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A DC9-30 was dispatched in non compliance with the aft cabin entry door warning inoperative but not inspected for being closed and locked. Aircraft lost pressurization and masks deployed due to door not closed.
| Attributes | |
| ACN | 499650 |
| Time | |
| Date | 200101 |
| Day | Tue |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | msl single value : 15000 |
| Environment | |
| Flight Conditions | VMC |
| Weather Elements | Ice |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : zzz.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | DC-9 30 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | departure : on vectors |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp pilot : instrument pilot : commercial pilot : multi engine |
| Experience | flight time last 90 days : 128 flight time total : 6022 flight time type : 1028 |
| ASRS Report | 499650 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : private pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 194 flight time total : 10382 flight time type : 3926 |
| ASRS Report | 499846 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure other anomaly other |
| Independent Detector | aircraft equipment other aircraft equipment : cabin alt indicator other other : 3 |
| Resolutory Action | flight crew : diverted to another airport |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : testing performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Prior to departure, captain asked lead flight attendant to check aft cabin door to be closed and locked as per the existing MEL 52-7C (door warning light system/aft cabin door). Watched flight attendant check the aft cabin door by cycling door from locked/unlocked/locked and then pull on the door handle. Door did not move and was assumed to be closed and locked. Flight attendant then gave captain the thumbs up indicating that the door was closed and locked. Aft cabin door was illuminated at pushback, but was expected with the MEL. At approximately 15000 ft, lead flight attendant opened flight deck door to report that the oxygen masks had deployed. Both captain and first officer quickly checked cabin altitude and rate of cabin climb, along with both air conditioning packs operating normally. Viewed both red cabin pressure and blue cabin altitude annunciator lights. No master caution or master warning lights were observed by either pilot. We both donned our oxygen masks immediately and requested a lower altitude back to 10000 ft. First officer assumed PF duties and ATC communication duties, while captain did red border checklist and PNF duties. Notified dispatch and returned to ZZZ. Maintenance personnel found aft cabin door not fully closed. The door pins were fully extended in the locked position between the door/bulkhead flange and a thin cosmetic trim piece on the lavatory wall restricting door movement.
Original NASA ASRS Text
Title: A DC9-30 WAS DISPATCHED IN NON COMPLIANCE WITH THE AFT CABIN ENTRY DOOR WARNING INOP BUT NOT INSPECTED FOR BEING CLOSED AND LOCKED. ACFT LOST PRESSURIZATION AND MASKS DEPLOYED DUE TO DOOR NOT CLOSED.
Narrative: PRIOR TO DEP, CAPT ASKED LEAD FLT ATTENDANT TO CHK AFT CABIN DOOR TO BE CLOSED AND LOCKED AS PER THE EXISTING MEL 52-7C (DOOR WARNING LIGHT SYS/AFT CABIN DOOR). WATCHED FLT ATTENDANT CHK THE AFT CABIN DOOR BY CYCLING DOOR FROM LOCKED/UNLOCKED/LOCKED AND THEN PULL ON THE DOOR HANDLE. DOOR DID NOT MOVE AND WAS ASSUMED TO BE CLOSED AND LOCKED. FLT ATTENDANT THEN GAVE CAPT THE THUMBS UP INDICATING THAT THE DOOR WAS CLOSED AND LOCKED. AFT CABIN DOOR WAS ILLUMINATED AT PUSHBACK, BUT WAS EXPECTED WITH THE MEL. AT APPROX 15000 FT, LEAD FLT ATTENDANT OPENED FLT DECK DOOR TO RPT THAT THE OXYGEN MASKS HAD DEPLOYED. BOTH CAPT AND FO QUICKLY CHKED CABIN ALT AND RATE OF CABIN CLB, ALONG WITH BOTH AIR CONDITIONING PACKS OPERATING NORMALLY. VIEWED BOTH RED CABIN PRESSURE AND BLUE CABIN ALT ANNUNCIATOR LIGHTS. NO MASTER CAUTION OR MASTER WARNING LIGHTS WERE OBSERVED BY EITHER PLT. WE BOTH DONNED OUR OXYGEN MASKS IMMEDIATELY AND REQUESTED A LOWER ALT BACK TO 10000 FT. FO ASSUMED PF DUTIES AND ATC COM DUTIES, WHILE CAPT DID RED BORDER CHKLIST AND PNF DUTIES. NOTIFIED DISPATCH AND RETURNED TO ZZZ. MAINT PERSONNEL FOUND AFT CABIN DOOR NOT FULLY CLOSED. THE DOOR PINS WERE FULLY EXTENDED IN THE LOCKED POS BTWN THE DOOR/BULKHEAD FLANGE AND A THIN COSMETIC TRIM PIECE ON THE LAVATORY WALL RESTRICTING DOOR MOVEMENT.
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.