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|
Attributes | |
ACN | 1618120 |
Time | |
Date | 201902 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | Climb |
Flight Plan | IFR |
Component | |
Aircraft Component | Pressurization Control System |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Instrument Flight Crew Multiengine Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | Pilot Not Flying First Officer |
Qualification | Flight Crew Air Transport Pilot (ATP) Flight Crew Multiengine Flight Crew Instrument |
Experience | Flight Crew Type 6 |
Events | |
Anomaly | Deviation - Procedural MEL Deviation - Procedural Published Material / Policy |
Narrative:
It was day two of a two day trip; [morning] sign in. The logbook had two mels; one fuel related; the other; a pressurization/landing elevation auto function. We were initially delayed due to the local ground crew handling another flight; the mobile air-stair was not in position; as such we were late getting on the airplane; and also subsequently late in beginning the boarding process. Following his exterior pre-flight; the first officer determined that the aircraft would require to be deiced. In addition to that; the number one flight attendant (flight attendant) told me that a headrest on one of the flight attendant jump-seats was broken; and that an ancillary med-kit was also missing. Additional interruptions and distractions included a passenger with a leg injury that required to be moved to an aisle seat; an overhead compartment that would not latch; and we were also dealing with a verbose irate ops-manager who was concerned about not getting his 'out' time.'needless to say we were busy; and I personally felt that I was getting a bit behind in dealing with the admin stuff. After briefly reviewing the directives on the mels for compliance; we pushed to the deicing pad. Following deicing; and after reconfiguring the aircraft for engine start and taxi; I spoke to first officer (first officer) about leaving the manual altitude setting at 6;000 feet; just in case we had an emergency that required us to return; or to divert to another high altitude airport with a systems problem. He agreed; and I asked him to remind me to reset it to [the destination] field elevation once we were at cruise altitude. At this point I looked to see if the landing elev man message; (which was required by the MEL) was displayed on the lower ECAM. Either it was not visible; or I just missed it; (I'm not sure which). First officer and I then discussed if we needed to press the cabin pressure switch in order to display the MEL required message.without knowing it; at this point; we had set the table for a self-induced problem. In retrospect; I had somehow confused the cabin press sd message with the elev man message; and that by pressing the cabin pressurization switch; I thought that I had satisfied the systems logic; and was in compliance with the MEL directive. [By the way;] it was my leg; an uneventful taxi; and we departed; on an RNAV rnp departure. Passing approximately 9;000 feet. MSL; the master warning/ECAM 'cabin pressure excess cabin altitude illuminated.' I performed the standard litany; 'my aircraft;' we then identified the problem; and cancelled the master warning. First officer picked up the QRH and determined that it was neither a quick action nor an ECAM exception. We both looked at the immediate action item on the ECAM; which stated that we manually deploy the passenger oxygen masks. At this point; both of us were aware that the cabin was climbing past 10;000 feet and with that in mind; we subsequently donned our oxygen masks and established comms. In order to avoid a rapid climb; I shallowed out our rate and began to accelerate to 250 kts. We had a brief exchange; and then decided that it was more important to try and stop the cabin rate of cabin climb; rather than to immediately deploy the passenger oxygen masks. (My thinking was that option would always be available). I told [my first officer] that I would handle ATC; and I asked him to reference the QRH for additional guidance; and to also continue to monitor and call out the cabin altitude on the sd. I informed center that we had a pressurization issue; and that we needed to remain clear of terrain; preferably at or below 14k; and that we needed some time to run a checklist and to troubleshoot the problem. (We were VFR throughout the entire departure and climb; and we could clearly see all of the terrain along the RNAV SID). ATC subsequently assigned us 13;000 feet followed by a climb to 14k. First officer told me that the QRH ECAM message section 'cab in pr excess cabin attendant altitude' had taken him to the page for the volcanic ash procedure instead of what we expected to see: the cabin altitude follow up. ([By the way;] that's another issue best left to folks who wrote the most recent QRH change). With that in mind; we decided to enter holding; and just use some common pilot-sense to try trouble shoot our problem.the first step that we agreed to do was to put the system back in auto; and see if it would reduce the cabin elevation back to normal parameters. That did not work. I made a quick PA to the passengers; and told them that we were experiencing some minor pressurization problems; and that we would be entering holding while we solved the problem. We then decided to go back to manual pressurization mode; and use the toggle switch on the pressurization panel to control the outflow valve. [The first officer] then attempted to bring the cabin altitude back down to normal tolerances. Long story short; he did a great job; and he quickly got the cabin altitude down to 6;000 feet and also back to a normal delta-p; (3.5 or so). At this point we decided to try and put the system back into auto mode; and see if it maintained the current cabin altitude and pressurization. It worked; and the cabin altitude remained stable. We then discussed and decided that it was safe to proceed to our destination. At this point we took off our oxygen masks; and I made a brief PA to the passengers regarding our progress. I then told ATC that we had resolved our issue; and that we'd like to exit the hold and resume our flight planned route. The rest of the flight was uneventful. While en-route; we 'walked back' how we had committed this mental chain of errors; and in doing so; we came to realize that other than verifying switch positions during pre-flights; neither of us had ever touched the pressurization panel; and as such; my systems knowledge had probably atrophied a bit. It was an 'own goal' on my part; and I'm embarrassed that I had confused the manual elevation system with the manual pressurization system; and I had undoubtedly simply misread and/or misunderstood the MEL procedures; along with the synoptic display messages that had confused us. Contributing factors were the high altitude layover; which precluded me getting my usual good rest. More importantly; I allowed myself to be rushed with a bunch of non-operational issues; and in doing so I didn't analyze and sufficiently understand the MEL procedures. Although the QRH was not a causal factor in the chain of events that occurred on the ground; neither of us could not find a single reference in any of the pages in the QRH that were related to the ECAM message 'cabin pressure excess cabin altitude illuminated.' that plus the page number problem which we were directed to; was a dead end. Just my two cents here; but someone needs to look at and review the pages for this type of ECAM (and there are dozens of them; and have the references in those pages direct us to the supplemental non-normals.just my opinion; but a lot of the airbus verbiage; a language construction in many of the checklists; QRH; pubs; MEL; etc. Is less than ideal; and can lead to some level of confusion. It seems to be written by engineers as opposed to operators. Of course; that's just my opinion.
Original NASA ASRS Text
Title: A319 flight crew reported experiencing pressurization problems on departure due to improper pressurization panel setup.
Narrative: It was day two of a two day trip; [morning] sign in. The logbook had two MELs; one fuel related; the other; a pressurization/landing elevation auto function. We were initially delayed due to the local ground crew handling another flight; the mobile air-stair was not in position; as such we were late getting on the airplane; and also subsequently late in beginning the boarding process. Following his exterior pre-flight; the First Officer determined that the aircraft would require to be deiced. In addition to that; the number one FA (Flight Attendant) told me that a headrest on one of the FA jump-seats was broken; and that an ancillary med-kit was also missing. Additional interruptions and distractions included a passenger with a leg injury that required to be moved to an aisle seat; an overhead compartment that would not latch; and we were also dealing with a verbose irate ops-manager who was concerned about not getting his 'out' time.'Needless to say we were busy; and I personally felt that I was getting a bit behind in dealing with the admin stuff. After briefly reviewing the directives on the MELs for compliance; we pushed to the deicing pad. Following deicing; and after reconfiguring the aircraft for engine start and taxi; I spoke to FO (First Officer) about leaving the manual altitude setting at 6;000 feet; just in case we had an emergency that required us to return; or to divert to another high altitude airport with a systems problem. He agreed; and I asked him to remind me to reset it to [the destination] field elevation once we were at cruise altitude. At this point I looked to see if the LANDING ELEV MAN message; (which was required by the MEL) was displayed on the lower ECAM. Either it was not visible; or I just missed it; (I'm not sure which). FO and I then discussed if we needed to press the cabin pressure switch in order to display the MEL required message.Without knowing it; at this point; we had set the table for a self-induced problem. In retrospect; I had somehow confused the CABIN PRESS SD message with the ELEV MAN message; and that by pressing the cabin pressurization switch; I thought that I had satisfied the systems logic; and was in compliance with the MEL directive. [By the way;] it was my leg; an uneventful taxi; and we departed; on an RNAV RNP departure. Passing approximately 9;000 feet. MSL; the Master Warning/ECAM 'Cabin Pressure Excess Cabin Altitude illuminated.' I performed the standard litany; 'my aircraft;' we then identified the problem; and cancelled the master warning. FO picked up the QRH and determined that it was neither a quick action nor an ECAM exception. We both looked at the immediate action item on the ECAM; which stated that we manually deploy the passenger oxygen masks. At this point; both of us were aware that the cabin was climbing past 10;000 feet and with that in mind; we subsequently donned our Oxygen masks and established comms. In order to avoid a rapid climb; I shallowed out our rate and began to accelerate to 250 kts. We had a brief exchange; and then decided that it was more important to try and stop the cabin rate of cabin climb; rather than to immediately deploy the passenger oxygen masks. (My thinking was that option would always be available). I told [my FO] that I would handle ATC; and I asked him to reference the QRH for additional guidance; and to also continue to monitor and call out the cabin altitude on the SD. I informed Center that we had a pressurization issue; and that we needed to remain clear of terrain; preferably at or below 14k; and that we needed some time to run a checklist and to troubleshoot the problem. (We were VFR throughout the entire departure and climb; and we could clearly see all of the terrain along the RNAV SID). ATC subsequently assigned us 13;000 feet followed by a climb to 14k. FO told me that the QRH ECAM message section 'Cab in PR Excess CAB ALT' had taken him to the page for the volcanic ash procedure instead of what we expected to see: the Cabin Altitude follow up. ([By the way;] that's another issue best left to folks who wrote the most recent QRH change). With that in mind; we decided to enter holding; and just use some common pilot-sense to try trouble shoot our problem.The first step that we agreed to do was to put the system back in auto; and see if it would reduce the cabin elevation back to normal parameters. That did not work. I made a quick PA to the passengers; and told them that we were experiencing some minor pressurization problems; and that we would be entering holding while we solved the problem. We then decided to go back to manual pressurization mode; and use the toggle switch on the pressurization panel to control the outflow valve. [The FO] then attempted to bring the cabin altitude back down to normal tolerances. Long story short; he did a great job; and he quickly got the cabin altitude down to 6;000 feet and also back to a normal delta-p; (3.5 or so). At this point we decided to try and put the system back into auto mode; and see if it maintained the current cabin altitude and pressurization. It worked; and the cabin altitude remained stable. We then discussed and decided that it was safe to proceed to our destination. At this point we took off our oxygen masks; and I made a brief PA to the passengers regarding our progress. I then told ATC that we had resolved our issue; and that we'd like to exit the hold and resume our flight planned route. The rest of the flight was uneventful. While en-route; we 'walked back' how we had committed this mental chain of errors; and in doing so; we came to realize that other than verifying switch positions during pre-flights; neither of us had ever touched the pressurization panel; and as such; my systems knowledge had probably atrophied a bit. It was an 'own goal' on my part; and I'm embarrassed that I had confused the manual elevation system with the manual pressurization system; and I had undoubtedly simply misread and/or misunderstood the MEL procedures; along with the synoptic display messages that had confused us. Contributing factors were the high altitude layover; which precluded me getting my usual good rest. More importantly; I allowed myself to be rushed with a bunch of non-operational issues; and in doing so I didn't analyze and sufficiently understand the MEL procedures. Although the QRH was not a causal factor in the chain of events that occurred on the ground; neither of us could not find a single reference in any of the pages in the QRH that were related to the ECAM message 'Cabin Pressure Excess Cabin Altitude illuminated.' That plus the page number problem which we were directed to; was a dead end. Just my two cents here; but someone needs to look at and review the pages for this type of ECAM (and there are dozens of them; and have the references in those pages direct us to the supplemental non-normals.Just my opinion; but a lot of the Airbus verbiage; a language construction in many of the checklists; QRH; pubs; MEL; etc. is less than ideal; and can lead to some level of confusion. It seems to be written by engineers as opposed to operators. Of course; that's just my opinion.
Data retrieved from NASA's ASRS site 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.