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Attributes | |
ACN | 572909 |
Time | |
Date | 200301 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bur.airport |
State Reference | CA |
Altitude | msl bound lower : 10000 msl bound upper : 10500 |
Environment | |
Weather Elements | other |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 150 flight time total : 4000 flight time type : 900 |
ASRS Report | 572909 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 11000 flight time type : 1315 |
ASRS Report | 572908 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : cabin alt warning horn other flight crewa other flight crewb |
Resolutory Action | flight crew : became reoriented flight crew : overcame equipment problem other |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Takeoff and departure were normal (burbank runway 33, flaps 5 degrees, bleeds off) until cabin altitude warning horn sounded passing 10500 ft MSL. We immediately requested and received clearance to descend and maintain 10000 ft MSL. We accomplished the qrc for cabin altitude warning horn and discovered the cabin pressurization control panel selected to manual mode (outflow valve in open position). Automatic mode selected and aircraft pressurized normally. Human factors: prior to departing burbank, the first officer had given the airport fire department a cockpit orientation on various ep's, including securing running engines and electrical power, discharging the fire bottles, and execution of the evacuate/evacuation qrc the pressurization mode selector was inadvertently left in the manual dc position after evacuate/evacuation qrc demonstration. Captain was unaware of the demonstration of evacuate/evacuation qrc to the fire department. Supplemental information from acn 572908: the first officer had been asked to participate in a familiarization training session for the burbank fire department prior to departure. (Cap in operations.) while answering questions regarding the evacuate/evacuation checklist, first officer placed the mode selector in manual position and opened outflow valve. He later overlooked repositioning the selector to automatic. All other switches were positioned properly. Takeoff was packs off, bleeds on. Captain was PNF, packs were turned on SOP, and captain verified cabin 'pressurizing.' (cabin was actually climbing with aircraft.) did not notice the manual mode selected. (Bright day/green light, and switch parallel with normal position.) checked with flight attendants to verify condition of cabin and passenger.
Original NASA ASRS Text
Title: B737-300 CREW HAD A CABIN, HIGH ALT WARNING HORN DEPARTING BUR.
Narrative: TKOF AND DEP WERE NORMAL (BURBANK RWY 33, FLAPS 5 DEGS, BLEEDS OFF) UNTIL CABIN ALT WARNING HORN SOUNDED PASSING 10500 FT MSL. WE IMMEDIATELY REQUESTED AND RECEIVED CLRNC TO DSND AND MAINTAIN 10000 FT MSL. WE ACCOMPLISHED THE QRC FOR CABIN ALT WARNING HORN AND DISCOVERED THE CABIN PRESSURIZATION CTL PANEL SELECTED TO MANUAL MODE (OUTFLOW VALVE IN OPEN POS). AUTO MODE SELECTED AND ACFT PRESSURIZED NORMALLY. HUMAN FACTORS: PRIOR TO DEPARTING BURBANK, THE FO HAD GIVEN THE ARPT FIRE DEPT A COCKPIT ORIENTATION ON VARIOUS EP'S, INCLUDING SECURING RUNNING ENGS AND ELECTRICAL PWR, DISCHARGING THE FIRE BOTTLES, AND EXECUTION OF THE EVAC QRC THE PRESSURIZATION MODE SELECTOR WAS INADVERTENTLY LEFT IN THE MANUAL DC POS AFTER EVAC QRC DEMONSTRATION. CAPT WAS UNAWARE OF THE DEMONSTRATION OF EVAC QRC TO THE FIRE DEPT. SUPPLEMENTAL INFO FROM ACN 572908: THE FO HAD BEEN ASKED TO PARTICIPATE IN A FAMILIARIZATION TRAINING SESSION FOR THE BURBANK FIRE DEPT PRIOR TO DEP. (CAP IN OPS.) WHILE ANSWERING QUESTIONS REGARDING THE EVAC CHKLIST, FO PLACED THE MODE SELECTOR IN MANUAL POS AND OPENED OUTFLOW VALVE. HE LATER OVERLOOKED REPOSITIONING THE SELECTOR TO AUTO. ALL OTHER SWITCHES WERE POSITIONED PROPERLY. TKOF WAS PACKS OFF, BLEEDS ON. CAPT WAS PNF, PACKS WERE TURNED ON SOP, AND CAPT VERIFIED CABIN 'PRESSURIZING.' (CABIN WAS ACTUALLY CLBING WITH ACFT.) DID NOT NOTICE THE MANUAL MODE SELECTED. (BRIGHT DAY/GREEN LIGHT, AND SWITCH PARALLEL WITH NORMAL POS.) CHKED WITH FLT ATTENDANTS TO VERIFY CONDITION OF CABIN AND PAX.
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.