|
分享即成长。大家好，欢迎关注阮工频道
前面的文章：这2个引气系统MEL项，你能理解吗？
提出了两个问题，很多人都有参与讨论和回答。不知道大家心中都有答案了吗？
下面先来看一个事故的调查报告吧，就与之前提到的引气保留有关哦。
这份报告的英文版可以在这里下载：
http://sistema.cenipa.aer.mil.br/cenipa/paginas/relatorios/rf/en/PRGGE_06ABR2018-IG.ING..pdf
简介SYNOPSIS
This is the Final Report of the 06APR2018 serious incident with the 737-8EH aircraft, registration PR-GGE. The serious incident was classified as “[SCF-NP] System/Component Failure or Malfunction Non-Powerplant / Unintentional/explosive decompression”. 这是2018年4月6日，737-8EH飞机注册号：PR-GGE严重事故的最终报告。归类为“系统/部件故障或故障非动力装置/意外的/爆炸性的释压”的严重事故。
Shortly after reaching flight level FL250 (25,000ft), the cabin altitude alert sounded, indicating that the atmospheric pressure inside the aircraft (cockpit and passenger cabin) had reached values compatible with 10,000ft altitude. 飞行高度达到FL250(25,000英尺)后不久，机舱高度警报响起，表明飞机(驾驶舱和客舱)内的大气压已达到与10,000英尺高度对应的值。
The pilots started an emergency descent to the FL100 (10,000ft). 飞行员开始紧急降落FL100(10000英尺)。
During the descent, the oxygen masks of the passenger cabin fell down automatically. 在下降过程中，客舱的氧气面罩自动脱落。
When reaching 10,000ft of altitude, the situation was normalized and the flight proceeded to the destination at FL090. 当飞行高度达到10000英尺时，情况恢复正常，飞机在FL090继续飞往目的地。
The landing was performed without additional abnormalities. 着陆过程中没有出现其他异常。
The aircraft had no damage. 飞机没有损伤。
All occupants left unharmed. 没有人员受伤。
An Accredited Representative of the National Transportation Safety Board (NTSB) - USA, (State where the aircraft was designed and manufactured) was designated for participation in the investigation. 美国国家运输安全委员会（NTSB）的授权代表（飞机设计和制造地）被指定参与调查。
人员资质这些都不是问题，主要看下飞机信息部分。
飞机信息Aircraft information
The aircraft, serial number 35824, was manufactured by the Boeing Company, in 2008 and it was registered in the TPR category, having flown 34,778 hours since its manufacture. 这架序号为35824的飞机是波音公司2008年制造的，注册在TPR类别，自制造以来飞行了34778小时。
The aircraft had valid Airworthiness Certificate (CA). 飞机的适航证书（CA）有效。
The technical maintenance registers were with their records updated. 技术维修记录在更新。
The last inspection of the aircraft, the "Check A" type, was carried out on 06APR2018 by the GOL Airlines S.A. maintenance organization, in Recife–PE, having flown 8 hours and 20 minutes after the inspection. 这架飞机的最后一次检查是“A检”，于2018年4月6日由位于Recife–PE的GOL Airlines 维修公司进行，检查结束后飞行了8小时20分钟。
The aircraft had two engines located under the wings and an Auxiliary Power Unit (APU) located in the rear (tail) section. 飞机在机翼下方有两个发动机，在尾部有一个辅助动力装置(APU)。
Some aircraft systems and components were duplicated and worked redundantly. For purposes of differentiation between these systems and components, the manufacturer identified those located on the left side of the aircraft with number "1" and those located on the right side with number "2". When a system or component did not have redundancy, it was not identified with a number, for example: engine 1 (left side); engine 2 (right side) and APU (without redundancy). 一些飞机系统和组件工作上有多套和冗余。为了区分这些系统和部件，制造商将位于飞机左侧的系统编号为“1”，将位于右侧的系统编号为“2”。当一个系统或组件没有冗余时，它不是用数字来标识的，例如:engine 1(左侧);发动机2(右侧)和APU(无冗余)。
One of those systems, which provided the conditions for the aircraft to fly at high altitudes, was the pressurization and air-conditioning system. 其中的一个系统是增压和空调系统，提供飞机在高空飞行的条件。
Cabin pressurization systems have been widely used by commercial aviation airplanes for years and mostly have similar operating logic. Through air bleeding from the engines, valves keep the interior of the aircraft pressurized, providing to the occupants an environment compatible with the human physiology throughout the flight. 机舱增压系统已被广泛应用于商业航空飞机多年，大多具有类似的操作逻辑。即从发动机引气，活门保持飞机内部的压力，为乘员提供一个在整个飞行过程中符合人类生理机能的环境。
However, when the system does not operate properly, the cabin is depressurized. Under these conditions, airplane occupants need to use oxygen masks to avoid problems arising from atmospheric pressure at high altitudes. 然而，当系统不能正常运行时，机舱就会减压。在这种情况下，飞机上的乘客需要使用氧气面罩，以避免在高海拔地区的大气压引起的问题。
In situations of cabin depressurization, the safety procedure to be adopted consists generally of using oxygen masks and performing descent to a safe altitude where the atmospheric pressure values are compatible with the respiratory system of the human being. 在机舱释压的情况下，通常采用的安全程序包括使用氧气面罩和下降到一个安全的高度，在这个高度上的气压值，人的呼吸系统能适应。
After reaching safety altitude, it is possible to complete the flight without the occupants of the aircraft having to use oxygen masks to breathe. Usually this safety altitude is about 10,000ft. 到达安全高度后，飞机上的乘客无需使用氧气面罩就可以完成飞行。通常这个安全高度是10000英尺。
The aircraft was equipped with a pressurization and air conditioning system that had two main objectives: 这架飞机配备了增压和空调系统，主要有两个目的：
-keep the air pressure inside the aircraft in values consistent with human physiology, even when the airplane was flying at high altitudes where the atmospheric pressure was too low; and 保持飞机内的气压与人体生理机能相符，即使飞机在高空飞行时，外界大气压力过低;和
-keep the ambient temperature comfortable for crew and passengers. 为机组人员和乘客保持舒适的环境温度
According to the 737 Flight Crew Operations Manual (FCOM), the pressurization and air conditioning system processed air bleeding from engines 1 and 2 and/or APU, through bleed valves called Bleed 1, Bleed 2 and APU Bleed, respectively. The Bleeds regulated the amount of bleeding air, as demanded by other aircraft systems. 根据737飞行人员操作手册(FCOM)，增压和空调系统处理发动机1和2和/或APU的空气引入，分别通过称为# 1、# 2和APU的引气活门。引气系统根据其他飞机系统的要求控制引气量。
The air bleeding from the engines and/or the APU was supplied at high temperature values and therefore needed to be cooled before being used to acclimatize and pressurize the cockpit and passenger cabin. This cooling was accomplished through two air- conditioning valves, each one related to a system, denominated Pack 1 and Pack 2. These Packs sent air inside the aircraft and the temperature was adjusted by the crew, between 18° C and 30° C. 从发动机和/或APU引出的空气是在高温下提供的，因此需要在使用前进行冷却，以满足给驾驶舱和客舱增压的要求。这种冷却是通过两个空调活门完成的，每个活门都与一个系统相关，分别命名为Pack 1和Pack 2。这些组件将空气送入飞机内部，机组人员可在18°C到30°C之间温度对进行调节。
When on the ground, the air conditioning system could also be supplied by an external air source (Ground Air Source), which supplied air directly to the packs. In that case, it was not necessary to bleed the engines or the APU to acclimatize the interior of the aircraft. 在地面上时，空调系统也可以由外部气源(地面空气源)提供，它直接向组件提供空气。在这种情况下，没有必要使用发动机或APU引气来调节飞机内部。
The interaction of the pilots with the system was accomplished through a pressurization control panel installed in the upper right part of the Overhead Panel, located in the ceiling of the cockpit. The pressurization control panel had switches for system operation, instruments for monitoring parameters and warning lights for abnormal situations. 飞行员与系统的交互是通过安装在座舱顶部右上角的增压控制面板完成的。增压控制面板有系统操作开关、参数监测仪表和异常情况警示灯。
Figure 1 - Diagram of the pressurization and air conditioning system. 图1-增压和空调系统图。
Figure 2 - OverheadPanel. The circles with number 2 indicate controls and indicators related tothe pressurization and air conditioning system 图2-顶板。带有数字2的圆圈表示与增压和空调系统相关的控制和指示灯
Figure 3 - Overhead Panel cutting with the pressurization and air conditioning system control panel indicators: 1 - pressure differential; 2 - cabin altitude; 3 - ramp up / down ratio; 4 - pressure in the pneumatic ducts; and 5 - Outflow valve position indicator. 图3-切割后的带增压和空调系统控制面板指示灯的顶板：1-压差；2-座舱高度；3-上升/下降率；4-气源管道中的压力；5-外流活门位置指示器。
Located above and to the left of the pressurization control panel, there was a double gauge that showed the cabin altitude and pressure differential (Figure 3 - instruments 1 and 2). The pressure differential was shown on a scale that considered the atmospheric pressure inside the cabin compared to the atmospheric pressure of the outside air (actual altitude of the aircraft). 位于增压控制面板的上方和左侧，有一个显示客舱高度和压差的双表（图3-仪表1和2）。压差显示在一个刻度上，该刻度将机舱内的大气压力与外部空气的大气压力(飞机的实际高度)进行比较。
Just below this manometer, there was a cabin climb rate gauge (Figure 3 - instrument 3). This instrument measures the variation of the atmospheric pressure inside the cabin, translating this variation in a scale of thousands of ft./min. 在这个压力计下面有一个座舱爬升速率表(图3 -仪表3)。这个仪表测量座舱内气压的变化，以千英尺/分钟的刻度来指示这种变化。
There was another pressure gauge indicating the pressure in the system ducts (instrument 4 of Figure 3). This instrument had two pointers identified with the letters "L" and "R" that allowed the monitoring of the pressure in each of the ducts that carried bleeding air to the Packs. If the pressure in one of the ducts was "zero," it would mean that the Pack on that side was not receiving bleeding air from any Bleed. 另有一个压力表指示系统管道内的压力(图3中的仪表4)。该仪表有两个指针，指针上标有字母“L”和“R”，用于监测每侧管道内的压力，这些管道将引出的空气输送到空调组件内。如果其中一个管道的压力为“零”，这就意味着那一边的管道没有从任何引气中得到引入的空气。
Above and to the right there was an Outflow valve position indicator (instrument 5 of Figure 3), which allowed to monitor when the valve was open, closed or in an intermediate position. 在上方右侧有一个外流活门位置指示器(图3中的仪表5)，它可以监视活门何时打开、关闭或处于中间位置。
In the open position, the valve allowed the air inside the cabin to be expelled, depressurizing the aircraft. On the other hand, when the valve closed, it kept the air confined inside the cabin. 在打开位置，活门允许机舱内的空气排出，降低机内的压力。另一方面，当活门关闭时，它把空气限制在舱内。
These openings and closures occurred automatically when the valve knob (in the lower right corner of Figure 3) was in the AUTO position. When the knob was placed in the MAN position, the Outflow opening and closing control was performed by the pilots using the switch located just below the position indicator. 当活门旋钮(图3右下角)处于自动位置时，活门会自动开和关。当旋钮置于人工位置时，驾驶员通过位于位置指示器下方的开关来控制外流活门的打开和关闭。
Each of the Bleeds (engine 1, engine 2 and APU) had an ON / OFF switch. The operating logic for each of the positions was as follows: 每个引气(发动机1、发动机2和APU)都有一个开关。每个位置的工作逻辑如下:
-ON：the valve remained open whenever the corresponding engine was in operation; and ON:当相应的发动机工作时，活门保持打开;和
-OFF：the valve was closed. OFF:活门关闭。
Each of the Packs (1 and 2) had an OFF / AUTO / HIGH switch. The operating logic for each of the positions was as follows: 每个组件(1和2)都有一个OFF / AUTO / HIGH开关。每个位置的工作逻辑如下:
-OFF：the Pack remained off; 关：组件保持关闭
-AUTO： 自动： -the Pack adjusted the airflow to low whenever both Packs were running； 当两个组件都在工作时，每个组件调节至低流量; -the Pack regulated the airflow to high whenever only one Pack was operating, provided that the aircraft was in flight and the flaps were retracted; and 如果只有一个组件工作，且襟翼收回，则将工作组件调节至高流量;和 -the Pack regulated the airflow to high when a Pack was being powered by the APU (Bleed from both engines to OFF). 当APU 为一个组件供气时（两台发动机引气电门关），调节到高流量。
-HIGH：the Pack regulated the airflow to high. When on the ground and powered by the APU in the HIGH position, this Pack provided the maximum airflow. 高:组件调节到高流量。在地面， APU 为组件供气时，PACK提供最大流量。
Between the two Packs switches, there was the Isolation Valve switch with three positions: AUTO; OPEN and CLOSE. The operating logic for each of the positions was as follows: 在两个组件开关之间，有一个三位的隔离活门开关:自动;打开和关闭。每个位置的工作逻辑如下:
-AUTO 自动 -the valve remained closed if the Bleeds 1 and 2 switches were in the ON position and the switches of both Packs were in AUTO or HIGH; and 如果引气1和引气2电门打开, 并且两个空调组件开关在自动（AUTO）或者高流量（HIGH），将关闭隔离活门 -the valve will open automatically if the switch of any Bleed or Pack is in the OFF position. 如果任一发动机引气或者空调组件电门在关（OFF）位，将自动打开隔离活门。
-OPEN:the valve remained open.打开隔离活门
-CLOSE:the valve remained closed.关闭隔离活门
In normal situations, the pressurization system operated in isolation between the sides, with Bleed 1 providing air bleeding from engine 1 to Pack 1 and, similarly, Bleed 2 supplying air bleeding from engine 2 to Pack 2. The isolation between the two sides was performed through the Isolation Valve. 在正常情况下，增压系统在每侧独立运行，引气1提供从1号发动机到1号PACK的引气，同样，引气2提供从2号发动机到2号PACK的引气。两边的隔离是通过隔离活门进行的。
In normal flight conditions, the Isolation Valve was set to the AUTO position, but under abnormal operating conditions of one of the Bleeds, for example, the Isolation Valve could be set to the OPEN position. In this position, the valve remained open and allowed a cross feed, allowing Bleed 2 to provide air bleeding for Pack 1, or allowing bleed 1 to provide air bleeding to pack 2. 在正常飞行条件下，隔离活门设置为自动位置，但在其中一个引气异常的操作条件下，例如，隔离活门可以设置为打开位置。在这种位置，活门保持开启，允许交叉供气，允许引气2为PACK1提供引气，或者允许引气1为PACK2提供引气。
APU Bleed was directly attached to Pack 1 and, via the Isolation Valve, was able to deliver air also for Pack 2, if needed. APU引气直接连接到Pack 1上，如果需要的话，通过隔离活门也可以为Pack 2提供引气。
According to the operation manuals, each Bleed valve of the engines should only feed one Pack at a time. In return, the APU Bleed could feed the two Packs simultaneously on the ground or a single Pack in flight. The APU Bleed operation was restricted to 17,000ft altitude, according to manuals. 根据操作手册，发动机的每个引气活门一次只能给一个PACK供气。作为回应，APU“引气”可以在地面上同时供给两个PACK，也可以在飞行中供给一个PACK。根据操作手册，APU引气操作被限制在17000英尺的高度。
It is important to note that with the Bleed of a certain engine running, this meant the bleeding of air from the high-pressure compressor to supply other systems of the aircraft. 需要注意的是，当某台发动机的引气处于正常工作状态时，这就意味着高压压气机的空气在为飞机的其他系统供气。。
This air bleeding reduced the power generation capacity for the flight. In normal flight situations, this deficit did not represent significant limitations. However, in situations where maximum power was required, such as a short runway take-off or overcoming obstacles in the flight path, such a limitation could be of relative importance. 这种空气引出降低了飞机发动机的可用功率。在正常飞行情况下，这不是重大限制。但是，在需要最大推力的情况下，例如短跑道起飞或飞越路线上的障碍，这种限制可能是相对重要的。
At the top center of the panel, there was the DUAL BLEED warning, which consisted of a warning light of the pressurization system that was intended to prevent a Pack from being fed by more than one Bleed. This light went on whenever: 在面板的顶部中央，有一个双引气警告，它由一个增压系统的警示灯组成，目的是防止一个组件被多个气源提供引气。下列条件下灯亮:
-the APU Bleed was in the ON position;APU引气打开 -the Isolation Valve was in OPEN; and隔离活门打开，并且 -the Bleed from engine 1 or Bleed from engine 2 is ON.发动机1或发动机2引气打开。
心理方面Psychological aspects
The commander had sixteen years of aviation experience and had been in the company for twelve years. He had completed flight simulator training for the last time in July 2017 and Line Operation Flight Training (LOFT) in January 2018. He was returning from a vacation and consequent distancing from the air activity. 机长有16年的飞行经验，已经在公司工作了12年。他于2017年7月完成了最后一次飞行模拟器训练，并于2018年1月完成了航线运行飞行训练(LOFT)。他刚度假回来，因此有段时间没有飞行。
Coworkers have described him as a willing, communicative, well liked and a highly respected person. 同事们都说他是一个乐于助人、善于沟通、受人喜欢、备受尊重的人。
The copilot had fifteen years of experience in aviation and was in the company for eleven years. He had completed flight simulator training for the last time in December 2017. 副驾驶有15年的飞行经验，在公司工作了11年。他最后一次完成飞行模拟器训练是在2017年12月。
The chief flight attendant had been working for the company for thirteen years and had her operational training updated, as well as the other crewmembers. 乘务长已经在这家公司工作了13年，她和其他空乘人员都接受了最新的操作培训。
It was the first flight of the day for all components of that crew. 这是全体机组人员当天中第一次飞行。
Upon taking over the aircraft, the commander of this flight was warned by his predecessor about a problem related to the Bleeds. As a result of the report received, the commander who took the plane decided to request the presence of the company's maintenance team next to the aircraft. 在接手飞机时，前一班机组提醒这次飞行的机长有引气方面的问题。根据收到的报告，驾驶飞机的机长决定要求该公司的维修团队在飞机旁边待命。
The maintenance section made the necessary interventions and released the plane for the flight. However, during the beginning of the taxi for takeoff, the crew noticed the DUAL BLEED light on, which represented a problem related to the pressurizing system. As a result, they returned to the apron and requested, once again, the presence of the company's maintenance team. 维修部门进行了必要的检查后放行了飞机。然而，在开始滑行准备起飞时，机组人员注意到双引气灯亮着，这代表一个与增压系统有关的问题。结果，机组滑回到停机坪，再次要求公司的维修团队到场。
The maintenance technicians evaluated the condition presented and decided to dispatch the aircraft with the Bleed 1 valve closed and locked, rendering it inoperative. This action imposed some operational restrictions on the aircraft but did not impede the flight, in accordance with the manufacturer's manuals and current legislation. 维修技术人员评估了目前的情况，并决定关闭和锁定1发引气活门，使其无法工作。根据制造商手册和现行规定，这一措施对飞机施加了一些操作限制，但并不妨碍飞行。
The return of the aircraft to the apron and the performed maintenance actions had, consequently, a delay in the take-off time. The intervention time of the maintenance team lasted approximately one hour and ten minutes. After the completion of the work, it was decided to continue the flight, once the operational limitations imposed by the fact that Bleed 1 was inoperative allowed. 飞机滑回机坪和执行维护操作,因此,推迟了起飞时间。维修团队的工作时间持续了大约一小时十分钟。工作完成，1发引气失效保留带来操作限制被允许后，决定继续执行航班。
During the time it remained on the ground, the temperature inside the aircraft went up considerably. This created an environment of uncomfortable heat for crewmembers and passengers, who remained on board during the maintenance team's interventions. 在飞机停留在地面上的时间里，机舱内部的温度大幅上升。这为机组人员和乘客创造了一个不舒服的高温环境，他们在维修小组工作期间留在了飞机上。
According to crewmembers' perception, the flight delay, the maintenance management, and significant temperature increase inside the cabin, coupled with the implicit organizational pressure that exists for the flights punctuality in commercial aviation, created a work overload. 根据机组人员的看法，航班延误、维修管理、客舱内明显的温度升高，再加上商业航空中航班准时的隐性组织压力，造成了工作超负荷。
The operational restrictions resulting from the maintenance action required a specific configuration of the aircraft pressurization system. The operation with Bleed 1 disabled required pilots to adopt a procedure that was not usual for them. 维修行动造成的操作限制要求飞机增压系统要在特定构型。在Bleed 1被禁用的情况下，飞行员需要采用一个对他们来说并不常见的程序。
During an interview, both said it was an uncommon fact and reported not remembering when it would have been the last time they had to perform a takeoff in those conditions, with that procedure. Despite this, the pilots said they did not feel any discomfort when they faced the situation presented. 在接受采访时，两人都表示这是一个不常见的情况，并表示自己不记得上一次在这种情况下进行起飞是在什么时候。尽管如此，飞行员们说，他们面对当前的情况并没有感到任何不妥。
Still with the aircraft on the ground, the pilots consulted the operation manuals and made a briefing of the procedures that they would execute before, during and after the takeoff. Such procedures were intended to configure the pressurization system correctly for each of these phases. 飞机仍在地面上时，飞行员查阅了操作手册，简要介绍了起飞前、起飞期间和起飞后的操作程序。这些程序的目的是为每一个阶段正确配置增压系统。
After the take-off, the commander consulted the manuals again before reconfiguring the pressurization system in the operational condition of inoperative Bleed 1. This consultation was carried out under the cabin light that, according to the commander himself, did not provide a good luminosity (the flight happened at night). 起飞后，在引气1失效的情况下，重新配置增压系统之前，机长再次查阅了手册。这次协商是在客舱的灯光下进行的，根据机长自己的说法，灯光不是很亮(飞行是在夜间进行的)。
The commander read the specific item in the manual aloud, sharing the directions with the copilot. 机长大声念出手册中的具体条款，与副驾驶分享指令。
The copilot sometimes asked the commander about the procedures adopted and the correct operation of the pressurization system. The commander confirmed the information he had passed on and verbalized, on more than one occasion, that the system was working properly. On these occasions, the copilot agreed with the arguments presented by the commander. 副驾驶时不时向机长询问所采用的程序和增压系统的正确操作。指挥官证实了他所传递的信息，并不止一次地说，该系统工作正常。在这些情况下，副驾驶同意机长提出的论点。
The climb proceeded to the FL250 and, shortly after leveling, the cabin altitude alert sounded. The crew then made a descent to FL090 and, as they crossed the FL150, the passengers' oxygen masks fell down automatically. 接着爬升到FL250，在平飞后不久，机舱高度警报响起。机组人员随即决定下降到FL090，当他们下降到FL150时，旅客的氧气面罩自动掉了下来。
When leveling on FL090, they found that the cabin temperature had not been altered, and the chief flight attendant told the cabin crew that the oxygen masks had fallen from their compartments. 当到达FL090时，他们发现机舱内的温度并没有改变，乘务长告诉机组人员氧气面罩已经从客舱里掉了下来。
According to the report, the crew did not feel physiological symptoms of depressurization nor were there complaints of malaise on the part of the passengers. 根据报告，机组人员没有感到生理上的减压症状，乘客也没有感到不适。
The crew decided not to declare emergency because they found that they would quickly reach the safety level (FL100). 机组人员决定不宣布紧急状态，因为他们知道很快就会达到安全高度(FL100)。
In order to understand the event that had just occurred, the commander consulted the aircraft manual again and realized that he had confused the item relating to the operation of the aircraft with disabled Bleed 1. 为了弄清楚刚刚发生的事情，机长又看了一遍飞机手册，意识到他把与飞机操作有关的条目和失效的“引气1”搞混了。
The pilots decided, together with the company, not to return to the airport of origin, for administrative and operational reasons. The flight proceeded to the destination airport on FL090. 由于行政和操作方面的原因，飞行员和公司一起决定不返回始发机场。航班在FL090上飞往目的地机场。
All crewmembers reported being rested for the flight and there were no communication and / or relationship barriers in the cabin environment. 所有机组人员都报告说，他们在飞行途前休息了，机舱内没有任何沟通和/或关系障碍。
现场存留方面Survival aspects
事件发生后，调查人员发现客舱内的氧气面罩并没有全部从舱室掉落，以供乘客使用。厕所面罩“A”没有掉下来，在1R站位储藏盒内，面罩缠结在一起，无法条件。第12排D、E和F座上，面罩门没有打开。
与飞机氧气面罩操作有关的预防性维修任务不需要检查所有面罩。根据波音公司(Boeing)的维修计划，每隔12,000小时就会执行35-090-00 -01 / 02任务，制造商只要求检查10%的乘客面罩。
组织和管理制Organizational and management information
The airline had a robust and well-structured physical and functional structure. The Operations, Flight Schedule and Safety sectors worked in a coordinated and integrated manner, following defined criteria and in accordance with the legislation in force at the time. 航空公司部门结构稳健，职能良好。运行、飞行计划和安全部门以协调和综合的方式工作，遵循规定的标准并符合当时的法规。
Regarding the operational training, the crew considered the company rigorous as to the fulfillment of the program. 在进行运行培训时，机组人员认为公司对项目的执行十分严格。
Although they had their operational trainings up to date, the technical crew (pilots) did not remember when they had performed training of the situation they experienced. They usually trained rapid descent and emergency descent. 尽管他们进行了最新的操作训练，但飞行员不记得他们什么时候对此次经历的情况进行了训练。他们通常训练快速下降和紧急下降。
The flight schedule was considered adequate, with an average of eleven monthly departures per crewmember. The company had a good work environment, which allowed, consequently, a good relationship among colleagues. 航班计划被认为是适当的，每个机组成员每月平均有11次飞行。这家公司有良好的工作环境，因此同事之间的关系也很好。
操作信息Operational information
The aircraft was within the weight and balance limits specified by the manufacturer. 飞机的重量和平衡在制造商的规定范围内。
The aircraft took off from SBRJ to SBCF to conduct a regular passenger flight leg. 飞机执行从SBRJ到SBCF的定期客运航班。
It was the first stage of the day for that crew, with takeoff and landing scheduled for the nighttime. 这是机组人员当天的第一班飞行，夜间起飞和降落。
The takeoff straight line of SBRJ's 20L runway had natural obstacles known to pilots and required minimal aircraft performance to be overcome. For this reason, the use of engine Bleeds during the take-off from the SBRJ was conditioned to the performance of the aircraft, considering factors such as: weight, temperature, atmospheric pressure and wind prevailing at the aerodrome. 飞行员知道SBRJ的20L跑道起飞直线路线有自然障碍物，需要最低限度的飞机性能才能克服。因此，在从SBRJ起飞时发动机引气的使用是根据飞机的性能进行调整的，要考虑到以下因素:重量、温度、大气压和机场当前的风。
Depending on the scenario presented, it could be recommended, or even necessary, that the take-off was performed with the Bleeds of the engines in the OFF position and the Bleed of the APU in ON, in order not to bleed air from the engines and thus to use all the power available for take-off. In this condition, the APU Bleed would provide air for the Packs and pressurization would normally occur. 根据所面对的情况，可以建议，甚至有必要将发动机引气关闭、APU引气打开的情况下进行起飞，以避免发动机引气，从而使全部推力用来起飞。在这种情况下，APU引气将提供空气和空调增压。
In this flight, the pilots were informed that the aircraft would be dispatched in accordance with item 36-5-2 of the Minimum Equipment List (MEL). 在这次飞行中，飞行员被告知飞机将按照最低设备清单(MEL)的36-5-2项的规定放行。
According to the manufacturer's manuals, the aircraft had an altitude limitation of 25,000ft, when operating with only a Bleed of the engines running. In view of this, the flight planning was changed, so that the flight was performed in the FL250. 根据制造商的操作手册，飞机的飞行高度限制在25000英尺，只有一台发动机提供引气的情况下运行。由于这一点，改变了飞行计划，所以飞行是在FL250上进行的。
Sixteen minutes before takeoff, while the maintenance technicians completed the procedures to disable Bleed 1, the pilots held a briefing on the configuration of the pressurization panel in Bleed 1 inoperative condition. This dialogue was recorded by the CVR. 起飞前16分钟，维修技术人员完成了“左发引气”失效的程序，飞行员就“左发引气”失效状态下的增压面板配置进行了简报。这段对话被CVR记录了下来。
在本简报中，飞行员通过阅读图4所示36-5-2项的操作程序，步骤3，字母“B”(用于左发动机引气不工作)，正确遵循了MEL。两名飞行员口头上同意，根据MEL程序，引气2将用于为1号PACK提供引气，因此，在巡航高度飞行期间，隔离活门应保持开启状态。
Figure 4 - MEL Item 36-5-2, highlighting step 3, letter "B". 图4-MEL项目36-5-2，突出显示步骤3，字母“B”。
在介绍了巡航飞行中增压板的配置三分钟后，CVR记录了飞行员之间关于他们将采取的起飞程序的对话(起飞简报)。
On the day of the incident, the conditions prevailing in SBRJ were as follows: 事件发生当天，SBRJ的情况如下:
-aircraft weight: 61,765 kg;飞机重量:61,765公斤; -temperature: 26℃；温度:26℃ -atmospheric pressure: 1013 HPa;大气压力:1013hpa -direction / wind intensity: 020°/ 5kt；风向/风力:020°/ 5节
Under these conditions, it was possible to use the pressurization panel in two take-off configurations: 在这些情况下，可以使用两种增压面板起飞构型: -configuration A - Bleed 2 ON and APU Bleed OFF (maximum weight 62,000kg); and 构型A -引气2 ON和APU引气OFF(最大重量62,000kg);和 -configuration B - Bleed 2 OFF and APU Bleed ON (maximum weight 62,500kg). 构型B -引气2 OFF，APU引气ON(最大重量62,500公斤)。
在起飞简报期间，飞行员决定使用B构型(引气2 OFF，APU引气ON 。飞行员说，他们将配置增压面板如下: -APU Bleed ON; -Bleeds of the engines OFF; -Packs 1 and 2 in AUTO; and -Isolation Valve in OPEN.
起飞简报在没有参考飞机手册的情况下进行，飞行员对程序进行了讨论。然而，飞机手册的补充程序飞机推荐了一个不同的起飞程序用于APU引气增压飞机，如图5所示。 Figure 5 - Supplementary Procedures: #Bleeds OFF Takeoff - APU Bleed. 图5-补充程序：#无引气起飞-APU引气。
手册的程序规定，在起飞时应将隔离活门置于关闭位置，这一位置与飞行员对简报的讨论（打开）相反。
在APU引气的起飞简报结束后不久，飞行员回顾了他们将在起飞后采取的程序。最初对程序的修改是凭记忆进行的，这使飞行员对隔离活门的正确位置产生了怀疑(打开或关闭)。于是机长再次查看了MEL。
然而,在这个时候,机长错误地看成了MEL36-5-2步骤4,字母“A”、“B”(右发引气不工作)，而不是阅读步骤3,字母“A”(左发引气不工作)，两名飞行员一致认为隔离活门起飞后应处于关闭,这与他们在第一次简报中的意见不一样。
图6用绿色显示了这种情况下的正确步骤(左发动机引气失效);和错误的情况下的程序(右发动机引气失效)用红色。
Figure 6 - Operating procedures for Bleed inoperative. In green the procedure for bleed 1 inoperative (which should have been adopted) and in red the procedure for Bleed 2 inoperative (not applicable for that flight).图6-引气不工作操作程序。绿色表示引气1不工作的程序（本应采用），红色表示引气2不工作的程序（不适用于该航班）
这两种方法的区别之一是隔离活门的位置。引气1失效的程序(绿色)预先规定了活门处于开启位置，以使引气2能够为PACK1提供空气。相反，在引气2失效程序(红色)中，隔离活门被放置在CLOSE的位置，以确保直接给PACK1供气，并防止引气1向PACK 2提供空气。
维修工作结束后，机组人员被批准进行推出，随后发动机启动，滑行起飞。
作为专门针对桑托斯·杜蒙机场的指挥操作，操纵飞机的飞行员在起飞和爬升飞行阶段(PF)将是指令员，副驾驶将执行监控飞行员(PM)功能。
Before starting the taxi, the copilot set up the pressurization panel as agreed in the briefing: 在启动滑行之前，副驾驶按照简报中约定的方式设置了增压面板: -APU Bleed ON;APU引气ON -Bleeds of the engines OFF;双发引气OFF -Packs 1 and 2 in AUTO; and组件1和2 AUTO -Isolation Valve in OPEN.隔离活门OPEN
在这种构型下起飞后，飞机开始被APU引气增压，它供给两个PACK，如图7所示： Figure 7 - Pressurizing panel, as configured for taxi start. In this configuration, the APU Bleed was powering the Packs. 图7 -为滑出启动设置的增压面板。在这个构型中，APU引气使左右组件工作。
在襟翼收回后，当副驾驶与空中交通管制联系时，机长开始重新设置增压系统控制面板。应该指出的是，该面板位于上方，这是监控飞行员的责任，因而，在当时是副驾驶。
机长将引气2设置为打开位置，APU引气设置为关闭位置。副驾驶将注意力转回到面板上，他们一起完成了接下来的步骤。他们将Pack 2开关(右)设置为OFF并关闭隔离活门。
图8和图9说明了在驾驶员干预控制面板后增压系统将如何配置： Figure 8 - Pressurization panel, as configured after take-off. In this configuration, none of the Packs was being powered. 图8 -起飞后设置的增压面板。在这个设置下，没有一个组件是工作的。
Figure 9 - Pressurization panel of a B737-800 flight simulator, reconstituting the configuration adopted after take-off. 图9 - B737-800飞行模拟器上的增压板，重新设置为当时起飞后所采用的构型。
在这种设置中，隔离活门关闭，引气2，尽管在开启位置，但没有提供引气到PACK 1，也不会使PACK 2工作，因为PACK 2处于OFF(关闭)位置。
Pack 1处于自动(开启)状态，但是由于隔离活门处于CLOSE状态(关闭)，阻止交叉供气，所以无法从引气2获得引气。
在图9中可以看到，与左侧管道对应的指针(用字母“L”标识)在该设置中指示为零。这表明，在这一侧的管道没有增压，左侧的PACK没有收到任何来源的引气。
图10说明了如果飞行员正确地采用了项目36-5-2，步骤3，字母A(发动机左引气失效)中的MEL程序，增压面板应该如何配置。
Figure 10 - Pressurization panel, as recommended by MEL item 36-5-2, step 3, letter "A" (For left engine bleed inoperative). In this configuration, Pack 1 would be powered by Bleed 2. 图10-增压面板，如MEL项目36-5-2，步骤3，字母“A”所建议（用于左发动机引气不工作）。在此配置中，组件1将由引气2供气。
面板的错误配置后,副驾驶员表示怀疑正确的隔离活门位置，询问机长以确保过程是正确的。然而，机长又读了MEL36-5-2项第4步中的字母“B”(用于右发动机引气)，而没有读正确的程序(用于左发动机引气)。
值得一提的是，阅读MEL，或任何其他与飞机操作相关的检查清单，职责是负责监控飞行的飞行员的（PM），而不是操纵飞行飞行员的(PF)。然而，读MEL的人是当时的PF。
在飞机越过最低安全高度后不久，副驾驶阅读了起飞后的检查表。在那一刻，他说出了增压板上每个开关的位置，并再次表达了对程序的不信任。
机长指出，当飞机以每分钟3000英尺的速度爬升时，客舱却以每分钟1000英尺的速度爬升。副驾驶同意了机长的解释。
三分钟后，副驾驶再次质疑增压系统的指示是否一致。他意识到飞机内外的压差指示没有上升(压差在增加)。
机长说，指示器正在缓慢上升，并指出飞机正在飞越1.7万英尺的高度，而机舱高度只有4000英尺，副驾驶再次同意了机长的说法。
不久之后，飞行员说他们发现飞机内部的温度有点热。然而一直以来，增压控制面板的设置没有改变，爬升一直持续到FL250。
根据飞机操作手册，飞行员应该在升到巡航高度后检查增压系统参数。
对于FL250的飞行，制造商的手册建议压差应该是7.45psi，机舱高度应该大约是4000英尺，引气管道的压力应该在26到50psi之间。
Figure 11 – Level off check. 图11-平飞检查。
Figure 12 - Altitude and pressure differential check table. 图12-高度和压差检查表。
没来得及进行平飞检查。在到达巡航高度1分33秒后，客舱高度达到1万英尺，触发了客舱高度警告的声光警报。
作为机组人员的响应，这些警报后需要执行在快速参考手册(QRH)中给出的一系列行动，由于情况紧急，这些行动最初应该作为记忆项目来执行。这些所需行动的主要目的是防止飞行员因缺氧而丧失行动能力，并重新控制飞机增压系统。
飞行员在听到机舱高度警告声音或看到机舱高度警告灯时，应戴上氧气面罩，与飞行员建立联系，尽量控制机舱高度。这种控制需要将增压模式选择器置于MAN(手动)，并将外流活门开关往关闭位驱动，直到外流活门指示完全关闭。
如果机舱高度无法控制，机组人员应激活开关，放下旅客氧气面罩，即使在这种情况下有一个自动放下面罩系统，并进行紧急下降，直到FL100或该区域的最低安全高度(以较高的为准)。
Figure 13 - Cabin Altitude Warning or Rapid Depressurization non-normal checklist
图13 -机舱高度警告或快速释压非正常检查单
然而，紧急下降也没有遵循QRH中规定的全部程序。
在戴上面罩并相互沟通(客舱高度警告或快速释压程序的第1步和第2步)后，紧急下降检查单的第一项内容是通知机组人员和空中交通管制人员飞机下降的情况。
Figure 14 - Emergency descent checklist. 图14-紧急下降检查单。
机组人员在该区域发现通讯困难，在没有通知空中交通管制中心有关程序和没有在应答器上设置7600的情况下开始下降。飞行员一度被迫停止下降，让同一区域的另一架飞机上升高度。
使用减速板是检查单的第6项，它的使用被推迟了，直到飞机在下降过程中越过了FL220才开始使用。在下降过程中，飞机速度没有保持恒定在VMO (340kt)
当飞机飞越约15000英尺高度时，机舱高度达到14000英尺，乘客的氧气面罩自动落下。
尽管机舱高度警告或快速释压非正常检查单第5项中有规定，但飞行员并没有人工放下氧气面罩。
下降一直持续到FL090，然后飞到目的地，在这个高度，到落地没有其他异常.
分析ANALYSIS
这是一次常规的客运航班，从SBRJ起飞，飞往SBCF。
在事故中的机组人员接管飞机后，飞行员被告知放气活门有问题。
考虑到这种情况，机组人员请求维修团队的支持，维修团队在核实后放行了飞机。然而，在第一次滑出时，双引气灯亮了。飞行员决定滑回并再次请求维修协助。
识别故障需要在地面上等待1小时10分钟。在这段时间里，乘客们一直呆在飞机上。
在这期间，飞机的空调系统无法工作，因为问题涉及飞机增压和空调系统的组成部分。
结果，飞机内部的温度大幅上升，机组人员和乘客的环境变得不舒服。
导致飞机长时间停在地面的其他原因是机长对航班延误和对飞机恢复运行的处理，他必须同公司和空中交通管制部门进行一系列的联系。
经过维修团队的评估，决定在“引气1”失效的情况下放行飞机。这种特殊情况是制造商手册允许的，并包含在飞机MEL中，但会带来一些性能限制，直接影响飞行操纵剖面。
其中一个限制与增压控制面板的设置有关。在得知将在引气失效的情况下起飞后，飞行员们开始认真查阅飞行手册中有关这一情况的具体操作程序。
飞机MEL已经给出了引气1或引气2失效时如何设置面板。飞行员参考了手册，就执行飞行程序中关于增压面板的设置进行了简报。在此之前，该简报正确处理了引气无效情况的正确和适当的程序。
大约三分钟后，飞行员将注意力转移到APU引气的起飞程序上。虽然这不是一个例行程序，但在这次谈话中，飞行员并没有查阅飞机手册，而且这些程序都是根据记忆进行解释的。
The pilots verbalized that they would configure the pressurization panel as follows: 飞行员说，他们将增压面板设置如下: -APU Bleed ON;APU引气ON -Bleeds of the engines OFF;双发引气OFF -Packs 1 and 2 in AUTO; and组件1和2 AUTO -solation Valve in OPEN.隔离活门OPEN
但是，飞机手册补充程序建议在这种情况下关闭隔离活门。
这次简报结束后不久，飞行员们回顾了起飞后的程序。最初对程序的审查是凭记忆进行的，这使他们对隔离活门的正确位置(打开或关闭)产生了怀疑。于是机长又查看了MEL。
然而,在这时,指挥官错误地阅读MEL36-5-2步骤4,字母“A”、“B”(右发引气不工作)而不是阅读步骤3,字母“A”(左发引气不工作)，并且两名飞行员同意起飞后隔离活门处于关闭，不同于他们在第一次简报时上达成的一致意见。
“引气1”或“引气2”的失效程序相似，但不完全相同，而且彼此非常接近，在手册的同一页上有描述，没有强调“左”和“右”两个词，只根据文本和段落编号加以区分。
Figure 15 - Procedures of MEL 36-5-2.
图15-MEL程序
在这两种情况下，为了飞到17000英尺以上，所描述的程序确定应该使用PACK 1(左)来给飞机增压，而应该关闭PACK 2(右)。
它补充说，低于那个高度，PACK 2应该在自动位:“左空调组件用 APU 引气，右组件在隔离活门关闭的情况下使用右发引气”。在17000英尺以上，Pack 2应该设置为OFF，隔离活门应该打开。
由于引气1(左)失效，引气2(右)在17000英尺后提供给PACK 1(左)。根据系统的结构，这种供气是通过交输进行的，因此，只有在隔离活门打开的情况下才有可能。这是飞行员在事故发生当天所经历的情况。
因此，隔离活门的位置设定是程序之间最重要的区别。
这些简报是在维修人员关闭“引气1”时发出的。值得注意的是，当时飞机晚点，乘客在飞机上，舱内温度很高，飞行员在特殊的飞机调度条件下，还管理着与飞行计划相关的方面。
所有这些因素结合在一起，造成了机组人员的超负荷工作，尤其是飞行员的超负荷工作;因此，他们在机舱内的压力可能会增加，从而影响在飞机增压系统的管理和设置方面的行为。
在开始滑行之前，副驾驶根据讨论的简报设置了增压面板，也就是说，他让隔离活门处于开启状态。
根据操作手册，APU在飞行中只能给一个组件供电，所以起飞时应该关闭隔离活门。这种分歧不会影响飞机起飞时的增压或性能。然而，这表明飞行员对增压控制面板的正确设置有疑问。
在襟翼收回后，当副驾驶与空中交通管制联系时，机长开始重新设置增压系统的控制面板。
他将引气2放在开启位置，APU引气关闭。副驾驶将注意力转回到控制板，他们一起完成了程序，将Pack 2开关(右)关闭，隔离活门关闭。这些动作都是凭记忆执行的，没有读过MEL。
飞行时，机长执行操纵飞机的飞行员的任务，根据操作手册，机长应集中精力驾驶飞行。
其他任务，如重新设置增压面板和阅读MEL，则由监控飞机的飞行员负责监控，这是副驾驶在飞行期间执行的一项功能。
在飞行过程中，副驾驶在1万英尺以下执行了这些程序，其中包括:与空中交通管制取得联系和起飞之后的检查。
这次重新设置是在没有查阅MEL的情况下，由本应执行飞行任务的机组人员凭记忆进行的，这一事实表明机舱内存在一种非正式的环境，这种环境有利于不遵守当前的程序和未能分配任务，导致飞行员没有意识到他们在设置中所犯的错误。
值得一提的是，APU引气正确设置用于提供增压，飞机可以飞到17000英尺的高度，没有理由在起飞后不久重新设置增压面板。
起飞后所采用的程序基本正确，除了隔离活门的放置在CLOSE位。隔离活门关闭后，飞行员明确隔离左侧和右侧，防止交叉供气。结果，没有PACK得到来自2号发动机的引气，飞机逐渐开始失去在起飞时使用APU引气获得的压力。
在错误地重新设置增压面板后，副驾驶对隔离活门的正确位置表示怀疑。机长随后查阅了飞机手册。在判断期间，他再次错误阅读了引气2(右)失效程序，而不是正确阅读引气1(左)失效的程序。
不到一分钟后，在飞机越过最低安全高度后，副驾驶阅读了起飞后的检查单。当时，他再次对增压面板所采用的程序表示怀疑。
机长强调了飞机爬升率(3000英尺/分钟)和客舱爬升率(1000英尺/分钟)之间的差异。机长的声明让飞行员相信系统工作正常。毕竟，如果飞机释压，机舱爬升率将等于飞机的爬升率。
三分钟后，副驾驶意识到压差指示没有增加，于是再次询问机长。这又说明指示器是正常的，并指出飞机正在飞越17000英尺的高度，而客舱只在4000英尺的高度。机长的声明再一次让飞行员相信飞机是增压的。
Despite doubts as to the proper operation of the pressurization system, the copilot's interventions were not sufficiently assertive to raise the need to check other instruments related to the pressurization system. 尽管对增压系统的正确操作存在疑问，但副驾驶的干预不够果断，没有提出需要检查与增压系统相关的其他仪表。
Thus, even with the copilot's inquiries, the commander remained committed to the procedures performed, sustaining his position that the aircraft was being properly pressurized. 因此，即使有副驾驶的询问，机长仍然坚持执行程序，保持他的判断，即飞机正在正确增压。
The climb continued until leveling on the FL250. 继续爬升直到FL250。
When analyzing the dialogues recorded by the CVR, it was noticed that the pilots were based on the following parameters to evaluate if the cabin was or was not being pressurized: 在分析CVR记录的对话时，我们注意到飞行员根据以下参数来评估机舱是否增压: -rate of climb of the aircraft greater than the rate of climb of the cabin;飞机爬升率大于客舱爬升率; -aircraft altitude greater than cabin altitude; and飞机高度大于客舱高度;和 -pressure differential increasing.压差在增加。
飞行员没有检查一个重要的仪表，即显示管道压力的压力表。该仪表显示压力等于“零”的指针上的字母“L”(左管道)。这个信息，如果被观察到，将显示给飞行员在左管道没有增压空气，这将表明PACK 1号没有从任何气源接收引气。
值得注意的是，平飞压差检查的前提是管道内的压力要在26到50psi之间进行检查。此外，它还预测飞行员将把平飞时的座舱高度和压差常数与他们保持的飞行高度的预设值进行比较。
对于FL250，手册上说压差应该是7.45psi，机舱高度应该是大约4000英尺。然而，在平飞时，仪表显示客舱高度约为8000英尺，压差正在减小，已经低于7.45psi。
在使用APU起飞时，机舱被加压。然而，当飞行员通过关闭APU的引气来重新配置增压控制面板时，组件1停止接收来自APU的引气，组件2关闭。
飞行员打开了引气2，但是他们关闭了隔离活门。在这种情况下，Pack 1不再接收来自APU的引气，也不能接收来自引气2的引气。就这样，飞机逐渐失去了压力。
鉴于上述情况，可以肯定的是，飞行员在有疑问时所观察到的参数表明飞机没有正确增压。
据观察，飞行员的注意力被固定在少数几个参数上，以确定飞机在爬升过程中是否增压，这可能是由于他们对飞机增压系统的操作缺乏了解而导致的。
没有纠正这个问题,机舱释压和相关的座舱高度警告(视觉和听觉)触发。
一旦飞行员发现到释压，他们就开始朝安全高度FL100下降。
机舱释压紧急检查单,从第三项开始，试图通过增压选择为人工模式压选择器和关闭外流活门来控制客舱高度，以保持飞机的压力。
如果飞行员知道开关放错了位置，那么一些简单的操作，比如打开隔离活门，就可以重新给飞机增压。
然而，飞行员并没有按照清单上的步骤操作。相反，在旅客氧气面罩从舱内弹出之前，他们将注意力集中在下降到FL100上。当舱内海拔达到14000英尺以上时，就会发生这种情况。
在这个过程中，飞行员在与航区的ATC取得联系之前就开始了下降，并且没有在应答器上设置7600，这可能是因为他们相信自己能够通信，然而在整个下降过程中都没有成功。这一行动使飞行管制员无法指挥在该地区飞行的飞机离开事故飞机附近。因此，在下降过程中，飞机接近其他交通工具。因此，为了避免过度接近的情况，飞行员不得不改变飞行轨迹。
在空中交通繁忙的地区，在没有与空中交通管制部门沟通的情况下开始快速下降，可能会导致飞机与其他飞机相撞。这一行动给在该区域飞行的所有飞机带来了风险。
当他们经过FL150时，旅客的氧气面罩(报告中有例外)从舱里掉了下来。
需要注意的是，在这种情况下，为了避免损害乘客的健康，面罩是必不可少的，但有些面罩无法放下，这可以理解为飞机运行的潜在风险。
虽然有一项维护任务是确保氧气面罩在机舱释压时正确地弹出(任务35-090-00-01 / 02，每12000小时)，但不可能确保其中提供的检查是正确的。因此，目前还不清楚是什么因素影响了一些面罩的掉落。
事实Facts
a)the pilots had valid Aeronautical Medical Certificates (CMA); 飞行员持有有效的航空医学证明(CMA);
b)the pilots had valid B739 type aircraft (which included the 737-8EH model) and IFRA ratings. 飞行员拥有有效的B739型飞机(包括737-8EH型)和IFRA合格证。
c)the pilots were qualified and had experience in that kind of flight; 飞行员是合格的，有这种飞行的经验;
d)the aircraft had valid Airworthiness Certificate (CA); 飞机拥有有效的适航证书(CA);
e)the aircraft was within the weight and balance limits; 飞机在重量和平衡范围内;
f)the maintenance technical registers were with the records updated; 维修技术记录已更新;
g)the weather conditions were favorable for the flight; 天气条件对飞行有利;
h)when the crew involved in the incident took over the aircraft, the pilots were informed that there was a problem related to the Bleed valves; 当事故的机组人员接管飞机时，前一班机组已告知存在与引气活门有关的问题;
i)the crew requested support from the maintenance team; 机组请求维修团队的支持;
j)the maintenance technicians released the aircraft for the flight, after verifications; 维修技术人员确认后放行飞机飞行;
k)during the first taxi attempt for takeoff, the DUAL BLEED light turned on; 在第一次滑行出后，双引气灯亮起;
l)the pilots returned and requested the maintenance aid again; 飞行员滑回并再次请求维修援助;
m)the identification of the fault required a waiting time of one hour and ten minutes; 故障识别需要1小时10分钟;
n)during that time, the passengers remained on board; 在此期间，乘客留在机上;
o)the air conditioning of the aircraft was impaired during this period; 飞机的空调系统在这段期间不可用;
p)the temperature inside the aircraft went up considerably; 机舱内的温度大幅上升;
q)the environment became uncomfortable for crew and passengers; 机组人员和乘客的环境变得不舒适;
r)there was flight delay; 航班延误;
s)the aircraft was dispatched with Bleed 1 inoperative, according to the MEL; 这架飞机是根据MEL在引气1失效的情况下放行的;
t)procedures for Bleed 1 or 2 inoperative were similar and were located next to each other in the MEL; 引气1或2不工作的程序相似，且在MEL中彼此相邻;
u)during the briefings, the pilots demonstrated doubts and confusions about the procedures related to the pressurization system; 在通报过程中，飞行员对增压系统相关程序表示怀疑和困惑;
v)sometimes the pilots verbalized that they would perform different actions for the same procedure; 有时飞行员会说，他们会对同一程序执行不同的操作;
w)the take-off was performed with Bleeds 1 and 2 in OFF; the APU Bleed in ON; Packs 1 and 2 in AUTO and the Isolation Valve in OPEN; 起飞时引气1和2 关;APU引气开 ACK 1和2自动，隔离活门打开;
x)after take-off, the crew put Bleed 2 ON; Pack 2 OFF; the Isolation Valve in CLOSE and the APU Bleed in OFF; 起飞后，机组人员打开引气2;关闭PACK 2;隔离活门关闭，APU引气关闭;
y)this configuration prevented Pack 1 from receiving bleed air from Bleed 2 and the aircraft pressurization; 这种构型阻止了Pack 1接收来自右发的引气和给飞机增压;
z)the aircraft began to be slowly depressurized; 飞机开始缓慢释压;
aa)during the climb, the crew did not correctly interpret the indications of the pressurization system; 在爬升过程中，机组人员没有正确解读增压系统的指示;
bb) the crew did not have time to carry out the pressurizing check after leveling; 机组人员来不及进行平飞后的增压检查;
cc) the cabin has been depressurized; 机舱已释压；
dd) the masks fell automatically when the aircraft crossed the FL150; 当飞机飞越FL150时，面罩自动落下;
ee) the lavatory A mask did not fall from its compartment; 厕所A的面罩没有从储藏室里掉下来;
ff) masks of station 1R were tangled and unuseable; 1R门面罩缠结，无法使用;
gg) the compartments of the masks in the row 12, on seats D, E and F did not open; 12排D、E、F座面罩的门没有打开;
hh) after the depressurization, the crew did not perform all the actions required by the checklist for the situation; 释压后，机组没有执行检查单要求的所有措施；
ii) the pilots did not act, in order to attempt to control the cabin altitude prior to starting descent into the FL100; 飞行员没有采取试图在开始下降到FL100之前控制机舱高度的行动;
jj) the pilots had difficulties to contact the ATC; 飞行员难以与空中交通管制取得联系;
kk) the pilots started to descent to FL100 without establishing contact with the ATC and without setting 7600 on the transponder; 飞行员开始下降到高度100时，没有与空中交通管制建立联系，也没有在应答机上设置7600;
ll) the crew did not perform the emergency descent maneuver as recommended in the QRH; 机组人员没有按照QRH的建议进行紧急下降操作;
mm) the flight was stabilized and completed in the FL090; 在FL090飞行稳定并完成后续飞行；
nn) the landing on SBCF occurred without additional intercurrences; oo) the aircraft was not damaged; and 着陆到SBCF没有其他的异常;飞机没有损坏;和
pp) all occupants left unharmed. 所有乘客安然无恙。
影响因素Contributing factors
Attention – a contributor. 注意力因素
飞行员的注意力只集中在少数几个参数上，以确定飞机是否正在增压，这些参数加上对系统缺乏了解，使他们无法扩大对情况的分析，也无法采取必要的行动来纠正问题。
Attitude – a contributor. 态度因素
在飞行中的某些时候，机长抢了副驾驶(负责监控的飞行员)的职责，如在增压面板的配置中，即使没有查阅MEL，表明了一种不遵守操作手册中预先规定的程序的态度，这妨碍了驾驶舱问题的协调管理。
Communication – a contributor. 沟通因素
飞行员之间没有有效的沟通，影响了机组人员及时识别和纠正问题的能力，来避免飞机释压。
在对机长所执行的程序产生了怀疑时，副驾驶对机长关于增压系统正确操作的干预不够自信。相反，机长在这一交流中，仍然确信所采取的行动，使副驾驶依从。
Crew Resource Management–a contributor. 机组资源管理因素
与增压面板配置相关的任务是监控功能的飞行员(当时是副驾驶)的。然而，操纵飞机的飞行员(机长)在起飞后不久就主动设置了面板。配置是在没有参考MEL的情况下凭记忆执行的。这一事实否定了任务的划分，并导致飞行员没有意识到他们在配置中所犯的错误。
在飞行中有疑问的时候，PF是读MEL的人，这个任务应该由PM来完成。
Team dynamics – undetermined. 团队建设-待定
这种协作和合作在飞行中发生的方式，虽然很微妙，却导致了一种非正式的氛围，这种氛围没有考虑到正式为机组人员建立的责任，允许机长(在这次飞行中操纵飞机的飞行员)执行与监控飞行员功能相关的操作，除了执行基于记忆的程序之外。
Emotional state – undetermined. 情绪状态——待定
航班延误，加上组织上的影响和特殊的飞机调度情况，造成了工作负荷过重，可能增加了机舱内的压力水平，以至在阅读MEL程序时出现混淆，也可能影响了飞行员在飞机增压系统的管理和配置方面的执行。
安全建议SAFETY RECOMMENDATION
事故调查机构根据调查所得信息提出旨在防止事故或事件发生的建议，在任何情况下，其目的都不是为事故或事件建立责任或责任推定。除了从事故和事件调查中得出的安全建议外，安全建议可能来自各种来源，包括安全研究。
根据第7565/1986号法律，建议的提出完全是为了航空活动的运行安全，并应按照NSCA 3-13“巴西国家进行民用航空事故调查议定书”的规定处理。
本报告发表时提出的建议:
致巴西国家民用航空局(ANAC):
IG062 /CENIPA/2018 - 01于2019年12月18日发布
与GOL Airlines S.A.合作，以使该公司的飞行员培训强调飞机增压系统所有部件的操作和相互关系。
IG062 /CENIPA/2018 - 02于2019年12月18日发布
与GOL Airlines S.A.合作，使该公司的CRM培训强调在飞行期间的自信和正确的任务分配，特别是在阅读检查单和飞机系统开关的执行方面。
IG062 /CENIPA/2018 - 03于2019年12月18日发布
验证Gol航空公司S/A是否正确执行了任务35-090-00-01/02中规定的程序，以确保符合RBAC第121号中规定的关于为装有涡轮发动机的增压飞机乘客提供氧气的仪表和设备要求，因为在本事件中，在一些座位以及其中一个厕所，当客舱压力高度达到14000英尺以上时，氧气面罩没有自动释放。
已采取的措施制
CORRECTIVE OR PREVENTATIVE ACTION ALREADY TAKEN
机组人员接受CRM培训，重点是增压系统。
运营商在其CRM培训中加入了一些元素，这些元素有助于在发现故障时对所采取的行动进行关键性分析，以期对这些问题进行适当的映射、纠正和缓解。
维修部门对该公司的一些飞机进行了氧气面罩的释放测试，以验证在机舱释压的情况下，氧气面罩是否正确地从机舱中弹出。
On December 18th, 2019.
类似的气源/空调开关错误导致的空中释压还有：
提醒机组碰到类似情况时，一定要注意检查。
曾经还发生过更换CPC后，CPC静压口上的堵盖未取下，导致CPC感受到的机舱压力错误，造成CPC增加外流活门开度导致飞机释压的。
推荐阅读：
完 | 
更换HMU总结
整理总结的很直观全面的21空调系统
A320驾驶舱面板指南【01】
发表于 2020-3-24 15:14:11
