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|
Attributes | |
ACN | 451324 |
Time | |
Date | 199910 |
Day | Sat |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | navaid : vhp.vor |
State Reference | IN |
Altitude | msl bound lower : 5000 msl bound upper : 13500 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zid.artcc tracon : ind.tracon tower : ind.tower |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | climbout : intermediate altitude descent : approach descent : intermediate altitude |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : multi engine pilot : cfi pilot : atp |
Experience | flight time last 90 days : 174 flight time total : 4615 flight time type : 2214 |
ASRS Report | 451324 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : less severe inflight encounter : weather non adherence : far non adherence : published procedure non adherence : company policies other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : landed as precaution other |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Weather Flight Crew Human Performance |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
Upon departure, it was discovered that the aircraft was pressurizing abnormally. After troubleshooting the problem, the crew determined that the right air-conditioning pack was inoperative and that the flight would have to return instead of continuing on as scheduled. ATC was notified (13500 ft MSL, 34 DME on the vhp 263 degree radial), and the flight was given a vector back towards the airport and issued a descent. The crew then determined that fuel would need to be dumped, in order to meet the landing weight of our aircraft. Fuel dump calculations needed to be made along with the tasks of obtaining arrival information, notifying the company of our problem, briefing the instrument approach, and completing the approach checklist. Because of our close proximity to the airport, there was a lot to do in a very short time. During this high workload period, the fuel dump checklist was overlooked and fuel was dumped procedurally 'by memory.' the crew failed to notify ATC that fuel needed to be dumped as required by the company's fuel dumping checklist. 8000 pounds of fuel was dumped between 13500 ft MSL and approximately 5000 ft MSL. The flight landed uneventfully back at indianapolis at XA44 am local. The preoccupation with the possible causes of the pack failure and the deteriorating WX conditions back at indianapolis along with the high pilot workload were contributing factors to this occurrence. Crew fatigue, due to the late hour, also played large part. Because the aircraft and crew were in no immediate danger, coupled with the fact that the aircraft had plenty of fuel, the crew could and should have elected to notify ATC that a hold or delay vector would need to be initiated to make sure all required checklists were completed.
Original NASA ASRS Text
Title: ACR RETURNING TO LAND AFTER LOSING 1 AIR-CONDITIONING PACK DUMPS FUEL WITHOUT CONSULTING CHKLIST OR NOTIFYING ATC.
Narrative: UPON DEP, IT WAS DISCOVERED THAT THE ACFT WAS PRESSURIZING ABNORMALLY. AFTER TROUBLESHOOTING THE PROB, THE CREW DETERMINED THAT THE R AIR-CONDITIONING PACK WAS INOP AND THAT THE FLT WOULD HAVE TO RETURN INSTEAD OF CONTINUING ON AS SCHEDULED. ATC WAS NOTIFIED (13500 FT MSL, 34 DME ON THE VHP 263 DEG RADIAL), AND THE FLT WAS GIVEN A VECTOR BACK TOWARDS THE ARPT AND ISSUED A DSCNT. THE CREW THEN DETERMINED THAT FUEL WOULD NEED TO BE DUMPED, IN ORDER TO MEET THE LNDG WT OF OUR ACFT. FUEL DUMP CALCULATIONS NEEDED TO BE MADE ALONG WITH THE TASKS OF OBTAINING ARR INFO, NOTIFYING THE COMPANY OF OUR PROB, BRIEFING THE INST APCH, AND COMPLETING THE APCH CHKLIST. BECAUSE OF OUR CLOSE PROX TO THE ARPT, THERE WAS A LOT TO DO IN A VERY SHORT TIME. DURING THIS HIGH WORKLOAD PERIOD, THE FUEL DUMP CHKLIST WAS OVERLOOKED AND FUEL WAS DUMPED PROCEDURALLY 'BY MEMORY.' THE CREW FAILED TO NOTIFY ATC THAT FUEL NEEDED TO BE DUMPED AS REQUIRED BY THE COMPANY'S FUEL DUMPING CHKLIST. 8000 LBS OF FUEL WAS DUMPED BTWN 13500 FT MSL AND APPROX 5000 FT MSL. THE FLT LANDED UNEVENTFULLY BACK AT INDIANAPOLIS AT XA44 AM LCL. THE PREOCCUPATION WITH THE POSSIBLE CAUSES OF THE PACK FAILURE AND THE DETERIORATING WX CONDITIONS BACK AT INDIANAPOLIS ALONG WITH THE HIGH PLT WORKLOAD WERE CONTRIBUTING FACTORS TO THIS OCCURRENCE. CREW FATIGUE, DUE TO THE LATE HR, ALSO PLAYED LARGE PART. BECAUSE THE ACFT AND CREW WERE IN NO IMMEDIATE DANGER, COUPLED WITH THE FACT THAT THE ACFT HAD PLENTY OF FUEL, THE CREW COULD AND SHOULD HAVE ELECTED TO NOTIFY ATC THAT A HOLD OR DELAY VECTOR WOULD NEED TO BE INITIATED TO MAKE SURE ALL REQUIRED CHKLISTS WERE COMPLETED.
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.