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ASN Wikibase Occurrence # 171926
Last updated: 25 April 2019
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Date:21-NOV-2014
Time:12:03 UTC
Type:Silhouette image of generic A333 model; specific model in this crash may look slightly different
Airbus A330-343
Owner/operator:Swiss International Air Lines
Registration: HB-JHB
C/n / msn: 1018
Fatalities:Fatalities: 0 / Occupants: 178
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:near Zürich -   Switzerland
Phase: En route
Nature:International Scheduled Passenger
Departure airport:Newark-Liberty International Airport, NJ (EWR/KEWR)
Destination airport:Zürich-Kloten Airport (ZRH/LSZH)
Investigating agency: STSB Switzerland
Narrative:
On 21 November 2014, the scheduled flight (flight number SWR 19R) from Newark (KEWR) to Zurich (LSZH) was carried out with the commercial aircraft Airbus A330-343, registered as HB-JHB. There were two pilots, 10 cabin crew members and 166 passengers on board.
After an uneventful flight, the amber warning message CAB PR SYS 1 FAULT was displayed in the cockpit at 12:03:12 UTC during the descent from flight level (FL) 370 to FL 310. A single chime sounded a minute later and the amber warning message CAB PR SYS 1+2 FAULT was displayed simultaneously.
Subsequently, the flight crew decided to request an immediate further descent from Reims control and sent an urgency message (Pan Pan). The flight crew don their oxygen masks, initiated an emergency descent and informed the cabin crew of this. A short time later, the flight crew reported Mayday to air traffic control and received clearance to descend to FL 150.
The flight crew were of the view that the oxygen masks in the cabin had been released. Shortly afterwards, the commander initiated the corresponding ECAM1 procedure which, among other things, requests that the cabin altitude is to be controlled manually. The flight crew briefly discussed the displayed cabin altitude and found it to be okay. Approximately five minutes later, the commander mentioned that the cabin altitude was no longer being displayed.
The flight crew therefore decided to land as quickly as possible and to fully open the outflow valves manually during the approach at an altitude of approximately 4000 ft. This was to ensure that the cabin doors could be opened after landing. The commander subsequently informed the line maintenance department in Zurich that they no longer had the cabin altitude and differential pressure displays. At 12:11:47 UTC, the flight crew informed air traffic control that they would cancel Mayday.
After a frequency change to Zurich’s approach control, the flight crew was given clearance for an instrument approach to runway 14 with the aid of radar vectoring. Shortly before landing, the copilot noticed that the cabin altitude was being displayed again. At 12:38:08 UTC, the aircraft HB-JHB touched down on runway 14.
The passengers and the crew disembarked the aircraft normally. There were no injuries.

Causes:
The serious incident is attributed to the failure of the automatic cabin pressure regulation as a consequence of a jammed outflow valve and the fact that the procedure for its manual control was not applied fully.
The following factor was found to be causal:
- The flight crew intuitively initiated an emergency descent, without first having undertaken a structured analysis of the situation.
The following factor contributed to the serious incident:
- The system-related blanking out of the cabin altitude and the differential pressure displays when the cabin altitude reaches below -2060 ft.

Sources:


Accident investigation:
cover
  
Investigating agency: STSB Switzerland
Status: Investigation completed
Duration: 3 years and 11 months
Download report: Final report


Revision history:

Date/timeContributorUpdates
04-Dec-2014 20:27 harro Added
30-Oct-2018 18:25 harro Updated [Total occupants, Source, Narrative, Accident report, ]
30-Oct-2018 18:33 harro Updated [Operator, Location]

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