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|
Attributes | |
ACN | 136136 |
Time | |
Date | 199002 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : msp |
State Reference | MN |
Altitude | msl bound lower : 840 msl bound upper : 23000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zmp |
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 cruise other |
Route In Use | enroute airway : zmp |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 6000 flight time type : 1600 |
ASRS Report | 136136 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 224 flight time total : 3850 flight time type : 760 |
ASRS Report | 137003 |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : exited adverse environment none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Train of events started with power-back when first officer turned packs off because of fumes being drawn into cabin. During power-back ground called with taxi instructions to follow aircraft off to left onto taxiway C at msp for runway 29R. Captain and first officer became distracted trying to find other aircraft, which was compounded by following other aircraft in its turn, which was to 29L. Ground advised we were taxiing wrong direction. After this was straightened out, first officer reported taxi checklist complete. Started takeoff checklist to discover tps (takeoff performance date) did not include runway 29R. First officer tried several times to obtain tps through ACARS, finally having to call msp operations to have then contact dispatch for information and relay same. Meantime, we were approaching #1 for takeoff. As we completed hurry-up takeoff checklist, tower offered expedited takeoff clearance. After takeoff, when climb power was selected, 'no mode' appeared on tri (thrust rating indicator) for engine power. First officer was flying, captain tried to troubleshot while running checklists and communicating with ATC. Quick reference handbook had not tri abnormals listed for tri. As aircraft leveled at FL230, first officer noticed cabin altitude of 9500' and rising. Captain requested immediate descent to 10000', which ATC granted. Captain took over control of aircraft for emergency descent. When cabin altitude red alert light came on, O2 masks were deployed in cabin and emergency was declared. At 10000', emergency was terminated. Packs were both found in 'off' position. Packs were reinstated, cabin pressurized. Flight continued to destination west/O further problems. Event occurred by distrs while performing the checklists. Both captain and first officer missed the packs being off--first officer on taxi and takeoff checklists and captain on the checklist. Being hurried for takeoff sequence contributed. Also, no specific procedure in any manual to check packs on with 'no mode' illuminated on trip. Supplemental information from acn 137003: we continued the remainder of the flight to ord at 10000' with an unpressurized aircraft.
Original NASA ASRS Text
Title: FLT CREW SHUTS DOWN AIR CONDITIONING PACKS DURING POWER-BACK FROM GATE DUE TO FOUL FUMES. DISTRACTED BY SCHEDULE PRESSURE, THEY FAIL TO TURN THE PACKS BACK ON, CAUSING A PRESSURIZATION EMERGENCY AT FL230 WHEN DEPARTING MSP.
Narrative: TRAIN OF EVENTS STARTED WITH PWR-BACK WHEN F/O TURNED PACKS OFF BECAUSE OF FUMES BEING DRAWN INTO CABIN. DURING PWR-BACK GND CALLED WITH TAXI INSTRUCTIONS TO FOLLOW ACFT OFF TO LEFT ONTO TXWY C AT MSP FOR RWY 29R. CAPT AND F/O BECAME DISTRACTED TRYING TO FIND OTHER ACFT, WHICH WAS COMPOUNDED BY FOLLOWING OTHER ACFT IN ITS TURN, WHICH WAS TO 29L. GND ADVISED WE WERE TAXIING WRONG DIRECTION. AFTER THIS WAS STRAIGHTENED OUT, F/O RPTED TAXI CHKLIST COMPLETE. STARTED TKOF CHKLIST TO DISCOVER TPS (TKOF PERFORMANCE DATE) DID NOT INCLUDE RWY 29R. F/O TRIED SEVERAL TIMES TO OBTAIN TPS THROUGH ACARS, FINALLY HAVING TO CALL MSP OPS TO HAVE THEN CONTACT DISPATCH FOR INFO AND RELAY SAME. MEANTIME, WE WERE APCHING #1 FOR TKOF. AS WE COMPLETED HURRY-UP TKOF CHKLIST, TWR OFFERED EXPEDITED TKOF CLRNC. AFTER TKOF, WHEN CLB PWR WAS SELECTED, 'NO MODE' APPEARED ON TRI (THRUST RATING INDICATOR) FOR ENG PWR. F/O WAS FLYING, CAPT TRIED TO TROUBLESHOT WHILE RUNNING CHKLISTS AND COMMUNICATING WITH ATC. QUICK REF HANDBOOK HAD NOT TRI ABNORMALS LISTED FOR TRI. AS ACFT LEVELED AT FL230, F/O NOTICED CABIN ALT OF 9500' AND RISING. CAPT REQUESTED IMMEDIATE DSCNT TO 10000', WHICH ATC GRANTED. CAPT TOOK OVER CONTROL OF ACFT FOR EMER DSCNT. WHEN CABIN ALT RED ALERT LIGHT CAME ON, O2 MASKS WERE DEPLOYED IN CABIN AND EMER WAS DECLARED. AT 10000', EMER WAS TERMINATED. PACKS WERE BOTH FOUND IN 'OFF' POS. PACKS WERE REINSTATED, CABIN PRESSURIZED. FLT CONTINUED TO DEST W/O FURTHER PROBS. EVENT OCCURRED BY DISTRS WHILE PERFORMING THE CHKLISTS. BOTH CAPT AND F/O MISSED THE PACKS BEING OFF--F/O ON TAXI AND TKOF CHKLISTS AND CAPT ON THE CHKLIST. BEING HURRIED FOR TKOF SEQUENCE CONTRIBUTED. ALSO, NO SPECIFIC PROC IN ANY MANUAL TO CHK PACKS ON WITH 'NO MODE' ILLUMINATED ON TRIP. SUPPLEMENTAL INFO FROM ACN 137003: WE CONTINUED THE REMAINDER OF THE FLT TO ORD AT 10000' WITH AN UNPRESSURIZED ACFT.
Data retrieved from NASA's ASRS site as of July 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.