37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 538297 |
Time | |
Date | 200202 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lit.airport |
State Reference | AR |
Altitude | msl bound lower : 14000 msl bound upper : 21000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zme.artcc tower : lit.tower tower : sjc.tower |
Operator | general aviation : personal |
Make Model Name | Learjet 24 |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : initial climbout : intermediate altitude climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 25 flight time total : 3500 flight time type : 40 |
ASRS Report | 538297 |
Person 2 | |
Affiliation | other |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : company policies non adherence : published procedure other spatial deviation |
Resolutory Action | controller : issued new clearance controller : provided flight assist |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | vertical : 500 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
As I was taxiing out for takeoff, I forgot to turn on the pressurization. We took off. As we were climbing out I felt my ears popping several times trying to tell me the pressurization was amiss, but I just wasn't listening. When we went through 10000 ft the buzzer went off and I'm saying to myself, what is wrong? I looked straight at the cabin pressure gauge and thought it was all right. Then we went through 14000 ft and the masks dropped and it was now obvious what was going on, but I still didn't realize the switch was off. (This was what you would call the total confusion stage.) now we were at FL210 and I told center that we forgot something and needed to return to lit. They cleared us to turn and descend to lit. As we were going down I saw the switch and turned on the pressurization. Now I told center that we found what we were looking for and wanted to resume our trip. They gave us a new heading and altitude. It was at this point that we didn't hear some of the altitude and heading assignments properly. All we had to do was ask them to repeat what they said and everything would have been fine. But we were still shook up after the pressurization deal and didn't do anything right. It was just some sloppy flying on my part. I was heading 080 degrees because I thought he told me to, and then there was some confusion about whether I was supposed to be at FL220 or FL230 and they said I was off of my assigned altitude and heading, and I probably was. I wasn't even sure exactly what he had told me. I was just shook up and not doing a good job of flying the airplane. I think the moral of the story is don't miss anything on the checklist.
Original NASA ASRS Text
Title: AN LJ24 CREW, DEPARTING LIT, NEGLECTED TO TURN THE PRESSURIZATION SYS ON RESULTING IN, WARNINGS, MASKS DROPPING AND ALL AROUND CONFUSION UNTIL THE SYS WAS RESTORED.
Narrative: AS I WAS TAXIING OUT FOR TKOF, I FORGOT TO TURN ON THE PRESSURIZATION. WE TOOK OFF. AS WE WERE CLBING OUT I FELT MY EARS POPPING SEVERAL TIMES TRYING TO TELL ME THE PRESSURIZATION WAS AMISS, BUT I JUST WASN'T LISTENING. WHEN WE WENT THROUGH 10000 FT THE BUZZER WENT OFF AND I'M SAYING TO MYSELF, WHAT IS WRONG? I LOOKED STRAIGHT AT THE CABIN PRESSURE GAUGE AND THOUGHT IT WAS ALL RIGHT. THEN WE WENT THROUGH 14000 FT AND THE MASKS DROPPED AND IT WAS NOW OBVIOUS WHAT WAS GOING ON, BUT I STILL DIDN'T REALIZE THE SWITCH WAS OFF. (THIS WAS WHAT YOU WOULD CALL THE TOTAL CONFUSION STAGE.) NOW WE WERE AT FL210 AND I TOLD CTR THAT WE FORGOT SOMETHING AND NEEDED TO RETURN TO LIT. THEY CLRED US TO TURN AND DSND TO LIT. AS WE WERE GOING DOWN I SAW THE SWITCH AND TURNED ON THE PRESSURIZATION. NOW I TOLD CTR THAT WE FOUND WHAT WE WERE LOOKING FOR AND WANTED TO RESUME OUR TRIP. THEY GAVE US A NEW HEADING AND ALT. IT WAS AT THIS POINT THAT WE DIDN'T HEAR SOME OF THE ALT AND HEADING ASSIGNMENTS PROPERLY. ALL WE HAD TO DO WAS ASK THEM TO REPEAT WHAT THEY SAID AND EVERYTHING WOULD HAVE BEEN FINE. BUT WE WERE STILL SHOOK UP AFTER THE PRESSURIZATION DEAL AND DIDN'T DO ANYTHING RIGHT. IT WAS JUST SOME SLOPPY FLYING ON MY PART. I WAS HEADING 080 DEGS BECAUSE I THOUGHT HE TOLD ME TO, AND THEN THERE WAS SOME CONFUSION ABOUT WHETHER I WAS SUPPOSED TO BE AT FL220 OR FL230 AND THEY SAID I WAS OFF OF MY ASSIGNED ALT AND HEADING, AND I PROBABLY WAS. I WASN'T EVEN SURE EXACTLY WHAT HE HAD TOLD ME. I WAS JUST SHOOK UP AND NOT DOING A GOOD JOB OF FLYING THE AIRPLANE. I THINK THE MORAL OF THE STORY IS DON'T MISS ANYTHING ON THE CHKLIST.
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.