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20 Apr 2015 - The BFU has published its final report into the loss of cabin pressure incident to EI-DAH near Lugano on Apr 4th 2012.

Factual Information

On a passenger flight from Bergamo, Italy, to East Midlands, Great Britain, depressurisation occurred in Swiss airspace during the climb to cruise level. The crew performed an emergency descent and landed the airplane at Frankfurt-Hahn Airport. Thirteen passengers suffered minor injuries. The Swiss Accident Investigation Board (SAIB) delegated the investigation into the occurrence to the German Federal Bureau of Aircraft Accident Investigation (BFU).

Conclusions

The Serious Incident was caused by the following:

Immediate Causes:

 Due to an omission during the installation of the cabin pressure controller the shipping plug was not removed from the static port as required by written procedure.  During the flight a pressure difference was measured and the OFV opened which resulted in rapid decompression.

Systemic Causes

 The shipping plug was not clearly noticeable and did not carry a tag

 The pressurisation system ground test after installation was not suitable to detect the error.

The full report is available here
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*** Updated 05 Aug 2023 ***

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The CPC with shipping plug in place (Photo: BFU)

Safety Recommendation

On 18 June 2012 the BFU issued the following Safety Recommendations:

Recommendation No 24/2012 The Federal Aviation Administration (FAA) should require Boeing to re-design the shipping plugs in a way which makes them more recognisable. The shipping plugs should also be coupled with an eye-catching tag. Maintenance and Repair Organisations should only cover the static ports of a cabin pressure controller with a shipping plug which is clearly visible coupled with a tag.

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