Non use of after takeoff checklist results in oxygen mask deployment due to no cabin pressure.

Attributes
ACN	139408
Time
Date	199003
Day	Sun
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : sna
State Reference	CA
Altitude	msl bound lower : 3000 msl bound upper : 14000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : sna tower : ind
Operator	common carrier : air carrier
Make Model Name	Medium Large Transport, Low Wing, 2 Turbojet Eng
Flight Phase	climbout : intermediate altitude cruise other
Route In Use	departure other enroute other
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : instrument pilot : commercial pilot : atp
Experience	flight time last 90 days : 75 flight time total : 3000 flight time type : 75
ASRS Report	139408
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Events
Anomaly	aircraft equipment problem : less severe non adherence : published procedure non adherence other other anomaly other
Independent Detector	aircraft equipment other aircraft equipment : unspecified other flight crewa
Resolutory Action	flight crew : overcame equipment problem
Consequence	Other
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Flight, unpressurized, bleeds off takeoff (APU was inoperative). Cleared musel 5 departure to maintain 3000'. Prior to (or taking active) cleared to 2000'. Takeoff uneventful, first officer flying. Changed to departure and cleared to 3000'. Departure called traffic at 10 O'clock, first officer understood him to say cleared to 10000'. Passing 3000' departure cleared flight to 10000'. I do not believe an altitude deviation occurred, however, during all this distraction, the bleeds were not returned to the on position, and subsequently we had an altitude warning with an O2 mask deployment. The bleeds were returned to the on position and the aircraft pressurized normally. The problem was caused I feel by the combination of an unusual takeoff confign (unpressurized, bleeds off, APU inoperative) coupled with the very complex departure procedure from john wayne airport, and associated distrs caused by multiple altitude changes, traffic advisories, power reductions, deck angle changes, etc, necessary to meet noise requirements and/or avoid traffic. The departure from john wayne airport should be simplified.

Original NASA ASRS Text

Title: NON USE OF AFTER TKOF CHECKLIST RESULTS IN OXYGEN MASK DEPLOYMENT DUE TO NO CABIN PRESSURE.

Narrative: FLT, UNPRESSURIZED, BLEEDS OFF TKOF (APU WAS INOPERATIVE). CLRED MUSEL 5 DEP TO MAINTAIN 3000'. PRIOR TO (OR TAKING ACTIVE) CLRED TO 2000'. TKOF UNEVENTFUL, F/O FLYING. CHANGED TO DEP AND CLRED TO 3000'. DEP CALLED TFC AT 10 O'CLOCK, F/O UNDERSTOOD HIM TO SAY CLRED TO 10000'. PASSING 3000' DEP CLRED FLT TO 10000'. I DO NOT BELIEVE AN ALT DEVIATION OCCURRED, HOWEVER, DURING ALL THIS DISTR, THE BLEEDS WERE NOT RETURNED TO THE ON POSITION, AND SUBSEQUENTLY WE HAD AN ALT WARNING WITH AN O2 MASK DEPLOYMENT. THE BLEEDS WERE RETURNED TO THE ON POSITION AND THE ACFT PRESSURIZED NORMALLY. THE PROBLEM WAS CAUSED I FEEL BY THE COMBINATION OF AN UNUSUAL TKOF CONFIGN (UNPRESSURIZED, BLEEDS OFF, APU INOPERATIVE) COUPLED WITH THE VERY COMPLEX DEP PROC FROM JOHN WAYNE ARPT, AND ASSOCIATED DISTRS CAUSED BY MULTIPLE ALT CHANGES, TFC ADVISORIES, POWER REDUCTIONS, DECK ANGLE CHANGES, ETC, NECESSARY TO MEET NOISE REQUIREMENTS AND/OR AVOID TFC. THE DEP FROM JOHN WAYNE ARPT SHOULD BE SIMPLIFIED.

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.