37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 304121 |
Time | |
Date | 199505 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : cvg |
State Reference | OH |
Altitude | msl bound lower : 10000 msl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
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 | climbout : intermediate altitude |
Route In Use | departure other enroute airway : cvg |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 190 flight time total : 6100 flight time type : 900 |
ASRS Report | 304121 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | other Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
As we taxied to the runway, all the checklists were completed and everything was ok. We commenced our takeoff and climbing out of approximately 600 ft AGL we got the 'passenger door outer handle' caution message. We checked the pressurization and it seemed normal and was pressurizing. This caution message has been a nuisance message in the past. We continued to climb out and were still pressurizing. After completing our climb checklist, we proceeded to do the passenger door outer handle checklist which calls for us to check the pressurization and visually check the door. Through about 10000 ft we got another message 'overboard cool fail' caution which effects pressurization. At this point we started depressurizing and therefore stopped our climb and initiated a descent. We had just contacted our flight attendant and had her check the door. She told us that 3 of the 8 green marks that indicate the door is closed, were not lined up and that shortly after takeoff she heard a mechanical clunking noise come from the door. After talking with the flight attendant, we proceeded to do the appropriate part of the checklist. This called for us to go to manual pressurization and descend to at least 10000 ft plus then return for landing. We notified ATC we needed to return to cvg and told the passenger we returned for landing without further incident. However, the flight attendant said that on short final the other 5 green door marks disappeared and the red door unlocked flag appeared. This again, she said, was associated with another mechanical clunking noise within the door. On the ground, after talking to maintenance, they said there was 'quite a bit of play in the door handle' and 'it was probably something within the door mechanism' a day later when discussing this with a mechanic, he said that there was a history of this type of thing happening. In closing, although we did the proper procedure in the checklist, the checklist was somewhat confusing to follow because of the way it is set up. Callback conversation with reporter revealed the following information: the reporter suggests that this incident is the manifestation of an aircraft that was not actually designed for the mission it is flying. The original design was for a corporate aircraft that would fly 300 or 400 hours a yr and the doors would be opened and closed a couple of times a day on the days it flew. As a regional air carrier jet the aircraft flies 300 hours per month and the doors are opened and closed 10 or more times every day of the month. Consequently the latches are wearing loose and sloppy. He said the door is not exactly a plug type door but he believes that the latches are not what secures the door from opening in pressurized flight. Nevertheless, the flight attendant was so terrified she could not function as the flight attendant on the replacement aircraft and the passenger had to be overnighted and the replacement aircraft ferried empty to the destination. The checklist corrective action for the 'overboard cool fail' caution light on the ground is to check the passenger door for proper closing. There is no checklist for that light in-flight.
Original NASA ASRS Text
Title: 'PAX DOOR OUTER HANDLE' CAUTION LIGHT AND 'OVERBOARD COOL FAIL' CAUTION LIGHT CAME ON IN CLB PROMPTING THE CREW TO RETURN LAND.
Narrative: AS WE TAXIED TO THE RWY, ALL THE CHKLISTS WERE COMPLETED AND EVERYTHING WAS OK. WE COMMENCED OUR TKOF AND CLBING OUT OF APPROX 600 FT AGL WE GOT THE 'PAX DOOR OUTER HANDLE' CAUTION MESSAGE. WE CHKED THE PRESSURIZATION AND IT SEEMED NORMAL AND WAS PRESSURIZING. THIS CAUTION MESSAGE HAS BEEN A NUISANCE MESSAGE IN THE PAST. WE CONTINUED TO CLB OUT AND WERE STILL PRESSURIZING. AFTER COMPLETING OUR CLB CHKLIST, WE PROCEEDED TO DO THE PAX DOOR OUTER HANDLE CHKLIST WHICH CALLS FOR US TO CHK THE PRESSURIZATION AND VISUALLY CHK THE DOOR. THROUGH ABOUT 10000 FT WE GOT ANOTHER MESSAGE 'OVERBOARD COOL FAIL' CAUTION WHICH EFFECTS PRESSURIZATION. AT THIS POINT WE STARTED DEPRESSURIZING AND THEREFORE STOPPED OUR CLB AND INITIATED A DSCNT. WE HAD JUST CONTACTED OUR FLT ATTENDANT AND HAD HER CHK THE DOOR. SHE TOLD US THAT 3 OF THE 8 GREEN MARKS THAT INDICATE THE DOOR IS CLOSED, WERE NOT LINED UP AND THAT SHORTLY AFTER TKOF SHE HEARD A MECHANICAL CLUNKING NOISE COME FROM THE DOOR. AFTER TALKING WITH THE FLT ATTENDANT, WE PROCEEDED TO DO THE APPROPRIATE PART OF THE CHKLIST. THIS CALLED FOR US TO GO TO MANUAL PRESSURIZATION AND DSND TO AT LEAST 10000 FT PLUS THEN RETURN FOR LNDG. WE NOTIFIED ATC WE NEEDED TO RETURN TO CVG AND TOLD THE PAX WE RETURNED FOR LNDG WITHOUT FURTHER INCIDENT. HOWEVER, THE FLT ATTENDANT SAID THAT ON SHORT FINAL THE OTHER 5 GREEN DOOR MARKS DISAPPEARED AND THE RED DOOR UNLOCKED FLAG APPEARED. THIS AGAIN, SHE SAID, WAS ASSOCIATED WITH ANOTHER MECHANICAL CLUNKING NOISE WITHIN THE DOOR. ON THE GND, AFTER TALKING TO MAINT, THEY SAID THERE WAS 'QUITE A BIT OF PLAY IN THE DOOR HANDLE' AND 'IT WAS PROBABLY SOMETHING WITHIN THE DOOR MECHANISM' A DAY LATER WHEN DISCUSSING THIS WITH A MECH, HE SAID THAT THERE WAS A HISTORY OF THIS TYPE OF THING HAPPENING. IN CLOSING, ALTHOUGH WE DID THE PROPER PROC IN THE CHKLIST, THE CHKLIST WAS SOMEWHAT CONFUSING TO FOLLOW BECAUSE OF THE WAY IT IS SET UP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SUGGESTS THAT THIS INCIDENT IS THE MANIFESTATION OF AN ACFT THAT WAS NOT ACTUALLY DESIGNED FOR THE MISSION IT IS FLYING. THE ORIGINAL DESIGN WAS FOR A CORPORATE ACFT THAT WOULD FLY 300 OR 400 HRS A YR AND THE DOORS WOULD BE OPENED AND CLOSED A COUPLE OF TIMES A DAY ON THE DAYS IT FLEW. AS A REGIONAL ACR JET THE ACFT FLIES 300 HRS PER MONTH AND THE DOORS ARE OPENED AND CLOSED 10 OR MORE TIMES EVERY DAY OF THE MONTH. CONSEQUENTLY THE LATCHES ARE WEARING LOOSE AND SLOPPY. HE SAID THE DOOR IS NOT EXACTLY A PLUG TYPE DOOR BUT HE BELIEVES THAT THE LATCHES ARE NOT WHAT SECURES THE DOOR FROM OPENING IN PRESSURIZED FLT. NEVERTHELESS, THE FLT ATTENDANT WAS SO TERRIFIED SHE COULD NOT FUNCTION AS THE FLT ATTENDANT ON THE REPLACEMENT ACFT AND THE PAX HAD TO BE OVERNIGHTED AND THE REPLACEMENT ACFT FERRIED EMPTY TO THE DEST. THE CHKLIST CORRECTIVE ACTION FOR THE 'OVERBOARD COOL FAIL' CAUTION LIGHT ON THE GND IS TO CHK THE PAX DOOR FOR PROPER CLOSING. THERE IS NO CHKLIST FOR THAT LIGHT INFLT.
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.