aircraft off just above FL 300 at 04:14. At 04:15 the PIC broadcast a PAN and subsequently commenced a rapid descent.
At about 04:16, as the aircraft was descending through FL 290, the Master Warning (MW) activated, along with the ‘excessive cabin altitude’7 warning. The crew continued with the rapid descent and began actioning the Quick Reference Handbook (QRH) emergency procedures for ‘Excessive Cabin Altitude’ and ‘Emergency Descent’.
The aircraft levelled off at 10,000 ft, about 35 nm miles South West of Madang.
The PIC then commenced a right turn and proceeded direct to Madang at 10,000 ft. The aircraft was established in the hold at about 10,000 ft at 04:28, and remained in the hold for about 10 minutes before commencing the approach for runway 25. The aircraft landed at 04:46. The crew taxied the aircraft to the parking bay where a normal passenger disembarkation was carried out,
All 48 occupants of the aircraft; two pilots, three cabin crew and 43 passengers did not sustain injuries from the occurrence.
CAUSES:
The loss of cabin pressure inflight was due to the simultaneous faults with the PRSOV and SOTMV within the engine bleed systems.
The aircraft had recurrent defects on the bleed systems. The investigation found that no proper fault isolation and troubleshooting were applied to identify and address the underlying causes of the faults prior to the occurrence.
Moreover, due to the intermittent characteristics of the faults, the system tended to operate in a normal manner when subject to tests and resets done either by maintenance or flight crews whenever those faults appeared, which difficulted a more in-depth maintenance assessment and action.
Accident investigation:
 |
|
Sources:
AIC PNG
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 20-Mar-2020 06:45 | Petropavlovsk | Added |
| 20-Mar-2020 18:48 | RobertMB | Updated [Registration, Cn, Total fatalities, Other fatalities, Location, Departure airport, Destination airport, Source, Narrative] |
| 22-Mar-2020 16:12 | The2ndBaron | Updated [Aircraft type] |
| 20-Apr-2020 19:13 | harro | Updated [Time, Total occupants, Nature, Source, Narrative] |
| 19-Dec-2021 09:14 | harro | Updated [Source, Narrative, Accident report] |
| 19-Dec-2021 09:18 | harro | Updated [Accident report] |
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