37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 435530 |
Time | |
Date | 199904 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : uva.vor |
State Reference | FO |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : muha.tracon |
Operator | common carrier : air carrier |
Make Model Name | Boeing Company Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : flight engineer pilot : atp pilot : cfi |
Experience | flight time last 90 days : 120 flight time total : 15000 flight time type : 2800 |
ASRS Report | 435530 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Events | |
Anomaly | aircraft equipment problem : less severe cabin event other non adherence : company policies non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : cabin altitude warning horn |
Resolutory Action | flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Our company and boeing aircraft company have recently instituted a procedural change in the takeoff confign for our aircraft to include takeoff and departure with the pressurization packs off until established in climb. As we rotated for takeoff we blew out a tire which caused strong vibrations as the gear was raised. The 'return to normal pressurization with packs-off' procedure is to establish climb confign, turn on 1 pack, wait for the cabin climb rate to stabilize, turn on the automatic pressurization control and wait for it to stabilize, and finally to turn on the second pack. The initial steps of this procedure had been accomplished when departure control urged us to return to tower frequency for an important message. It took some time for us to eventually understand from the spanish speaking controller that we had in fact blown a tire. We returned to departure control and continued with the subsequent steps in the packs-off procedure, but the automatic controller was quite slow to stabilize and as we passed about 11000 ft MSL the cabin altitude warning light illuminated, indicating that we had exceeded a cabin altitude of 10000 ft. The aircraft was immediately leveled off, the second pack turned on, and the cabin altitude slowly returned to normal. There were several factors contributing to this event. 1) the packs-off takeoff procedure is a recent change, and only used on 1 of the 3 models of this aircraft that we fly. 2) the aircraft was unusually light and climbed at a very rapid rate. 3) the distraction of the blown tire and the additional radio communications that interrupted the normal after takeoff and climb checklist flow. 4) the slow response of the automatic pressurization controller during the completion of the 'return to normal pressurization' procedure.
Original NASA ASRS Text
Title: ACR ACFT CABIN ALT EXCEEDS 10000 FT.
Narrative: OUR COMPANY AND BOEING ACFT COMPANY HAVE RECENTLY INSTITUTED A PROCEDURAL CHANGE IN THE TKOF CONFIGN FOR OUR ACFT TO INCLUDE TKOF AND DEP WITH THE PRESSURIZATION PACKS OFF UNTIL ESTABLISHED IN CLB. AS WE ROTATED FOR TKOF WE BLEW OUT A TIRE WHICH CAUSED STRONG VIBRATIONS AS THE GEAR WAS RAISED. THE 'RETURN TO NORMAL PRESSURIZATION WITH PACKS-OFF' PROC IS TO ESTABLISH CLB CONFIGN, TURN ON 1 PACK, WAIT FOR THE CABIN CLB RATE TO STABILIZE, TURN ON THE AUTO PRESSURIZATION CTL AND WAIT FOR IT TO STABILIZE, AND FINALLY TO TURN ON THE SECOND PACK. THE INITIAL STEPS OF THIS PROC HAD BEEN ACCOMPLISHED WHEN DEP CTL URGED US TO RETURN TO TWR FREQ FOR AN IMPORTANT MESSAGE. IT TOOK SOME TIME FOR US TO EVENTUALLY UNDERSTAND FROM THE SPANISH SPEAKING CTLR THAT WE HAD IN FACT BLOWN A TIRE. WE RETURNED TO DEP CTL AND CONTINUED WITH THE SUBSEQUENT STEPS IN THE PACKS-OFF PROC, BUT THE AUTO CTLR WAS QUITE SLOW TO STABILIZE AND AS WE PASSED ABOUT 11000 FT MSL THE CABIN ALT WARNING LIGHT ILLUMINATED, INDICATING THAT WE HAD EXCEEDED A CABIN ALT OF 10000 FT. THE ACFT WAS IMMEDIATELY LEVELED OFF, THE SECOND PACK TURNED ON, AND THE CABIN ALT SLOWLY RETURNED TO NORMAL. THERE WERE SEVERAL FACTORS CONTRIBUTING TO THIS EVENT. 1) THE PACKS-OFF TKOF PROC IS A RECENT CHANGE, AND ONLY USED ON 1 OF THE 3 MODELS OF THIS ACFT THAT WE FLY. 2) THE ACFT WAS UNUSUALLY LIGHT AND CLBED AT A VERY RAPID RATE. 3) THE DISTR OF THE BLOWN TIRE AND THE ADDITIONAL RADIO COMS THAT INTERRUPTED THE NORMAL AFTER TKOF AND CLB CHKLIST FLOW. 4) THE SLOW RESPONSE OF THE AUTO PRESSURIZATION CTLR DURING THE COMPLETION OF THE 'RETURN TO NORMAL PRESSURIZATION' PROC.
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.