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Attributes | |
ACN | 1085402 |
Time | |
Date | 201305 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | Initial Climb |
Flight Plan | IFR |
Component | |
Aircraft Component | Door Warning System |
Person 1 | |
Function | Captain Pilot Not Flying |
Qualification | Air Traffic Control Fully Certified Flight Crew Multiengine Flight Crew Flight Engineer Flight Crew Air Transport Pilot (ATP) Flight Crew Instrument |
Experience | Air Traffic Control Radar 2 Flight Crew Last 90 Days 90 Flight Crew Total 15000 Flight Crew Type 2000 |
Events | |
Anomaly | Aircraft Equipment Problem Critical |
Narrative:
Company procedures require a packs off takeoff. On climb out the packs are turned on after the first power reduction. Following our normal checklist procedures we found the cabin pressure differential still at zero. I informed ATC that we would be leveling off at 10;000 feet due to a pressurization problem. We had been operating with a deferred 'bulk cargo door' message. I 'recalled' the EICAS messages and 'cargo doors' was displayed (indicating that more than one cargo door was open.) we returned without any further incident. On post flight we found the aft cargo door open approximately 4 inches. While maintenance was cycling the door opened and closed I noticed the EICAS message would change from 'bulk cargo door' to 'cargo doors'. Somewhere in my chain of events this change occurred with out notice. This message may have been there prior to our arrival at the aircraft. The loss of the word 'bulk' and an 'south' added to the 'door' could have been easily overlooked. The EICAS system will display each door individually; as long as another door is not opened. When another door opens the display just rearranges the words. If a separate line were to have been displayed; its presence would have been obvious and our situation would have been prevented. When a part of a warning system is defective and deferred such as this; it should be kept from being displayed; instead of being constantly being part of the normal operation. Since the B747 cargo door incident; I thought this problem had been resolved. As far as human factors are concerned; we had been operating this aircraft four nights in a row with 11 hours rest during the day. Sleep during the day averaged six hours.
Original NASA ASRS Text
Title: B767 Captain experiences a lack of pressurization after takeoff and EICAS recall reveals a Cargo Door warning message. The flight returns to the departure airport where the door is found to be open four inches. The aircraft had been operating for several days with a cargo door warning system deferral.
Narrative: Company procedures require a packs off takeoff. On climb out the packs are turned on after the first power reduction. Following our normal checklist procedures we found the cabin pressure differential still at zero. I informed ATC that we would be leveling off at 10;000 feet due to a pressurization problem. We had been operating with a deferred 'BULK CARGO DOOR' message. I 'recalled' the EICAS messages and 'CARGO DOORS' was displayed (indicating that more than one cargo door was open.) We returned without any further incident. On post flight we found the aft cargo door open approximately 4 inches. While Maintenance was cycling the door opened and closed I noticed the EICAS message would change from 'BULK CARGO DOOR' to 'CARGO DOORS'. Somewhere in my chain of events this change occurred with out notice. This message may have been there prior to our arrival at the aircraft. The loss of the word 'BULK' and an 'S' added to the 'DOOR' could have been easily overlooked. The EICAS system will display each door individually; as long as another door is not opened. When another door opens the display just rearranges the words. If a separate line were to have been displayed; its presence would have been obvious and our situation would have been prevented. When a part of a warning system is defective and deferred such as this; it should be kept from being displayed; instead of being constantly being part of the normal operation. Since the B747 cargo door incident; I thought this problem had been resolved. As far as human factors are concerned; we had been operating this aircraft four nights in a row with 11 hours rest during the day. Sleep during the day averaged six hours.
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.