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Air carrier medium large transport made takeoff with air conditioning packs off. When turned on at 10000' sudden pressure increase caused passenger injury pain and bleeding from nose and ears.
| Attributes | |
| ACN | 103707 |
| Time | |
| Date | 198902 |
| Day | Mon |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : dfw |
| State Reference | TX |
| Altitude | msl bound lower : 10000 msl bound upper : 10000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | enroute airway : zfw |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument |
| Experience | flight time last 90 days : 65 flight time total : 3650 flight time type : 65 |
| ASRS Report | 103707 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : instrument |
| Experience | flight time last 90 days : 112 flight time total : 9000 flight time type : 112 |
| ASRS Report | 103746 |
| Events | |
| Anomaly | non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified |
| Resolutory Action | other |
| Consequence | other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Air conditioning packs not turned on after engine start. Takeoff made with packs off. Packs turned on at 10000'. Cabin altitude dropped rapidly causing a passenger to bleed from ears and nose. Captain and first officer new to the medium large transport about 2 months since chkout and less than 100 hours in type aircraft. Aircraft had a history of pressurization problems. Captain used slightly different starting procedure. First officer failed to turn on air conditioning packs after engine start. After takeoff the thrust rating panel was not operating properly (due to lack of pressurization). This caused a delay in starting the after takeoff checklist to 6000' MSL. On this checklist pressurization is checked. When pressurization was checked, a flow light was discovered. This indicates that the cabin altitude is rising with the cabin outflow valve full closed. Checklist procedures for a pressurization flow light did no good because the assumption is that packs are on for takeoff. The captain scanned the panel and discovered the packs were off and immediately turned them on. Because of trouble shooting the outflow valve was in the manual position and full closed. The sudden increase in pressure caused the cabin altitude to drop rapidly, causing pain to several passenger. The moral to this story has been said many times--use the checklist carefully and crew members back each other up.
Original NASA ASRS Text
Title: ACR MLG MADE TKOF WITH AIR CONDITIONING PACKS OFF. WHEN TURNED ON AT 10000' SUDDEN PRESSURE INCREASE CAUSED PASSENGER INJURY PAIN AND BLEEDING FROM NOSE AND EARS.
Narrative: AIR CONDITIONING PACKS NOT TURNED ON AFTER ENG START. TKOF MADE WITH PACKS OFF. PACKS TURNED ON AT 10000'. CABIN ALT DROPPED RAPIDLY CAUSING A PAX TO BLEED FROM EARS AND NOSE. CAPT AND F/O NEW TO THE MLG ABOUT 2 MONTHS SINCE CHKOUT AND LESS THAN 100 HRS IN TYPE ACFT. ACFT HAD A HISTORY OF PRESSURIZATION PROBS. CAPT USED SLIGHTLY DIFFERENT STARTING PROC. F/O FAILED TO TURN ON AIR CONDITIONING PACKS AFTER ENG START. AFTER TKOF THE THRUST RATING PANEL WAS NOT OPERATING PROPERLY (DUE TO LACK OF PRESSURIZATION). THIS CAUSED A DELAY IN STARTING THE AFTER TKOF CHKLIST TO 6000' MSL. ON THIS CHKLIST PRESSURIZATION IS CHKED. WHEN PRESSURIZATION WAS CHKED, A FLOW LIGHT WAS DISCOVERED. THIS INDICATES THAT THE CABIN ALT IS RISING WITH THE CABIN OUTFLOW VALVE FULL CLOSED. CHKLIST PROCS FOR A PRESSURIZATION FLOW LIGHT DID NO GOOD BECAUSE THE ASSUMPTION IS THAT PACKS ARE ON FOR TKOF. THE CAPT SCANNED THE PANEL AND DISCOVERED THE PACKS WERE OFF AND IMMEDIATELY TURNED THEM ON. BECAUSE OF TROUBLE SHOOTING THE OUTFLOW VALVE WAS IN THE MANUAL POS AND FULL CLOSED. THE SUDDEN INCREASE IN PRESSURE CAUSED THE CABIN ALT TO DROP RAPIDLY, CAUSING PAIN TO SEVERAL PAX. THE MORAL TO THIS STORY HAS BEEN SAID MANY TIMES--USE THE CHKLIST CAREFULLY AND CREW MEMBERS BACK EACH OTHER UP.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.