37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 432807 |
Time | |
Date | 199904 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : msp.airport |
State Reference | MN |
Altitude | msl single value : 1000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zmp.artcc |
Operator | common carrier : air carrier |
Make Model Name | DC-9 50 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : other published ifr departure |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 11000 flight time type : 3000 |
ASRS Report | 432807 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : cabin altitude warning other flight crewa |
Resolutory Action | aircraft : equipment problem dissipated controller : issued new clearance flight crew : overcame equipment problem |
Consequence | Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
ATC gave us climb to 17000 ft but when we got to 10000 ft the master warning light illuminated along with the red cabin altitude light. I looked and immediately saw that the pressurization controller on pedestal was in manual position and the cabin altitude was at 10000 ft. We told ATC we need to stay at 10000 ft and began the process if bringing the cabin back down. I do not know how the controller got in manual but there are 3 possibilities. 1) I was interrupted during preflight and missed it. I don't think this is the case because I remember no such interruption and preflight went normal with lots of time. 2) I was flying with new copilot who could have hit it while climbing into seat. (All you have to do is push handle down.) 3) a mechanic came up after preflight and while leaning over the pedestal could have inadvertently knocked it down to manual. Scenario #2 and #3 seem very plausible but the bottom line is, PNF missed it on the climb flow out of 3000 ft AGL. I should have done my own flow to back him up since he was very new to aircraft.
Original NASA ASRS Text
Title: A DC9-50 IN CLB AT 10000 FT EXPERIENCED THE CABIN ALT WARNING AND MASTER WARNING CAUSED BY THE MANUAL PRESSURE CTL INADVERTENTLY ENGAGED.
Narrative: ATC GAVE US CLB TO 17000 FT BUT WHEN WE GOT TO 10000 FT THE MASTER WARNING LIGHT ILLUMINATED ALONG WITH THE RED CABIN ALT LIGHT. I LOOKED AND IMMEDIATELY SAW THAT THE PRESSURIZATION CONTROLLER ON PEDESTAL WAS IN MANUAL POS AND THE CABIN ALT WAS AT 10000 FT. WE TOLD ATC WE NEED TO STAY AT 10000 FT AND BEGAN THE PROCESS IF BRINGING THE CABIN BACK DOWN. I DO NOT KNOW HOW THE CONTROLLER GOT IN MANUAL BUT THERE ARE 3 POSSIBILITIES. 1) I WAS INTERRUPTED DURING PREFLT AND MISSED IT. I DON'T THINK THIS IS THE CASE BECAUSE I REMEMBER NO SUCH INTERRUPTION AND PREFLT WENT NORMAL WITH LOTS OF TIME. 2) I WAS FLYING WITH NEW COPLT WHO COULD HAVE HIT IT WHILE CLBING INTO SEAT. (ALL YOU HAVE TO DO IS PUSH HANDLE DOWN.) 3) A MECH CAME UP AFTER PREFLT AND WHILE LEANING OVER THE PEDESTAL COULD HAVE INADVERTENTLY KNOCKED IT DOWN TO MANUAL. SCENARIO #2 AND #3 SEEM VERY PLAUSIBLE BUT THE BOTTOM LINE IS, PNF MISSED IT ON THE CLB FLOW OUT OF 3000 FT AGL. I SHOULD HAVE DONE MY OWN FLOW TO BACK HIM UP SINCE HE WAS VERY NEW TO ACFT.
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.