37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1083240 |
Time | |
Date | 201304 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | EMB ERJ 145 ER/LR |
Operating Under FAR Part | Part 121 |
Flight Phase | Climb |
Flight Plan | IFR |
Person 1 | |
Function | Pilot Flying Captain |
Person 2 | |
Function | First Officer Pilot Not Flying |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy Inflight Event / Encounter Fuel Issue |
Narrative:
I was the captain. We were delayed about an hour while maintenance performed a windshield heat repair. We departed after about an hour of taxiing and were climbing through approximately 17;500 ft when we realized that there was an issue with the cabin pressurization and requested a leveloff at FL180. The cabin altitude was approaching 10;000 ft. We put on our oxygen masks; declared an emergency with ATC and got a descent clearance to 10;000 ft. The cabin altitude was rising steadily but not rapidly so we did an expeditious descent. The cabin altitude reached a maximum of 11;000 ft. We informed the flight attendant of our pressurization issue and ATC of our intent to return to [our departure airport] and we were cleared to descend further to 7;000 ft. After leveling off at 7;000 ft I noticed that the pressurization controller on the panel was in the dump mode and we quickly realized that there was no mechanical problem with the pressurization system but that a serious crew oversight was to blame. Realizing that the problem with the pressurization system was no longer an issue; we did a fuel calculation to see if we would still be able to re climb and continue to our destination but unfortunately we did not have adequate fuel on board to do so. We returned to [departure airport] with the intention of refueling the airplane and getting re-dispatched but we were instead given an aircraft swap to continue with. We did inform maintenance; dispatch and management that the aircraft had no mechanical issues and that a crew error was responsible for the air return. I take full responsibility for this unnecessary; pilot induced pressurization malfunction and air return. Regardless of any outside circumstances that may have been a factor leading up to the incident; the root cause was me not verifying that the pressurization controller was in the automode during the pre departure flow and checklist. As a crew; we had numerous chances on the initial climbout to recognize and correct our error and it should have been caught. The aircraft had just been returned from maintenance and was pressurized on the ground as part of the procedure. A contributing factor was that the pressurization controller was left in the dump position when returned to the line. The position of the controller is in the same general vicinity whether in the dump or automode and I believe this contributed to me not recognizing the abnormality although I should have also physically checked the position of the controller. Another consideration is the short overnight that we had the previous night. Our schedules were not updated until sometime overnight to indicate a 9 hour overnight so as far as we knew we were reporting from an 8 hour overnight until we had already awoken in the am. I had about 4 and a half hours of sleep during this rest period which I am sure contributed to my lack of sharpness and effectiveness as a crew member. Closer attention paid to my preflight duties would have helped me catch this error. Additionally; as a crew we could have been more attentive to the pressurization indications on the EICAS during the climb. As far as maintenance is concerned; placing switches back in their normal operating position when completed would take out one of the contributing factors leading up to an event like this. Lastly; I believe that we as crew members perform below average in our duties following a short overnight with less than a normal nights sleep so I am looking forward to the new FAA rest requirements.
Original NASA ASRS Text
Title: The pilots of an EMB-145 failed to notice that the pressurization controller was left in the 'dump' mode after Maintenance action and departed on their scheduled flight. Climbing through about 17;500 FT they noticed that the aircraft was not pressurizing; leveled off at FL180; declared an emergency; and descended down to 10;000. It was then that they noticed the cause of the problem; corrected it; but now fuel was an issue and they returned to the departure airport.
Narrative: I was the Captain. We were delayed about an hour while Maintenance performed a windshield heat repair. We departed after about an hour of taxiing and were climbing through approximately 17;500 FT when we realized that there was an issue with the cabin pressurization and requested a leveloff at FL180. The cabin altitude was approaching 10;000 FT. We put on our oxygen masks; declared an emergency with ATC and got a descent clearance to 10;000 FT. The cabin altitude was rising steadily but not rapidly so we did an expeditious descent. The cabin altitude reached a maximum of 11;000 FT. We informed the Flight Attendant of our pressurization issue and ATC of our intent to return to [our departure airport] and we were cleared to descend further to 7;000 FT. After leveling off at 7;000 FT I noticed that the pressurization controller on the panel was in the dump mode and we quickly realized that there was no mechanical problem with the pressurization system but that a serious crew oversight was to blame. Realizing that the problem with the pressurization system was no longer an issue; we did a fuel calculation to see if we would still be able to re climb and continue to our destination but unfortunately we did not have adequate fuel on board to do so. We returned to [departure airport] with the intention of refueling the airplane and getting re-dispatched but we were instead given an aircraft swap to continue with. We did inform Maintenance; Dispatch and management that the aircraft had no mechanical issues and that a crew error was responsible for the air return. I take full responsibility for this unnecessary; pilot induced pressurization malfunction and air return. Regardless of any outside circumstances that may have been a factor leading up to the incident; the root cause was me not verifying that the pressurization controller was in the automode during the pre departure flow and checklist. As a crew; we had numerous chances on the initial climbout to recognize and correct our error and it should have been caught. The aircraft had just been returned from maintenance and was pressurized on the ground as part of the procedure. A contributing factor was that the pressurization controller was left in the dump position when returned to the line. The position of the controller is in the same general vicinity whether in the dump or automode and I believe this contributed to me not recognizing the abnormality although I should have also physically checked the position of the controller. Another consideration is the short overnight that we had the previous night. Our schedules were not updated until sometime overnight to indicate a 9 hour overnight so as far as we knew we were reporting from an 8 hour overnight until we had already awoken in the am. I had about 4 and a half hours of sleep during this rest period which I am sure contributed to my lack of sharpness and effectiveness as a crew member. Closer attention paid to my preflight duties would have helped me catch this error. Additionally; as a crew we could have been more attentive to the pressurization indications on the EICAS during the climb. As far as maintenance is concerned; placing switches back in their normal operating position when completed would take out one of the contributing factors leading up to an event like this. Lastly; I believe that we as crew members perform below average in our duties following a short overnight with less than a normal nights sleep so I am looking forward to the new FAA rest requirements.
Data retrieved from NASA's ASRS site as of July 2013 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.