B767-300 crew experiences pressurization problem while dealing simultaneously with irregular system ...

Attributes
ACN	443965
Time
Date	199907
Day	Thu
Local Time Of Day	0601 To 1200
Place
Locale Reference	airport : muha.airport
State Reference	FO
Altitude	msl single value : 2000
Environment
Flight Conditions	VMC
Weather Elements	Thunderstorm
Light	Daylight
Aircraft 1
Controlling Facilities	tower : dfw.tower
Operator	common carrier : air carrier
Make Model Name	B767-300 and 300 ER
Operating Under FAR Part	Part 121
Flight Phase	climbout : initial climbout : intermediate altitude ground : takeoff roll
Route In Use	departure : on vectors
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial
Experience	flight time last 90 days : 150 flight time total : 20000 flight time type : 875
ASRS Report	443965
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 inflight encounter : weather non adherence : company policies
Independent Detector	other flight crewa other flight crewb
Resolutory Action	controller : issued new clearance flight crew : overcame equipment problem flight crew : overrode automation
Supplementary
Problem Areas	Aircraft Flight Crew Human Performance ATC Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

First officer flying, captain performing PNF duties, pre departure clearance cleared to FL240. During takeoff roll, havana tower advised us to stop climb at 2000 ft. The SID requires no acceleration until 2000 ft and we had prebriefed flap retraction at 2000 ft. After gear retraction we called havana departure control. As we leveled at 2000 ft, began flap retraction. Concurrently, departure controller gave us a southeast heading (runway 6 takeoff) for traffic, then a heading back to the northeast with a climb to 4000 ft. While this activity was occurring, we retracted flaps and I got the 2 packs on. With the pauses necessary to let the pressurization stabilize between steps, I was interrupted by one of the radio calls with heading and altitude change, support for the PF with MCP inputs and concern for thunderstorm buildups in front of us. We were then cleared to FL240 and direct to tadpo intersection. Passing 10000 ft, the cabin altitude horn began to sound. I looked over on the overhead panel to figure out what the problem was. The first officer leveled the aircraft at 11000 ft saving the deployment of oxygen masks. I realized the pressurization switch was still in manual. I reconfigured the system and soon cabin pressure was back under control. We continued climb to FL240 and completed the flight to mia. Air carrier B767-300 aircraft have had compressor stall problems at or immediately after takeoff. The 'fix' until all engines are modified to rectify the problem is to take off with packs off and pressurization switch in manual versus automatic. We typically fly this aircraft to south america out of mia with a 3 man crew, so the jump seat first officer typically handles the pack/pressurization reconfign. Nonetheless, even with a 2 man operation, oversaturation of PNF by events such as these can lead to errors. It is difficult to see the pressurization switches from the captain's seat. They are above the first officer's head. To prevent a recurrence, I believe the captain should make all takeoffs in 2 man operations until after takeoff checklist complete at 3000 ft, then xfer control to first officer if it's the first officer's leg to fly. I also believe this is a training issue for this nonstandard manual operation on an automatic/electric airplane. The after takeoff checklist does not address the reconfign of the pressurization. Callback conversation with reporter revealed the following information: reporter states that he has contacted the air carrier and union safety personnel concerning the 'temporary' and hazardous procedure. He has spoken with several other crews that have had the same occurrence and has actually spoken with one crew just after an incident just like this report. He states that on or approximately xa/aug/99, this new procedure has been halted. The procedure now is to operate the air conditioning and pressurization systems in the manner stated in the flight manuals. The reporter feels that the feedback from crews was instrumental in getting the procedure re-revised.

Original NASA ASRS Text

Title: B767-300 CREW EXPERIENCES PRESSURIZATION PROB WHILE DEALING SIMULTANEOUSLY WITH IRREGULAR SYS OP, ATC CLRNC CHANGES, AND WX AVOIDANCE AT LOW ALT AT HAVANA.

Narrative: FO FLYING, CAPT PERFORMING PNF DUTIES, PDC CLRED TO FL240. DURING TKOF ROLL, HAVANA TWR ADVISED US TO STOP CLB AT 2000 FT. THE SID REQUIRES NO ACCELERATION UNTIL 2000 FT AND WE HAD PREBRIEFED FLAP RETRACTION AT 2000 FT. AFTER GEAR RETRACTION WE CALLED HAVANA DEP CTL. AS WE LEVELED AT 2000 FT, BEGAN FLAP RETRACTION. CONCURRENTLY, DEP CTLR GAVE US A SE HDG (RWY 6 TKOF) FOR TFC, THEN A HDG BACK TO THE NE WITH A CLB TO 4000 FT. WHILE THIS ACTIVITY WAS OCCURRING, WE RETRACTED FLAPS AND I GOT THE 2 PACKS ON. WITH THE PAUSES NECESSARY TO LET THE PRESSURIZATION STABILIZE BTWN STEPS, I WAS INTERRUPTED BY ONE OF THE RADIO CALLS WITH HDG AND ALT CHANGE, SUPPORT FOR THE PF WITH MCP INPUTS AND CONCERN FOR TSTM BUILDUPS IN FRONT OF US. WE WERE THEN CLRED TO FL240 AND DIRECT TO TADPO INTXN. PASSING 10000 FT, THE CABIN ALT HORN BEGAN TO SOUND. I LOOKED OVER ON THE OVERHEAD PANEL TO FIGURE OUT WHAT THE PROB WAS. THE FO LEVELED THE ACFT AT 11000 FT SAVING THE DEPLOYMENT OF OXYGEN MASKS. I REALIZED THE PRESSURIZATION SWITCH WAS STILL IN MANUAL. I RECONFIGURED THE SYS AND SOON CABIN PRESSURE WAS BACK UNDER CTL. WE CONTINUED CLB TO FL240 AND COMPLETED THE FLT TO MIA. ACR B767-300 ACFT HAVE HAD COMPRESSOR STALL PROBS AT OR IMMEDIATELY AFTER TKOF. THE 'FIX' UNTIL ALL ENGS ARE MODIFIED TO RECTIFY THE PROB IS TO TAKE OFF WITH PACKS OFF AND PRESSURIZATION SWITCH IN MANUAL VERSUS AUTO. WE TYPICALLY FLY THIS ACFT TO SOUTH AMERICA OUT OF MIA WITH A 3 MAN CREW, SO THE JUMP SEAT FO TYPICALLY HANDLES THE PACK/PRESSURIZATION RECONFIGN. NONETHELESS, EVEN WITH A 2 MAN OP, OVERSATURATION OF PNF BY EVENTS SUCH AS THESE CAN LEAD TO ERRORS. IT IS DIFFICULT TO SEE THE PRESSURIZATION SWITCHES FROM THE CAPT'S SEAT. THEY ARE ABOVE THE FO'S HEAD. TO PREVENT A RECURRENCE, I BELIEVE THE CAPT SHOULD MAKE ALL TKOFS IN 2 MAN OPS UNTIL AFTER TKOF CHKLIST COMPLETE AT 3000 FT, THEN XFER CTL TO FO IF IT'S THE FO'S LEG TO FLY. I ALSO BELIEVE THIS IS A TRAINING ISSUE FOR THIS NONSTANDARD MANUAL OP ON AN AUTOMATIC/ELECTRIC AIRPLANE. THE AFTER TKOF CHKLIST DOES NOT ADDRESS THE RECONFIGN OF THE PRESSURIZATION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATES THAT HE HAS CONTACTED THE ACR AND UNION SAFETY PERSONNEL CONCERNING THE 'TEMPORARY' AND HAZARDOUS PROC. HE HAS SPOKEN WITH SEVERAL OTHER CREWS THAT HAVE HAD THE SAME OCCURRENCE AND HAS ACTUALLY SPOKEN WITH ONE CREW JUST AFTER AN INCIDENT JUST LIKE THIS RPT. HE STATES THAT ON OR APPROX XA/AUG/99, THIS NEW PROC HAS BEEN HALTED. THE PROC NOW IS TO OPERATE THE AIR CONDITIONING AND PRESSURIZATION SYSTEMS IN THE MANNER STATED IN THE FLT MANUALS. THE RPTR FEELS THAT THE FEEDBACK FROM CREWS WAS INSTRUMENTAL IN GETTING THE PROC RE-REVISED.

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.

B767-300 crew experiences pressurization problem while dealing simultaneously with irregular system operation, ATC clearance changes, and WX avoidance at low altitude at havana.