37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 198405 |
Time | |
Date | 199201 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ord |
State Reference | IL |
Altitude | msl bound lower : 10000 msl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ord tower : jfk |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 60 flight time total : 5500 flight time type : 225 |
ASRS Report | 198405 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 98 flight time total : 3500 flight time type : 98 |
ASRS Report | 198695 |
Events | |
Anomaly | aircraft equipment problem : less severe |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | aircraft : equipment problem dissipated flight crew : overcame equipment problem |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Climbing through 10000 MSL the aircraft cabin altitude warning system activated. As the first officer troubleshot the malfunction I coordinated with ATC a level off at 10000 ft. We discovered the cabin altitude control lever out of its normal position of 'up.' there are 2 problems surrounding this occurrence -- training and design. Initial training excludes operating this system. The only time it would be used is for failure of the automatic system. Although all switches are moved during the course of training and later during actual preflts, this lever is never moved. Design is the other factor. Most switches are either placed in the 'on' or 'off', automatic or manual position. Not this one. Neither are there any indices which mark the required position of the lever. The difference between taking off depressurized is about 2 inches. Another design glitch brought to you by the same people who designed the only wing which requires deicing on a clear summer's day.
Original NASA ASRS Text
Title: IN CLB AT 10000 FT CABIN ALT ALERT OF NON PRESSURIZATION CAME ON. FLC OBSERVED MANUAL PRESSURIZATION LEVER IN MANUAL, PLACED IN AUTO AND CABIN BEGAN TO PRESSURIZE.
Narrative: CLBING THROUGH 10000 MSL THE ACFT CABIN ALT WARNING SYS ACTIVATED. AS THE FO TROUBLESHOT THE MALFUNCTION I COORDINATED WITH ATC A LEVEL OFF AT 10000 FT. WE DISCOVERED THE CABIN ALT CTL LEVER OUT OF ITS NORMAL POS OF 'UP.' THERE ARE 2 PROBLEMS SURROUNDING THIS OCCURRENCE -- TRAINING AND DESIGN. INITIAL TRAINING EXCLUDES OPERATING THIS SYS. THE ONLY TIME IT WOULD BE USED IS FOR FAILURE OF THE AUTOMATIC SYS. ALTHOUGH ALL SWITCHES ARE MOVED DURING THE COURSE OF TRAINING AND LATER DURING ACTUAL PREFLTS, THIS LEVER IS NEVER MOVED. DESIGN IS THE OTHER FACTOR. MOST SWITCHES ARE EITHER PLACED IN THE 'ON' OR 'OFF', AUTO OR MANUAL POS. NOT THIS ONE. NEITHER ARE THERE ANY INDICES WHICH MARK THE REQUIRED POS OF THE LEVER. THE DIFFERENCE BTWN TAKING OFF DEPRESSURIZED IS ABOUT 2 INCHES. ANOTHER DESIGN GLITCH BROUGHT TO YOU BY THE SAME PEOPLE WHO DESIGNED THE ONLY WING WHICH REQUIRES DEICING ON A CLR SUMMER'S DAY.
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.