AMTA329

Air Conditioning and Pressurization System Failure

Virgin Blue Airlines Boeing 737-700 Flight DJ-988

Submitted by: Lava, Magtibay, Tappa, Zafra

Course & Section: BS AET 3B

Aircraft: Boeing 737-700

Registration: VH-VBC

Flight Number: DJ-998

Origin: Coolangatta

Destination: Melbourne

Passengers: 145

Crew: 6

Operator: Virgin Blue

Description:

On 17 November 2007 a Boeing 737-700 being operated by Virgin Blue on a scheduled

passenger service from Coolangatta to Melbourne experienced a failure of the right-hand engine
bleed during the take off. The flight was continued but subsequently, during the climb in night
IMC to FL350, the left air conditioning pack failure and an emergency descent followed with
passenger oxygen masks deploying as cabin altitude exceeded 14000 feet. A diversion was made
to Brisbane

Investigation
An Investigation was carried out by the ATSB.

It was found that the initial fault has occurred below 80 KIAS during the take-off roll. An
attempt at reset after becoming airborne but when still below MSA was not successful and with
APU air not available above FL170, it was initially decided to cruise at FL250, a lower level
than planned. Once there, however, icing conditions were encountered and it was decided to
continue the climb to FL350 so as to be able to cruise clear of cloud. Then, at FL318 during the
climb, about 135 nm south west of Coolangatta, the left air conditioning pack failed, and an
emergency descent was made to 10000 feet. During this descent, cabin altitude exceeded 14000
feet, which led to the passenger oxygen masks deploying automatically. Thereafter, the diversion
to Brisbane was achieved by making a track reversal to an airport near to but larger than the
departure airport. It was noted that maintenance action on the incident aircraft immediately prior
to departure had cleared a reported fault of an open left-hand air-conditioning ram air door made
by the previous operating flight crew. Although this subsequently turned out to be a symptom of
the split in the flexible hose that contributed to the failure of the left-hand bleed supply en-route,
it was considered equally possible that the reported open ram air door might have been a result of
a fault with the door actuator, as diagnosed by maintenance and the reason which had led them to
lock the ram air inlet door open as a way to permit continued operation of the aircraft. It was
noted also that the Master Caution during take-off activated at less than 80 kts and that the
failure to reject the take-off was therefore contrary to Operator SOPs and had increased the risk
of the underlying aircraft problem having an effect during the flight. Similarly, the decision to
deal with the bleed failure soon after take-off instead of waiting until above Minimum Sector
Altitude, was considered to have increased the risk of the crew being distracted from their
primary flying tasks at a critical phase of the flight. It was observed that a bleed trip-off was less
likely in the 737 NG types than 737 Classic types because of system design changes which was
the reason why the possibility of using engine anti-ice to facilitate system reset after a bleed trip
off was not documented for the 737 NG aircraft. Given that the aircraft was certified for
operation up to a maximum ceiling of FL410 on a single air conditioning pack and the bleed-trip
occurred post-dispatch, it was notes that the Minimum Equipment List (MEL) maximum
operating altitude of FL250 was of no relevance to the decision on an appropriate cruise altitude.
However, the climb to FL350 had placed additional load on the left, degraded, air conditioning
pack which was "not capable of operating at the maximum ceiling" and this was considered to
have increased the chances that a single pack might trip off.

Contributing Safety Factors

 During a No Engine Bleed Takeoff, a defective high-stage valve allowed a pressure

increase in the aircraft’s right bleed air system that triggered the system’s
overpressure switch to activate the right bleed trip off. Attempts by the flight crew
to reset the system were unsuccessful.
 The flight crew continued the flight and climbed above FL250, which was the
aircraft’s minimum equipment list-specified ceiling with a single air conditioning
pack operating.
 The left and only operating air conditioning pack tripped off due to a reduced air
flow over the system’s heat exchanger due to a damaged flexible hose. As a result,
the aircraft depressurized.

Other Safety Factors

 The action to continue the takeoff was contrary to the operator’s procedures and
increased the risk of the (at that time) unknown underlying aircraft problem having
effect during the remainder of the flight.
 The action to address the right bleed system fault soon after takeoff increased the
risk of the flight crew being distracted from their primary flying tasks at a critical
phase of the flight.
 Following the no engine bleed takeoff, the flight crew did not reconfigure the air
system controls in accordance with the supplementary procedure, inadvertently
isolating the right-wing anti-ice system from the operating bleed air source, and
putting the aircraft at risk of asymmetric wing icing.
  The flight crew did not activate the aircraft’s engine anti-ice systems when
operating in icing conditions, increasing the risk of an engine icing event.
 The cabin crew displayed an inconsistent knowledge of the operation of the cabin
oxygen system, increasing the risk of reduced cabin staff performance or passenger
injury.

Other Key Findings

 A published procedure to reset bleed trips in earlier model B737 aircraft, and that
may have been of use in this case, was not published for the B737 NG.
 The cabin supervisor exhibited very good situational awareness, acting to secure
the cabin without specific advice from the flight crew as to the nature of the
emergency.

Safety Action taken during the course of the Investigation by the Aircraft Operator was noted to
have included the amendment of manuals to provide further guidance to crews on oxygen mask
operation and a modification to the pre-take-off passenger safety demonstration to include advice
that oxygen would flow through passengers’ masks even though individual bags may not have
inflated.