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大韓航空公司 KE-0691 班機於高空巡航時艙壓失效

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事故類別
非發動機之系統/組件故障或失效(Non-Powerplant)(SCF-NP)
發生時間
95-05-11
事故機型
Airbus/A300
發生地點
機場外/B-576航路上

事故簡介

民國95年5月11日，大韓航空公司KE0691班機，國籍標誌及登記號碼為HL-7297，機型A300-B4622R，機上載有117名乘客、9名客 艙組員與正、副駕駛員，於上午當地時間0846時自韓國仁川國際機場起飛，目的地為台北中正國際機場。該機於1017時，高度32,000呎，於B- 576航路上，離SALMI交接點南方約30浬，座艙出現艙壓調節器失效警告，同時艙壓垂直速率表上升至2,000~3,000呎，艙壓高度上升至10K 呎。飛航組員依緊急程序下降高度並通知航管人員，航機於高度10K呎改平，艙壓控制經重置後恢復正常。該機於1104時在桃園中正國際機場落地，人、機均 安。　

調查階段

調查發現

    與可能肇因有關
    1. A broken flange in the automatic mode motor drive componentcaused the FWD outflow valve failed and the subsequent failureof both auto modes in driving the FWD outflow valve. The failedvalve in both auto modes caused the cabin pressure loss. 
    2. The flight crew did not apply the manual mode to control thecabin pressure. 
    3. There is no integrated procedures defined when both of cabinpressure regulators failed and rapid decompression happened,whether the flight crew shall continuously complete the “CABINPRESS REG FAULT” procedure or direct to the “EMERGENCYDESCENT” procedure.
    與風險有關
    1. The flight crew did not follow the standard procedures to initiate aturn when conducted the “EMER DESCENT” procedures.
    其他
    1. The flight crew members were properly certified and qualified inaccordance with the applicable Korean Civil Aviation Regulations.
    2. There was no evidence indicating the crew had any physical orpsychological problems, nor any use of alcohol or drugs. 
    3. The aircraft was operated within allowable weight and balancelimitations. 
    4. There were no adverse weather conditions at the time of theoccurrence. 
    5. The LIEBHERR AEROSPACE did not conduct more detailedexploration on that specific damaged flange of the motor drivecomponent.

改善建議

    致大韓航空公司
  1. 檢視並整合艙壓失效相關緊急操作程序。
  2. 確認飛航組員遵守並精練各項緊急程序。
    致韓國交通建設部
  1. 監督大韓航空公司對上述改善建議之執行。
    致法國LIEBHERR-AEROSPACE公司
  1. 對該項失效之組件進行細部測試，以瞭解其失效原因。

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