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|
Attributes | |
ACN | 139662 |
Time | |
Date | 199003 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sna |
State Reference | CA |
Altitude | msl bound lower : 0 msl bound upper : 16000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : noise abatement enroute : on vectors enroute airway : zla |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 19000 flight time type : 1500 |
ASRS Report | 139662 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | none taken : detected after the fact none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Prior to takeoff received clearance from sna to sfo, initial altitude 3000'. When cleared onto runway, altitude changed to 2000'. After takeoff on runway 19L using noise abatement procedure, first officer flying, I performed power cutback at 1000', changed to departure control, reclred to 3000', set altitude, observed first officer making turn to 175 degrees as per procedure, received traffic advisory of traffic at 10 O'clock, 2500'. Looked for traffic. Looked back into cockpit. First officer thought we were cleared to 10000' (from 10 O'clock traffic call). We were just going through 3000'. I said, '3000' to first officer. He started to level off, but we received clearance to 10000' at this time, immediately followed by another traffic advisory. I was performing after takeoff checklist during this time, however, somewhere in all this was distracted and did not accomplish changeover from unpressurized bleeds off, takeoff (APU inoperative) procedure. Now cleared to 16000'. Somewhere between 10000 and 14000' heard cabin pressure warning, followed almost immediately by master caution and overhead panel lights. Cabin O2 masks had deployed. Immediately told first officer to open bleed valves. He was already accomplishing this. Pressurized aircraft normally and continued to sfo. I feel this near altitude bust at 3000', and failure to pressurize aircraft after takeoff, was caused by the excessively restrictive noise requirements at sna. The power reductions, excessive initial deck angle (24.5 degrees) and deck angle changes required by this procedure, when coupled with multiple altitude changes, traffic advisories necessitating looking for other aircraft while in very nose high attitude, and an unusual takeoff confign (APU inoperative, bleeds off, unpressurized, required to meet noise limits) creates an overload condition virtually inviting problems. The noise limits at sna are excessive and should be reduced to the point where normal noise abatement procedures will suffice.
Original NASA ASRS Text
Title: FLT CREW FAILED TO PRESSURIZE ACFT DURING CLIMB AND O2 MASKED DEPLOYED.
Narrative: PRIOR TO TKOF RECEIVED CLRNC FROM SNA TO SFO, INITIAL ALT 3000'. WHEN CLRED ONTO RWY, ALT CHANGED TO 2000'. AFTER TKOF ON RWY 19L USING NOISE ABATEMENT PROC, F/O FLYING, I PERFORMED PWR CUTBACK AT 1000', CHANGED TO DEP CTL, RECLRED TO 3000', SET ALT, OBSERVED F/O MAKING TURN TO 175 DEGS AS PER PROC, RECEIVED TFC ADVISORY OF TFC AT 10 O'CLOCK, 2500'. LOOKED FOR TFC. LOOKED BACK INTO COCKPIT. F/O THOUGHT WE WERE CLRED TO 10000' (FROM 10 O'CLOCK TFC CALL). WE WERE JUST GOING THROUGH 3000'. I SAID, '3000' TO F/O. HE STARTED TO LEVEL OFF, BUT WE RECEIVED CLRNC TO 10000' AT THIS TIME, IMMEDIATELY FOLLOWED BY ANOTHER TFC ADVISORY. I WAS PERFORMING AFTER TKOF CHKLIST DURING THIS TIME, HOWEVER, SOMEWHERE IN ALL THIS WAS DISTRACTED AND DID NOT ACCOMPLISH CHANGEOVER FROM UNPRESSURIZED BLEEDS OFF, TKOF (APU INOP) PROC. NOW CLRED TO 16000'. SOMEWHERE BTWN 10000 AND 14000' HEARD CABIN PRESSURE WARNING, FOLLOWED ALMOST IMMEDIATELY BY MASTER CAUTION AND OVERHEAD PANEL LIGHTS. CABIN O2 MASKS HAD DEPLOYED. IMMEDIATELY TOLD F/O TO OPEN BLEED VALVES. HE WAS ALREADY ACCOMPLISHING THIS. PRESSURIZED ACFT NORMALLY AND CONTINUED TO SFO. I FEEL THIS NEAR ALT BUST AT 3000', AND FAILURE TO PRESSURIZE ACFT AFTER TKOF, WAS CAUSED BY THE EXCESSIVELY RESTRICTIVE NOISE REQUIREMENTS AT SNA. THE PWR REDUCTIONS, EXCESSIVE INITIAL DECK ANGLE (24.5 DEGS) AND DECK ANGLE CHANGES REQUIRED BY THIS PROC, WHEN COUPLED WITH MULTIPLE ALT CHANGES, TFC ADVISORIES NECESSITATING LOOKING FOR OTHER ACFT WHILE IN VERY NOSE HIGH ATTITUDE, AND AN UNUSUAL TKOF CONFIGN (APU INOP, BLEEDS OFF, UNPRESSURIZED, REQUIRED TO MEET NOISE LIMITS) CREATES AN OVERLOAD CONDITION VIRTUALLY INVITING PROBS. THE NOISE LIMITS AT SNA ARE EXCESSIVE AND SHOULD BE REDUCED TO THE POINT WHERE NORMAL NOISE ABATEMENT PROCS WILL SUFFICE.
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.