Final Report VT-SYZ

Final Investigation Report on Serious Incident to
M/s SpiceJet Ltd. Aircraft VT-SYZ (Boeing 737-800)

in PATNA Airspace on 17 November 2021
Gp Capt Rajendra Pratap Singh VSM (Retd.) (Ajendra Singh)

Investigator-in-Charge Investigator
1
FORWORD
In accordance with Annex13 to the Convention on International Civil Aviation Organization
(ICAO) and Rule 3 of Aircraft (Investigation of Accidents and Incidents), Rules 2017, the sole
objective of the investigation of an accident shall be the prevention of accidents and incidents
and not to apportion blame or liability. The investigation conducted in accordance with the
provisions of the above said rules shall be separate from any judicial or administrative
proceedings to apportion blame or liability.
This document has been prepared based upon the evidences collected during the investigation,
opinion obtained from the experts and laboratory examination of various components.
Consequently, the use of this report for any purpose other than for the prevention of future
accidents or incidents could lead to erroneous interpretations.
2
CONTENTS
SYNOPSIS ........................................................................................................................................ 5
1. FACTUAL INFORMATION ........................................................................................................... 7
1.1 History of Flight ........................................................................................................................... 7
1.2 Injuries to Persons....................................................................................................................... 8
1.3 Damage to the Aircraft ............................................................................................................... 8
1.4 Other Damages ............................................................................................................................ 9
1.5 Personal information .................................................................................................................. 9
1.6 Aircraft Information .................................................................................................................. 10
1.7 Meteorological Information ..................................................................................................... 17
1.8 Aids to Navigation ..................................................................................................................... 17
1.9 Communication ......................................................................................................................... 17
1.10 Aerodrome Information............................................................................................................ 18
1.11 Flight Recorders......................................................................................................................... 18
1.12 Wreckage and Impact Information .......................................................................................... 24
1.13 Medical and Pathological Information ..................................................................................... 24
1.14 Fire ............................................................................................................................................. 25
1.15 Survival Aspects ........................................................................................................................ 25
1.16 Tests and Research .................................................................................................................... 25
1.17 Organizational and Management Information ............................................................................ 25
1.18 Additional information ............................................................................................................. 31
1.19 Useful or Effective Investigation Techniques ........................................................................... 31
2. ANALYSIS ................................................................................................................................ 31
2.1 General ...................................................................................................................................... 31
2.2 Failure of Pressurization System .............................................................................................. 32
2.3 Sequence of events ................................................................................................................... 33
2.4 Maintenance actions ................................................................................................................. 35
2.5 Crew Resource Management ................................................................................................... 36
2.6 Pilot training on pressurization system in manual mode before and after subject serious
incident ................................................................................................................................................. 37
3. CONCLUSION .......................................................................................................................... 38
3.1 Finding ....................................................................................................................................... 38
3.2 Probable Cause of the Serious Incident ................................................................................... 40
4. SAFETY RECOMMENDATIONS ................................................................................................. 41
Appendix ....................................................................................................................................... 42
3
GLOSSARY
AAIB Aircraft Accident Investigation Bureau
APP Approach Control
ATC Air Traffic Controller
ASR Approach Control Surveillance Approach Radar
ATPL Airline Transport Pilot License
ADIRU Air Data Inertial Reference Unit
AME Aircraft Maintenance Engineer
BITE Built in Test Equipment
B1 Mechanical stream
B2 Avionics stream
CPC Cabin Pressure Controller
CPL Commercial Pilot License
DFDR Digital Flight Data Recorder
DME Distance Measuring Equipment
Ft Feet
FC Flight Computer
FIM Fault Isolation Manual
ICAO International Civil Aviation Organization
LAV Lavatory
LRU Line Replacement Unit
LSU Lavatory Service Unit
MSG Message
NM Nautical Miles
NNC Non Normal Checklist
OFV Outflow Valve
PSU Passenger Service Unit
PA Passenger Announcement
PIC Pilot in Command
PZTC Pack Zone Temperature Controller
QDM Quick deployment mask
RSR Route Surveillance Radar
SCC Senior Cabin Crew
SLFPM Sea Level Feet Per Minute
TUC Time of Useful Consciousness
UTC Co-ordinated Universal Time
VMC Visual Meteorological Conditions
VHF Very High Frequency
4
SYNOPSIS
M/s SpiceJet Ltd., Boeing 737-800 aircraft (VT-SYZ) on 17th November 2021, was operating flight no.
SG-391, sector Ahmedabad (AMD) – Patna (PAT). This was second sector of the day for the aircraft and
cockpit crew. The aircraft was chocks off at 03:02:00 UTC. The flight was uneventful till cruise.
However, during descent the MASTER CAUTION along with AUTO FAIL LIGHT of pressurization system
illuminated. The crew did not execute the NNC actions in the prescribed order and commanded the
outflow valve open in manual mode leading to annunciation of MASTER CAUTION and CABIN
ALTITUDE warning. The delay by the PIC to don oxygen mask during the decompression event
probably resulted in momentary incapacitation (Hypoxia) of PIC for a short duration while in command
of a passenger aircraft. The crew initiated rapid descent and thereafter MAYDAY was declared, which
was cancelled during final approach. The aircraft landed safely at Patna at 04:57:46 UTC.
The occurrence was classified as a ‘Serious Incident’ in accordance with the Aircraft (Investigation of
Accidents and Incidents) Rules, 2017. DG, AAIB ordered an investigation into this occurrence vide
order no INV: 12011/7/2021-AAIB, dated: 24 Nov 2021. Corrigendum dated 11th Jan 2022 appointed
Gp Capt Rajendra Pratap Singh VSM (Retd), as Investigator-in-Charge and Mr. Ajendra Singh, as an
Investigator to investigate into the cause of the Serious Incident.
Unless otherwise indicated, recommendations in this report are addressed to the regulatory
authorities of the State having the responsibility for the matters with which the recommendation is
concerned. It is for those authorities to decide what action is taken.
5
Aircraft and Incident details of M/s SpiceJet Ltd Aircraft (BOEING 737- 800) VT-SYZ
on 17 November 2021
1. Aircraft Type Boeing 737-800

Nationality Indian
Call Sign / Registration VT-SYZ
2. Owner SASOF III A19 Aviation Ireland DAC
3. Operator Spice jet Limited India
4. Country of manufacture USA
Pilot–in –Command APTL Holder
5. Extent of Injuries No Injuries
Co-Pilot CPL Holder
7. No. of Persons on board 184+06
8. Date & Time of Incident 17/11/2021 at 04:34:32 UTC
9. Place of Incident Patna Airspace
10. Incident Site (Location) 108 nautical mile from Patna during descent
11. Last point of Departure Ahmedabad
12. Intended place of Landing Patna
13. Type of Operation Scheduled Passenger Operation
14. Phase of Operation Descent from FL 350
15. Type of Occurrence Component failure or malfunction
(Non-power plant)
(All the timings in this report are in UTC unless otherwise specified)
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1. FACTUAL INFORMATION
1.1 History of Flight
On 17 November 2021, the first sector of the flight of VT-SYZ from Delhi to Ahmedabad was
uneventful. In second sector SG-391, VT-SYZ was scheduled to operate flight from Ahmedabad to
Patna with 184 passengers along with 02 cockpit crew and 04 cabin crew on board. The aircraft
departed from Ahmedabad at 03:02:00 UTC. The climb and cruise phase of the flight was uneventful.
At 03:50:58 UTC, aircraft levelled off at FL 350. After the cruise phase, the aircraft started descending
from FL350 at 04:34:05 UTC in coordination with ATC. At 04:34:32 the Master Caution came on for 08
second at altitude of 34292 Ft (Baro) along with auto fail light of pressurization system. Without
following memory action, non normal checks (NNC) were initiated by the PIC and cabin altitude
started climbing from 8000 Ft. to higher cabin altitude. The Co-pilot moved the pressurization control
system mode selector switch control module from AUTO to ALTN. However, alternate system did not
take over and auto fail light remained illuminated. The cabin altitude kept on climbing abruptly at the
rate of approximately 4000 Ft/min.
The Co-pilot after moving the pressurization mode selector switch to Manual, continued with the NNC
check list to move the outflow valve switch to open or close as needed to control cabin altitude and
rate, the Co-pilot announced that I am closing it captain. PIC requested the Co-pilot to read the
checklist again. Co-pilot read the checklist again and stated ‘outflow valve switch moves to open or
close as needed to control cabin altitude and rate’. The PIC told Co-pilot to slowly open the out flow
valve and match with the cabin altitude as per the table given at control panel. The Co-pilot said that
she is just flicking the out flow control valve, however PIC stopped the Co-pilot and advised to go little
down. The Co-pilot informed the PIC that cabin altitude is climbing. At 04:37:07 UTC the cabin altitude
warning light came on at altitude of 28207 Ft (Baro) and remained on for 05 min and 10 seconds. The
cabin altitude warning horn also got activated, which was deactivated by the crew at 04:37:57. The PIC
moved the out flow valve from partially open position to fully open position in one go (kept the
outflow valve switch pressed for 20 seconds) which resulted in total loss of aircraft pressurization.
At 04:37:07 UTC, the PIC declared emergency and gave a MAYDAY call at flight altitude of 28207 Ft and
requested for emergency descent. The ATC enquired about the reason for MAYDAY which was
confirmed by the PIC that they have pressurization issues. Emergency descent was coordinated by
crew with Patna control. Due to rapid depressurization and high rate of descent the passengers
reported pain in ear, dizziness and headache.
The Co-pilot don the mask as per SOP and advised PIC to wear the oxygen mask. After that at 04:37:43
UTC, the Co-pilot deployed the passenger mask manually at an altitude of 26565 ft. The oxygen mask
of seat number 5A, 5B, 5C and lavatory failed to deploy. As per cabin crew statement they used
manual release tool for releasing the passenger mask of seat 5A, 5B, 5C, but did not succeed. The
cabin crew shifted the passenger of seat 5A, 5B, 5C to seat 1A, 1B and 1C. As per the Co-pilot
statement, the PIC delayed the donning of mask by 3 to 4 minutes, which probably lead to momentary
incapacitation (Hypoxia) of PIC for 60 to 90 seconds. At 04:39:28 UTC, senior cabin crew was called by
the PIC to flight desk to brief her about the emergency. At 04:39:57 UTC, when the aircraft was
descending passing FL180 for FL 090, the Senior Cabin Crew (SCC) entered the cockpit without oxygen
mask, where she was briefed by the PIC about the aircraft pressurization issue and emergency
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descent. The cabin crew left the cockpit at 04:40:08. At 04:40:19 at an altitude of 17126 Ft the
emergency descent call was given by PIC to the passenger and requested them to return to their seats.
The auto fail light came on at an altitude of 34292 Ft, the cabin altitude warning came on an altitude of
28207 Ft. When cabin altitude increased from 8000 Ft to 10000 Ft, Mayday was declared at 28207 Ft.
At 04:40:28 UTC, emergency descent non normal checklist was read out by the Co-pilot, and aircraft
was cleared for ILS approach on Runway 25 at Patna. At 04:41:15 UTC, at an altitude of 14535 ft the
SCC announced on PA system to passenger for wearing of oxygen masks. Aircraft was further cleared
for descent to FL60 at 04:42:20 UTC. At 04:42:50 UTC, the PIC reported that cabin altitude is around
7000 Ft and requested the Co-pilot to remove the oxygen mask if she is ok. At 04:43:38 PIC removed
the oxygen mask.
At 04:44:07 on 7661 Ft the crew carried out the rapid depressurization check list and there after
aircraft was further cleared for descent to 3000 Ft. The Patna ATC requested the crew to inform in
case any other assistance is required. The Co-pilot checked with the cabin crew, the conditions of the
passengers, to which the cabin crew replied that all passenger are screaming and they have not been
able to check the condition of all the passengers as cabin crew were told to occupy their seats by the
PIC. Further, the cabin crew requested the Co-pilot for the permission to go to cabin to secure it. The
Co-pilot after checking with the PIC informed the cabin crew to come back and sit as aircraft will be
landing in a short while. By this time (04:46:27) the aircraft descended to 5000 Ft altitude.
At 04:46:27 UTC, the crew started doing descent checks, approach briefing, emergency descent check
list, deferred items, rapid descent checks, recall checks, approach checklist etc. At 04:52:01 UTC, the
PIC made an announcement on PA that aircraft had some pressurization issue which is under control
now and that aircraft is going to land at Patna in about 05 to 07 minutes. He requested the crew for
prepare the cabin for landing. At 04:52:55 UTC, after the aircraft reached at safe altitude of 3000 Ft,
the PIC cancelled the MAYDAY call. The crew after making an ILS approach for runway 25 landed
safely at Patna at 04:57:46 UTC. On landing the Co-pilot enquired from the senior cabin crew regarding
any medical assistance required for any passenger. The cabin crew informed that they have not been
able to check all the passengers and requested the permission from the PIC to go and check the
passengers, which was denied by the PIC and cabin crew were told to wait as the aircraft was about to
park.
Post landing and shut down of aircraft during disembarking of passengers, the PIC stood next to SCC to
check the condition of the passengers. No passenger reported any need for medical assistance.
Thereafter, the PIC contacted the Aircraft Maintenance Engineer (AME) and briefed him about the
occurrence during the flight.
1.2 Injuries to Persons
Injuries Crew Passengers Others
Fatal Nil Nil Nil
Serious Nil Nil Nil
None 06 (02+04) 184 ---
1.3 Damage to the Aircraft
There was no damage to the aircraft.
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1.4 Other Damages
There was no other damages.
1.5 Personal information
Flight Crew held valid licenses and were qualified to operate the flight.
1.5.1 Pilot-in-Command
Nationality Indian
Date of Joining to the Organization 01 Jun 2011
Age 33 Years
License ATPL
Date of Issue 20-01-15
Valid up to 19-01-22
Category Aeroplane
Date of Class I Med. Exam. 26-10-21
Class I Medical Valid up to 02-11-22
Date of issue FRTOL License 16-02-14
FRTO License Valid up to 15-02-24
Endorsements as PIC C-152A, P-68C, B737 700-900, MAX
Total flying experience 8037.02 Hrs.
Total flying experience on type 7812.20 Hrs.
Last Flown on type (Boeing 737-800) 17.11.2021
Total flying experience during last 01 year 471.10 Hrs.
Total flying experience during last 06 Months 167.54 Hrs.
Total flying experience during last 30 days 58.22 Hrs.
Total flying experience during last 07 Days 18.28 Hrs.
Total flying experience during last 24 Hours 01.40 Hrs.(first flight of the day)
Rest period before first flight on 17.11.2021 30 Hrs.
Whether involved In Accident/Incident earlier No
Date of latest Flight Checks, Ground Classes Route Check (29/9/2021), Annual Ground Refresher
and Refresher (05/04/2021 -10/04/2021)
1.5.2 Co-Pilot
Nationality Indian
Date of Joining to the Organization 02 Jun 2018
Age 26 Years
License CPL
Date of Issue 28-12-2016
Valid up to 27-12-2021
Category Aeroplane
Date of Class I Med. Exam. 11-06-21
Class I Medical Valid up to 15-06-22
Date of issue FRTOL License 20554 28-12-16
FRTO License Valid up to 27-12-21
Endorsements as PIC C-172
Total flying experience 1788.00 Hrs.
Total flying experience on type 1586.45 Hrs.
9
Last Flown on type 17-11-21
Total flying experience during last 01year 397.21 Hrs.
Total flying experience during last 06 Months 148.59 Hrs.
Total flying experience during last 30 days 37.55 Hrs.
Total flying experience during last 07 Days 05:00 Hrs.
Total flying experience during last 24 Hours 01:40 Hrs. (Previous Leg)
Rest period before first flight on 17.11.2021 72:00 Hrs.
Whether involved in Accident/Incident earlier No
Date of latest Flight Checks, Ground ALRC-12/01/2021 and Annual Refresher-17/07/2021
Classes & Refresher
1.5.3 Cabin Crew Information
Cabin Crew Date of Joining Total experience as on 17 Nov 2021 Last recurrent training
SCC 01 Aug 2014 7.3 Years 16 Jul 21
Crew 1 22 May 2019 3.5 Years 26 Apr 21
Crew 2 04 Jun 2019 3.5 Years 26 Apr 21
Crew 3 22 May 2018 4.5 Years 21 Mar 21
1.6 Aircraft Information
1.6.1 Aircraft VT-SYZ Information
Aircraft Model Boeing 737-800
Aircraft S/N 34803
Year of Manufacturer 2007
Name of Owner SASOF III A19 Aviation Ireland DAC
C of R 5121/2 Validity: 07-02-2023
Airworthiness Review Certificate 4-98/2019-AI (1)/ARC/7224
Category A
C of A Validity Valid -Subject to validity of ARC
ARC issued on 05-02-2021
ARC valid up to 07-02-2022
Aircraft Empty Weight & Empty weight CG 43159.35 Kg // 659.52 Inch (16.75 meter) aft of
datum. (CG=20.81 %MAC)
Maximum Take-off weight 79,015 KG
Date of Aircraft Weighment 19-May-21
Empty Weight 43159.35 Kg
Max Usable Fuel 22137 Kg
Max Payload with full fuel 12662.65 Kg
Next Weighing due 18-May-26
Total Aircraft Hours 53527:14
Last major inspection 10 Yearly Check done on 21 July 2021
List of Repairs carried out after last major C Check was done in July 2021
inspection till date of incidence
Engine Type CFM
Engine Sl. No.(LH) LH 892825
Date of Manufacture (LH) 13-Mar-2006
Last major inspection (LH) OVH
List of Repairs carried out after last major Engine Shop Visit dated 16-Apr-2017
inspection till date of incidence(LH)
10
Total Engine Hours/Cycles (LH) 40994:02 hrs. /28771 cycles
Engine Sl. No. (RH) 890427
Date of Manufacture (RH) 14-Apr-2014
Last major inspection (RH) OVH
List of Repairs carried out after last major Engine Shop Visit dated 02-Oct-2018
inspection till date of incidence(RH)
Total Engine Hours/Cycles(RH) 52314:49 hrs./31465 cycles
Aero mobile License A-010/148/RLO(NR)
AD, SB, Modification Complied with
The details of outflow valve, Part no. 21230-03 AC, Serial No. 07101936 are as follows:
• TSN – 53528.56
• CSN – 25420
• Date of Manufacture – 01.01.2007
• Date of removal from aircraft – 17.11.2021
1.6.2 Air Pressurization System Description (Aircraft Maintenance Manual Chapter 21-30-00)
Introduction
Cabin pressurization is controlled during all phases of airplane operation by the cabin pressure control
system. The cabin pressure control system includes two identical automatic controllers available by
selecting AUTO or ALTN and a manual (MAN) pilot–controlled mode. The system uses bleed air
supplied to and distributed by the air conditioning system. Pressurization and ventilation are
controlled by modulating the outflow valve and the overboard exhaust valve.
Pressure Relief Valves – Two pressure relief valves provide safety pressure relief by limiting the
differential pressure to a maximum valve. A negative relief valve prevents external atmospheric
pressure from exceeding internal cabin pressure.
Cabin Pressure Controller – Cabin altitude is normally rate–controlled by the cabin pressure controller
up to a cabin altitude of 8,000 Ft at the airplane maximum certified ceiling of 41,000 Ft. The cabin
pressure controller controls cabin pressure in the following modes:
• AUTO – Automatic pressurization control; the normal mode of operation; uses DC motor.
• ALTN – Automatic pressurization control; the alternate mode of operation; uses DC motor.
• MAN – Manual control of the system; uses DC motor.
The Air Data Inertial Reference Units (ADIRUs) provides ambient static pressure, BARO corrected
altitude, non-corrected altitude and calibrated airspeed to both automatic controllers. The ADIRUs
receive barometric corrections from the PIC’s and Co-pilot’s BARO reference selectors.
11
The automatic controllers also receive throttle position from both stall management computers and
signals from the air/ground sensors.
Copyright © Boeing. Reprinted with permission of The Boeing Company

Fig 1: Cabin Pressure Control System Schematic
Pressurization Outflow – Cabin air outflow is controlled by the outflow valve (OFV) and the overboard
exhaust valve. Under normal conditions, a small amount of air is also exhausted through toilet and
galley vents, miscellaneous fixed vents, and by fuselage/door seal leakage.
Outflow Valve (OFV) – The OFV is the overboard exhaust exit for the majority of the air circulated
through the passenger cabin. Passenger cabin air is drawn through foot level grills, down around the
aft cargo compartment, where it provides heating, and is discharged overboard through the outflow
valve.
Overboard Exhaust Valve – On the ground and in flight with low differential pressure, the overboard
exhaust valve is open and warm air from the E & E bay is discharged overboard. In flight, at higher
cabin differential pressures, the overboard exhaust valve is normally closed and exhaust air is diffused
to the lining of the forward cargo compartment. However, the overboard exhaust valve is driven open
12
if either pack switch is in high or the right recirculation fan is off. This allows for increased ventilation
in the smoke removal configuration.
Auto Mode Operation – The AUTO system consists of two identical controllers, with one controller
alternately sequenced as the primary operational controller for each new flight. The other automatic
controller is immediately available as a backup. In the AUTO or ALTN mode, the pressurization control
panel is used to preset two altitudes into the auto controllers:
• FLT ALT (flight or cruise altitude)
• LAND ALT (landing or destination airport altitude)
Takeoff airport altitude (actually cabin altitude) is fed into the auto controllers at all times when on the
ground. The air/ground safety sensor signals whether the airplane is on the ground or in the air. On
the ground and at lower power settings, the cabin is depressurized by driving the outflow valve to the
full open position.
Manual Mode Operation – A green MANUAL light illuminates with the pressurization mode selector in
the MAN position. Manual control of the cabin altitude is used if both the AUTO and ALTN mode are
inoperative or during a non-normal situation. In the MAN mode, the Flight Crew changes the position
of the outflow valve using the Outflow Valve switch.
In MAN mode, a separate DC motor, powered by the DC standby system, drives the outflow valve at a
faster rate than during AUTO or ALTN modes. In MAN mode, the outflow valve full range of motion
takes up to 20 seconds. This faster movement of the outflow valve allows the crew to quickly
depressurize the airplane during certain non-normal situations, including following a tail strike event.
Flight Crew can verify the position of the outflow valve by monitoring the cabin altitude panel and
valve position on the outflow valve position indicator.
Non-normal situations that direct the flight crew to manually control the aircraft pressurization
system, the caution mentioned below should be followed by the flight crew.
CAUTION: A small movement of the outflow valve can cause a large change in cabin rate of climb or
descent. Manual actuation of the outflow valve can produce large, rapid changes in cabin pressure
which could result in passenger and crew discomfort and/or injury.
1.6.3 Aircraft Maintenance Manual
As per Boeing 737-800 Aircraft Maintenance Manual Chapter 21-30-00 these conditions cause the
auto fail function.
• High rate of descent initiated by the PIC which was beyond the controlling capability of
pressurization system
• Power loss
• Cabin altitude rate of change is too high (> 2,000 Sea Level Feet Per Minute)
• Cabin altitude is too high (> 15,800 ft.)
• Wiring failures
• Outflow valve component failures
• CPC1 & CPC2 failure
• Cabin differential pressure is too high (> 8.75 psi)
13
• Cabin pressure selector panel fault, P5
Note: In case of dual channel failure i.e. when both the CPC system fail.
1. The auto fails and master caution light comes on.
2. The flight ALT and land ALT display shows five dashes (- - - - -)
If both CPC fail, the ALTN light does not come on. This indicates that the system cannot transfer
control to an operative automatic controller.
1.6.4 Maintenance Actions by AME post Serious Incident
Post landing it was found that the
outflow valve selector switch was in
manual position and the out flow
valve was in fully open position.
B1 & B2 AME were detailed by
SpiceJet for snag rectification of
pressurization system. Replacement
of OFV of pressurization system was
under taken based on the fault
message shown during CPC BITE
check. The complete BITE check as
per FIM 21-31 task 801 was not
Fig 2: Selection of manual mode
undertaken by AME before
replacement of OFV.
As OFV LRU FAIL MSG was stored in CPC,
respective FIM task 21-31, task-801 was
referred and as per the FIM, the possible
cause for the fault code was Cabin
Pressure Outflow Valve V48. Hence, the
outflow valve was replaced and post
installation checks, the system was found
working satisfactory.
After change of OFV the CPC BITE test was
carried out and the ground test passed.
Further, pressurization system manual
mode test & cabin pressure control
system ground aircraft was carried-out
Fig 3: LRU Fail Message before replacement of OFV and the same were found satisfactory.
14
Cabin galley and LAVS were checked and
found that all PSU panels were in dropped
condition. However, during LAV A inspection
it was observed that latch door was getting
stuck during deployment.
Chemical oxygen generators were checked Mask did not deploy
and found that all chemical oxygen
generators fired except for seat 5A, 5B & 5C.
Seat 5A, 5B & 5C oxygen mask did not
deploy as the door latching spring was found
faulty.
All three LAVS and control cabin oxygen
masks were also found removed from
stowage box.
Mask did not deploy
Fig 4: Seat no. 5 mask did not deploy (above); LAV A

mask did not deploy (below)
The crew oxygen bottle pressure was checked and

found that the cockpit crew oxygen pressure was
sufficient (approx. 1500 PSI).
Fig 5: Crew oxygen pressure level after occurrence
1.6.5 Pilot defect report and history of outflow valve removal from operator fleet
Investigation Team scrutinized operator records for the period January 2021 to August 2022
and found that
• A total of 661 pilot defect reports had been recorded with respect to snags relating to air-
conditioning and pressurization system on Boeing 737-800 fleet.
• Total 07 outflow valve have been removed from the operator’s fleet of 42 Boeing 737-800 aircraft
between Apr 2021 and December 2021.
1.6.6 Snag related to pressurization system on VT-SYZ
Total eight snags pertaining to pressurization system had been recorded on VT-SYZ aircraft from 10 Jan
2021 to 29 Dec 2021 and one snag pertaining to high rate of Cabin descent occurrence recorded on 26
Mar 2022.
The work order related to these event has been scrutinized and found that different components have
15
been replaced during snag rectification to clear the defects. No defect has been confirmed in certain
cases during fault isolation as per laid down procedure given in the AAM & FIM.
1.6.7 NNC Procedure for Auto Fail as per FCOM
As per B737 Flight Crew Operations Manual following NNC procedure is to be followed in event of
Auto Fail.
1.6.8 Pilot seat oriented action as per FCOM

Actions for this serious incident demand that both pilots perform the actions in a coordinated manner.
PIC is overall responsible to ensure that the memory items are completed correctly. The switches are
operated by the pilots as per the area of responsibility. In this case, since the overhead panel falls
under the area of responsibility of the First Officer, the pressurisation panel switches are operated by
the First officer as PM under instructions of the PIC. The Emergency or Rapid Descent actions are
carried out by the PIC as PF.
1.6.9 Emergency Descent procedure as per FCOM
As per B737 Flight Crew Operations Manual following procedure to be followed in event of emergency
descent.
Condition: One or more of these occur:
• Cabin altitude cannot be controlled
• A rapid descent is needed
1. Announce the emergency descent. The pilot flying will advise the cabin crew, on the PA system, of
impending rapid descent. The pilot monitoring will advise ATC and obtain the area altimeter
setting.
16
2. Passenger signs . . . . . . . . . . . . . . . . . . . . .. ON
3. Without delay, descend to the lowest safe altitude or 10,000 feet, whichever is higher.
4. Engine Start switches (both) . . . . . . . . . CONT
5. Thrust levers (both) . . . . . . . . . Reduce thrust to minimum or as needed for anti-ice
6. Speed brake . . . . . . . . . . . . . . .. Flight Detent
If structural integrity is in doubt, limit speed as much as possible and avoid high manoeuvring loads.
7. Set target speed to Mmo/Vmo.
8. When approaching the level off altitude: Smoothly lower the SPEED BRAKE lever to the DOWN
detent and level off. Add thrust and stabilize on altitude and airspeed.
9. Crew oxygen regulators . . . . . . . . . . . . . Normal
Flight crew must use oxygen when cabin altitude is above 10,000 feet. To conserve oxygen, move the
regulator to Normal.
10. Engine Start switches (both) . . . . . . As needed
11. The new course of action is based on weather, oxygen, fuel remaining and available airports. Use
of long range cruise may be needed.
1.7 Meteorological Information
As per Indian Metrological Department (IMD) Metrological (MET) office situated at Patna The weather
(METAR) on 17 Nov 2021 at Patna Airport (VEPT) is as followed. The weather was not a cause of
serious incident.
Met Report at VEPT At 04:30 At 05:00
Wind 060 Degrees 3Kt 080 Degrees 3Kt
Temperature 0
22 C 230 C
Dew Point 110 C 100 C
QNH 1017 hPa 1016 hPa
QFE 1011 hPa 1011 hPa
Visibility 2500 M 2500 M
Trend NOSIG(No significant change) BECMG 3000 HZ
1.8 Aids to Navigation
All Navigational Aids available at Patna airport were reported to be serviceable.
1.9 Communication
At the time of incident, the aircraft was in contact with Patna Approach on frequency 121.1 MHz and
then with tower on frequency118.3 MHz. A positive two-way communication was always maintained
between ATC unit and involved aircraft as per the ATC tape and CVR recording.
17
1.10 Aerodrome Information
Airport Name : Jay Prakash Narayan International Airport, Patna
IATA code : PAT
ICAO code : VEPT
Airport Elevation : 170 ft.
Hours of Operation : H24
Aerodrome Category : B
Patna Air Traffic controlling unit is divided mainly into Tower, Approach, and Area etc.
1.11 Flight Recorders
1.11.1 FDR – Flight data recorder was installed on aircraft. FDR PN 2100-4043-00, OEM L-
Communications, Model - FDR 2100. DFDR data was made available to investigation team. Using
altitude and time.
Using FDR data following graph has been drawn to know rate of descent, vertical speed with reference
to altitude and time.
Fig 6: Graph Time v/s Rate of Descent
18
Fig 7: Graph Altitude and Vertical Speed v/s Time
The aircraft rate of descent from top of the climb (35004 ft at 04:34:01UTC) to the point of
annunciation of Master Caution and Auto Fail light on (34292 ft at 03:34:32UTC) was approx. 1378
Ft/min.
The DFDR read out indicate that there was no power loss.
Engine parameter during Serious Incident

Time BARO SELECTED SELECTED LEFT ENG RIGHT LEFT ENG RIGHT
CORRECTED TRA TRA N1 ENG N1 N2 ENG N2
PALT FILTERED FILTERED TACHO TACHO TACHO TACHO
(derived) #1 #2
04:34:01 35004 62.8 62.6 89.75 89.10 93.88 93.75
04:34:38 34040 35.5 36.2 40.13 40.50 75.25 76.13
04:35:00 33025 35.7 36.2 39.44 39.80 74.63 75.25
04:35:24 32017 35.7 36.2 38.69 39.10 74.13 74.75
04:35:51 31008 47.1 47.5 59.81 60.70 83.25 83.50
04:36:22 30004 52 52.2 71.25 71.40 87.38 87.50
04:36:53 29017 35.9 36.6 54.53 52.10 83.38 83.00
04:37:12 28000 38.5 39.2 41.56 42.10 77.50 77.63
04:37:30 27043 49.4 50.1 64.00 65.50 85.00 85.63
19
The throttle position and engine RPM indicate that the air was being delivered to the pressurization
system.
Altitude V/S Time [TRA, N1, N2]

36000
TRA #1:
62.8, #2:
35000 TRA #1:

35004 35.5, #2:
36.2
34000 N1 #1:
TRA #1:
40.13, N1
34040 35.7, #2:
#2: 40.50
36.2
33000 N2 #1:
N1 #1: TRA #1:
75.25, N2
39.44,
33025N1 35.7, #2:
#2: 76.13
#2: 39.80 36.2
32000 N2 #1: N1 #1:
74.63, N2 TRA #1:
38.69,
32017 N1
#2: 75.25 47.1, #2:
Altitude
#2: 39.10
47.5
31000 N2 #1:
N1 #1: TRA #1: 52,
74.13, N2
59.81, N1 #2: 52.2
31008
#2: 74.75
#2: 60.70 N1 #1:
30000 N2 #1: 71.25, N1
83.25, N2 30004 TRA #1:
#2: 71.40
#2: 83.50 35.9, #2:
N2 #1:
29000 36.6
87.38, N2
N1 #1: TRA #1:
#2: 87.50 29017
54.53, N1 38.5, #2:
28000 #2: 52.10 39.2
N2 #1: N1 #1:
83.38, N2 28000 TRA #1:
41.56, N1 49.4, #2:
#2: 83.00 #2: 42.10
27000 50.1
N2 #1: N1 #1:
27043
77.50, N2 64.00, N1
#2: 77.63 #2: 65.50
26000
4:34:01 4:34:38 4:35:00 4:35:24 4:35:51 4:36:22 4:36:53 4:37:12 N2 #1:
4:37:30
85.00, N2
Time #2: 85.63
Fig 6: Aircraft parameter Altitude V/S Time [TRA, N1, N2]
1.11.2 CVR – PN 2100-1020-00, OEM L- 3 Communications, Model CVR 2100.Four channel

recording- First observer, Co-pilot, PIC and Area Mike. The complete CVR has been analyzed from
beginning of the flight to top of descent and communication was normal. CVR data of VT-SYZ reveals
that the flight had read back correctly to the instructions given by Controller. The relevant portion of
the CVR recording is as follows:
Timing From Text
(UTC)
4:34:33 P1(PIC) Master Caution air conditioning….ahhh Auto Fail…
P2(Co-pilot) Auto Fail
P1 Auto Fail light non normal checklist
P2 2.4
Okay…Auto Fail non normal checklist or Unscheduled Pressurization
Change
Auto may or may not be illuminated Condition: One or more of these
4:34:56 P2 occur:
• Automatic pressurization mode has failed
20
• The cabin altitude is uncontrollable.
P1 Yeah its climbing…
P2 It’s climbing…
P1 Okay okay…
P2 Okay. Cabin altitude is uncontrollable
P1 Controlled he….
Increase thrust may ensure sufficient air supply to control cabin
altitude. Pressurization mode selector – ALTN Pressurization mode
P2 selector alternate PIC
4:35:31 P1 Yeah Check
Check
Choose one: AUTO FAIL light is extinguished and cabin altitude is
P2 controllable
Negative….Not extinguished
AUTO FAIL light is illuminated or cabin altitude is uncontrollable – Go
P2 to step 4
Pressurization mode selector – MAN
Going manual
4:35:41 P1 SG-391, request further descent
ATC SG-391 roger, contact VNS control 128.15
P1 VNS control 128.15, SG-391
Outflow VALVE switch - Move to OPEN or CLOSE as needed to control
P2 cabin altitude and rate
I’m closing it PIC
P1 Sorry read it again…
P2 Outflow VALVE switch move to OPEN or CLOSE as needed to control
cabin
altitude and rate
4:36:07 P1 Yes…. slowly you have to open…slowly…. keep on flicking and match
with
the…..slowly kardo (do it slowly)
P2 Haan ji (Yes)…30…
6000 ft. chahiye na (6000 feet is required?)
P1 Slowly
P2 Yeah…I’m just flicking….
4:36:31 P1 Rukh jao..rukh jao (stop stop)..So let us go little down…
P2 Yeah…cabin altitude climb is increasing PIC
4:36:41 ATC SG-391 descent to FL150
P1 150 SG-391
P2 Check
4:37:06 P1 Radar SG-391
4:37:07 Cabin Altitude
Warning horn
activated
ATC SG-391, radar
P1 MAYDAY MAYDAY MAYDAY, SG-391, we have pressurization issue,
request further descent
ATC SG-391 roger MAYDAY, request say again….report reason
21
P1 Pressurization issue SG-391
ATC SG-391 roger MAYDAY, report reason for MAYDAY
P1 We have a pressurization issue, SG-391
ATC Roger continue descent to FL90, report preferred RWY
4:37:42 Crew donned
oxygen mask
4:37:56 Cabin chime
annunciated
4:37:57 Cabin Altitude
Warning horn
deactivated
4:38:03 ATC SG-391 radar if ready contact PAT 121.1
4:38:07 Cabin chime
annunciated
P2 121.1 SG-391
ATC SG-391 radar
P2 SG-391 sir how do you read?
ATC SG-391, if ready contact PAT 121.1, RWY 25, use any convenient RWY
How do you read sir? How do you read sir?
P2 to P1 How do you read sir? Can you hear me??
P1 All good all good….
4:38:54 P1 Emergency descent non normal checklist
ATC SG-391 radar…
4:39:24 Cabin chime
annunciated
4:39:28 P1 SCC to flight deck
4:39:34 ATC SG-391, radar
P2 How do you read sir
ATC Contact PAT 121.1
P2 121.1, SG-391
ATC Confirm all OPS normal now.
P2 Negative sir, we are in emergency descent, descending to FL90,
MAYDAY only
ATC Roger report in contact with PAT, RWY 25
P2 Copied sir copy….
P2 Continue descent FL70, SG-391
4:39:57 SCC enter
cockpit
SCC Yes PIC
P1 Pressurization issue
SCC Sorry
P1 Emergency descent
SCC Emergency descent
4:40:08 SCC leaves
cockpit
4:40:19 P1 on PA Emergency Descent Emergency Descent Emergency Descent, return
to your seats.
4:40:25 P2 Can you read me now
22
P1 Yeah…
Emergency Descent non normal checklist
One or more of these occur:
4:40:28 P2 • Cabin altitude cannot be controlled
• A rapid descent is needed.
P1 Check
4:41:15 SCC on Yathriyon se nivedan he apne mask pehan le (Passenger are
PA requested to wear their masks)…
4:42:50 P1 Okay…cabin altitude is around 7000…. You can remove your mask if
you are okay…
4:43:13 P2 (P2 removed her oxygen mask) Stable….okay I’m good….
P1 Check your controls
4:43:38 P1 Removed his oxygen mask
4:44:07 P1 All checklist complete right??
P2 Rapid depressurization checklist nahi ki(Not done)….
P1 Tumne dekha tha na (didn’t you see?)…
P2 Pehle kar diya tha (had done before)…..oxygen is donned, passenger
sign is ON
4:44:20 ATC SG-391, report total persons on board
P2 Standby sir…..184 total POB
ATC Roger, any other assistance required, please advised
P2 Will let you know sir
4:44:44 ATC SG-391, descent to 3000ft , QNH 1017, TL FL 50
P2 3000ft, 1017, TL 50, SG-391
P2 3000 Ft. set
4:45:02 P2 I will ask the cabin attendant….
4:45:08 SCC PIC
P2 Is everything alright?
SCC Bache kafi roo rahe he ma’am (The kids are crying a lot ma’am)
P2 Uncha bolo kya (speak loudly, what)???
SCC Bache kafi roo rahe he ma’am ((The kids are crying a lot ma’am) …we
are not able to listen to you ma’am because kaan pore bandh ho gaye
he (because Ears are blocked.)…
P2 Everybody is fine at the back?
SCC No ma’am, all are screaming….passengers
P2 All are screaming…but kisi ko chott ayi he (anyone got hurt)???
SCC Ma’am cabin me abhi tak gaye hi nahi na…PIC ne bol diya bet
jao(Ma’am not been to the cabin yet, the PIC told go and sit)…
P2 Loud bolo ma’am loud bolo(speak Loud ma’am speak Loud)
SCC PIC ne bola tha bet jao aaram se (The PIC had told to sit comfortably)
P2 Acha…chalo….(All right) we are landing, cabin galley secure just
confirm me once
SCC Ma’am, can we go in the cabin?
P2 Say again
SCC Can we go in the cabin?
P2 Yeah you guys are same, you can go cabin, secure it and come back
and sit. We are landing in another….very quickly we are landing…
SCC Okay mask is required now?
23
P2 Yeah what is required
SCC Oxygen mask are required otherwise I will use the oxygen cylinder
P2 Right now it is not required. Right now we are at 5000ft altitude
SCC Okay fine ma’am.
P2 Okay….
4:50:31 P2 Approach checklist Altimeter
P1 1017…3000
P2 1017… 3000 check
Outflow VALVE switch - Move to OPEN until the outflow VALVE
P2 indication shows fully open to depressurize the airplane. It is fully
OPEN
P1 Okay
P2 Standing by for Landing checklist
Well this is your PIC from flight deck, we had some pressurization
4:52:01 P1 on PA issue and it is under control. Will be landing in PAT in about 5-7 mins
from now and cabin crew prepare the cabin for landing. Thank you
4:59:05 SCC Ma’am
P2 Do we need any medical assistance for any passenger
Ma’am, I didn’t check yet, 4 mins me landing ki he, mid cabin tak tho
SCC (Landing was done in 04 minutes, till mid cabin I have checked) I have
checked all the passenger, so I will go in the cabin for passenger
assistance, if anybody needs help, will inform you.
P2 Standby give me 1 min
PIC, she had checked till mid cabin, she has to go right now if anybody
P2 need assistance then she will get back to me. Do you want it right now
P1 No tell her to wait
P2 Okay… I will tell her to sit
P2 Ma’am, abhi rehne do….wait karlo abhi ( just wait…….wait now) …we
are about to park
SCC Okay ma’am
5:03:23 Shut Down
checklist was
carried out as
per SOP
5:03:42 AME Good morning PIC
P1 We had a Auto Fail light and then NNC was done which led to Cabin
Altitude Warning
1.12 Wreckage and Impact Information
There was no damage to aircraft or any property on ground.
1.13 Medical and Pathological Information
On the day of incident, both crew did not undergo pre-flight medical examination. They signed the
declaration form, as per the DGCA requirement, declaring that they are not under the influence of
alcohol or psychoactive substance at Delhi Airport in accordance with the DGCA Circular applicable on
date of incident issued in view of outbreak of COVID 19 pandemic.
24
1.14 Fire
There was no fire.
1.15 Survival Aspects
The incident was survivable.
1.16 Tests and Research
1.16.1 Outflow valve tear down report
As per tear down report of the component (Refer Appendix 01) received from Nord-Micro Frankfurt,
Germany, “the performed potentiometer tests indicate that the removed outflow valve P/N 21230-
03AC S/N 07101936 failed in Poti synchronism test (open 4,40V / 115°) on 09 Mar 2022. As per the
report, the outflow valve had to undergo major repairs and the defects are as follows: -
a. The Gear box functional incoming test failed, so gear box defective bearings were replaced.
b. Anti-skating foils were damaged/ missing which were replaced
c. Teflon seals were bent and hence replaced
d. Rod ends were found sluggish/ stuck and hence replaced
e. Aumot 1 brake function was defective which was renewed
f. Worn-out bonding cables were replaced
g. Potentiometer was replaced as it was out of tolerance
The cap of the Potentiometer that is assigned to the manual mode of the CPCS showed a feedback
voltage of 4.40V DC in fully open position, which is slightly out of tolerance in accordance with CMM
21-31-34. This error leads to an indication of the OFV position in the cockpit which slightly differs from
the real OFV fully open position.
As per OEM of the OFV the described damages are normal wear and tear for OFV with +15 year of
service. Mechanical wear out of OFV is considered as likely cause of malfunction in auto mode;
however, manual operation of the OFV was possible.
1.17 Organizational and Management Information
Spice Jet is an Indian low-cost airline with headquarters in Gurgaon, Haryana. The airline operates 630
daily flights to 64 destinations, including Indian and international destinations from its hubs at Delhi
and Hyderabad. The airline operates a fleet of Boeing 737 and Bombardier Dash 8 (Q400) aircraft.
1.17.1 Safety and Emergency Procedures (SEP) Manual of the Company
As per Para 4.3 of the SEM Manual, in case of Rapid Decompression and Cabin Pressurization Problems
(Slow Decompression), the undermentioned procedure is to be followed.
a. General
There is insufficient oxygen in the atmosphere at high altitudes to sustain life, therefore the
passenger’s compartments of an aircraft have to be pressurized. The pressurization system of the
aircraft is used to create a dense atmosphere within the cabin so that crew and passengers are kept
comfortable and continue to breathe normally. Sudden loss of cabin pressure is termed as
decompression. In other words, decompression is increase in cabin altitude and decrease in cabin
25
pressure. Decompression occurs whenever cabin altitude exceeds the preset altitude in an
uncontrolled way. It could be slow, at which time remedial action such as descent to a safe level is
taken, with little chance of causing damage to the cabin or its occupants. Cabin Crew may be aware of
a slow decompression if the oxygen masks drop down. In this event, it is essential for Cabin Crew
members to grab an oxygen mask and put it on regardless of how normal cabin conditions may
appear. However, due to various technical, structural reasons, a rapid decompression might occur and
will require an emergency descent by the flight deck crew and immediate action by the Cabin Crew.
b. Command from Flight Deck – There can be a command heard from the flight deck - ''Emergency
descent, emergency descent, emergency descent. This is your captain, return to your seats and use
your oxygen masks"'.
c. Slow Decompression – Slow decompression is gradual loss of cabin pressure which can be caused
by failure or malfunctioning of pressurization system or a slow leak in the fuselage.
Physiological Effects - Physiological effects may include hypoxia, blurred vision, headache, giddiness or
impaired judgment.
Crew Procedure – The procedure is a follows:
1. SCC will establish communication with PIC.
2. Flight deck Crew shall advise Cabin Crew of the situation.
3. If time permits, Crew to check Lavatories.
4. PA announcement to be made when the cabin altitude exceeds 14,000 feet and oxygen masks
drop down from the PSU.
Announcement for reference: "Instructing all passengers to don the Oxygen masks
immediately".
5. Cabin Crew members to occupy jump seats and engage shoulder harness.
6. Cabin Crew shall don oxygen masks by pulling the lanyard of the oxygen mask as it will lower
the mask and activate the flow of oxygen.
7. Await further Instructions from the Flight deck.
d. Rapid Decompression – Rapid decompression is sudden/ rapid loss of cabin pressure. It is caused
by structural damage of the fuselage. There is always a remote possibility of a rapid loss of cabin
pressure in any pressurized aircraft. The signs of rapid decompression are:
1. A rush of air
2. Loud bang
3. Rapid drop in temperature
4. Cabin filled with dust, debris, loose objects
5. Noise level will increase considerable
6. Moisture will condense in the form of fine mist
Rapid Decompression Physiological Effects - Physiological effects could be serious to crew and
passengers in a few seconds. The physiological effects on a person are due to lack of oxygen and the
expansion of gases trapped in the body cavities following the fall in pressure. They are usually
accompanied by the following signs, which might be of short duration but are still dangerous:
26
1. There is a sudden expansion of the chest and air is blown out through the nose and mouth
causing difficulties in breathing.
2. Cold sensation
3. Sinuses and ears may feel full momentarily
4. Speaking will be more difficult
5. Abdominal distension sufficient to cause discomfort or pain.
Rapid decompression mechanical Signs
1. Automatic illumination of cabin lights to bright mode, if on night mode.
2. Illumination of fasten seat belt sign.
3. Deployment of oxygen masks when cabin altitude reaches 14,000 feet.
Rapid decompression - Crew Procedure
1. Don Oxygen mask immediately and secure self on the nearest seat and fasten seat belt.
2. Make PA if possible: ‘Instructing all passengers to don their Oxygen masks immediately’.
3. Once the aircraft has reached a safer altitude, flight crew will make PA ‘Cabin Crew resume
duties’
e. Safe Altitude – It is an altitude at which passengers can breathe normally without the assistance of
external aid (Oxygen).
Purpose of rapid descent - The purpose of Rapid Descent is to reach the safe altitude and breathe
normally.
f. Post Decompression Duties
1. Cabin Crew shall conduct Post Decompression walk around using portable oxygen
bottles.
2. Check Flight deck, lavatories and passenger injuries in cabin.
3. Ensure oxygen masks have deployed and activated
4. Check structural damage in the cabin.
5. Reseat passengers away from structural damage (it possible)
6. Provide First aid and assistance to passengers
7. Inform PIC about injuries to passengers, structural damage and cases of decompression
sickness.
1.17.2 Time of useful consciousness (TUC)
As per Para 4.3.1 of SEP Manual, TUC is defined as the amount of time an individual is able to perform
flying duties efficiently in an environment of inadequate oxygen supply. It is the period of time from
the interruption of the oxygen supply or exposure to an oxygen poor environment to the time when
useful function is lost, and the individual is no longer capable of taking proper corrective and
protective action, it is not the time to total unconsciousness. At the higher altitude, the TUC becomes
very short. The table below reflects various altitudes with the corresponding average TUC:
27
Time of Useful Consciousness
Altitude (Ft.) Passive Subject Active Subject
14000 Unlimited Unlimited
20000 10 minutes 5 minutes
25000 5 minutes 2-3 minutes
30000 75 seconds 45 seconds
40000 20-30 seconds 10-15 seconds
50000 Less than 10 seconds Less than 10 seconds
Note: A rapid decompression can reduce the TUC by up to 50 per cent caused by the forced
exhalation of the lungs during decompression.
Emergency Oxygen System – For Cabin Crew and passenger's safety, aircraft is fitted with emergency
oxygen system. Loss of cabin pressure in flight will be sensed by a device which automatically activates
a system which supplies oxygen to passenger compartment. Provision is made for manual operation
by the flight crew in case the automatic system fails.
If the cabin altitude reaches 14000 feet, the oxygen masks will drop down from:
1. Passengers Service Unit {PSU) above passenger seats.
2. Attendant Service Unit (ASU) above each Cabin Crew jump seat and on the ceiling between G1
and G2 galley.
The flight deck is equipped with a separate oxygen system and a special quick donning mask is
installed ready for immediate use at each crew station.
1.17.3 Crew Resource Management
1. While individual error may occur during aviation operations, they seldom propagate to the point of
serious incident because of the many safe guards built into these systems. Traditionally, CRM has
been defined as the utilization of all resources available to the crew to manage human error.
ICAO Human Factors Training Manual also states, (Part 1, Paragraph 1.4.25), that
‘Crew coordination is the advantage of teamwork over a collection of highly skilled individuals. Its
prominent benefits are:
• An increase in safety by redundancy to detect and remedy individual errors; and
• An increase in efficiency by the organized use of all existing resources, which improves the in-
flight management.’
One of the basic elements of CRM involves checklist discipline. The general concept involves one
pilot performing a check, while the other pilot confirms or monitors to ensure that the proper
actions have been taken.
2. ICAO Manual further states, (Part 1, Paragraph 1.4.26), that
‘The basic variables determining the extent of crew coordination are the attitudes, motivation, and
training of the team members. Especially under stress (physical, emotional, or managerial), there is
a high risk that crew coordination will break down. The results are a decrease in communication
28
(marginal or no exchange of information), and increase in errors (e.g. wrong decisions), and a lower
probability of correcting deviations either from standard operating procedures or the desired flight
path.’
The Manual further adds (Part 1, Paragraph 1.4.27), that
‘The high risks associated with a breakdown of crew coordination show the urgent need for Crew
Resource Management training, this kind of training ensures that:
• The pilot has the maximum capacity for the primary task of flying the aircraft and making
decisions;
• The workload is equally distributed among the crew members, so that excessive workload for
any individual is avoided; and
• A coordinated cooperation - including the exchange of information, the support of fellow crew
members and the monitoring of each other’s performance - will be maintained under both
normal and abnormal conditions.’
3. One of the important reasons for adherence to good CRM practices is to ensure checklist discipline
and to make effective use of existing resources to improve safety of flight, by using the “team”
approach to overcome inherent human errors. If one of two pilots in a cockpit displays less-than-
optimal discipline in performing checklists and is not as effective in dealing with non-normal
situations. Good CRM would enable a two-pilot crew to function as a team in order to avoid
inadvertent omissions, to rectify them as soon as possible, and to effectively and swiftly manage
non-normal situations. Good CRM also involves cooperation between the flight crew and cabin
crew for certain non-normal events, particularly pressurization problems.
A number of past airline accidents and incidents have been associated with pilots’ lack of adherence to
proper checklist procedures. If one of two pilots in a cockpit displays less-than-optimal discipline in
performing checklists, the team is not as effective in dealing with non-normal situations. In this regard,
the Investigation Team observed the following:
• According to training records, the PIC and Co-pilot had received CRM training in Apr 2021 and
July 2021, respectively. Records also showed that the all four cabin attendants had received
CRM training on 21 Mar 2021, 26 Apr 2021 and 16 Jul 2021 respectively.
• The flight crew were grossly engrossed in handling the emergency and didn’t check with the
cabin crew about their health and did not given time to the cabin crew to check the condition
of the passengers, use of mask and any other physical condition even when the aircraft
descended to safe altitude below 10000 Ft. and till the time aircraft landed at Patna.
Good CRM would have enabled a two-pilot crew to function as a team in order to avoid inadvertent
omissions, to rectify them as soon as possible, and to effectively and swiftly manage non-normal
situations.
29
1.17.4 Pilot training procedure regarding pressurization system in manual mode
In SpiceJet Ltd, prior to the serious incident, the pilot training for manual pressurisation control was
being carried out as per the supplementary procedure provided in Boeing Flight Crew Operations
Manual (FCOM Vol 1), page SP 2.3 titled Manual Mode Operation. As per regulatory requirement, the
pressurisation system is to be covered once every year during training of the crew. Both the crew have
undergone training prior to the serious incident as per regulations.
However, during the investigation, it has been observed that the training provided to the crew on the
manual control of pressurisation system was not elaborate, as this was second back up system after
failure of pressurisation control both in AUTO and ALTN mode.
Flight Operations Technical Bulletin issued by Boeing
As per Flight Operations Technical Bulletin (19-01 R1), dated 13.04.2020 issued by Boeing, there have
been several reports of flight crew confusion regarding cabin altitude and cabin rate of climb
indications that occurred as a result of depressurization events or the flight crew having to manually
control cabin pressure. Additionally, there have been some reports where manual control of cabin
pressure led to excessively high rates of cabin altitude changes as well as cabin over-pressurization
conditions which led to the abnormal indications. This in turn led to flight crew confusion as what was
actually occurring with airplane pressurization. Without an understanding of the situation, continued
flight crew action led to amplification of the already abnormal situation. Some of these events
30
reportedly led to passenger injuries, flight with an over-pressurized cabin and landings with a
pressurized cabin.
To address these issue, on 13 April, 2020 Boeing issued Flight Operations Technical Bulletin (19-01 R1)
on Cabin Altitude Indications in Over-Pressure Situation, High Cabin Rate of Climb Indications and
Manual Pressurization Control. The reason for issue of Flight Operations Technical Bulletin was to
provide information to the flight crew of abnormal cabin pressure indications and techniques for
manual pressure control.
Investigation Team observed that this was not made part of any operational documents issued by
Spicejet as on date of incident. However, this bulletin was included by Spicejet post this serious
incident in their training circular TC 03/22 dated 29.03.2022 and 05/22 dated 05.12.2022 respectively.
1.17.5 On Job Training Syllabus of Aircraft Maintenance Engineer
As per OJT booklets for AME (B1& B2) related to Boeing 737-700/800/900 of M/s SpiceJet Ltd. dated
14 May 2020 approved by DGCA, the OJT on replacement of OFV of pressurization system is the part
of OJT syllabus of Chapter 21 applicable for AME (B1). This task is marked as Complex OJT tasks listed
in the booklet. However, this activity of Chapter 21 is not applicable for AME (B2) as per approved OJT
syllabus by DGCA.
1.18 Additional information
Nil
1.19 Useful or Effective Investigation Techniques
Nil
2. ANALYSIS
2.1 General
The incident occurred on 17 November 2021 on Flight VT-SYZ (Type: BOEING 737-800). On the day of
incident, VT-SYZ was scheduled to operate its flight from Ahmedabad to Patna. The PIC and Co-pilot
were licensed and qualified in accordance with the applicable regulation and operator’s requirement.
The duty time, flying time, rest time and duty activity pattern were according to the regulations. The
cabin attendants were trained and qualified to perform their duties in accordance to existing
requirements. Visual meteorological conditions prevailed on departure and along the route of flight,
and at destination was not a factor in the serious incident.
The aircraft was certified, equipped and maintained in accordance with regulations and approved
procedures. The aircraft did not have any preexisting airframe or power plant problems. It departed
with load and trim data within limits and no deferred items were pending in the logbook.
The investigation team examined the evidence to determine the cause of the serious incident and the
analysis including examination of under mentioned documents and procedures.
• Pilot training procedure
• Action by Flight Crew
• Factors related to Safety Management System
• DFDR & CVR recordings
31
• FCOM
• QRH
• Initial Response from OEM, Nord-Micro Frankfurt, Germany
• Teardown report of out flow valve Serial no. 07101936 (work order no. 44754578) received
from OEM post incident dated 09 Mar 2022
• Records of the Operator’s outflow valve removals Feb 2020 to Nov 2021 prior to the serious
incident
• Maintenance records related to the event aircraft air conditioning and pressurization systems
from January 2021 through June 2022
• Shop findings of SpiceJet related to outflow valves removals.
2.2 Failure of Pressurization System
The aircraft got airborne from Ahmedabad for Patna at 03:02:00 UTC. The takeoff, climb and cruise
segment of the flight was uneventful. However, as soon as the pilot initiated descent from FL 350, the
master annunciator came on with air conditioning and pressurization system followed by auto fail light
of pressurization system. The crew changed over the mode from AUTO to ALTN, however the
alternate system did not take over. Failure of auto pressurization control system could be due to the
following reasons (refer B 737-800 AMM Chap. 21-30-00 page 38)
1. High rate of descent initiated by the PIC beyond the controlling capability of the system –
The aircraft rate of descent from top of the climb (35004 ft at 04:34:01UTC) to the point of
annunciation of master caution and auto fail light on (34292 ft at 04:34:32UTC) was approx.
1378 ft/min. This data alone is inadequate to conclude that initiation of warning was due to
high rate of descent (Refer Fig 6: Time v/s Rate of descent graph)
2. Power Loss – The DFDR read out does not indicate power loss as the reason for failure of auto
control system of pressurization. (Refer Fig 8)
3. Cabin altitude rate of change is too high – The cabin rate of change could be a reason for
failure of auto system if air outflows (through the fuselage, systems, doors/seals, and outflow
valve) exceeds cabin air pressurization system requirements resulting in high rate of change of
cabin altitude. There was no evidence that cabin altitude rate of climb was too high or
evidence of any significant air outflows through the fuselage, systems, doors/seals, etc.
4. Cabin altitude is too high (> 15000 Ft) – Cabin altitude reached 15800 ft due to malfunction of
out flow valve which was unable to control the cabin pressure.
5. Wiring failure – Wiring failure is ruled out, as post change of the outflow valve, the system was
found satisfactory.
6. Outflow valve component failure – As per tear down report of defective component received
from Nord-Micro Frankfurt, Germany, “the performed potentiometer tests indicate that the
removed outflow valve P/N 21230-03AC S/N 07101936 failed in Poti synchronism test (open
4,40V / 115°) on 09 Mar 2022.
As per work performed in teardown report the outflow valve had to undergo major repairs, as
follows. (Refer teardown report placed as appendix 01)
32
a. The Gear box functional incoming test failed, so gear box defective bearings were replaced.
b. Anti-skating foils were damaged/ missing which were replaced.
c. Teflon seals were bent and hence replaced.
d. Rod ends were found sluggish/ stuck and hence replaced.
e. Aumot 1 brake function was defective which was renewed.
f. Worn-out bonding cables were replaced.
g. Potentiometer was replaced as it was out of tolerance.
As per the OEM, the above damages were considered to be normal wear and tear for OFV with
+15 year of service but contributed in malfunction of OFV in auto mode operation, however,
manual operation of OFV was still possible. This was also confirmed during check of the fault
history of outflow valve post landing at Patna during fault rectification. This was further
confirmed after replacement of OFV at Patna during snag rectification by AME, after
performing full performance checks of the pressurization system post replacement of OFV. The
snag was not repeated post replacement of OFV.
7. CPC1 and CPC2 Failure – Failure of CPC1 & CPC2 are ruled out because the 5 dashes were not
displayed on FLT ALT & LAND ALT display and during post incident BITE test of the system no
such fault was noticed.
8. Cabin differential pressure too high – Cabin differential pressure was in the normal operating
range as per altitude.
9. Cabin pressure control module (P5) selector panel fault – During BITE test no such fault was
noticed.
The aircraft was cleared post incident after replacement of out flow valve of pressurization system.
The aircraft VT-SYZ has flown 2128.21 Hrs. and 1015 cycles without encountering similar defect.
2.3 Sequence of events
2.3.1 Pre-Departure
On 17 November 2021, the first sector of the flight from Delhi to Ahmadabad was uneventful for the
aircraft and cockpit crew. In second sector, SG-391 VT-SYZ was scheduled to operate its flight from
Ahmedabad to Patna. The investigation team reviewed the maintenance records of work performed
on the aircraft by the Ground Engineers prior to its departure from Ahmedabad airport, as well as the
Aircraft Tech Log entries and the AMM procedures/tasks recorded in the log book. No defect was
pending on the aircraft.
2.3.2 Preflight
The investigation team considered various aspects of the flight crew’s performance, beginning with
the preflight phase and until landing at Patna airport. All available data from the FDR, CVR were used
33
for analysis of the incident and to gain insight into actions by the flight crew. Preflight actions
performed by flight crew were as per procedure and no deviations were noticed.
2.3.3 Takeoff, Climb and Cruise
Take-off, climb and cruise phase of the flight was uneventful.
2.3.4 Descent and Approach
The aircraft was cleared for descent from FL 350 to FL270 initially. During descent the master caution
along with auto fail light illuminated at FL340.
a. The crew initiated action as per auto fail Non Normal Checklist (NNC) procedures
i. The Co-pilot started reading the NNC and started performing action.
ii. The pressurization mode selector switch was moved from AUTO to ALTN position. However,
the auto fail light did not extinguish and cabin altitude was not controllable.
iii. The pressurization mode selector was moved to MANUAL position.
iv. The airflow valve control switch was moved to open position by Co-pilot in single flick, which
was than fully opened by PIC by pressing the OFV control switch for 20 second. The crew rather
than closing the OFV to contain the pressure opened the OFV fully. This led to complete loss of
pressurization from the aircraft and the cabin altitude started climbing.
b. Crew action of opening the outflow valve instead of closing led to complete loss of aircraft
pressurization. It was assumed by the crew that the pressure is uncontrollable and they left the
outflow valve in fully open position till landing and shutdown of aircraft.
c. Post opening of out flow valve, the crew observed that the cabin altitude started increasing rapidly
at the rate of 4000 Ft/min leading to Cabin Altitude Warning annunciation. After that copilot
deployed the passenger mask at an altitude of 28207 ft. The oxygen mask of seat number 5A, 5B,
5C and lavatory failed to deploy. The cabin crew shifted the passenger of seat 5A, 5B, 5C to seat
1A, 1B and 1C.
d. Co-pilot donned oxygen mask and advised PIC to do the same. However, PIC delayed donning of
mask.
e. Instead of performing memory actions for Cabin Altitude warning or Rapid Depressurization, PIC
declared MAYDAY and asked for Emergency descent checklist.
f. PIC expedited descent from FL350 to FL100 in 08 min 11 seconds and did not carry out memory
actions of Emergency Descent as per procedure.
g. PIC did not announce Emergency Descent on Passenger Announcement (PA) as per NNC (when
emergency descent was initiated at 28207 Ft). Emergency descent was announced quite later
when aircraft was descending from 17126 Ft. The aircraft descended close to 11000 Ft after cabin
attitude warning came on and 17000 Ft from the time auto fail light came on. During emergency
descent the PIC directed the SCC to enter flight deck to inform about the occurrence which was to
be communicated on PA system as per procedure.
34
h. As per CVR and DFDR data correlation at an altitude of 17126 Ft, Emergency descent NNC was read
and done wherein PIC made a PA to passengers regarding emergency descent and to return back
to their seats. However, he did not announce passengers to wear oxygen mask as per procedure.
i. During further descent the crew carried out Cabin Altitude Warning or Rapid Depressurization non-
normal checklist.
j. ATC cleared the aircraft to descent to FL60 and when cabin altitude reached 7000 Ft, crew
removed their oxygen mask.
k. Co-pilot contacted the SCC through intercom and enquired about the situation in the cabin.
l. Following information was passed on to flight deck by SCC (while in conversation with Co-pilot):
➢ All passengers in the cabin were screaming
➢ The cabin crew were not able to check the physical condition of the passengers as they were
told to occupy their seats during emergency descent.
m. Co-pilot ordered SCC to go in the cabin for securing the galley equipment as they were about
to land.
n. Sequence of the NNC was not maintained and hence descent, approach and landing checklist were
carried out as per the deferred items of Cabin Altitude Warning or Rapid Depressurization NNC.
o. PIC cancelled the MAYDAY call after reaching at an altitude of 1588 Ft. and 20 Nm from
touchdown.
2.3.5 Landing
• After an ILS approach on runway 25 aircraft landed safely at PATNA (PAT).
• ATC enquired whether any assistance was required, to which the PIC replied in negative.
• During taxi-in, the Co-pilot enquired from SCC about the condition of the passengers, to which SCC
replied that the check was carried till mid row only during the descent. If required she will go and
check it now which was refused by the PIC as the aircraft was about to be parked.
• Post parking at bay the PIC debriefed the issues to AME.
2.4 Maintenance actions
2.4.1 The AMEs replaced the OFV based on the fault message (OFV LRU FAIL). The complete BITE
check was not undertaken as per the procedure laid down in FIM before replacing OFV. Post
replacement of OFV, BITE check and Pressurization check of aircraft was undertaken and no leak
of pressure was observed from the aircraft.
2.4.2 As per record of on job training submitted to Investigation Team by SpiceJet with respect AME
(B1), it is evident that B1 was authorised to the task undertaken. However, during OJT, he had not
performed replacement of OFV of pressurization system, since a candidate has an option to complete
at least 50% of tasks for each ATA chapter for OJT completion as per DGCA approved syllabus.
Whereas this activity was covered in the approved syllabus of OJT.
2.4.3 As per record of on job training submitted to Investigation Team by SpiceJet with respect AME
35
(B2), it is evident that AME (B2) was authorised to undertaken task related to BITE test. However, he
had not performed replacement of OFV of pressurization system during OJT as it not was covered in
the approved syllabus of OJT for AME (B2).
2.4.4 From the history of outflow valve removals from April 2021 to Nov 2021 on different aircraft of
SpiceJet, it is evident that in all the 07 cases outflow valve have been removed/replaced due to auto
fail light coming on.
2.4.5 It has been analyzed with help of PDR that from Jan 2021 to Aug 2022, a total of 661 PDR had
been reported on snag related to air conditioning and pressurization system. This reflects poor
maintenance standards being followed by the operator. Further, Investigation Team observed that
frequent swapping of components is being resorted to, by the operator to undertake defect
rectification which is not a healthy maintenance practice.
2.5 Crew Resource Management
2.5.1 It is well established that scores of past airline accidents and incidents have been associated
with pilots’ lack of adherence to proper checklist procedures. One of the important reasons for
adherence to good CRM practices is to ensure checklist discipline and to make effective use of existing
resources to improve safety of flight, by using the “team” approach to overcome inherent human
errors. If one of two pilots in a cockpit displays less-than-optimal discipline in performing checklists,
the team is not as effective in dealing with non-normal situations. Good CRM would have enabled a
two-pilot crew to function as a team in order to avoid inadvertent omissions, to rectify them as soon
as possible, and to effectively and swiftly manage non-normal situations.
2.5.2 The Investigation Team examined the Crew Resource Management issues related to the
sequence of events of flight SG-391 in order to understand the underlying reasons for the serious
incident.
2.5.3 According to training records, the PIC and Co-pilot had received CRM training in Apr 2021 and
July 2021, respectively. Records also showed that all the cabin attendants had received CRM training in
year 2021. The circumstances of the serious incident as discussed in paragraphs that follow, indicate a
breakdown in crew coordination and inadequate CRM that did not mitigate individual errors made at
several stages of the emergency situation.
2.5.4 During the emergency descent the SSC was called by the PIC to the cockpit, the SSC was
without portable oxygen bottle when she entered the cockpit. The pressurization failed at altitude
34249 ft. (baro) at 04:34:33 UTC and cabin altitude warning came on at altitude 28207ft (baro) at
04:37:08 UTC. The cabin crew don the mask after cabin altitude warning came on. The PIC & Co-pilot
failed to advice the SCC to use the portable oxygen cylinder.
2.5.5 The cabin crew did not insist upon the PIC to allow them for a quick check of passenger
condition and donning of mask by them after they were told to occupy their seat during emergency
descent, which is required to be undertaken post decompression checks as per NNC. The cabin crew
were not at all allowed by the PIC to review the health condition of the passengers till the flight landed
which was required as per safety emergency procedure. The shows lack of situational awareness.
2.5.6 As per memory check list, during operation of OFV in manual mode, the crew is supposed to
36
check the position of outflow valve in case the cabin rate of climb is rising. However, input of Co-pilot
requesting to close the outflow valve was not clearly monitored by the PIC and he advised the Co-pilot
to open it. When the Co-pilot flicked it open, the cabin rate of climb increased further, which
aggravated the situation, when PIC moved the out flow valve to fully open position leading to
complete depressurization of aircraft. The Co-pilot also did not advice the PIC to close the out flow
valve which was suggested initially during the beginning of the emergency handling.
2.5.7 The aircraft got into non normal situation after 25 seconds from the time the aircraft started
descent from FL350, for which both the crew failed to address emergency action by not maintaining
the sequence of NNC, leading to selection of manual pressurization control before increasing thrust of
the engines to ensure sufficient air supply to pressurization system while carrying out the descent
approach and landing check list as defined in climb of cabin altitude warning and rapid
depressurization NNC. The thrust was increased only after 63 seconds of auto fail light coming on by
the crew as indicated in the DFDR report.
2.5.8 The crew did not inform the passenger and cabin crew about the aircraft pressurization
emergency and initiated emergency descent and lost crucial time to be given to the cabin crew to
check the condition of the passengers, use of mask and any other physical condition even after aircraft
reached safe altitude.
2.5.9 The cabin altitude warning came on above 10000 Ft of cabin altitude, at this stage as per
standard operative procedure both the PIC and Co-pilot are supposed to don the oxygen mask,
however PIC delayed donning of mask for almost 3 to 4 minutes, which probably led to momentary
incapacitation (Hypoxia) for 60 to 90 seconds during the flight (which was also confirmed during CVR
analysis and from statement of the crew). The Co-pilot did not impress immediate donning of mask by
the PIC at critical stage of flight which could have resulted in serious consequences.
2.6 Pilot training on pressurization system in manual mode before and after subject serious incident
2.6.1 The Investigation Team visited the training facility of SpiceJet where crew undergoes IR, PPC,
Refresher, skill test training and other trainings. Investigation Team observed that training in
controlling of pressurization in non-normal situation of auto fail/ALTN Fail /Manual mode is being
provided to the Flight Crew. However, it was found that not much emphasis was being given during
training on the detailed procedure of manipulation of OFV opening and closing to maintain the desired
cabin altitude as per the aircraft altitude as redundancies are available in case of failure of normal
mode of operation.
2.6.2 On April 13 2020, Boeing issued Flight Operations Technical Bulletin (19-01 R1) on Cabin
Altitude Indications in Over-Pressure Situation, High Cabin Rate of Climb Indications and Manual
Pressurization Control, which found not complied in the crew training. However, this Flight Operations
Technical Bulletin was issued to provide information to the flight crew of abnormal cabin pressure
indications and techniques for manual pressure control as well as updated information on the
electrical control of the outflow valve. This bulletin was not made part of any operational document
issued by operator as on date of serious incident. However, it was circulated for information to all the
crew through electronic media.
2.6.3 Post serious incident SpiceJet has issued two new training circulars with special emphasis on
37
control of aircraft pressurization system in manual mode.
S. No Date Subject Nature

SEJ-OPS-05-TC-B 05 Dec 2022 Management of non-normal Mandatory
TC 05/22 situations
SEJ-OPS-05-TC-B 29 Mar 2022 Improving pilot performance Informatory
TC 03/2022 feedback cycle 1
SpiceJet has included the Boeing FOTB 19-01 R1 (Flight Operations Technical Bulletin) dated
13/04/2020 in their training circular SEJ-OPS-05-TC-B, TC 05/22 dated 05 Dec 2022. Now training is
being imparted as per this circular.
3. CONCLUSION
3.1 Finding
3.1.1 Flight Crew
1. The flight crew were licensed and qualified for the flight in accordance with applicable regulations.
2. The flight crew held valid medical certificates and were medically fit to operate the flight.
3. The flight crew were adequately rested and their flight and duty times were in compliance with
DGCA and Operator requirements.
4. After the cruise phase aircraft started descending from FL 350, the Master Caution come on for 08
second at altitude of 34292 Ft along with auto fail light of pressurization system. The crew failed to
manipulate the position of outflow valve in manual mode to maintain the cabin pressure/cabin
altitude as per cabin requirement mentioned on cabin pressure control module(P5).
5. The Co-pilot had don the mask as per SOP and advised PIC to wear the oxygen mask. However, the
PIC delayed the donning of mask by 3 to 4 minutes, which probably lead to momentary
incapacitation (Hypoxia) of PIC for 60-90 seconds.
6. PIC after opening the outflow valve manually never made an attempt to close the outflow valve to
maintain the cabin pressure, which lead to complete depressurization of aircraft. The PIC also did
not adhere to the caution given in FCOM .The serious incident could have been prevented if
manual operation of the OFV would have been conducted according to SOP in place.
7. The PIC failed to deploy the QDM (Quick Deployment Mask) in first attempt as soon as the cabin
altitude warning came on.
8. After the cabin altitude warning came on, the flight crew did not inform the cabin crew about the
problem with pressurization system, which lead to chaos in passenger cabin and lack of situational
awareness among the crew members.
9. PIC did not follow seat oriented actions as per non normal procedure given in B737 FCOM and
declared MAYDAY. Thereafter, he asked for Emergency Descent Checklist without carrying out
memory actions of Emergency Descent NNC. The handling of emergency was not as per laid down
SOP.
10. The PIC declared the MAYDAY call and cancelled it later during final approach without knowing the
38
conditions of passenger in the cabin. This shows lack of situational awareness.
11. Even after landing when ATC enquired about any assistance required from the aircraft, PIC
responded in negative, which showed lack of situational awareness. The passengers had reported
ear pain, headache, and dizziness and discomfort due to rapid descent of the aircraft.
12. The PIC did not announce emergency descent on PA system as per NNC and during emergency
descent directed the SSC to enter in cockpit to inform about the same.
13. Cabin crew were not given sufficient time to conduct post depressurization check/duties in the
cabin and to know about their well-being as the landing was expedited by the flight crew.
14. Sequence of NNC was not maintained and hence the descent, approach and landing check list
were carried out as per the deferred items of cabin altitude warning or rapid depressurization.
3.1.2 Ground Engineers
1. The component replacement by the B1 AME was under taken based on fault message displayed in
existing fault history and no BITE check was performed to identify the root cause of failure of
outflow valve in Auto/ALTN mode. The complete BITE check could have identified the fault code
through which the root cause of failure of out flow valve could have been established.
2. B2 AME deployed for fault isolation was authorized to undertake task. However, he had never
undertaken the replacement outflow valve before subject serious incident. The procedure
followed by AME for fault isolation was not as per laid down procedure in FIM 21-31 task 801.
3.1.3 Operator
1. On April 13, 2020 Boeing issued Flight Operations Technical Bulletin (19-01 R1) on Cabin Altitude
Indications in Over-Pressure Situation, High Cabin Rate of Climb Indications and Manual
Pressurization Control. The advisory circular issued by Boeing was not incorporated in the training
circular prior to the date of incident. However, it was circulated for information to all the crew
through electronic media after the serious incident.
2. The training imparted to the crew on manual control of operation of aircraft pressurization system
prior to the date of serious incident was not elaborate, as this was second back up system after
failure of pressurisation control both in AUTO and ALTN mode. Hence, the crew were not familiar
with the manual manipulating of OFV (opening and closing) to maintain the desired aircraft
altitude VS cabin altitude and cabin differential pressure.
3. During questioning of B2 AME it was evident that B2 AME deployed for fault isolation and
component change had never replaced outflow valve before subject incident and B1 AME was not
having sufficient experience of fault isolation and BITE check with respect to pressurisation system
snag analysis. The AME did not follow the complete procedure as laid down in FIM 21-31 task card
801 before changing the out-flow valve.
3.1.4 Cabin Crew
1. The cabin crew members were trained and qualified in accordance with existing regulations.
2. The cabin crew members were adequately rested and their duty times were in accordance with
39
existing regulations.
3. The cabin crew did not play a proactive role in communicating with flight crew about the condition
of passengers during emergency and performing post decompression duties.
4. The SCC was without portable oxygen bottle when called by PIC to the flight deck, which is a
violation of SOP.
3.1.5 Aircraft
1. The aircraft held a valid Certificate of Airworthiness.
2. The mass and center of gravity (CG) of the aircraft were within prescribed limits.
3. Scrutiny of the tech log pages revealed that no similar snag was reported recently on this aircraft
prior to the date of serious incident.
4. From the scrutiny of maintenance record of pressurization system and Cabin high rate of descent
occurrence it is evident that frequent swapping of components for fault isolation /snag
rectification is being practiced by operator. Swapping is not considered a good maintenance
practice from the system reliability point of view.
5. The strip examination report of the OFV from OEM indicated that some components of OFV were
found damaged and worn out. These damages were considered to be normal wear and tear for
OFV with +15 year of service but contributed in malfunction of OFV in auto mode operation.
However, manual operation of OFV was still possible.
6. All the aspects of Auto Fail/ ALTN failure light were analysed including reasons given at para 1.6.2
and it is opined that auto fail light came on probably due to outflow valve malfunctioning in Auto
Mode. This is further evident from OFV LRU FAIL message during system test and the fact that
after change of OFV, the aircraft has flown over 2000 hrs. without snag being repeated.
3.1.6 Maintenance
1. As high as 661 PDRs related to air conditioning and pressurization have been recorded from Jan
2021 to Aug 2022 which reflects about maintenance standards being followed in the organization.
2. In most of the cases (including this incident) various snag (like auto fail, ROCI fluctuation, cabin
attitude warning, etc.) related to pressurization have been rectified by replacement/swapping of
out flow valves which is not a healthy maintenance practice.
3.1.7 ATC
1. The MAYDAY call was handled by ATC as per the laid down procedures
3.2 Probable Cause of the Serious Incident

3.2.1 Direct Cause
The PIC did not adhere to the standard operating procedure to maintain cabin pressure during
AUTO/ALT FAIL condition due to inadequate knowledge in handling of pressurization system in manual
mode.
40
3.2.2 Latent cause(s)
1. Inadequate application of Crew Resource Management (CRM) principles by the flight crew.
2. Inadequacy of training in handling pressurization control and control of outflow valve in manual
mode.
4. SAFETY RECOMMENDATIONS
It is recommended that
4.1 SpiceJet shall reiterate the procedure for handling the pressurization failure/emergency
decompression in detail during the training given to the pilots, which includes identification of the
fault, knowledge of the system, etc.
4.2 SpiceJet shall review the CRM training being imparted to all crew (including cabin crew) to ensure
that the crew follows seat-oriented actions and there is proper co-ordination between the cockpit
crew and cabin crew in emergency situations such as these.
4.3 SpiceJet should develop a procedure to ensure that the authorized engineering personnel
deputed for the maintenance task have undertaken similar maintenance task in the past.
4.4 SpiceJet should evaluate their maintenance practices to ensure that the maintenance tasks are
carried out as per the laid down standards. The practice of swapping of components between
airplanes for the purpose of trouble shooting should be strictly avoided.
(Rajendra Pratap Singh) (Ajendra Singh)

Investigator-in-Charge Investigator
Date: 21 June 2023

Place: New Delhi
41
Appendix
Teardown report of OFV from shop
42
43
44
45

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Final Investigation Report on Serious Incident to

M/s SpiceJet Ltd. Aircraft VT-SYZ (Boeing 737-800)

Gp Capt Rajendra Pratap Singh VSM (Retd.) (Ajendra Singh)

1. Aircraft Type Boeing 737-800

Copyright © Boeing. Reprinted with permission of The Boeing Company

Mask did not deploy

Fig 4: Seat no. 5 mask did not deploy (above); LAV A

The crew oxygen bottle pressure was checked and

1.6.8 Pilot seat oriented action as per FCOM

Fig 6: Graph Time v/s Rate of Descent

Engine parameter during Serious Incident

Altitude V/S Time [TRA, N1, N2]

35000 TRA #1:

Fig 6: Aircraft parameter Altitude V/S Time [TRA, N1, N2]

1.11.2 CVR – PN 2100-1020-00, OEM L- 3 Communications, Model CVR 2100.Four channel

S. No Date Subject Nature

3.2 Probable Cause of the Serious Incident

(Rajendra Pratap Singh) (Ajendra Singh)

Date: 21 June 2023

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