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directional control is experienced during reversethrust
operation, reduce thrust as required and
select forward idle, if necessary, to maintain or
regain directional control.”
Bleed-air Switches
Omitted During Climb Check
Boeing 737-200 Advanced. No damage.
No injuries.
Soon after the flight crew established the
airplane in cruise at Flight Level (FL) 320
(approximately 32,000 feet) during a flight
from Spain to Ireland, the cabin-altitude
warning horn sounded. The crew donned their
oxygen masks, selected the “SEAT BELTS” sign
and conducted the “Cabin Altitude Warning”
checklist.
The incident report said that the crew were not
able to reduce the cabin altitude, which was
about 11,000 feet to 12,000 feet and increasing
at slightly less than 2,000 feet per minute.
The captain called for the “Emergency Descent”
checklist and initiated an emergency descent. The
fi rst offi cer said that maximum cabin altitude was
about 15,000 feet.
During the descent to FL 100, the crew observed
that the engine bleed-air switches were in the
“OFF” position and that the auxiliary power unit
(APU) was engaged. The cabin-services supervisor
said that the passenger oxygen masks deployed
and that several passengers were trying to don
their masks before pulling them down. A cabin
attendant said that some passengers showed signs
of hypoxia.
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 2005 49
A C C I D E N T S / I N C I D E N T S
“Some [passengers] appeared to be dizzy and
laughing, and some did not bother to put on
their oxygen masks,” the report said.
The cabin crew then demonstrated the proper
use of the masks. The fl ight crew diverted the
fl ight and landed without further incident at an
airport in France. None of the 116 occupants was
injured.
The incident report said that the captain had
been asked by the ground-handling agent to
expedite his departure to accommodate an arriving
aircraft and had started the engines 18
minutes ahead of schedule. Because the airplane
was at maximum certified takeoff weight and
the departure procedure required a turn soon
after takeoff, the crew selected the APU “ON”
and the bleed-air switches “OFF” for departure.
The crew said that they conducted the “After
Takeoff ” checklist and the “Passing FL 100”
checklist and observed no cabin-pressure abnormalities.
The report said that the APU can
supply bleed air for one air-conditioning pack
up to 17,000 feet.
“It is clear that the ‘After Takeoff ’ checklist was
not fully accomplished, as the engine-bleed
switches remained in the ‘OFF’ position for the
entire climb,” the report said. “The APU did supply
bleed air to the bleed-air duct and achieved
aircraft pressurization up to the very initial stage
of the cruising level.”
Broken Bracket Found
After Gear Failure
Britten-Norman BN-2A Islander.
Substantial damage. No injuries.
Daytime visual meteorological conditions prevailed
for a scheduled air-taxi fl ight in the
United States. The pilot, who had two passengers
aboard, said that he felt a signifi cant airframe vibration
and heard a rumbling noise as the airplane
slowed during the landing roll.
When the pilot applied the wheel brakes, the
airplane veered left. The pilot said that he was
unable to keep the airplane on the runway. It
rolled off the runway and struck a drainage
ditch.
The report said that maintenance personnel found
a broken landing gear oleo attachment bracket on
the left main landing gear strut assembly.
Engine-out Drill
Leads to Control Loss
British Aerospace Jetstream 32.
Substantial damage. One minor injury.
The pilots were conducting a scheduled fl ight
in Sweden in daytime visual meteorological
conditions and with no passengers or fl ight
attendant aboard the airplane. Before takeoff,
they had discussed simulating an engine failure
to help prepare the 29-year-old copilot, who had
660 fl ight hours, including 237 fl ight hours in
type, for an upcoming profi ciency check.
The report said that the 64-year-old commander,
who had 31,000 flight hours, including 2,000
fl ight hours in type, had experience as a fl ight
instructor but was not qualifi ed or authorized by
the company to serve as a fl ight instructor in the
Jetstream.
During initial climb, the commander moved the
right throttle lever to idle to reduce thrust. The
　
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