37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 578325 |
Time | |
Date | 200303 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : hmv.vortac |
State Reference | TN |
Altitude | msl single value : 17000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : ztl.artcc |
Operator | common carrier : charter |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 135 |
Navigation In Use | other vortac |
Flight Phase | climbout : vacating altitude cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 170 flight time total : 2746 flight time type : 301 |
ASRS Report | 578325 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 125 flight time total : 850 flight time type : 570 |
ASRS Report | 578326 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance flight crew : overcame equipment problem other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On mar/sun/03, my first officer and I arrived at huntington tri-state airport for our flight crew to clt. We performed our first flight crew of the day checklist, and noticed the maintenance crew returned the aircraft to us from its overnight checks with the WX radar left on and the rudder trim out of position. We departed huntington and performed the after takeoff checklist with all indications normal. We climbed to our cruise altitude of 17000 ft, at which point, we performed the cruise checklist. Moments later, the flight crew noticed the cabin was not pressurized, despite an absence of the cabin altitude high indicator. We performed the oxygen use checklist while descending to an assigned altitude of 10000 ft, and the cabin altitude checklist once level at 10000 ft. The pressurization switch was discovered in the 'dump' position, and was repositioned to 'press.' the cabin was repressurized, and the flight crew continued to charlotte without incident. Upon reaching clt, the crew noticed the alternate static port static switch on the captain's side had been left on, out of its guard position by maintenance, which I missed during the first flight crew of the day checklist. Note to self, that I need to slow down while doing checklists to prevent such a thing from recurring. A subsequent test flight crew, within hours, to 11000 ft with maintenance personnel in attendance, demonstrated failure of the cabin attitude high warning system to activate.
Original NASA ASRS Text
Title: FLC OF B190 DISCOVERED ACFT DID NOT PRESSURIZE WHEN LEVEL AT 17000 FT. DSNDED TO 10000 FT, PERFORMED CHKS AND DISCOVERED MAINT HAD LEFT SEVERAL SWITCHES IN INAPPROPRIATE POS, INCLUDING THE PRESSURIZATION SWITCH IN THE 'DUMP' POS.
Narrative: ON MAR/SUN/03, MY FO AND I ARRIVED AT HUNTINGTON TRI-STATE ARPT FOR OUR FLT CREW TO CLT. WE PERFORMED OUR FIRST FLT CREW OF THE DAY CHKLIST, AND NOTICED THE MAINT CREW RETURNED THE ACFT TO US FROM ITS OVERNIGHT CHKS WITH THE WX RADAR LEFT ON AND THE RUDDER TRIM OUT OF POS. WE DEPARTED HUNTINGTON AND PERFORMED THE AFTER TKOF CHKLIST WITH ALL INDICATIONS NORMAL. WE CLBED TO OUR CRUISE ALT OF 17000 FT, AT WHICH POINT, WE PERFORMED THE CRUISE CHKLIST. MOMENTS LATER, THE FLC NOTICED THE CABIN WAS NOT PRESSURIZED, DESPITE AN ABSENCE OF THE CABIN ALT HIGH INDICATOR. WE PERFORMED THE OXYGEN USE CHKLIST WHILE DSNDING TO AN ASSIGNED ALT OF 10000 FT, AND THE CABIN ALT CHKLIST ONCE LEVEL AT 10000 FT. THE PRESSURIZATION SWITCH WAS DISCOVERED IN THE 'DUMP' POS, AND WAS REPOSITIONED TO 'PRESS.' THE CABIN WAS REPRESSURIZED, AND THE FLT CREW CONTINUED TO CHARLOTTE WITHOUT INCIDENT. UPON REACHING CLT, THE CREW NOTICED THE ALTERNATE STATIC PORT STATIC SWITCH ON THE CAPT'S SIDE HAD BEEN LEFT ON, OUT OF ITS GUARD POS BY MAINT, WHICH I MISSED DURING THE FIRST FLT CREW OF THE DAY CHKLIST. NOTE TO SELF, THAT I NEED TO SLOW DOWN WHILE DOING CHKLISTS TO PREVENT SUCH A THING FROM RECURRING. A SUBSEQUENT TEST FLT CREW, WITHIN HRS, TO 11000 FT WITH MAINT PERSONNEL IN ATTENDANCE, DEMONSTRATED FAILURE OF THE CABIN ATTITUDE HIGH WARNING SYS TO ACTIVATE.
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.