2002-1
AIRCRAFT SERIOUS INCIDENT
INVESTIGATION REPORT
ALL NIPPON AIRWAYS
AIRBUS A320-200, JA8947
(DECOMPRESSION IN AN AIRCRAFT CABIN)
September 27, 2002
Aircraft and Railway Accidents Investigation Commission
Ministry of Land, Infrastructure and Transport
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AIRCRAFT SERIOUS INCIDENT INVESTIGATION REPORT
ALL NIPPON AIRWAYS FLIGHT 465
AIRBUS A320-200, JA8947
DECOMPRESSION IN AN AIRCRAFT CABIN
OVER THE SEA OF JAPAN 75 KM N.W. OF TOYAMA CITY, TOYAMA
PREFECTURE, JAPAN
AT ABOUT 11:45 JST, DECEMBER 27, 2001
September 27, 2002
Decision by the Aircraft and Railway Accidents Investigation
Commission(Air Sub-committee Meeting)
Chairman Junzo Sato
Member Ryouhei Katsuno
Member Susumu Kato
Member Sumio Matsuura
Member Yukiko Kakimoto
Member Kozaburo Yamane
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1. PROCESS AND PROGRESS OF THE SERIOUS INCIDENT
INVESTIGATION
1.1 Summary of the Serious Incident
On Thursday December 27, 2001, an Airbus A320-200 of All Nippon Airways (ANA),
registration JA8947 (hereinafter referred to as the said aircraft), departed Niigata Airport
at 11:20 (JST) as scheduled passenger flight 465 to Naha Airport. The aircraft was cruising
at flight level (FL) 350 bound for Naha Airport over the Sea of Japan approximately 75km
northwest of Toyama City when a drop in cabin air pressure occurred at around 11:45. As a
result, the said aircraft made an emergency descent and diverted to Osaka International
Airport, where it landed at 12:25.
There were 55 persons on board flight 465—49 passengers, the Captain and five other
crew members. There were no injuries to persons on board.
This incident was treated as a serious incident under Civil Aviation Regulation
Operating Standard Article 166 Section 4 Item 10 “Abnormal drop of cabin pressure in an
aircraft”.
1.2 Outline of the Serious Incident Investigation
1.2.1 The Organization of the Investigation
On December 27, 2001, the Aircraft and Railway Accidents Investigation Commission
(ARAIC) assigned an Investigator-in-Charge and two other investigators with responsibility
for investigating this serious incident.
1.2.2 Cooperating Parties
Personnel from the Ministry of Land, Infrastructure and Transport’s Civil Aviation
Bureau (CAB) cooperated in the investigation of the aircraft and other matters in relation to
this serious incident.
1.2.3 Cooperation by Foreign Authorities
The German Federal Bureau of Aircraft Accident Investigation (BFU) cooperated as
witnesses to the detailed investigation of safety valves of the cabin pressurization system.
1.2.4 The Implementation of the Investigation
The investigation proceeded as follows.
December 28–29, 2001 Investigation of the aircraft and
collection of witness statements.
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December 28, 2001–January 10, 2002 Analysis of DFDR data and CVR
recordings
December 31, 2001 Collection of witness statements
January 8–24, 2002 Safety valve investigation
February 6–8, 2002 Additional safety valve investigation at
the manufacturer’s facility (witnessed
by the BFU)
1.2.5 Hearings from Persons relevant to the Cause of the Serious Incident
Hearings were held to hear the opinions of persons concerned with the cause of this
incident.
2. FACTUAL INFORMATION
2.1 Flight History
On December 27, 2001, the said aircraft was planned to operate as All Nippon Airways
(hereinafter referred to as the said company) scheduled flight 465 from Niigata Airport to
Naha Airport.
The flight plan of the said aircraft submitted to Niigata Airport Office of the Civil
Aviation Bureau was as follows:
FLIGHT RULES: IFR, DEPARTURE AERODROME: Niigata Airport, CRUISE
SPEED:456kt, CRUISE ALTITUDE: FL350, ROUTE: HAKUBA (Fixed point)–V30–JEC
(Miho VORTAC)–V54–HKC (Kagoshima VORTAC)–A582–ONC (Erabu VORTAC)–NHC
(Naha VORTAC), DESTINATION AERODROME: Naha Airport, TIME:02:10UTC,
TOTAL EET: 2 hours 42minutes, ENDURANCE: 4 hours 24 minutes.
The said aircraft took off from Niigata Airport at 11:20 with 55 persons on board—49
passengers and six crew members. At around 11:45, while cruising at FL350 over the Sea of
Japan approximately 75km northwest of Toyama City, the pressure altitude of the cabin
(the cabin altitude), which had been maintained at 6,000ft, started to increase. Since this
indicated that the air pressure in the cabin was dropping, the said aircraft made an
emergency decent to a flight altitude of 12,000ft and diverted to Osaka International
Airport, where it landed at 12:25.
(1) The outline of the circumstances of the occurrence of this serious incident based on the
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