Accidents and Incidents

This directory contains articles about particular Accidents and Incidents that are considered illustrative of the contemporary safety issues and recommended potential solutions. The information contained in the article summarising an individual accident or incident is derived from the published official investigation report, which may in each case be found on the SKYbrary bookshelf wherever possible in English as provided by the publishing Investigation Agency. A direct link to each official report is provided at the end of each summary article. The complete list of events is provided on this and the following pages in the order of the ICAO aircraft type designator in alphabetical order.

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Showing below 1402 results in range #501 to #600.


B734, Exeter UK, 2021 On 19 January 2021, a Boeing 737-400SF on an ILS approach to Exeter became unstabilised below 500 feet but despite multiple EGPWS ‘SINK RATE’ Alerts, a go-around was not initiated. The subsequent touchdown recorded 3.8g and caused such extensive damage that the aircraft was declared a hull loss. The Investigation found that the First Officer, who had more hours flying experience than the 15,000 hour Captain, had failed to adequately control the flight path below 500 feet and noted that whilst the Captain had commented on the excessive rate of descent, he had not called for a go around.

B734, Kabul Afghanistan, 2016 On 10 December 2016, a Boeing 737-400 main gear leg collapsed on landing after an approach at excessive speed was followed by a prolonged float prior to touchdown on the high-altitude Kabul runway. The Investigation found that the collapse had followed a severe but very brief wheel shimmy episode in the presence of a number of factors conducive to this risk which the aircraft operator s pilots had not been trained to avoid. It was also found that although the aircraft operator regularly undertook wet lease contract flying, their pilot training policy did not include any route or aerodrome competency training.

B734, Lahore Pakistan, 2015 On 3 November 2015, a Boeing 737-400 continued an unstabilised day approach to Lahore. When only the First Officer could see the runway at MDA, he took over from the Captain but the Captain took it back when subsequently sighting it. Finally, the First Officer took over again and landed after recognising that the aircraft was inappropriately positioned. Both main gear assemblies collapsed as the aircraft veered off the runway. The Investigation attributed the first collapse to the likely effect of excessive shimmy damper play and the second collapse to the effects of the first aggravated by leaving the runway.

B734, Palembang Indonesia, 2008 On 2 October 2008, a Boeing 737-400 being used for flight crew command upgrade line training unintentionally landed off a non precision approach at Palembang in daylight on a taxiway parallel to the landing runway. Neither pilot realised their error until the aircraft was already on the ground when they saw a barrier ahead and were able to brake hard to stop only 700 metres from touchdown. It was found that the taxiway involved had served as a temporary runway five years earlier and that previously obliterated markings from that use had become visible.

B734, Sharjah UAE, 2015 On 24 September 2015, a Boeing 737-400 cleared for a night take-off from Sharjah took off from the parallel taxiway. The controller decided that since the taxiway was sterile and the aircraft speed was unknown, the safest option was to allow the take-off to continue. The Investigation noted that the taxiway used had until a year previously been the runway, becoming a parallel taxiway only when a new runway had been opened alongside it. It was noted that the controller had lost visual watch on the aircraft and regained it only once the aircraft was already at speed.

B734, Timbuktu Mali, 2017 On 5 May 2017, a Boeing 737-400 made a visual approach to Timbuktu and slightly overran the end of the 2,170 metre-long runway into soft ground causing one of the engines to ingest significant quantities of damaging debris. The Investigation found that the landing had been made with a significantly greater than permitted tailwind component but that nevertheless had the maximum braking briefed been used, the unfactored landing distance required would have been well within that available. The preceding approach was found to have been comprehensively unstable throughout with no call for or intent to make a go around.

B734, vicinity East Midlands UK, 1989 On 8 January 1989, the crew of a British Midland Boeing 737-400 lost control of their aircraft due to lack of engine thrust shortly before reaching a planned en route diversion being made after an engine malfunction and it was destroyed by terrain impact with fatal or serious injuries sustained by almost all the occupants. The crew response to the malfunction had been followed by their shutdown of the serviceable rather the malfunctioning engine. The Investigation concluded that the accident was entirely the consequence of inappropriate crew response to a non-critical loss of powerplant airworthiness.

B734, vicinity Lyon France, 2010 On 7 September 2010, a Turkish operated Boeing 737-400 flew a non precision approach at Lyon Saint-Exupéry in IMC significantly below the procedure vertical profile throughout and only made a go around when instructed to do so by ATC following an MSAW activation. The minimum recorded radio height was 250 feet at 1.4nm from the runway threshold.

B734, Yogyakarta Indonesia, 2007 On 7 March 2007, a Boeing 737-400 being operated by Garuda landed on a scheduled passenger flight from Jakarta to Yogyakarta overran the end of the destination runway at speed in normal daylight visibility after a late and high speed landing attempt ending up 252 metres beyond the end of the runway surface in a rice paddy field. There was a severe and prolonged fire which destroyed the aircraft (see the illustration below taken from the Investigation Report) and 21 of the 140 occupants were killed, 12 seriously injured, 100 suffered minor injuries and 7 were uninjured.

B734, Zurich Switzerland, 2013 On 11 October 2013, the commander of a Boeing 737-400 taxiing on wet taxiways at night after landing at Zurich became uncertain of his position in relation to the clearance received and when he attempted to manoeuvre the aircraft off the taxiway centreline onto what was believed to be adjacent paved surface, it became bogged down in soft ground. The Investigation considered the direct cause of the taxiway excursion was not following the green centreline lights but it recommended improvements in the provision of clear and consistent taxi instructions and in taxiway designations in the area of the event.

B735, Denver USA, 2008 Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind Conditions.

B735, en-route, North East of London UK, 1996 On 5 September 1996, a Boeing 737-500 operated by British Midland, encountered severe wake turbulence whilst in the hold over London. The wake was attributed to a B767 some 6 nm ahead.

B735, en-route, north northwest of Jakarta Indonesia, 2021 On 9 January 2021, a Boeing 737-500 was climbing though 10,700 feet less than five minutes after departing Jakarta in daylight when it began to descend at an increasing rate from which no recovery occurred and 23 seconds later was destroyed by sea surface impact killing all 62 occupants. The Investigation concluded that the departure from controlled flight was unintentional and the result of the pilots’ inattention to their primary flight instruments when, during a turn with the autopilot engaged, an autothrottle malfunction created apparently unrecognised thrust asymmetry which culminated in a wing drop and a consequent  loss of control.

B735, en-route, SE of Kushimoto Wakayama Japan, 2006 On 5 July 2006, during daytime, a Boeing 737-500, operated by Air Nippon Co., Ltd. took off from Fukuoka Airport as All Nippon Airways scheduled flight 2142. At about 08:10, while flying at 37,000 ft approximately 60 nm southeast of Kushimoto VORTAC, a cabin depressurization warning was displayed and the oxygen masks in the cabin were automatically deployed. The aircraft made an emergency descent and, at 09:09, landed on Chubu International Airport.

B735, Jos Nigeria, 2010 On 24 August 2010, a Boeing 737-500 made an uncontrolled touchdown on a wet runway at Jos in daylight after the approach was continued despite not being stabilised. A lateral runway excursion onto the grass occurred before the aircraft regained the runway centreline and stopped two-thirds of the way along the 3000 metre-long runway. Substantial damage was caused to the aircraft but none of the occupants were injured. The aircraft commander was the Operator's 737 Fleet Captain and the Investigation concluded that the length of time he had been on duty had led to fatigue which had impaired his performance.

B735, Newark NJ USA, 2006 On 21 August 2006, a Boeing 737-500 suffered a nose landing gear collapse during towing at the Newark Liberty International Airport. A technical crew was repositioning the aircraft in visual meteorological conditions during the occurrence. No persons were injured and minor aircraft damage occurred.

B735, vicinity Billund Denmark, 1999 On 3rd December 1999, a Boeing 737-500 being operated by Maersk Air on a scheduled passenger flight from Birmingham to Copenhagen made a successful diversion to Billund in conditions of poor weather across the whole of the destination area after a go around at the intended destination but but landed with less than Final Reserve Fuel.

B735, vicinity Kazan Russia, 2013 On 17 November 2013, the crew of a Boeing 737-500 failed to establish on the ILS at Kazan after not following the promulgated intermediate approach track due to late awareness of LNAV map shift. A go around was eventually initiated from the unstabilised approach but the crew appeared not to recognise that the autopilot used to fly the approach would automatically disconnect. Non-control followed by inappropriate control led to a high speed descent into terrain less than a minute after go around commencement. The Investigation found that the pilots had not received appropriate training for all-engine go arounds or upset recovery.

B735, vicinity London Heathrow UK, 2007 On 7 June 2007, a Boeing 737-500 operated by LOT Polish Airlines, after daylight takeoff from London Heathrow Airport lost most of the information displayed on Electronic Flight Instrument System (EFIS). The information in both Electronic Attitude Director Indicator (EADI) and Electronic Horizontal Situation Indicators (EHSI) disappeared because the flight crew inadvertently mismanaged the Flight Management System (FMS). Subsequently the crew had difficulties both in maintaining the aircraft control manually using the mechanical standby instruments and communicating adequately with ATC due to insufficient language proficiency. Although an emergency situation was not declared, the ATC realized the seriousness of the circumstances and provided discrete frequency and a safe return after 27 minutes of flight was achieved.

B735, vicinity Madrid Barajas Spain, 2019 On 5 April 2019, a Boeing 737-500 crew declared an emergency shortly after departing Madrid Barajas after problems maintaining normal lateral, vertical or airspeed control of their aircraft in IMC. After two failed attempts at ILS approaches in unexceptional weather conditions, the flight was successfully landed at a nearby military airbase. The Investigation found that a malfunction which probably prevented use of the Captain’s autopilot found before departure was not documented until after the flight but could not find a technical explanation for inability to control the aircraft manually given that dispatch without either autopilot working is permitted.

B735, vicinity Perm Russian Federation, 2008 On September 13 2008, at night and in good visual conditions*, a Boeing 737-500 operated by Aeroflot-Nord executed an unstabilised approach to Runway 21 at Bolshoye Savino Airport (Perm) which subsequently resulted in loss of control and terrain impact.

B735, vicinity Port Harcourt Nigeria, 2019 On 3 January 2019, a Boeing 737-500 en-route to Port Harcourt experienced signs of intermittent distress to an engine which subsequently failed during final approach there. After a mismanaged initial response before and after a go around, the failed engine was eventually shut down. After a delay of about 20 minutes, an attempted second approach was discontinued when it could not be stabilised. A third approach was then successfully completed. The engine was damaged beyond economic repair and the Investigation found that the operator had been aware of the intermittent malfunction of both engines over several months but ignored it.

B735/B733, Dallas-Fort Worth TX USA, 2001 On 16 August 2001, a Continental Boeing 737-500 which had just landed on runway 18R at Dallas-Fort-Worth crossed runway 18L in daylight in front of a Delta Boeing 737-300 which had originally been believed to be holding position but was then seen to be taking off from the same runway. The Delta aircraft rotated early and sharply to overfly the crossing aircraft and suffered a tail strike in doing so. Clearance was estimated to have been about 100 feet. Both aircraft were being operated in accordance with valid ATC clearances issued by the same controller.

B736, Montréal QC Canada, 2015 On 5 June 2015, a Boeing 737-600 landed long on a wet runway at Montréal and the crew then misjudged their intentionally-delayed deceleration because of an instruction to clear the relatively long runway at its far end and were then unable to avoid an overrun. The Investigation concluded that use of available deceleration devices had been inappropriate and that deceleration as quickly as possible to normal taxi speed before maintaining this to the intended runway exit was a universally preferable strategy. It was concluded that viscous hydroplaning had probably reduced the effectiveness of maximum braking as the runway end approached.

B737 / A320, Los Angeles CA USA, 2007 On 16 August 2007, a Westjet Boeing 737-700 which had just landed began to cross a runway in normal daylight visibility from which an Airbus A320 was taking off because the crew had received a clearance to do so after an ambiguous position report given following a non-instructed frequency change. When the other aircraft was seen, the 737 was stopped partly on the runway and the A320 passed close by at high speed with an 11 metre clearance. The AMASS activated, but not until it was too late to inform a useful controller response.

B737 / A332, Seatle-Tacoma WA USA, 2008 On 2 July 2008, an Air Tran Airways B737-700 which had just landed at night on runway 34C at Sea-Tac failed to hold clear of runway 34R during taxi as instructed and passed almost directly underneath a North West Airlines A330-200 which had just become airborne from Runway 32R. The Investigation found that the 737 crew had been unaware of their incursion and that the alert provided by ASDE-X had not provided an opportunity for ATC to usefully intervene to stop prevent the potential conflict

B737 / B737, vicinity Geneva Switzerland, 2006 On 11 May 2006, B737-700 taking off from Geneva came into close proximity with a Boeing Business Jet (BBJ) on a non revenue positioning flight which had commenced a go around from the same runway following an unstabilised approach. The Investigation attributed the conflict to the decision of ATC to give take off clearance to the departing aircraft when the approach of the inbound aircraft could have been seen as highly likely to result is a go around which would lead to proximity with the slower departing aircraft.

B737 / B738, vicinity Amsterdam Netherlands, 2018 On 29 March 2018, a Boeing 737-700 commenced a late go-around from landing at Amsterdam on a runway with an extended centreline which passed over another runway from which a Boeing 737-800 had already been cleared for takeoff. An attempt by the controller responsible for both aircraft to stop the departing aircraft failed because the wrong callsign was used, so low level divergent turns were given to both aircraft and 0.5nm lateral and 300 feet vertical separation was achieved. The Investigation concluded that the ATC procedure involved was potentially hazardous and made a safety recommendation that it should be withdrawn.

B737 / F100, vicinity Geneva Switzerland, 2006 On 29 December 2006, Geneva ATC saw the potential for runway 23 conflict between a departing 737 and an inbound F100 and instructed them to respectively reject take off and go around respectively. Although still at a relatively slow speed, the 737 continued its take off and subsequently lost separation in night IMC against the F100. The Investigation noted that take off clearance for the 737 had been delayed by a slow post-landing runway clearance by a business jet and that the 737 had not begun take off after clearance to do so until instructed to do so immediately.

B737 en-route, Glen Innes NSW Australia, 2007 On 17 November 2007 a Boeing 737-700 made an emergency descent after the air conditioning and pressurisation system failed in the climb out of Coolangatta at FL318 due to loss of all bleed air. A diversion to Brisbane followed. The Investigation found that the first bleed supply had failed at low speed on take off but that continued take off had been continued contrary to SOP. It was also found that the actions taken by the crew in response to the fault after completing the take off had also been also contrary to those prescribed.

B737, Amsterdam Netherlands, 2003 n 22 December 2003, a Boeing 737-700 being operated by UK Operator Easyjet on a scheduled passenger flight from Amsterdam to London Gatwick was taxiing for departure at night in normal visibility and took a different route to that instructed by ATC. The alternative route was, unknown to the flight crew, covered with ice and as a consequence, an attempt to maintain directional control during a turn was unsuccessful and the aircraft left wing collided with a lamp-post. The collision seriously damaged the aircraft and the lamp post. One passenger sustained slight injuries because of the impact. The diagram below taken from the official investigation report shows the area where the collision occurred.

B737, Burbank CA USA, 2018 On 6 December 2018, a Boeing 737-700 overran the 1,770 metre-long landing runway at destination by 45 metres after entering the EMAS. Normal visibility prevailed but heavy rain was falling and a 10 knot tailwind component existed. The event was attributed to the pilots’ continuation bias in the face of deteriorating conditions and a late touchdown on the relatively short runway. A lack of guidance from the operator on the need for pilots to re-assess the validity of landing data routinely obtained at the top of descent was identified.

B737, Chicago Midway IL, USA 2011 On 26 April 2011 a Southwest Boeing 737-700 was assessed as likely not to stop before the end of landing runway 13C at alternate Chicago Midway in daylight and was intentionally steered to the grass to the left of the runway near the end, despite the presence of a EMAS. The subsequent investigation determined that the poor deceleration was a direct consequence of a delay in the deployment of both speed brakes and thrust reverser. It was noted that the crew had failed to execute the  Before Landing Checklist which includes verification of speed brake arming.

B737, Chicago Midway USA, 2005 On 8 December 2005, a delay in deploying the thrust reversers after a Boeing 737-700 touchdown at night on the slippery surface of the 1176 metre-long runway at Chicago Midway with a significant tailwind component led to it running off the end, subsequently departing the airport perimeter and hitting a car before coming to a stop. The Investigation concluded that pilots lack of familiarity with the autobrake system on the new 737 variant had distracted them from promptly deploying the reversers and that inadequate pilot training provision and the ATC failure to provide adequate braking action information had contributed.

B737, en-route, northwest of Philadelphia PA USA, 2018 On 17 April 2018, sudden uncontained left engine failure occurred to a CFM56-7B powered Boeing 737-700 when climbing through approximately FL320. Consequent damage included a broken cabin window causing rapid decompression and a passenger fatality. Diversion to Philadelphia without further significant event then followed. A single fan blade was found to have failed due to undetected fatigue. The Investigation noted that the full consequences of blade failure had not been identified during engine / airframe type certification nor fully recognised during investigation of an identical blade failure event in 2016 which had occurred to another of the same operator s 737-700s.

B737, en-route, west southwest of Pensacola FL USA, 2016 On 27 August 2016, debris from sudden uncontained failure of the left CFM56-7B engine of a Boeing 737-700 climbing through approximately FL 310 west southwest of Pensacola in day VMC penetrated the fuselage barrel and caused a rapid depressurisation. An emergency descent and a diversion to Pensacola followed without further event. The Investigation found that collateral damage had followed low-cycle fatigue cracking of a single fan blade due to a previously unrecognised weakness in the design of this on-condition component which, because it had not been detected during the engine certification process, meant its consequences “could not have been predicted”.

B737, Fort Nelson BC Canada, 2012 On 9 January 2012, an Enerjet Boeing 737-700 overran the landing runway 03 at Fort Nelson by approximately 70 metres after the newly promoted Captain continued an unstabilised approach to a mis-managed late-touchdown landing. The subsequent Investigation attributed the accident to poor crew performance in the presence of a fatigued aircraft commander.

B737, Gran Canaria Spain, 2016 On 7 January 2016, a Boeing 737-700 was inadvertently cleared by ATC to take off on a closed runway. The take-off was commenced with a vehicle visible ahead at the runway edge. When ATC realised the situation, a 'stop' instruction was issued and the aircraft did so after travelling approximately 740 metres. Investigation attributed the controller error to lost situational awareness. It also noted prior pilot and controller awareness that the runway used was closed and that the pilots had, on the basis of the take-off clearance crossed a lit red stop bar to enter the runway without explicit permission.

B737, manoeuvring, west of Norwich UK 2009 On 12 January 2009, the flight crew of an Easyjet Boeing 737-700 on an airworthiness function flight out of Southend lost control of the aircraft during a planned system test. Controlled flight was only regained after an altitude loss of over 9000 ft, during which various exceedences of the AFM Flight Envelope occurred. The subsequent investigation found that the Aircraft Operators procedures for such flights were systemically flawed.

B737, Mildura VIC Australia, 2013 On 18 June 2013, a Boeing 737-800 crew en route to Adelaide learned that un-forecast below-minima weather had developed there and decided to divert to their designated alternate, Mildura, approximately 220nm away where both the weather report and forecast were much better. However, on arrival at Mildura, an un-forecast rapid deterioration to thick fog had occurred with insufficient fuel to divert elsewhere. The only available approach was flown to a successful landing achieved after exceeding the minimum altitude by 240 feet to gain sight of the runway. An observation immediately afterwards gave visibility 900 metres in fog with cloudbase 100 feet.

B737, New York La Guardia USA, 2013 On 22 July 2013 the Captain of a Boeing 737-700 failed to go around when the aircraft was not stabilised on final approach at La Guardia and then took control from the First Officer three seconds before touchdown and made a very hard nose first touchdown which substantially damaged the aircraft. The Investigation concluded that the accident had been a consequence of the continued approach and the attempt to recover with a very late transfer of control instead of a go around as prescribed by the Operator. The aircraft was substantially damaged.

B737, New York La Guardia USA, 2016 On 27 October 2016, a Boeing 737-700 crew made a late touchdown on the runway at La Guardia and did not then stop before reaching the end of the runway and entered - and exited the side of - the EMAS before stopping. The Investigation concluded that the overrun was the consequence of a failure to go around when this was clearly necessary after a mishandled touchdown and that the Captain's lack of command authority and a lack of appropriate crew training provided by the Operator to support flight crew decision making had contributed to the failure to go around.

B737, Singapore Seletar, 2017 On 16 November 2017, a Boeing 737-700 departing Singapore Seletar was observed by ATC to only become airborne very near the end of the runway and to then climb only very slowly. Ten approach lights were subsequently found to have been impact-damaged by contact with the aircraft. The Investigation found that after the crew had failed to follow procedures requiring them to validate the FMC recalculation of modified takeoff performance data against independent calculations made on their EFBs, takeoff was made with reduced thrust instead of the full thrust required. The modification made was also found not to have been required.

B737, Southend UK, 2010 On 21 Nov 2010, a Boeing 737-700 being operated by Arik Air on a non revenue positioning flight from Southend to Lagos with only the two pilots on board carried out a successful take off in daylight and normal ground visibility from runway 06 but became airborne only just before the end of the runway.

B737, vicinity Branson MO USA, 2014 On 12 January 2014, a Boeing 737-700 making a night visual approach to Branson advised 'field in sight' approximately 20 miles out and was transferred to TWR and given landing clearance at approximately 6,000 feet. However, the crew had misidentified the airport and subsequently landed on a similarly-orientated runway at a different airport. The Investigation found that required flight crew procedures for such an approach had not been followed and also that applicable ATC procedures for approval of visual approaches by IFR flights were conducive to pilot error in the event that airports were located in close proximity.

B737/C212 en-route/manoeuvring, near Richmond NSW Australia, 2011 On 5 November 2011, ATC cleared a Virgin Australia Boeing 737-700 to climb without speed restriction through an active parachute Drop Zone contrary to prevailing ATC procedures. As a result, prescribed separation from the drop zone was not maintained, but an avoiding action turn initiated by the 737 crew in VMC upon recognising the conflict eliminated any actual risk of collision with either the drop aircraft or its already-departed free-fall parachutists. The incident was attributed to a combination of inadequate controller training and inadequate ATC operational procedures.

B737/LJ45, Chicago Midway, USA 2011 On 1 December 2011 a Southwest Boeing 737-700 was cleared to taxi in after landing on a route which included crossing another active runway before contacting GND and the controller who had issued that clearance then inadvertently issued a take off clearance to a Gama Charters Learjet 45 for the runway to be crossed. One of the 737 pilots saw the approaching Learjet and warned the PF to stop as the runway crossing was about to begin. The departing aircraft then overflew the stationary 737 by 62 feet after rotating shortly before the crossing point without seeing it.

B738 / A319, Dublin Ireland, 2010 On 16 October 2010, in day VMC, a Boeing 737-800 being operated by Turkish Airlines on a passenger flight from Dublin to Istanbul entered runway 28 at Dublin whilst an Airbus A319 being operated by Germanwings on a scheduled passenger flight from Koln to Dublin was about 0.5nm from touchdown on the same runway. The Airbus immediately initiated a missed approach from approximately 200 ft aal simultaneously with an ATC call to do so.

B738 / A320, Edinburgh UK, 2018 On 13 August 2018, a Boeing 737-800 arriving at Edinburgh came to within 875 metres of an Airbus A320 departing from the same runway. Landing clearance was given one minute prior to touchdown which occurred when the departing aircraft was passing 60 feet aal and both aircraft were over the runway surface at the same time which constituted a runway incursion under local procedures. The Investigation found that the TWR position had been occupied by a trainee controller who had not received sufficient support from their supervisor after failing to act appropriately to ensure that the prescribed separation was maintained.

B738 / AS25, en-route, near Frankfurt Hahn Germany, 2013 On 25 April 2013, the experienced pilot of an en-route motor glider which was not under power at the time and therefore not transponding observed a potentially conflicting aircraft in Class 'E' airspace near Frankfurt Hahn and commenced avoiding action. Although the glider was within their field of view, neither of the pilots of the other aircraft, a Boeing 737 in a descent, was aware of the proximity of the glider until it passed them on an almost parallel opposite-direction track 161 feet below them at a range of 350 metres as their aircraft was passing approximately 6,500 feet QNH.

B738 / AT46, Jakarta Halim Indonesia, 2016 On 4 April 2016, a Boeing 737-800 crew taking off in normal night visibility from Jakarta Halim were unable to avoid an ATR 42-600 under tow which had entered their runway after ambiguity in its clearance. Both aircraft sustained substantial damage and caught fire but all those involved escaped uninjured. The Investigation concluded that contributory to the accident had been failure to use a single runway occupancy frequency, towing of a poorly lit aircraft, the potential effect on pilot detection of an obstruction of embedded approach lighting ahead of the displaced landing threshold and issues affecting controller traffic monitoring effectiveness.

B738 / B738 / B752, Birmingham UK, 2020 On 8 September 2020, an airport maintenance team driving at night on the centreline of the active runway at Birmingham were unaware that an inadequately secured 2 metre-long ladder had fallen from their pickup truck. Three aircraft then landed in the following half hour narrowly missing the ladder before it was discovered and the runway closed. The Investigation found that a more suitable alternative vehicle was available and that the completely inadequate method used to secure the ladder in their vehicle had failed to restrain it when the vehicle accelerated after passing the aiming point markings in the touchdown zone.

B738 / B738, Dublin Ireland, 2014 On 7 October 2014, a locally-based Boeing 737-800 taxiing for departure from runway 34 at Dublin as cleared in normal night visibility collided with another 737-800 stationary in a queue awaiting departure from runway 28. Whilst accepting that pilots have sole responsible for collision avoidance, the Investigation found that relevant restrictions on taxi clearances were being routinely ignored by ATC. It also noted that visual judgement of wingtip clearance beyond 10 metres was problematic and that a subsequent very similar event at Dublin involving two 737-800s of the same Operator was the subject of a separate investigation.

B738 / B738, en-route, south of Écija Spain, 2019 On 16 July 2019, a Boeing 737-800 inbound to Malaga and another Boeing 738-800 inbound to Seville and under area radar control lost separation after the Malaga-bound aircraft was unexpectedly given radar headings to extend its destination track miles after early handover to a control  sector which it had not yet entered. With no time to achieve resolution, the two aircraft, both descending, came within 1.3 nm of each other at the same level. The Investigation attributed the conflict to an overly-permissive Letter of Agreement between Seville Centre and Malaga Approach and recommended that it be revised to improve risk management.

B738 / B738, Malaga Spain, 2019 On 11 September 2019, a Boeing 737-800 landed at night on Runway 13 at Malaga only 520 metres behind a departing Boeing 737-800 which was about to become airborne from the same runway. The Investigation noted the relatively low level of aircraft movements at the time, that both aircraft had complied with their respective clearances and that the landing aircraft crew had judged it safer to land than to commence a late go around. The conflict was attributed to non-compliance with the regulatory separation minima and deficient planning and decision making by the controller.

B738 / B738, Perth Australia, 2018 On 28 April 2018, a Boeing 737-800 exited the landing runway at Perth and without clearance crossed a lit red stop bar protecting the other active runway as another 737 was accelerating for takeoff. This aircraft was instructed to stop due to a runway incursion ahead and passed 15 metres clear of the incursion aircraft which by then had also stopped. The Investigation concluded that, after failing to refer to the aerodrome chart, the Captain had mixed up two landing runway exits of which only one involved subsequently crossing the other active runway and decided the stop bar was inapplicable.

B738 / B738, Seville Spain, 2012 On 13 April 2012 a Boeing 737-800 being taxied off its parking stand for a night departure by the aircraft commander failed to follow the clearly and correctly marked taxi centrelines on the well-lit apron and instead took a short cut towards the taxiway centreline which resulted in the left winglet striking the left horizontal stabiliser and elevator of another Ryanair aircraft correctly parked on the adjacent stand causing damage which rendered both aircraft unfit for flight. The pilot involved was familiar with the airport and had gained almost all his flying experience on the accident aircraft type.

B738 / B738, Toronto Canada, 2018 On 5 January 2018, an out of service Boeing 737-800 was pushed back at night into collision with an in-service Boeing 737-800 waiting on the taxiway for a marshaller to arrive and direct it onto the adjacent terminal gate. The first aircraft s tail collided with the second aircraft s right wing and a fire started. The evacuation of the second aircraft was delayed by non-availability of cabin emergency lighting. The Investigation attributed the collision to failure of the apron controller and pushback crew to follow documented procedures or take reasonable care to ensure that it was safe to begin the pushback.

B738 / B744, Los Angeles USA, 2004 On 19 August 2004, a Boeing 747-400 operated by Asiana Airlines, was given a landing clearance for runway 24L at Los Angeles (LAX). At the same time, a Boeing 737-800 operated by Southwest Airlines was given line up and wait instruction for the same runway. The B744 initiated a go-around as the crew spotted the B738 on the runway.

B738 / C172, en route, near Falsterbo Sweden, 2014 On 20 July 2014, the pilot of a VFR Cessna 172 became distracted and entered the Class 'C' controlled airspace of two successive TMAs without clearance. In the second one he was overtaken by a Boeing 738 inbound to Copenhagen with less than 90 metres separation. The 738 crew reported a late sighting of the 172 and seemingly assessed that avoiding action was unnecessary. Although the 172 had a Mode C-capable transponder, it was not transmitting altitude prior to the incident and the Investigation noted that this had invalidated preventive ATC and TCAS safety barriers and compromised flight safety.

B738 / CRJ1, New York La Guardia USA, 2007 On 5 July 2007, in daylight and good visibility, a Comair CRJ100 on an outbound scheduled service flight was cleared by a GND Controller to taxi across active runway 22 on which a Delta AL Boeing 737-800 also operating a scheduled service flight had already been cleared to land by the (TWR) local controller. The crossing to be made did not allow the CRJ100 crew to see up the runway towards the landing threshold until they had almost completed the crossing. When they did see the by then landed B738 coming towards them, they immediately increased thrust on the single operating engine to accelerate clear.

B738 / DV20, vicinity Reus Spain, 2019 On 12 May 2019, a Boeing 737-800 making its second procedural ILS approach to runway 25 at Reus came into conflict with an opposite direction light aircraft as the latter approached one of the designated VFR entry points having been instructed to remain well above the altitude which normally ensures separation of IFR and VFR traffic. The collision risk was resolved by TCAS RA promptly followed by the 737. The Investigation concluded that limiting the TWR radar display to the ATZ for controller training purposes had resulted in neither the trainee controller nor their supervisor being aware of the risk.

B738 / E110, Brasilia Brazil, 2018 On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a smaller aircraft which had just landed on the same runway and was ahead until it appeared in the landing lights with rotation imminent. After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway. The Investigation attributed the conflict primarily to controller use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.

B738 / E135, en-route, Mato Grosso Brazil, 2006 On 29 September 2006, a Boeing 737-800 level at FL370 collided with an opposite direction Embraer Legacy at the same level. Control of the 737 was lost and it crashed, killing all 154 occupants. The Legacy's crew kept control and successfully diverted to the nearest suitable airport. The Investigation found that ATC had not instructed the Legacy to descend to FL360 when the flight plan indicated this and soon afterwards, its crew had inadvertently switched off their transponder. After the consequent disappearance of altitude from all radar displays, ATC assumed but did not confirm the aircraft had descended.

B738 / F100, Geneva Switzerland, 2014 On 31 March 2014, a Geneva TWR controller believed it was possible to clear a light aircraft for an intersection take off ahead of a Fokker 100 already lining up on the same runway at full length and gave that clearance with a Boeing 737-800 6nm from touchdown on the same runway. Concluding that intervention was not necessary despite the activation of loss of separation alerts, the controller allowed the 737 to continue, issuing a landing clearance whilst the F100 was still on the runway. Sixteen seconds later, the 737 touched down three seconds after the F100 had become airborne.

B738 / Vehicle, Palma Spain, 2020 On 19 July 2020, a Boeing 737-800 was instructed to reject its night takeoff on runway 24R at Palma after the driver of an airport vehicle already on the same runway in accordance with its own clearance heard the takeoff clearance being issued to the 737 and advised the controller of his position. The Investigation found that the TWR controller involved had not adhered to relevant procedures set out in the applicable Operating Manual and the provisions of the Air Traffic Regulation in regard to the use of phraseology, active listening and surveillance of the airport manoeuvring area.

B738 vicinity Canberra Australia 2014 On 9 May 2014, the crew of a Boeing 737-800 found that rotation during take off required significantly more back pressure on the control column than would be expected. It was found that a party of 87 primary school children all seated together at the rear of the cabin had been checked in as adults so that the aircraft had been up to 5 tonnes lighter and with a significantly different trim requirement than the certified and accepted loadsheet stated. The error was attributed to the inadequate group check arrangements of the airline involved.

B738, Alicante Spain, 2013 On 27 March 2013, a Ryanair Boeing 737-800 was mis-handled during take off and a minor tailstrike occurred. The crew were slow to respond and continued an uninterrupted climb to FL220 before deciding to return to land and beginning the corresponding QRH drill. When the cabin pressurisation outflow valve was fully opened at FL130, the cabin depressurised almost instantly and the crew temporarily donned oxygen masks. The Investigation noted the absence of any caution on the altitude at which the QRH drill should be used but also noted clear guidance that the procedure should be actioned without delay.

B738, Alicante Spain, 2018 On 7 June 2018, a Boeing 737-800 operated by a non-Spanish speaking crew was given takeoff clearance at Alicante after the same supervised student controller had previously cleared two vehicles to begin a full-length opposite-direction runway inspection in Spanish. The controller error was only recognised when the vehicles were able to transmit that they were still on the runway, the aircraft crew being unaware of the conflict until then told to reject the takeoff. The maximum speed reached by the aircraft was 88 knots and minimum separation between the aircraft and the closest vehicle was never less than 1000 metres.

B738, Amsterdam Netherlands, 2018 On 10 June 2018, a Boeing 737-800 departing Amsterdam with line training in progress and a safety pilot assisting only became airborne just before the runway end. The Investigation found that the wrong reduced thrust takeoff performance data had been used without any of the pilots noticing and without full thrust being selected as the end of the runway approached. The operator was found to have had several similar events, not all of which had been reported. The implied absence at the operator of a meaningful safety culture and its ineffective flight operations safety oversight process were also noted. 

B738, Amsterdam Netherlands, 2019 On 6 September 2019, a Boeing 737-800 began a night takeoff at Amsterdam on a parallel taxiway instead of the runway. A high speed rejected takeoff followed only on ATC instructions. The locally based and experienced crew lost situational awareness and failed to distinguish taxiway from runway lighting or recognise that the taxiway used was only half the width of the nearby runway. It was concluded that an airport commitment to prioritise mitigation of the taxiway takeoff risk based on recommendations made after a previous such event had not led to any action after pushback collisions became a higher priority.

B738, Auckland New Zealand, 2013 On 7 June 2013, stabiliser trim control cable, pulley and drum damage were discovered on a Boeing 737-800 undergoing scheduled maintenance at Auckland. The Investigation found the damage to have been due to a rag which was found trapped in the forward cable drum windings and concluded that the integrity of the system which provided for stabiliser trim system manual control by pilots had been compromised over an extended period. The rag was traced to a specific Australian maintenance facility which was run by the Operator's parent company and which was the only user of the particular type of rag.

B738, Barcelona Spain, 2015 On 12 December 2015, whilst a Boeing 737-800 was beginning disembarkation of passengers via an air bridge which had just been attached on arrival at Barcelona, the bridge malfunctioned, raising the aircraft nose gear approximately 2 metres off the ground. The door attached to the bridge then failed and the aircraft dropped abruptly. Prompt cabin crew intervention prevented all but two minor injuries. The Investigation found that the occurrence had been made possible by the failure to recognise new functional risks created by a programme of partial renovation being carried out on the air bridges at the Terminal involved.

B738, Belfast International UK, 2017 On 21 July 2017, a Boeing 737-800 taking off from Belfast was only airborne near the runway end of the runway and then only climbed at a very shallow angle until additional thrust was eventually added. The Investigation found that the thrust set had been based on an incorrectly input surface temperature of -52°C, the expected top of climb temperature, instead of the actual surface temperature. Although inadequate acceleration had been detected before V1, the crew did not intervene. It was noted that neither the installed FMC software nor the EFBs in use were conducive to detection of the data input error.

B738, Birmingham UK, 2020 On 21 July 2020, a Boeing 737-800 flight crew identified significant discrepancies when comparing their Operational Flight Plan weights and passengers by category with those on the Loadsheet presented. After examining them and concluding that the differences were plausible based on past experience, the loadsheet figures were used for takeoff performance purposes with no adverse consequences detected. It was found that a system-wide IT upgrade issue had led to the generation of incorrect loadsheets and that ineffective communication and an initially ineffective response within the operator had delayed effective risk resolution although without any known flight safety-related consequences.

B738, Busan South Korea, 2019 On 7 September 2019, the crew of a Boeing 737-800 completed a circling approach to runway 18R by making their final approach to and a landing on runway 18L contrary to their clearance. The Investigation found that during the turn onto final approach, the Captain flying the approach had not appropriately balanced aircraft control by reference to flight instruments with the essential visual reference despite familiarity with both the aircraft and the procedure involved.It was concluded that the monitoring of runway alignment provided by the relatively low experienced first officer had been inadequate and was considered indicative of insufficient CRM between the two pilots.

B738, Calicut (Kozhikode) India, 2020 On 7 August 2020, a Boeing 737-800 making its second attempt to land at Calicut off a night ILS approach with a significant tailwind component became unstabilised and touched down approximately half way down the 2,700 metre-long wet table top runway and departed the end of it at 85 knots before continuing through the RESA and a fence and then dropping sharply onto a road. This caused the fuselage to separate into three pieces with 97 of the 190 occupants including both pilots being fatally or seriously injured and 34 others sustaining minor injuries. Significant fuel spillage occurred but there was no fire.

B738, Christchurch New Zealand, 2015 On 11 May 2015, a Boeing 737-800 crew making a night landing at Christchurch had to react quickly when braking action deteriorated and only just succeeded in preventing an overrun. The Investigation found that a damp rather than wet runway had been assumed despite recent rain and that the aircraft operator had recently changed their procedures so that a damp runway should be considered as dry rather than wet for runway performance purposes. The questionable determination of the crew that the runway was likely to be damp, not wet, was attributed to a relatively high workload prior to final approach.

B738, Darwin Australia, 2016 On 6 December 2016, a Boeing 737-800 approaching Darwin at night in the vicinity of thunderstorm activity suddenly encountered very heavy rain just before landing which degraded previously good visual reference. After drifting right of centreline just before and after touchdown, the right main gear left the runway for 400 metres before regaining. The landing and taxi-in was subsequently completed. The Investigation attributed the excursion to difficulty in discerning lateral drift during the landing flare to an abnormally wide runway with no centreline lighting in poor night visibility and noted similar previous outcomes had been consistently associated with this context.

B738, Delhi India, 2014 On 5 January 2014, a Boeing 737-800 operating a domestic flight into Dehli diverted to Jaipur due to destination visibility being below approach minima but had to break off the approach there when the aircraft ahead was substantially damaged during landing, blocking the only runway. There was just enough fuel to return to Dehli as a MAYDAY flight and successfully land below applicable minima and with minimal fuel remaining. The Investigation found that a different alternate with better weather conditions would have been more appropriate and that the aircraft operator had failed to provide sufficient ground-based support to the flight.

B738, Djalaluddin Indonesia, 2013 On 6 August 2013, a Boeing 737-800 encountered cows ahead on the runway after landing normally in daylight following an uneventful approach and was unable to avoid colliding with them at high speed and as a result departed the runway to the left. Parts of the airport perimeter fencing were found to have been either missing or inadequately maintained for a significant period prior to the accident despite the existence of an airport bird and animal hazard management plan. Corrective action was taken following the accident.

B738, Dubai UAE, 2013 On 6 December 2013, a Boeing 737-800 passenger aircraft was flown from Amman to Dubai out of revenue service with a quantity of 'live' boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance. As a result of the investigation, a previously unreported flight by the same operator in revenue service which had also carried live oxygen generators was disclosed.

B738, East Midlands UK, 2020 On 9 February 2020, a Boeing 737-800 rejected its takeoff from East Midlands from a speed above V1 after encountering windshear in limiting weather conditions and was brought to a stop with 600 metres of runway remaining. The Investigation found that the Captain had assigned the takeoff to his First Officer but had taken control after deciding that a rejected takeoff was appropriate even though unequivocal QRH guidance that high speed rejected takeoffs should not be made due to windshear existed. Boeing analysis found that successful outcomes during takeoff windshear events have historically been more likely when takeoff is continued.

B738, Eindhoven Netherlands, 2010 On 4 June 2010, a Boeing 737-800 rejected take off from above V1 at Eindhoven when the First Officer, who was PF  had the feeling that the aircraft was unsafe to fly after which the Captain selected the thrust reversers and the aircraft stopped 500m before the end of the 3000m runway. The Investigation found no evidence of an airworthiness fault or any relevant external atmospheric effects which would support the reported  feeling . It was also noted that no prior call had preceded the reject and that any reject decision above 80 KIAS should be made by the aircraft commander.

B738, Eindhoven Netherlands, 2012 On 11 October 2012, the crew of a Ryanair Boeing 737-800 did not change frequency to TWR when instructed to do so by GND whilst already backtracking the departure runway and then made a 180° turn and took off without clearance still on GND frequency. Whilst no actual loss of ground or airborne safety resulted, the Investigation found that when the Captain had queried the receipt of a take off clearance with the First Officer, he had received and accepted a hesitant confirmation. Crew non-compliance with related AIP ground manoeuvring restrictions replicated in their airport briefing was also noted.

B738, en-route, Aegean Sea, 2019 On 22 August 2019, the left engine of a Boeing 737-800 failed for unknown reasons soon after reaching planned cruise level of FL360 twenty minutes after departing Samos, Greece and two attempted relights during and after descent to FL240 were unsuccessful. Instead of diverting to the nearest suitable airport as required by applicable procedures, the management pilot in command did not declare single engine operation and completed the planned flight to Prague, declaring a PAN to ATC only on entering Czech airspace. The Investigation noted that engine failure was due to fuel starvation after failure of the engine fuel pump.

B738, en-route, Arabian Sea, 2010 On 26 May 2010, a Boeing 737-800 being operated by Air India Express on a passenger flight from Dubai UAE to Pune, India was in the cruise at night at FL370 near PARAR when a sudden high speed descent occurred without ATC clearance during which nearly 7000 feet of altitude was lost in a little over 30 seconds before recovery was made. The remainder of the flight was uneventful. Despite the abnormal pitch, pitch change and  g variation, none of the 113 occupants had been injured.

B738, en-route, Colorado Springs CO USA, 2006 B738 diversion into KCOS following in-flight fire. The fire started after a passenger's air purifier device caught fire whilst in use during the flight. The user received minor burns and the aircraft cabin sustained minor damage.

B738, en-route, east of Asahikawa Japan, 2010 On 26 October 2010, an All Nippon Boeing 737-800 was radar vectored towards mountainous terrain and simultaneously given descent clearance to an altitude which was 5000 feet below the applicable MVA whilst in IMC without full flight crew awareness. Two TAWS  PULL UP hard warnings occurred in quick succession as a result. The flight crew responses were as prescribed and the subsequent investigation found that the closest recorded proximity to terrain had been 655 feet. It was established that the controller had  forgotten about MVA.

B738, en-route, east southeast of Adelaide Australia, 2017 On 13 September 2017, the airspeed of a Boeing 737-800 unexpectedly increased during an intentionally high speed descent and the Captain’s overspeed prevention response, which followed his taking over control without following the applicable procedure, was inappropriate and led directly to cabin crew injuries, one of which was serious. The Investigation found that the speed increase had been the result of a sudden decrease in tailwind component associated with windshear and noted that despite moderate clear air turbulence being forecast for the area, this had not resulted in the seat belt signs being on or any consequent cabin crew briefing.

B738, en-route, near Cuneo northwest Italy, 2021 On 25 July 2021, a Boeing 737-800 which had previously been manoeuvring visually around storm cells over the Alps during the initial descent into Nice turned back on track believing the avoidance action was complete but was then unable to avoid penetrating a further cell during which severe turbulence caused a serious injury to one of the cabin crew and a lesser injury to another. Multiple aircraft in the area had been simultaneously requesting track deviations at the time with ATC displays not showing weather returns. In the absence of plans to introduce this, a corresponding safety recommendation was made.

B738, en-route, near Lugano Switzerland, 2012 On 4 April 2012, the cabin pressurisation controller (CPC) on a Boeing 737-800 failed during the climb passing FL305 and automatic transfer to the alternate CPC was followed by a loss of cabin pressure control and rapid depressurisation because it had been inadvertently installed with the shipping plug fitted. An emergency descent and diversion followed. The subsequent Investigation attributed the failure to remove the shipping plug to procedural human error and the poor visibility of the installed plug. It was also found that the pressurisation system ground test after CPC installation was not suitable to detect the error.

B738, en-route, near Sydney Australia 2018 On 12 July 2018, a Boeing 737-800 was climbing through FL135 soon after takeoff from Sydney with First Officer line training in progress when the cabin altitude warning horn sounded because both air conditioning packs had not been switched on. The Captain took control and descended the aircraft to FL100 until the situation had been normalised and the intended flight was completed. The Investigation noted that although both pilots were experienced in command on other aircraft types, both had limited time on the 737 and concluded that incorrect system configuration was consequent on procedures and checklists not being managed appropriately.

B738, en-route, near Toyama Japan, 2018 On 8 July 2018, a Boeing 737-800 discontinued three consecutive approaches at its intended destination Toyama because, despite unexceptional weather conditions, it was in each case, impossible to achieve or continue a stabilised approach within the operator s applicable criteria. Diversion to the designated alternate was then commenced with just sufficient fuel to reach it without using final reserve fuel. However, en-route the crew became concerned at their fuel status and ATC initially had difficulty receiving their emergency communications resulting in a MAYDAY declaration. An expedited routing then followed with a landing which just avoided the use of final reserve fuel.

B738, en-route, northeast of Lanzarote Canaries Spain, 2018 On 10 February 2018, soon after a Boeing 737-800 en-route to Fuerteventura had begun its cleared descent from FL370 to FL130, the controller changed the clearance limit to FL360 after noticing a previously overlooked potential loss of separation with traffic below at FL350. The attempt to level off as instructed resulted in a mismanaged manual intervention which led to an upset lasting about a minute during which a passenger carrying a small child fell and sustained serious injury. The significant delay in getting the injured passenger to hospital after landing led to systemic deficiencies in airport medical assistance being identified.

B738, en-route, south east of Marseilles France, 2011 On 6 July 2011 the First Officer of a Ryanair Boeing 737-800 was suddenly incapacitated during a passenger flight from Pisa to Las Palmas. The Captain declared a  medical emergency and identified the First Officer as the affected person before diverting uneventfully to Girona. The subsequent investigation focused particularly on the way the event was perceived as a specifically medical emergency rather than also being an operational emergency as well as on the operator procedures for the situation encountered.

B738, en-route, south south west of Brisbane Australia, 2013 On 25 February 2013, a Boeing 737-800 about to commence descent from FL390 began to climb. By the time the crew recognised the cause and began to correct the deviation - their unintended selection of a inappropriate mode - the cleared level had been exceeded by 900 feet. During the recovery, a deviation from track occurred because the crew believed the autopilot had been re-engaged when it had not. The Investigation noted the failure to detect either error until flight path deviation occurred and attributed this to non-compliance with various operator procedures related to checking and confirmation of crew actions.

B738, en-route, south west of Beirut Lebanon, 2010 On 25 January 2010, a Boeing 737-800 being operated by Ethiopian Airlines on a scheduled passenger flight from Beirut to Addis Ababa in night IMC disappeared from ATC radar soon after departure from Runway 21 and was subsequently found to have impacted the sea in an unintentional out of control condition some five miles south west of the airport less than five minutes after getting airborne Impact resulted in the destruction of the aircraft and the death of all 90 occupants.

B738, en-route, southern Austria, 2010 On 9 May 2010, Boeing 737-800 being operated by Swedish operator Viking Airlines on a public transport charter flight from Sharm el Sheikh, Egypt to Manchester UK and which had earlier suffered a malfunction which affected the level of redundancy in the aircraft pressurisation system, experienced a failure of the single air conditioning pack in use when over southern Austria and an emergency descent and en route diversion to Vienna were made. There were no injuries to any of the 196 occupants.

B738, en-route, southwest of Metz France, 2018 On 13 July 2018, a Boeing 737-800 cruising at FL370 at night experienced a sudden rapid depressurisation. An emergency descent to FL 090 followed but the cabin altitude was not manually controlled and after the cabin pressure had risen to that equivalent to 7000 feet below sea level, immediate equalisation of cabin and actual altitudes resulted in a second sudden depressurisation. Diversion to Frankfurt Hahn was completed without further event. The first depressurisation had resulted from a transient and rare pressure controller malfunction but passenger injuries were considered attributable to a complete absence of pressurisation control during the emergency descent.

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