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ASN Wikibase Occurrence # 208784
Last updated: 19 April 2018
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Date:01-JUL-2016
Time:16:10
Type:Silhouette image of generic RJ85 model; specific model in this crash may look slightly different
Avro RJ85
Owner/operator:Cityjet
Registration: EI-RJW
C/n / msn: E.2371
Fatalities:Fatalities: 0 / Occupants: 93
Other fatalities:0
Airplane damage: None
Category:Serious incident
Location:near Paris-Charles de Gaulle Airport (CDG/LFPG) -   France
Phase: En route
Nature:International Scheduled Passenger
Departure airport:Paris-Charles de Gaulle Airport (CDG/LFPG)
Destination airport:Newcastle Airport (NCL/EGNT)
Investigating agency: AAIU
Narrative:
During climb out from Paris Charles de Gaulle Airport (LFPG), France, on a scheduled passenger flight to Newcastle (EGNT), United Kingdom, the flight crew noticed that the cabin rate of climb and cabin altitude had increased rapidly, and that a white PRESSN advisory light (pressurisation fault) had illuminated on the Central Warning Panel (CWP). This was followed by a pressurisation system caution light (pressurisation failure). As the flight crew were completing the abnormal operation checklist, a CABIN HI ALT (cabin high altitude) warning was generated. This resulted in the flight crew declaring an emergency (Mayday) to Air Traffic Control (ATC), donning their oxygen masks and performing an emergency descent.
During completion of the cabin high altitude checklist, they discovered that a ram air switch on the overhead panel, which controls the position of the ram air valve, was in the OPEN position instead of the normal SHUT position. The flight crew moved the switch to the SHUT
position, which closed the ram air valve and restored normal system operation. The flight was continued to EGNT without further incident.
It was subsequently found that a non-return valve in the aircraft’s ram air system had been installed the wrong way round. This incorrectly installed valve, in combination with the ram air valve being in the open position on the occurrence flight, prevented the aircraft from pressurising correctly

Probable Cause:
Failure of the aircraft to correctly pressurise after take-off due the inadvertent selection of the ram air switch to OPEN, combined with an incorrectly fitted ram air non-return valve.
Contributory Cause:
There are no design features that preclude an incorrect installation of the ram air non-return valve.

Sources:

http://www.aaiu.ie/sites/default/files/report-attachments/REPORT%202018-005.pdf

Accident investigation:
cover
  
Investigating agency: AAIU
Status: Investigation completed
Duration: 1 year and 9 months
Download report: Final report


Revision history:

Date/timeContributorUpdates
04-Apr-2018 16:32 harro Added
04-Apr-2018 16:57 harro Updated [Narrative]

Corrections or additions? ... Edit this accident description