Narrative:

On the morning of 10/thu/90, we pushed back from the gate at san as flight to las. As we were pushing back the ground controller seemed anxious to clear the alley so another air carrier widebody transport could get to his gate, so I elected to taxi out on O1 engine to expedite our taxi. As we approached the taxiway I instructed the first officer to start engine #2. There were several other aircraft pushing from the other terminals with their tails toward the taxiway, so I instructed the first officer to do the complete start procedure so that I could concentrate on taxiing by the traffic. During the start a circuit breaker popped behind the first officer and the lights went out on the left side and center INS panel and the overhead panel, so I turned on the dome lights. After the #2 engine had started the F/east completed the after start flow. I looked over and checked the switch positions for the flow and they all appeared normal. I called for the after start checklist and it was completed. Upon reaching the holding bay for runway 27 I stopped and found the #1 TR circuit breaker had popped. After resetting the breaker everything appeared normal, so we continued the departure. Immediately after takeoff I noted that the cabin was not pressurizing. I told the first officer to go to standby and try to control the cabin. That didn't work, so he went to manual and noted the outflow valve was closed but was still unable to control the cabin. I leveled off at 10000' and at that point felt that the problem might be electrical and related to the circuit breaker problem. I told san departure we had a pressurization problem and had to return for landing. After landing and parking at the gate I did the shutdown flow and noted both packs were in the off position. I checked the switch position after the first officer did the after start flow, but apparently the lighting problem and the distrs of other traffic led me to believe the packs were in automatic position when they were off. Supplemental information from acn 159529: after the engine start, I did the captain's after start flow. The captain was watching me do this and after I finished made no comment. (At this time the cockpit was darkened.) we then started looking for the light problem. I thought I had done the after start flow correctly. Apparently I didn't. We didn't have time to look at the problem. Hindsight being 20/20, and assuming all the before takeoff events happened as they did, we should have leveled off, slowed to 210 KTS and asked departure to drive us around in a big loop back to runway 27, giving us the time to really look at the problem. This is just another example of how distraction, a broken flow of continuity and not recognizing the sings can lead one down the primrose path.

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Original NASA ASRS Text

Title: ACR MLG RETURN LANDS AFTER BEING UNABLE TO PRESSURIZE ACFT AFTER TKOF.

Narrative: ON THE MORNING OF 10/THU/90, WE PUSHED BACK FROM THE GATE AT SAN AS FLT TO LAS. AS WE WERE PUSHING BACK THE GND CTLR SEEMED ANXIOUS TO CLR THE ALLEY SO ANOTHER ACR WDB COULD GET TO HIS GATE, SO I ELECTED TO TAXI OUT ON O1 ENG TO EXPEDITE OUR TAXI. AS WE APCHED THE TXWY I INSTRUCTED THE F/O TO START ENG #2. THERE WERE SEVERAL OTHER ACFT PUSHING FROM THE OTHER TERMINALS WITH THEIR TAILS TOWARD THE TXWY, SO I INSTRUCTED THE F/O TO DO THE COMPLETE START PROC SO THAT I COULD CONCENTRATE ON TAXIING BY THE TFC. DURING THE START A CB POPPED BEHIND THE F/O AND THE LIGHTS WENT OUT ON THE LEFT SIDE AND CENTER INS PANEL AND THE OVERHEAD PANEL, SO I TURNED ON THE DOME LIGHTS. AFTER THE #2 ENG HAD STARTED THE F/E COMPLETED THE AFTER START FLOW. I LOOKED OVER AND CHKED THE SWITCH POSITIONS FOR THE FLOW AND THEY ALL APPEARED NORMAL. I CALLED FOR THE AFTER START CHKLIST AND IT WAS COMPLETED. UPON REACHING THE HOLDING BAY FOR RWY 27 I STOPPED AND FOUND THE #1 TR CB HAD POPPED. AFTER RESETTING THE BREAKER EVERYTHING APPEARED NORMAL, SO WE CONTINUED THE DEP. IMMEDIATELY AFTER TKOF I NOTED THAT THE CABIN WAS NOT PRESSURIZING. I TOLD THE F/O TO GO TO STANDBY AND TRY TO CTL THE CABIN. THAT DIDN'T WORK, SO HE WENT TO MANUAL AND NOTED THE OUTFLOW VALVE WAS CLOSED BUT WAS STILL UNABLE TO CTL THE CABIN. I LEVELED OFF AT 10000' AND AT THAT POINT FELT THAT THE PROB MIGHT BE ELECTRICAL AND RELATED TO THE CB PROB. I TOLD SAN DEP WE HAD A PRESSURIZATION PROB AND HAD TO RETURN FOR LNDG. AFTER LNDG AND PARKING AT THE GATE I DID THE SHUTDOWN FLOW AND NOTED BOTH PACKS WERE IN THE OFF POS. I CHKED THE SWITCH POS AFTER THE F/O DID THE AFTER START FLOW, BUT APPARENTLY THE LIGHTING PROB AND THE DISTRS OF OTHER TFC LED ME TO BELIEVE THE PACKS WERE IN AUTO POS WHEN THEY WERE OFF. SUPPLEMENTAL INFO FROM ACN 159529: AFTER THE ENG START, I DID THE CAPT'S AFTER START FLOW. THE CAPT WAS WATCHING ME DO THIS AND AFTER I FINISHED MADE NO COMMENT. (AT THIS TIME THE COCKPIT WAS DARKENED.) WE THEN STARTED LOOKING FOR THE LIGHT PROB. I THOUGHT I HAD DONE THE AFTER START FLOW CORRECTLY. APPARENTLY I DIDN'T. WE DIDN'T HAVE TIME TO LOOK AT THE PROB. HINDSIGHT BEING 20/20, AND ASSUMING ALL THE BEFORE TKOF EVENTS HAPPENED AS THEY DID, WE SHOULD HAVE LEVELED OFF, SLOWED TO 210 KTS AND ASKED DEP TO DRIVE US AROUND IN A BIG LOOP BACK TO RWY 27, GIVING US THE TIME TO REALLY LOOK AT THE PROB. THIS IS JUST ANOTHER EXAMPLE OF HOW DISTR, A BROKEN FLOW OF CONTINUITY AND NOT RECOGNIZING THE SINGS CAN LEAD ONE DOWN THE PRIMROSE PATH.

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.