<< >> NASA ASRS Report 366470, April 1997

An air carrier medium large transport flight crew loses their pressurization system and descend toward 10000 ft, but go below. They were distraction and fatigued.

Attributes
ACN	366470
Time
Date	199704
Day	Thu
Local Time Of Day	0601 To 1200
Place
Locale Reference	airport : den
State Reference	CO
Altitude	msl bound lower : 9600 msl bound upper : 10000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : den
Operator	common carrier : air carrier
Make Model Name	Commercial Fixed Wing
Operating Under FAR Part	Part 121
Flight Phase	climbout : intermediate altitude descent other other
Route In Use	departure other departure sid : sid
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
ASRS Report	366470
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : commercial pilot : instrument
Events
Anomaly	aircraft equipment problem : critical altitude deviation : overshoot non adherence : far non adherence : clearance
Independent Detector	other flight crewa
Resolutory Action	flight crew : returned to intended course or assigned course flight crew : declared emergency
Consequence	Other
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

On departure from den airport we experienced pressurization problems while climbing through 11000 ft MSL. We immediately requested descent to 10000 ft in order to deal with the problem. In the confusion of handling the abnormal checklist, flying the aircraft, and an ATC frequency change, I inadvertently descended to 9600 ft, after which I immediately returned to 10000 ft. The first officer and myself were on the last leg of 5 days of flying. I had not been sleeping well and I believe that was a primary factor in the deviation. The aircraft problem was also a major contributor to the event. This stresses the importance to me of being rested and healthy any time you go flying.

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Original NASA ASRS Text

Title: AN ACR MLG FLC LOSES THEIR PRESSURIZATION SYS AND DSND TOWARD 10000 FT, BUT GO BELOW. THEY WERE DISTR AND FATIGUED.

Narrative: ON DEP FROM DEN ARPT WE EXPERIENCED PRESSURIZATION PROBS WHILE CLBING THROUGH 11000 FT MSL. WE IMMEDIATELY REQUESTED DSCNT TO 10000 FT IN ORDER TO DEAL WITH THE PROB. IN THE CONFUSION OF HANDLING THE ABNORMAL CHKLIST, FLYING THE ACFT, AND AN ATC FREQ CHANGE, I INADVERTENTLY DSNDED TO 9600 FT, AFTER WHICH I IMMEDIATELY RETURNED TO 10000 FT. THE FO AND MYSELF WERE ON THE LAST LEG OF 5 DAYS OF FLYING. I HAD NOT BEEN SLEEPING WELL AND I BELIEVE THAT WAS A PRIMARY FACTOR IN THE DEV. THE ACFT PROB WAS ALSO A MAJOR CONTRIBUTOR TO THE EVENT. THIS STRESSES THE IMPORTANCE TO ME OF BEING RESTED AND HEALTHY ANY TIME YOU GO FLYING.

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.