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Flight crew failed to activate the engine bleed air for pressurization after takeoff resulting in the passenger masks 'dropping down' at high altitude.
| Attributes | |
| ACN | 250389 |
| Time | |
| Date | 199308 |
| Day | Sun |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : jac |
| State Reference | WY |
| Altitude | msl bound lower : 29000 msl bound upper : 29000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zlc tower : alb |
| 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 climbout : takeoff cruise other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 170 flight time total : 7530 flight time type : 1820 |
| ASRS Report | 250389 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : commercial |
| Experience | flight time total : 10100 |
| ASRS Report | 250625 |
| Events | |
| Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
| Resolutory Action | flight crew : exited adverse environment flight crew : overcame equipment problem |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
A bleeds-off takeoff (copilot flying) was performed at jac. During initial climb we were distracted by other operational considerations, initially by another aircraft in the pattern, and then a route change which required reprogramming the FMS. Consequently, we failed to complete the after takeoff checklist, resulting in the engine bleed not being turned on. Jac is an uncontrolled airport and from our TCASII it appeared that during our circling climb the other aircraft could be a factor. Sometime around top of climb at 29000 ft, the captain turned off the APU, causing a complete loss of bleed air. When the cabin altitude warning horn came on, we initially took it to be an anomalous takeoff warning horn and before we recognized the problem the cabin altitude reached 14000 ft, causing the master caution light to come on and the cabin pressure controller to switch to standby. We immediately turned on the engine bleeds and we donned our oxygen masks and started the cabin down. We also asked for a lower altitude and started a normal descent. Upon communicating with the 'a' flight attendant, we found that the passenger masks had dropped and that the flight attendants were performing their duties in assisting the passenger. At this point, the captain made a PA that everything was under control. After this, we descended and landed normally. During descent, maximum cabin rate-of-change was 1000-1500 FPM. During deplaning there were no passenger complaints of ear problems and no one seemed distressed.
Original NASA ASRS Text
Title: FLC FAILED TO ACTIVATE THE ENG BLEED AIR FOR PRESSURIZATION AFTER TKOF RESULTING IN THE PAX MASKS 'DROPPING DOWN' AT HIGH ALT.
Narrative: A BLEEDS-OFF TKOF (COPLT FLYING) WAS PERFORMED AT JAC. DURING INITIAL CLB WE WERE DISTRACTED BY OTHER OPERATIONAL CONSIDERATIONS, INITIALLY BY ANOTHER ACFT IN THE PATTERN, AND THEN A RTE CHANGE WHICH REQUIRED REPROGRAMMING THE FMS. CONSEQUENTLY, WE FAILED TO COMPLETE THE AFTER TKOF CHKLIST, RESULTING IN THE ENG BLEED NOT BEING TURNED ON. JAC IS AN UNCTLED ARPT AND FROM OUR TCASII IT APPEARED THAT DURING OUR CIRCLING CLB THE OTHER ACFT COULD BE A FACTOR. SOMETIME AROUND TOP OF CLB AT 29000 FT, THE CAPT TURNED OFF THE APU, CAUSING A COMPLETE LOSS OF BLEED AIR. WHEN THE CABIN ALT WARNING HORN CAME ON, WE INITIALLY TOOK IT TO BE AN ANOMALOUS TKOF WARNING HORN AND BEFORE WE RECOGNIZED THE PROB THE CABIN ALT REACHED 14000 FT, CAUSING THE MASTER CAUTION LIGHT TO COME ON AND THE CABIN PRESSURE CTLR TO SWITCH TO STANDBY. WE IMMEDIATELY TURNED ON THE ENG BLEEDS AND WE DONNED OUR OXYGEN MASKS AND STARTED THE CABIN DOWN. WE ALSO ASKED FOR A LOWER ALT AND STARTED A NORMAL DSCNT. UPON COMMUNICATING WITH THE 'A' FLT ATTENDANT, WE FOUND THAT THE PAX MASKS HAD DROPPED AND THAT THE FLT ATTENDANTS WERE PERFORMING THEIR DUTIES IN ASSISTING THE PAX. AT THIS POINT, THE CAPT MADE A PA THAT EVERYTHING WAS UNDER CTL. AFTER THIS, WE DSNDED AND LANDED NORMALLY. DURING DSCNT, MAX CABIN RATE-OF-CHANGE WAS 1000-1500 FPM. DURING DEPLANING THERE WERE NO PAX COMPLAINTS OF EAR PROBS AND NO ONE SEEMED DISTRESSED.
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.