AIRCRAFT SERIOUS INCIDENT

INVESTIGATION REPORT

ALL NIPPON AIRWAYS FLIGHT 198

AIRBUS INDUSTRIIE A321 – 131, JA102A

Arde, Anthony Jr.

Castro, Daniel III
Fontamillas, Julianne
Lim, Karl Ryanne
Flight Information
Operator: All Nippon Airways Flight 198
Aircraft Type: Airbus 321
Registration: JA102A
Investigators: Aircraft and Railway Accidents
Investigation Commission (ARAIC)
Damage to the Aircraft: None
Injuries: None

Summary of the Incident

Flight 198, the Airbus Industries A321 operated by All Nippon
Airways Ltd. took off from Oita Airport on September 29, 2005
for Tokyo International Airport on scheduled service. When
traveling approximately 90 kilometers east-southeast of Chubu
International Airport, the aircraft's both air-conditioning packs
failed. The plane then began an emergency descent, and the crew
manually deployed the passenger oxygen masks. The plane
touched down at Tokyo International Airport. There were 172
people on board, including the pilot-in-command, five other
crew members, and 166 passengers and there were no casualties.
Analysis
Based on the investigation reports, it is estimated that the factors
contributing largely to the serious incident aircraft's air-
conditioning system failure was caused by contamination and
consequent efficiency deterioration of air-conditioning system
components particularly complete name (FCVs) and complete
name (CPNOHs) which prevented the air-conditioning system
from functioning normally and results to failure of the system.

The problem started when the contaminants from the upstream

components of the air conditioning system that were present in
the bleed air blocked the filter of Flow Control Valve’s Probe 1
of both Packs which affects the normal flow-rate control (100%)
of the FCV.
The bleed air flow rate of the packs exceeds its normal flow rate,
which causes the compressor to operate faster resulting in a
higher temperature to the compressor outlets. Increasing the
flow control rate in both PACK’s with an air flow greater-than-
normal, the compressor continues to operate, until it reaches its
minimum temperature. However, the contaminated Compressor
Pneumatic Overheat Sensor (CPNOH) is unable to properly
operate in releasing pressure as temperature changes which
prevents the FCV from closing. As a result of these conditions,
aircraft conditioning packs overheated and ultimately failed.

Preventive Measures and Modifications

Considering this kind of incident, improvements for appropriate
repair, replacement, etc. were put to adopt measures in
monitoring air conditioning system operation.
The company made specific modifications of FCV’s to their type
of filter to be used, periodic replacement of the FCV P1 probe
filters, replacements of CPNOH with prescribed maintenance
and established a monitoring in-flight system for each PACKs of
an aircraft.