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‘Defective Pressure Controller And Maintenance Error’ Caused Flight’s Plunge

Experts Demand Improvements Following Interim Report Findings


Aviation lawyers representing British passengers injured when a Ryanair flight dropped 20,000ft as a result of cabin pressure problems have revealed their concerns after an interim accident investigation report determined that a problem with a cabin pressure controller, plus a design and maintenance error on the backup pressure controller, caused the incident.
The Boeing 737-800 flying more than 100 passengers from Bergamo to East Midlands Airport on April 4th 2012 diverted to Frankfurt-Hahn Airport when serious cabin pressure problems forced the crew to make an emergency descent which left 13 people physically injured. 
A German Federal Bureau of Aircraft Accident Investigation interim report has revealed the chain of events that led to this incident. The Boeing 737-800 has two cabin pressure controllers, one controls cabin pressure during flight and the other acts as a backup system. 

The day before the accident the aircraft is reported to have experienced a cabin pressure problem, so one of the pressure controllers was replaced.  The report concludes that unfortunately the engineer did not remove the shipping plug, meaning that the pressure controller could not function correctly. 

When the aircraft took off on the flight in question, the other pressure controller was controlling cabin pressure with the replaced one acting as the redundant backup.  During the climb a fault occurred with the active pressure controller causing it to revert to standby, meaning the replaced pressure controller had to take over. 

Due to the shipping plug not being removed, the backup pressure controller could not control cabin pressure which required the crew to initiate an emergency descent to 10,000 feet, so that the passengers could breathe the air without the need for cabin pressurisation.  

As a result of this incident, the interim report made safety recommendations including that the US Federal Aviation Authority should require Boeing to redesign the shipping plugs to make them more recognisable and couple them with an eye catching tag.
Jim Morris, a former RAF Boeing AWACS pilot and Partner in Irwin Mitchell’s specialist aviation law team, commenting on the interim report said it confirmed his initial view that a technical or design fault had caused the accident.  “From my experience and the initial news reports on the accident, the cause was likely to be a problem with the aircraft, not an error by the crew. 

“The interim report from the German authorities concludes that this incident was caused by a combination of a faulty cabin pressure controller together with a poorly designed shipping plug which resulted in a maintenance error. This chain of events created an emergency situation for the Ryanair pilots, who took immediate action to safeguard their passengers and landed the aircraft safely without loss of life.
 “While it is welcome that the causes of this incident have been identified in the interim report, a fault with one pressure controller and a badly designed shipping plug on the other gives rise to serious concerns.

“These are essential components in a critical life support system used within this Boeing airliner. We hope Boeing and the aviation authorities are able to provide assurances that such issues have been rectified to prevent a similar accident happening again.”
Two of the passengers that Jim represents are Nottingham couple Melvin and Jacqueline Frater.  The pair were travelling back from a holiday in northern Italy when the problems emerged just 20 minutes into the flight. They have been monitored by medical experts for psychological and physical injuries following the incident.
Melvin Frater said: “When we boarded that flight we put our trust in experts managing and operating the aircraft, so we’re obviously really shocked to see the findings of the investigation so far.
“Everyone was shocked and scared following the incident and to see an error behind this is a massive concern. We hope that aviation authorities, Ryanair and Boeing all take steps to stop anyone else facing what we have had to endure.”

The interim report from the German Authorities will be followed by a final report although it is not known when this will be released or whether any of the interim findings will be altered.

Irwin Mitchell's Aviation law team has represented victims and their families following a number of Boeing 737-800 crashes including recent fatal accidents shortly after take-off from Cameroon and Beirut.