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|
Attributes | |
ACN | 216039 |
Time | |
Date | 199207 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : cyn |
State Reference | NY |
Altitude | msl bound lower : 33000 msl bound upper : 41000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zny |
Operator | general aviation : corporate |
Make Model Name | Small Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise other descent other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 30 flight time total : 7500 flight time type : 200 |
ASRS Report | 216039 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : clearance other anomaly other anomaly other other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : declared emergency flight crew : exited adverse environment flight crew : regained aircraft control |
Consequence | other |
Supplementary | |
Primary Problem | Aircraft |
Narrative:
Situation: small transport single pilot executive jet. Total instantaneous loss of pressurization FL410 in contact with ZNY, VFR conditions, daylight at about XA00Z. Departure was from a coastal airport, martha's vineyard, of high humidity. A coastal fog was in progress upon landing and departure. On the ground it was later found to be a hose problem at the water separator. A metal tube, approximately 4 inch diameter, pulled out of a flex hose coupling on top of the water separator. Conclusion was the separator bag might have frozen plugging the pressurization system, no other cause can be found. The clamp, hose and tube do not show any damage, and the system was inspected recently. No overheat nor over pressurization annunciator lights were evident. Both overheat and over pressurization system were checked, and were functioning properly. Removal of the water separator sock showed excess water. At the place of separation, emergency pressurization does not work, or is of no benefit in this situation. The loss was so great that cabin was at FL330 when I got to that altitude. Events: shortly after reaching FL390 center asked if I would take FL410, and after about 5 mins at FL410 the aircraft system had an instantaneous pressurization loss. The pressure wave to the ears was most painful. In pulling on my quick donning oxygen mask, grabbing it from over my left shoulder with my right hand caused me to bump the autoplt disengage switch on the left side of the control wheel with my right elbow which I did not know. How much time elapsed from putting on the oxygen mask, actuating the passenger mask drop switch and looking at the pressurization cabin gauge, pulling back power, and actuating the speed brakes, turning the seat belt light on and telling the passenger to put the oxygen masks on I do not know. Center tells me I'm in a descent and called lower crossing traffic while I was busy trying to push my glasses back in place which the quick donning mask pushed sideways off my face. In the meantime I'm trying to tell center my problem, they are telling me about my low altitude. It seems both our transmissions were blocking each other. I called center with no answer other than a voice saying that I was descending which I could not see because my glasses were sideways and the autoplt was turned off, what else could go wrong. After this point in the flight I'm not quite sure what I said other than I needed down right now because of a total pressurization loss. Center told me to stay at FL410. I decided I was not talking to them and got the column hand microphone and repeated the message and was told to stay at FL410. I told them I needed down right now and they cleared me to FL330 if that was going to do any good. I knew using the hand microphone was causing a problem for me because my voice was sounding funny in the ear piece. Put the oxygen mask back on and fly was my thought. I checked my descent speed and turned around in my seat to the right because of the scream in the cabin by a small child who would not keep his oxygen mask on, and whose father had moved from his seat to hold the child. The father did not realize he pulled his oxygen mask off and was almost passed out between the seats. I tipped my oxygen mask up to yell at the father and again my glasses lost position on my face, thus more time straightening out a constant problem. I got mind overload, seat belt lights on, speed, people passed out maybe, speed of descent, altitude, etc, and center saying stop at FL330 and 'what were my intentions.' at this point I still do not know if I declared an emergency. Hand microphone, oxygen mask, people all blurred together thus I'm not sure about a lot of things other than I wanted down now. I can remember center giving me turns or heading changes, altitude restrictions and center saying, 'further descent was not possible because of lower traffic, as I cascaded down with stops from FL330, FL270, FL190, 17000 ft, and me telling them, 'I need lower,' and center saying 'what are your intentions.' all this time I'm having trouble hearing so I'm missing instructions or am I? Checking airspeed, altitude, people and 'what are your intentions.' I gotenough problems without center asking again and again, 'what are your intentions,' and I keep telling them get me down or lower, 'I have no pressurization,' and I cannot get out of my seat to attend to others. To look back on this it seems totally crazy, sure maybe I did not declare an emergency, I do not remember, a lot of things were happening at the same time, but center must have known I was having a problem because I know I told them I had total loss of pressurization and needed down right now. If you have never been here or there, are you in for a surprise! Side note: the air expandable hood, catcher mask type, oxygen masks should not be allowed to be used with anyone who wears eye glasses. Any abrupt type of movement causes eye glasses to pull, slide or dislodge from the face. Pulling this type of mask over the face takes 2 hands, one to hold the glasses while the mask is pulled down. How this mask was ever approved as a quick donning type is beyond human knowledge. P.south. Everyone came out ok!
Original NASA ASRS Text
Title: PLT OF SMT EXECUTIVE JET ACFT HAD TOTAL LOSS OF CABIN PRESSURIZATION AT HIGH ALT.
Narrative: SITUATION: SMT SINGLE PLT EXECUTIVE JET. TOTAL INSTANTANEOUS LOSS OF PRESSURIZATION FL410 IN CONTACT WITH ZNY, VFR CONDITIONS, DAYLIGHT AT ABOUT XA00Z. DEP WAS FROM A COASTAL ARPT, MARTHA'S VINEYARD, OF HIGH HUMIDITY. A COASTAL FOG WAS IN PROGRESS UPON LNDG AND DEP. ON THE GND IT WAS LATER FOUND TO BE A HOSE PROBLEM AT THE WATER SEPARATOR. A METAL TUBE, APPROX 4 INCH DIAMETER, PULLED OUT OF A FLEX HOSE COUPLING ON TOP OF THE WATER SEPARATOR. CONCLUSION WAS THE SEPARATOR BAG MIGHT HAVE FROZEN PLUGGING THE PRESSURIZATION SYS, NO OTHER CAUSE CAN BE FOUND. THE CLAMP, HOSE AND TUBE DO NOT SHOW ANY DAMAGE, AND THE SYS WAS INSPECTED RECENTLY. NO OVERHEAT NOR OVER PRESSURIZATION ANNUNCIATOR LIGHTS WERE EVIDENT. BOTH OVERHEAT AND OVER PRESSURIZATION SYS WERE CHKED, AND WERE FUNCTIONING PROPERLY. REMOVAL OF THE WATER SEPARATOR SOCK SHOWED EXCESS WATER. AT THE PLACE OF SEPARATION, EMER PRESSURIZATION DOES NOT WORK, OR IS OF NO BENEFIT IN THIS SITUATION. THE LOSS WAS SO GREAT THAT CABIN WAS AT FL330 WHEN I GOT TO THAT ALT. EVENTS: SHORTLY AFTER REACHING FL390 CTR ASKED IF I WOULD TAKE FL410, AND AFTER ABOUT 5 MINS AT FL410 THE ACFT SYS HAD AN INSTANTANEOUS PRESSURIZATION LOSS. THE PRESSURE WAVE TO THE EARS WAS MOST PAINFUL. IN PULLING ON MY QUICK DONNING OXYGEN MASK, GRABBING IT FROM OVER MY L SHOULDER WITH MY R HAND CAUSED ME TO BUMP THE AUTOPLT DISENGAGE SWITCH ON THE L SIDE OF THE CTL WHEEL WITH MY R ELBOW WHICH I DID NOT KNOW. HOW MUCH TIME ELAPSED FROM PUTTING ON THE OXYGEN MASK, ACTUATING THE PAX MASK DROP SWITCH AND LOOKING AT THE PRESSURIZATION CABIN GAUGE, PULLING BACK PWR, AND ACTUATING THE SPD BRAKES, TURNING THE SEAT BELT LIGHT ON AND TELLING THE PAX TO PUT THE OXYGEN MASKS ON I DO NOT KNOW. CTR TELLS ME I'M IN A DSCNT AND CALLED LOWER XING TFC WHILE I WAS BUSY TRYING TO PUSH MY GLASSES BACK IN PLACE WHICH THE QUICK DONNING MASK PUSHED SIDEWAYS OFF MY FACE. IN THE MEANTIME I'M TRYING TO TELL CTR MY PROBLEM, THEY ARE TELLING ME ABOUT MY LOW ALT. IT SEEMS BOTH OUR TRANSMISSIONS WERE BLOCKING EACH OTHER. I CALLED CTR WITH NO ANSWER OTHER THAN A VOICE SAYING THAT I WAS DSNDING WHICH I COULD NOT SEE BECAUSE MY GLASSES WERE SIDEWAYS AND THE AUTOPLT WAS TURNED OFF, WHAT ELSE COULD GO WRONG. AFTER THIS POINT IN THE FLT I'M NOT QUITE SURE WHAT I SAID OTHER THAN I NEEDED DOWN RIGHT NOW BECAUSE OF A TOTAL PRESSURIZATION LOSS. CTR TOLD ME TO STAY AT FL410. I DECIDED I WAS NOT TALKING TO THEM AND GOT THE COLUMN HAND MICROPHONE AND REPEATED THE MESSAGE AND WAS TOLD TO STAY AT FL410. I TOLD THEM I NEEDED DOWN RIGHT NOW AND THEY CLRED ME TO FL330 IF THAT WAS GOING TO DO ANY GOOD. I KNEW USING THE HAND MICROPHONE WAS CAUSING A PROBLEM FOR ME BECAUSE MY VOICE WAS SOUNDING FUNNY IN THE EAR PIECE. PUT THE OXYGEN MASK BACK ON AND FLY WAS MY THOUGHT. I CHKED MY DSCNT SPD AND TURNED AROUND IN MY SEAT TO THE R BECAUSE OF THE SCREAM IN THE CABIN BY A SMALL CHILD WHO WOULD NOT KEEP HIS OXYGEN MASK ON, AND WHOSE FATHER HAD MOVED FROM HIS SEAT TO HOLD THE CHILD. THE FATHER DID NOT REALIZE HE PULLED HIS OXYGEN MASK OFF AND WAS ALMOST PASSED OUT BTWN THE SEATS. I TIPPED MY OXYGEN MASK UP TO YELL AT THE FATHER AND AGAIN MY GLASSES LOST POS ON MY FACE, THUS MORE TIME STRAIGHTENING OUT A CONSTANT PROBLEM. I GOT MIND OVERLOAD, SEAT BELT LIGHTS ON, SPD, PEOPLE PASSED OUT MAYBE, SPD OF DSCNT, ALT, ETC, AND CTR SAYING STOP AT FL330 AND 'WHAT WERE MY INTENTIONS.' AT THIS POINT I STILL DO NOT KNOW IF I DECLARED AN EMER. HAND MICROPHONE, OXYGEN MASK, PEOPLE ALL BLURRED TOGETHER THUS I'M NOT SURE ABOUT A LOT OF THINGS OTHER THAN I WANTED DOWN NOW. I CAN REMEMBER CTR GIVING ME TURNS OR HDG CHANGES, ALT RESTRICTIONS AND CTR SAYING, 'FURTHER DSCNT WAS NOT POSSIBLE BECAUSE OF LOWER TFC, AS I CASCADED DOWN WITH STOPS FROM FL330, FL270, FL190, 17000 FT, AND ME TELLING THEM, 'I NEED LOWER,' AND CTR SAYING 'WHAT ARE YOUR INTENTIONS.' ALL THIS TIME I'M HAVING TROUBLE HEARING SO I'M MISSING INSTRUCTIONS OR AM I? CHKING AIRSPD, ALT, PEOPLE AND 'WHAT ARE YOUR INTENTIONS.' I GOTENOUGH PROBLEMS WITHOUT CTR ASKING AGAIN AND AGAIN, 'WHAT ARE YOUR INTENTIONS,' AND I KEEP TELLING THEM GET ME DOWN OR LOWER, 'I HAVE NO PRESSURIZATION,' AND I CANNOT GET OUT OF MY SEAT TO ATTEND TO OTHERS. TO LOOK BACK ON THIS IT SEEMS TOTALLY CRAZY, SURE MAYBE I DID NOT DECLARE AN EMER, I DO NOT REMEMBER, A LOT OF THINGS WERE HAPPENING AT THE SAME TIME, BUT CTR MUST HAVE KNOWN I WAS HAVING A PROBLEM BECAUSE I KNOW I TOLD THEM I HAD TOTAL LOSS OF PRESSURIZATION AND NEEDED DOWN RIGHT NOW. IF YOU HAVE NEVER BEEN HERE OR THERE, ARE YOU IN FOR A SURPRISE! SIDE NOTE: THE AIR EXPANDABLE HOOD, CATCHER MASK TYPE, OXYGEN MASKS SHOULD NOT BE ALLOWED TO BE USED WITH ANYONE WHO WEARS EYE GLASSES. ANY ABRUPT TYPE OF MOVEMENT CAUSES EYE GLASSES TO PULL, SLIDE OR DISLODGE FROM THE FACE. PULLING THIS TYPE OF MASK OVER THE FACE TAKES 2 HANDS, ONE TO HOLD THE GLASSES WHILE THE MASK IS PULLED DOWN. HOW THIS MASK WAS EVER APPROVED AS A QUICK DONNING TYPE IS BEYOND HUMAN KNOWLEDGE. P.S. EVERYONE CAME OUT OK!
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.