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| Date: | Friday 5 February 2021 |
| Time: | 00:35 LT |
| Type: |  Airbus A330-202 |
| Owner/operator: | Qantas |
| Registration: | VH-EBK |
| MSN: | 945 |
| Year of manufacture: | 2008 |
| Engine model: | GE CF6-80E1A4 |
| Fatalities: | Fatalities: 0 / Occupants: |
| Other fatalities: | 0 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | 435 km SW of Adelaide -
 Australia
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Sydney-Kingsford Smith International Airport, NSW (SYD/YSSY) |
| Perth Airport, WA (PER/YPPH) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
Qantas flight QF583, an Airbus A330-202, was en-route from Melbourne to Perth at about 1405 UTC (0035 CSuT) when the flight crew conducted an emergency descent from 40,000 feet to 10,000 feet due to a depressurisation indication. An emergency was declared to air traffic control and the aircraft diverted to Adelaide, where it safely landed at 1533 UTC (0203 CSuT).
Contributing factors
• Due to a design limitation associated with the aircraft’s cabin pressure controller (CPC) systems:
-- The controlling CPC was unable to detect a fault with its pressure sensor, resulting in the loss of cabin pressure control and the subsequent increase in cabin altitude.
-- While the backup CPC triggered the CAB PR EXCESS CAB ALT alert as required when the cabin altitude exceeded 9,550 ft, the data presented to the flight crew indicated normal cabin altitude.
• The flight crew responded to the CAB PR EXCESS CAB ALT alert procedure by observing that there was no confirmatory data and, in seeking evidence to verify the failure, delayed executing the required procedure.
• A preamble to the CAB PR EXCESS CAB ALT alert procedure was introduced as a procedural mitigation for the CPC system design limitation. This required flight crew to rely on the alert even if not confirmed by other system data. This mitigation had significant potential for error as:
-- although a critical component to the procedure, the preamble requirement was not part of the ‘read & do’ procedural steps and was reliant on memory recall
-- the required procedural action was contrary to both the operator and aircraft manufacturer’s procedural philosophy of confirming alerts with system data before executing abnormal procedures
• An Airbus service bulletin (SB), introduced as a mitigation to the CPC design limitation, would have prevented the loss of cabin pressure control from the pressure sensor fault. However, the SB had not been incorporated on this aircraft.
• The mitigations introduced by Airbus to counter the design limitation associated with the A330 cabin pressure control systems were ineffective because:
-- changes to the CAB PR EXCESS CAB ALT alert operational procedure did not ensure appropriate management of the fault
-- the service bulletin had very limited uptake in the A330/A340 global fleet. [Safety Issue]
• The operator’s training system did not adequately cover the unique requirements of the CAB PR EXCESS CAB ALT alert procedure, increasing the risk of an incorrect or delayed application of the required procedure. [Safety Issue]
Accident investigation:
 |
|
Sources:
http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-005/
https://uk.flightaware.com/live/flight/VHEBK/history/20210204/0840Z/YSSY/YPAD
History of this aircraft
Other occurrences involving this aircraft
| 19 January 2025 | VH-EBK | Qantas | 0 | 150 km W of Pormpuraaw, QLD | |
non |
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 10-Feb-2021 20:17 | harro | Added |
Corrections or additions? ... Edit this accident description
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