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First officer of an mdt failed to position the bleed air valve for cabin pressurization properly resulting in loss of cabin pressure and an emergency descent.
| Attributes | |
| ACN | 301258 |
| Time | |
| Date | 199503 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : esc |
| State Reference | MI |
| Altitude | msl bound lower : 17000 msl bound upper : 17000 |
| Environment | |
| Flight Conditions | Mixed |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Commercial Fixed Wing |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | cruise other |
| Route In Use | enroute airway : zmp |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 275 flight time total : 6500 flight time type : 2500 |
| ASRS Report | 301258 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : commercial |
| Events | |
| Anomaly | aircraft equipment problem : less severe other anomaly other |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
| Resolutory Action | flight crew : returned to intended course or assigned course flight crew : overcame equipment problem |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Aircraft |
| Air Traffic Incident | Pilot Deviation |
Narrative:
We departed marquette, mi, and climbed to 17000 ft. As we were completing the cruise checklist, our master warning and cabin pressure lights began to flash. I called for memory items and quick reference handbook cabin pressure checklist, then immediately began a rapid descent. As my first officer reviewed the checklist, I advised center of our descent and requested an altitude below 10000 ft. As the first officer performed the checklist, he discovered that he had failed to turn the bleed air flow control knob fully clockwise after takeoff as required by our aircraft pilot operating manual. Therefore, there was not adequate air available to pressurize the cabin. The first officer adjusted the knob, and we climbed back to altitude without any further problem. It was the first officer's mistake that caused this particular problem, but I must take part of the blame. The first officer missed at least 1 checklist item on each of several legs prior to this flight. As PIC, I should have insisted that he pay closer attention to his duties.
Original NASA ASRS Text
Title: FO OF AN MDT FAILED TO POS THE BLEED AIR VALVE FOR CABIN PRESSURIZATION PROPERLY RESULTING IN LOSS OF CABIN PRESSURE AND AN EMER DSCNT.
Narrative: WE DEPARTED MARQUETTE, MI, AND CLBED TO 17000 FT. AS WE WERE COMPLETING THE CRUISE CHKLIST, OUR MASTER WARNING AND CABIN PRESSURE LIGHTS BEGAN TO FLASH. I CALLED FOR MEMORY ITEMS AND QUICK REF HANDBOOK CABIN PRESSURE CHKLIST, THEN IMMEDIATELY BEGAN A RAPID DSCNT. AS MY FO REVIEWED THE CHKLIST, I ADVISED CTR OF OUR DSCNT AND REQUESTED AN ALT BELOW 10000 FT. AS THE FO PERFORMED THE CHKLIST, HE DISCOVERED THAT HE HAD FAILED TO TURN THE BLEED AIR FLOW CTL KNOB FULLY CLOCKWISE AFTER TKOF AS REQUIRED BY OUR ACFT PLT OPERATING MANUAL. THEREFORE, THERE WAS NOT ADEQUATE AIR AVAILABLE TO PRESSURIZE THE CABIN. THE FO ADJUSTED THE KNOB, AND WE CLBED BACK TO ALT WITHOUT ANY FURTHER PROB. IT WAS THE FO'S MISTAKE THAT CAUSED THIS PARTICULAR PROB, BUT I MUST TAKE PART OF THE BLAME. THE FO MISSED AT LEAST 1 CHKLIST ITEM ON EACH OF SEVERAL LEGS PRIOR TO THIS FLT. AS PIC, I SHOULD HAVE INSISTED THAT HE PAY CLOSER ATTN TO HIS DUTIES.
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.