37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 260655 |
Time | |
Date | 199312 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : guc |
State Reference | CO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ogg |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | observation : company check pilot oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 13000 flight time type : 1200 |
ASRS Report | 260655 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight crew began as a routine gvc airport qualification. I was the captain of record, but was performing the first officer duties. At cruise altitude, I set the cabin altitude for destination at 3600 ft. This was what the automatic controller had taken the cabin to in cruise, so I just matched it (FL280). Normally I set the destination elevation of 7673 ft at gvc, but since we were cruising at lower altitudes for headwinds, I set 3600 ft to provide more comfort and less fatigue for passenger and crew. Upon descent I was busy explaining all of the special gvc procedures and normal FMC procedures. I forgot to reset the pressurization window to 7673 ft. 70 seconds after touchdown the automatic controller should depressurize the B757, in the event the pressurization is not set correctly. It failed to depressurize. At the gate, we noticed the mistake and set the cabin altitude to 7673 ft. However, before the aircraft could fully depressurize, the aft cargo door was opened. A baggage handler was injured slightly and the inner aft cargo liner was damaged. The above problem occurred due to human error and an automatic equipment failure. Most pilots tend to think if the landing checklist is complete, not too much can go wrong. Maybe pressurization needs to be put back on the landing checklist on the more modern aircraft, so we can double-check ourselves and the automation.
Original NASA ASRS Text
Title: CKP OF A B757 ACR ACFT FAILED TO RESET THE ACFT PRESSURIZATION TO ARPT ELEVATION IN TIME TO DEPRESSURIZE THE CARGO HOLDS RESULTING IN INJURY TO CGP CARGO HANDLER AND DAMAGE TO THE ACFT CARGO COMPARTMENT.
Narrative: FLC BEGAN AS A ROUTINE GVC ARPT QUALIFICATION. I WAS THE CAPT OF RECORD, BUT WAS PERFORMING THE FO DUTIES. AT CRUISE ALT, I SET THE CABIN ALT FOR DEST AT 3600 FT. THIS WAS WHAT THE AUTOMATIC CTLR HAD TAKEN THE CABIN TO IN CRUISE, SO I JUST MATCHED IT (FL280). NORMALLY I SET THE DEST ELEVATION OF 7673 FT AT GVC, BUT SINCE WE WERE CRUISING AT LOWER ALTS FOR HEADWINDS, I SET 3600 FT TO PROVIDE MORE COMFORT AND LESS FATIGUE FOR PAX AND CREW. UPON DSCNT I WAS BUSY EXPLAINING ALL OF THE SPECIAL GVC PROCS AND NORMAL FMC PROCS. I FORGOT TO RESET THE PRESSURIZATION WINDOW TO 7673 FT. 70 SECONDS AFTER TOUCHDOWN THE AUTOMATIC CTLR SHOULD DEPRESSURIZE THE B757, IN THE EVENT THE PRESSURIZATION IS NOT SET CORRECTLY. IT FAILED TO DEPRESSURIZE. AT THE GATE, WE NOTICED THE MISTAKE AND SET THE CABIN ALT TO 7673 FT. HOWEVER, BEFORE THE ACFT COULD FULLY DEPRESSURIZE, THE AFT CARGO DOOR WAS OPENED. A BAGGAGE HANDLER WAS INJURED SLIGHTLY AND THE INNER AFT CARGO LINER WAS DAMAGED. THE ABOVE PROB OCCURRED DUE TO HUMAN ERROR AND AN AUTOMATIC EQUIP FAILURE. MOST PLTS TEND TO THINK IF THE LNDG CHKLIST IS COMPLETE, NOT TOO MUCH CAN GO WRONG. MAYBE PRESSURIZATION NEEDS TO BE PUT BACK ON THE LNDG CHKLIST ON THE MORE MODERN ACFT, SO WE CAN DOUBLE-CHK OURSELVES AND THE AUTOMATION.
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.