37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 322170 |
Time | |
Date | 199511 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : amg |
State Reference | GA |
Altitude | msl bound lower : 31000 msl bound upper : 31000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zjx |
Operator | common carrier : air carrier |
Make Model Name | L-1011 Tri-Star All Series |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument pilot : flight engineer |
Experience | flight time last 90 days : 204 flight time total : 9767 flight time type : 1655 |
ASRS Report | 322170 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 21000 flight time type : 10000 |
ASRS Report | 322584 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency flight crew : overcame equipment problem |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | other |
Narrative:
So didn't turn on air-conditioning packs #1 and #3 after takeoff. We leveled off at FL280 (I think) and started a climb to FL310. At FL300 to FL310 a horn went off. I said 'isn't that the cabin horn?' the so said the cabin was at 10500 ft and we donned oxygen masks and stopped climb while getting clearance to descend to FL240. Somewhere during this time I said to 'make sure your packs are on.' the so said something about the outflow valves were closed and he couldn't control the cabin. We declared an emergency and center had us turn to approximately east 90 degrees or right 110 degrees. As we continued to descend, I noticed 2 aircraft on TCASII. I believe the closest was 2300 ft below and 5-7 mi away (yellow or TA) on TCASII. At this point, I thought the so had acknowledged my 'pack check,' but he hadn't. The captain told him to turn on packs #1 and #3 and the cabin recovered immediately. We told center we were ok and got as low as 19800 ft and leveled at FL200 and proceeded on course. During descent we told the passenger we were having difficulty controling the cabin pressure and after level off at FL200 we told them everything was ok. Problems: so didn't turn on packs after takeoff (after takeoff checklist). So didn't hear me tell him to check the packs were on. Hearing. So missed the packs on the emergency checklist. Pack switches are difficult to pick out when viewed from captain seat and impossible to see from first officer seat without gymnastic training. So was (maybe) nervous as it was his first so flight after IOE (downbid to so). (Also, nervous about FAA inspector on board maybe.) solution: differentiate pack switches. Paint a green border around them. Be aware of new guy/nervous syndrome. Be aware older so's may not hear well.
Original NASA ASRS Text
Title: NEW SO DID NOT TURN ON #1 AND #3 AIR-CONDITIONING SYS IN ACCORDANCE WITH AFTER TKOF SILENT CHKLIST. AT ABOUT FL300 1 AIR-CONDITIONING PRESSURIZATION SYS UNABLE TO MAINTAIN 10500 FT ALT IN THE CABIN. CABIN ALT WARNING PROMPTS CREW TO DON OXYGEN MASKS AND COMMENCE EMER DSCNT. #1 AND #3 AIR-CONDITIONING SYS TURNED ON AND NORMAL PRESSURIZATION RESTORED.
Narrative: SO DIDN'T TURN ON AIR-CONDITIONING PACKS #1 AND #3 AFTER TKOF. WE LEVELED OFF AT FL280 (I THINK) AND STARTED A CLB TO FL310. AT FL300 TO FL310 A HORN WENT OFF. I SAID 'ISN'T THAT THE CABIN HORN?' THE SO SAID THE CABIN WAS AT 10500 FT AND WE DONNED OXYGEN MASKS AND STOPPED CLB WHILE GETTING CLRNC TO DSND TO FL240. SOMEWHERE DURING THIS TIME I SAID TO 'MAKE SURE YOUR PACKS ARE ON.' THE SO SAID SOMETHING ABOUT THE OUTFLOW VALVES WERE CLOSED AND HE COULDN'T CTL THE CABIN. WE DECLARED AN EMER AND CTR HAD US TURN TO APPROX E 90 DEGS OR R 110 DEGS. AS WE CONTINUED TO DSND, I NOTICED 2 ACFT ON TCASII. I BELIEVE THE CLOSEST WAS 2300 FT BELOW AND 5-7 MI AWAY (YELLOW OR TA) ON TCASII. AT THIS POINT, I THOUGHT THE SO HAD ACKNOWLEDGED MY 'PACK CHK,' BUT HE HADN'T. THE CAPT TOLD HIM TO TURN ON PACKS #1 AND #3 AND THE CABIN RECOVERED IMMEDIATELY. WE TOLD CTR WE WERE OK AND GOT AS LOW AS 19800 FT AND LEVELED AT FL200 AND PROCEEDED ON COURSE. DURING DSCNT WE TOLD THE PAX WE WERE HAVING DIFFICULTY CTLING THE CABIN PRESSURE AND AFTER LEVEL OFF AT FL200 WE TOLD THEM EVERYTHING WAS OK. PROBS: SO DIDN'T TURN ON PACKS AFTER TKOF (AFTER TKOF CHKLIST). SO DIDN'T HEAR ME TELL HIM TO CHK THE PACKS WERE ON. HEARING. SO MISSED THE PACKS ON THE EMER CHKLIST. PACK SWITCHES ARE DIFFICULT TO PICK OUT WHEN VIEWED FROM CAPT SEAT AND IMPOSSIBLE TO SEE FROM FO SEAT WITHOUT GYMNASTIC TRAINING. SO WAS (MAYBE) NERVOUS AS IT WAS HIS FIRST SO FLT AFTER IOE (DOWNBID TO SO). (ALSO, NERVOUS ABOUT FAA INSPECTOR ON BOARD MAYBE.) SOLUTION: DIFFERENTIATE PACK SWITCHES. PAINT A GREEN BORDER AROUND THEM. BE AWARE OF NEW GUY/NERVOUS SYNDROME. BE AWARE OLDER SO'S MAY NOT HEAR WELL.
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.