37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 575081 |
Time | |
Date | 200302 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : rno.airport |
State Reference | NV |
Altitude | msl single value : 13000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : rno.tracon |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 11000 flight time type : 7000 |
ASRS Report | 575081 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : multi engine pilot : instrument |
Experience | flight time last 90 days : 80 |
ASRS Report | 575201 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : cabin altimeter other flight crewa other flight crewb other other : cab 3 |
Resolutory Action | none taken : anomaly accepted other |
Consequence | other other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Loss of pressurization. Flight attendant was unable to close forward entry door, so I closed it. On climb out from rno, the 'a' flight attendant called to tell me the forward entry door was open. The light was out, but the cabin altitude was climbing with the aircraft altitude, so I placed the packs on high and went to 'altitude' on the pressurization panel. The rate of climb decreased to about 500 FPM. I asked for minimum vectoring altitude and was given 13000 ft. I got out the checklist and ran the QRH procedure for 'automatic fail/unscheduled pressurization change.' going to 'man' full closed was no help. The cabin altitude climbed to 11000 ft, and we asked for lower when able. At this point I was thinking it will take as much time to go back to reno as to continue to sjc, so we pressed on. I was also thinking maintenance is closer in sjc than rno. In retrospect, I should have turned back before climbing above 1000 ft, but I thought we had regained at least some control of the pressurization. 2 things bother me about this incident -- I believe there is a design flaw in the door in that I was able to get the door closed and the light out, but the door was not sealed. According to maintenance, the door 'was not closed properly.' how can that be? Why doesn't the QRH give us some guidance on what to do if the cabin exceeds 10000 ft, such as, don oxygen mask (I mistakenly was thinking the masks don't drop until almost 14000 ft so 11000 ft is ok)? Supplemental information from acn 575201: on departure from rno prior to reaching 1000 ft after takeoff, the flight attendant rang the cockpit to inform us of a loud air noise coming from the forward entry door. We checked to reconfirm all door lights extinguished and monitored the pressurization. We then noticed the aircraft cabin was climbing at same rate as the aircraft. Reviewed the checklist and switched packs to high and made sure outflow valve was closed manually. During this time, we asked for minimum vectoring altitude in the area and were informed it was 13000 ft. We climbed to 13000 ft, which put the cabin altitude at 11000 ft. We assumed since we were able to maintain the cabin altitude below 14000 ft and prevent the masks from dropping, it was ok to continue to sjc. As soon as we were able to descend to 10000 ft, we did so. Rest of flight was uneventful. I was contacted by the chief pilot's office and informed that by allowing the cabin altitude to go above 1000 ft, it involved fom and far violations, and was asked to submit this report.
Original NASA ASRS Text
Title: B737-300 CREW WAS UNABLE TO PRESSURIZE THE ACFT ON DEP FROM RNO. THE CREW CONTINUED, OVER THE SIERRA MOUNTAINS TO SJC WITH A CABIN ALT OF 11000 FT.
Narrative: LOSS OF PRESSURIZATION. FLT ATTENDANT WAS UNABLE TO CLOSE FORWARD ENTRY DOOR, SO I CLOSED IT. ON CLBOUT FROM RNO, THE 'A' FLT ATTENDANT CALLED TO TELL ME THE FORWARD ENTRY DOOR WAS OPEN. THE LIGHT WAS OUT, BUT THE CABIN ALT WAS CLBING WITH THE ACFT ALT, SO I PLACED THE PACKS ON HIGH AND WENT TO 'ALT' ON THE PRESSURIZATION PANEL. THE RATE OF CLB DECREASED TO ABOUT 500 FPM. I ASKED FOR MINIMUM VECTORING ALT AND WAS GIVEN 13000 FT. I GOT OUT THE CHKLIST AND RAN THE QRH PROC FOR 'AUTO FAIL/UNSCHEDULED PRESSURIZATION CHANGE.' GOING TO 'MAN' FULL CLOSED WAS NO HELP. THE CABIN ALT CLBED TO 11000 FT, AND WE ASKED FOR LOWER WHEN ABLE. AT THIS POINT I WAS THINKING IT WILL TAKE AS MUCH TIME TO GO BACK TO RENO AS TO CONTINUE TO SJC, SO WE PRESSED ON. I WAS ALSO THINKING MAINT IS CLOSER IN SJC THAN RNO. IN RETROSPECT, I SHOULD HAVE TURNED BACK BEFORE CLBING ABOVE 1000 FT, BUT I THOUGHT WE HAD REGAINED AT LEAST SOME CTL OF THE PRESSURIZATION. 2 THINGS BOTHER ME ABOUT THIS INCIDENT -- I BELIEVE THERE IS A DESIGN FLAW IN THE DOOR IN THAT I WAS ABLE TO GET THE DOOR CLOSED AND THE LIGHT OUT, BUT THE DOOR WAS NOT SEALED. ACCORDING TO MAINT, THE DOOR 'WAS NOT CLOSED PROPERLY.' HOW CAN THAT BE? WHY DOESN'T THE QRH GIVE US SOME GUIDANCE ON WHAT TO DO IF THE CABIN EXCEEDS 10000 FT, SUCH AS, DON OXYGEN MASK (I MISTAKENLY WAS THINKING THE MASKS DON'T DROP UNTIL ALMOST 14000 FT SO 11000 FT IS OK)? SUPPLEMENTAL INFO FROM ACN 575201: ON DEP FROM RNO PRIOR TO REACHING 1000 FT AFTER TKOF, THE FLT ATTENDANT RANG THE COCKPIT TO INFORM US OF A LOUD AIR NOISE COMING FROM THE FORWARD ENTRY DOOR. WE CHKED TO RECONFIRM ALL DOOR LIGHTS EXTINGUISHED AND MONITORED THE PRESSURIZATION. WE THEN NOTICED THE ACFT CABIN WAS CLBING AT SAME RATE AS THE ACFT. REVIEWED THE CHKLIST AND SWITCHED PACKS TO HIGH AND MADE SURE OUTFLOW VALVE WAS CLOSED MANUALLY. DURING THIS TIME, WE ASKED FOR MINIMUM VECTORING ALT IN THE AREA AND WERE INFORMED IT WAS 13000 FT. WE CLBED TO 13000 FT, WHICH PUT THE CABIN ALT AT 11000 FT. WE ASSUMED SINCE WE WERE ABLE TO MAINTAIN THE CABIN ALT BELOW 14000 FT AND PREVENT THE MASKS FROM DROPPING, IT WAS OK TO CONTINUE TO SJC. AS SOON AS WE WERE ABLE TO DSND TO 10000 FT, WE DID SO. REST OF FLT WAS UNEVENTFUL. I WAS CONTACTED BY THE CHIEF PLT'S OFFICE AND INFORMED THAT BY ALLOWING THE CABIN ALT TO GO ABOVE 1000 FT, IT INVOLVED FOM AND FAR VIOLATIONS, AND WAS ASKED TO SUBMIT THIS RPT.
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.