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|
Attributes | |
ACN | 400725 |
Time | |
Date | 199804 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : cvg |
State Reference | OH |
Altitude | msl bound lower : 25000 msl bound upper : 25000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | artcc : zid |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude descent other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 2550 flight time type : 100 |
ASRS Report | 400725 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 190 flight time total : 20000 flight time type : 17000 |
ASRS Report | 400722 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Following the announcement to prepare the cabin for departure, the aft flight attendant notified me of a loud noise at the aft left service door. The door annunciator light on my panel was extinguished indicating the door was locked closed. I informed the captain of the noise and checked to see if the aircraft was pressurizing normally. The aircraft had pressurized normally with the flight/grd switch on the pressurization controller in the flight position (cabin reading .125 psid). Following a discussion of the information available, the captain and I felt this was a leaky door seal which would seal up once the aircraft differential increased. I informed the flight attendant that we felt the noise would soon diminish as the aircraft continued to pressurize. Following takeoff, the aircraft continued to pressurize normally with a rate of climb of 300-500 FPM and a steadily increasing differential. During the climb out the cargo V closed light on the flight engineer panel illuminated indicating the cargo heat outflow had closed. I informed the captain that the light had illuminated and also advised him that all other indications were normal. Cabin altitude was around 4000 ft and differential was still increasing through 5 inches. During the climb, the aft flight attendant again called the cockpit and explained that the noise had gotten worse and the passenger were becoming concerned. Feeling this must be a poor seal, the captain and I agreed that it could be sealed using paper towels. I made this suggestion to the flight attendant and continued to monitor the pressurization controller. Passing through FL220 to FL230, the differential stopped increasing at 5.8 psid (normal is 8.6 psid) and the cabin altitude continued to climb. The lead flight attendant entered the cockpit and requested I go aft and investigate the door as the paper towels had not worked and were sucked from under the door. Prior to requesting permission from the captain to go aft, I noticed the cabin rate of climb increase from 500 FPM to 1000 FPM. I informed the captain that the cabin was becoming uncontrollable and told the lead flight attendantthat I would not be able to leave my station. As the cabin altitude was passing through 9000 ft, the captain instructed the first officer to coordinate a descent and return to departure field with ATC while we completed the loss of pressurization procedures. Soon after beginning the descent and switching the pressurization controller to manual, the cabin altitude began to descend at around 300 FPM. I informed the captain and first officer that I had control of the cabin. After dumping fuel to reduce to maximum landing weight, a normal landing was completed without further incident. Maintenance inspection of the door revealed the rollers on the bottom had failed to engage allowing the bottom hinged portion of the door to remain ajar while still giving a locked indication. Upon completion of maintenance action and documentation, the flight was continued. Multiple factors contributed to allow this situation to occur. All pilots assumed this noise was simply a leak of the door seal which is a fairly common complaint. We also assumed this 'leaky seal' would gradually correct itself as the cabin differential increased and the door seated itself against the seal. The closed and locked indication and initial normal pressurization indications bolstered this impression. The aft flight attendant failed to properly report the status of the door. Initially, the only information provided to the cockpit was a noise. As it turned out, the noise was accompanied by a gap at the bottom of the door sufficiently large enough to allow paper towels to exit the aircraft. Additionally, it wasn't until the aircraft had returned to the departure airfield that the flight attendant informed the captain that the noise was loud engine noise. The captain stated had he known this, he never would have continued the flight. Finally, in my opinion, the desire to complete an on-time takeoff in lieu of returning to the gate to correct an assumed nuisance gripe allowed us to complete the takeoff without properly diagnosing the situation and taking corrective action. Instead of accepting limited information from the flight attendant and assuming a 'best case' scenarioinregards to the door, the proper course of action would have been to send me back to inspect the door prior to takeoff. Additionally, the flight attendants should have been more assertive in adequately explaining the situation to the cockpit crew members. Enhanced CRM techniques used by all crew members could have prevented this situation.
Original NASA ASRS Text
Title: A B727 IS MANDATED TO RETURN LAND WHEN THE CABIN ALT STARTS TO CLB WHEN ACFT IS NEAR FL240. FLT ATTENDANTS HAD RPTED A 'NOISE' PRIOR TO DEP BUT COCKPIT CREW ASSUMED IT WAS A LEAKY DOOR SEAL SINCE THE DOOR LIGHTS WERE OUT. THE ROLLERS ON THE DOOR WERE NOT ENGAGED IN THE LOCKING MECHANISM.
Narrative: FOLLOWING THE ANNOUNCEMENT TO PREPARE THE CABIN FOR DEP, THE AFT FLT ATTENDANT NOTIFIED ME OF A LOUD NOISE AT THE AFT L SVC DOOR. THE DOOR ANNUNCIATOR LIGHT ON MY PANEL WAS EXTINGUISHED INDICATING THE DOOR WAS LOCKED CLOSED. I INFORMED THE CAPT OF THE NOISE AND CHKED TO SEE IF THE ACFT WAS PRESSURIZING NORMALLY. THE ACFT HAD PRESSURIZED NORMALLY WITH THE FLT/GRD SWITCH ON THE PRESSURIZATION CTLR IN THE FLT POS (CABIN READING .125 PSID). FOLLOWING A DISCUSSION OF THE INFO AVAILABLE, THE CAPT AND I FELT THIS WAS A LEAKY DOOR SEAL WHICH WOULD SEAL UP ONCE THE ACFT DIFFERENTIAL INCREASED. I INFORMED THE FLT ATTENDANT THAT WE FELT THE NOISE WOULD SOON DIMINISH AS THE ACFT CONTINUED TO PRESSURIZE. FOLLOWING TKOF, THE ACFT CONTINUED TO PRESSURIZE NORMALLY WITH A RATE OF CLB OF 300-500 FPM AND A STEADILY INCREASING DIFFERENTIAL. DURING THE CLBOUT THE CARGO V CLOSED LIGHT ON THE FE PANEL ILLUMINATED INDICATING THE CARGO HEAT OUTFLOW HAD CLOSED. I INFORMED THE CAPT THAT THE LIGHT HAD ILLUMINATED AND ALSO ADVISED HIM THAT ALL OTHER INDICATIONS WERE NORMAL. CABIN ALT WAS AROUND 4000 FT AND DIFFERENTIAL WAS STILL INCREASING THROUGH 5 INCHES. DURING THE CLB, THE AFT FLT ATTENDANT AGAIN CALLED THE COCKPIT AND EXPLAINED THAT THE NOISE HAD GOTTEN WORSE AND THE PAX WERE BECOMING CONCERNED. FEELING THIS MUST BE A POOR SEAL, THE CAPT AND I AGREED THAT IT COULD BE SEALED USING PAPER TOWELS. I MADE THIS SUGGESTION TO THE FLT ATTENDANT AND CONTINUED TO MONITOR THE PRESSURIZATION CTLR. PASSING THROUGH FL220 TO FL230, THE DIFFERENTIAL STOPPED INCREASING AT 5.8 PSID (NORMAL IS 8.6 PSID) AND THE CABIN ALT CONTINUED TO CLB. THE LEAD FLT ATTENDANT ENTERED THE COCKPIT AND REQUESTED I GO AFT AND INVESTIGATE THE DOOR AS THE PAPER TOWELS HAD NOT WORKED AND WERE SUCKED FROM UNDER THE DOOR. PRIOR TO REQUESTING PERMISSION FROM THE CAPT TO GO AFT, I NOTICED THE CABIN RATE OF CLB INCREASE FROM 500 FPM TO 1000 FPM. I INFORMED THE CAPT THAT THE CABIN WAS BECOMING UNCTLABLE AND TOLD THE LEAD FLT ATTENDANTTHAT I WOULD NOT BE ABLE TO LEAVE MY STATION. AS THE CABIN ALT WAS PASSING THROUGH 9000 FT, THE CAPT INSTRUCTED THE FO TO COORDINATE A DSCNT AND RETURN TO DEP FIELD WITH ATC WHILE WE COMPLETED THE LOSS OF PRESSURIZATION PROCS. SOON AFTER BEGINNING THE DSCNT AND SWITCHING THE PRESSURIZATION CTLR TO MANUAL, THE CABIN ALT BEGAN TO DSND AT AROUND 300 FPM. I INFORMED THE CAPT AND FO THAT I HAD CTL OF THE CABIN. AFTER DUMPING FUEL TO REDUCE TO MAX LNDG WT, A NORMAL LNDG WAS COMPLETED WITHOUT FURTHER INCIDENT. MAINT INSPECTION OF THE DOOR REVEALED THE ROLLERS ON THE BOTTOM HAD FAILED TO ENGAGE ALLOWING THE BOTTOM HINGED PORTION OF THE DOOR TO REMAIN AJAR WHILE STILL GIVING A LOCKED INDICATION. UPON COMPLETION OF MAINT ACTION AND DOCUMENTATION, THE FLT WAS CONTINUED. MULTIPLE FACTORS CONTRIBUTED TO ALLOW THIS SIT TO OCCUR. ALL PLTS ASSUMED THIS NOISE WAS SIMPLY A LEAK OF THE DOOR SEAL WHICH IS A FAIRLY COMMON COMPLAINT. WE ALSO ASSUMED THIS 'LEAKY SEAL' WOULD GRADUALLY CORRECT ITSELF AS THE CABIN DIFFERENTIAL INCREASED AND THE DOOR SEATED ITSELF AGAINST THE SEAL. THE CLOSED AND LOCKED INDICATION AND INITIAL NORMAL PRESSURIZATION INDICATIONS BOLSTERED THIS IMPRESSION. THE AFT FLT ATTENDANT FAILED TO PROPERLY RPT THE STATUS OF THE DOOR. INITIALLY, THE ONLY INFO PROVIDED TO THE COCKPIT WAS A NOISE. AS IT TURNED OUT, THE NOISE WAS ACCOMPANIED BY A GAP AT THE BOTTOM OF THE DOOR SUFFICIENTLY LARGE ENOUGH TO ALLOW PAPER TOWELS TO EXIT THE ACFT. ADDITIONALLY, IT WASN'T UNTIL THE ACFT HAD RETURNED TO THE DEP AIRFIELD THAT THE FLT ATTENDANT INFORMED THE CAPT THAT THE NOISE WAS LOUD ENG NOISE. THE CAPT STATED HAD HE KNOWN THIS, HE NEVER WOULD HAVE CONTINUED THE FLT. FINALLY, IN MY OPINION, THE DESIRE TO COMPLETE AN ON-TIME TKOF IN LIEU OF RETURNING TO THE GATE TO CORRECT AN ASSUMED NUISANCE GRIPE ALLOWED US TO COMPLETE THE TKOF WITHOUT PROPERLY DIAGNOSING THE SIT AND TAKING CORRECTIVE ACTION. INSTEAD OF ACCEPTING LIMITED INFO FROM THE FLT ATTENDANT AND ASSUMING A 'BEST CASE' SCENARIOINREGARDS TO THE DOOR, THE PROPER COURSE OF ACTION WOULD HAVE BEEN TO SEND ME BACK TO INSPECT THE DOOR PRIOR TO TKOF. ADDITIONALLY, THE FLT ATTENDANTS SHOULD HAVE BEEN MORE ASSERTIVE IN ADEQUATELY EXPLAINING THE SIT TO THE COCKPIT CREW MEMBERS. ENHANCED CRM TECHNIQUES USED BY ALL CREW MEMBERS COULD HAVE PREVENTED THIS SIT.
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.