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|
Attributes | |
ACN | 588245 |
Time | |
Date | 200307 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl bound lower : 26000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : charter |
Make Model Name | Citation II S2/Bravo |
Operating Under FAR Part | Part 135 |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : charter |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 30 flight time total : 8700 flight time type : 30 |
ASRS Report | 588245 |
Person 2 | |
Affiliation | company : charter |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : cabin altitude indicator other flight crewa other flight crewb |
Resolutory Action | aircraft : automation overrode flight crew controller : issued new clearance flight crew : declared emergency flight crew : diverted to another airport |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : testing performance deficiency : repair performance deficiency : fault isolation performance deficiency : unqualified personnel performance deficiency : training |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During descent from FL350 to FL260 and passing through FL270, I noticed that the cabin was climbing at approximately 500 FPM with a cabin altitude of approximately 5000 ft. Normal cabin attendant altitude should have been approximately 3000 ft. The captain and I discussed the fact that this particular aircraft had experienced a rapid depressurization with similar initial symptoms approximately 1 month ago. The captain and I further discussed changing the pressurization source, and pulled out the emergency/abnormal checklist to seek additional guidance. We asked the center controller for a lower altitude and were told to expect one shortly. The emergency abnormal checklist contained no insightful information and we were preparing to reaffirm our request for a lower altitude when the aircraft rapidly depressurized. We donned our oxygen masks, declared an emergency, initiated an emergency descent and ensured that our passengers were breathing from their oxygen masks. We complied with all applicable emergency and abnormal procedures and checklists as we descended to 10000 ft MSL. We then informed our passengers of the nature of the problem, and completed a normal landing at ZZZ airport approximately 15 mins later. Callback conversation with reporter revealed the following information: the reporter stated this airplane had four serious incidents of rapid depressurization within a period of one month. The reporter said two of the incidents occurred while he was flying the airplane and this report covers the third incident. The reporter stated the first and second incident of rapid depressurization were corrected by company maintenance with the replacement of the cabin pressure controllers. The reporter said in this third event an emergency was declared and descent to 10000 ft with no injuries to crew or passengers. The reporter stated the diversion airport just happened to be a authorized manufacturers service center and the airplane was turned over to them for a positive fix. The reporter said at this maintenance facility clamps were tightened, connections and hoses were replaced and the airplane was returned to service. The reporter stated after departing the authorized manufacturers repair facility and cruising at FL350 the fourth incident of cabin attendant depressurization occurred. The reporter said the airplane was flown depressurized to the company base were maintenance found a defective intermittent squat switch that would fail in the ground mode causing the outflow valve to go to the full open position in flight.
Original NASA ASRS Text
Title: A CESSNA 550 CITATION DURING DSCNT FROM FL350 AND PASSING THROUGH FL270 CREW NOTED CAB CLIMBING. DURING ABNORMAL CHKLIST THE CAB RAPIDLY DEPRESSURIZED. DECLARED AN EMER AND DIVERTED.
Narrative: DURING DSCNT FROM FL350 TO FL260 AND PASSING THROUGH FL270, I NOTICED THAT THE CABIN WAS CLIMBING AT APPROX 500 FPM WITH A CABIN ALT OF APPROX 5000 FT. NORMAL CAB ALT SHOULD HAVE BEEN APPROX 3000 FT. THE CAPT AND I DISCUSSED THE FACT THAT THIS PARTICULAR ACFT HAD EXPERIENCED A RAPID DEPRESSURIZATION WITH SIMILAR INITIAL SYMPTOMS APPROX 1 MONTH AGO. THE CAPT AND I FURTHER DISCUSSED CHANGING THE PRESSURIZATION SOURCE, AND PULLED OUT THE EMER/ABNORMAL CHKLIST TO SEEK ADDITIONAL GUIDANCE. WE ASKED THE CENTER CTLR FOR A LOWER ALT AND WERE TOLD TO EXPECT ONE SHORTLY. THE EMER ABNORMAL CHKLIST CONTAINED NO INSIGHTFUL INFO AND WE WERE PREPARING TO REAFFIRM OUR REQUEST FOR A LOWER ALT WHEN THE ACFT RAPIDLY DEPRESSURIZED. WE DONNED OUR OXYGEN MASKS, DECLARED AN EMER, INITIATED AN EMER DSCNT AND ENSURED THAT OUR PASSENGERS WERE BREATHING FROM THEIR OXYGEN MASKS. WE COMPLIED WITH ALL APPLICABLE EMER AND ABNORMAL PROCS AND CHKLISTS AS WE DESCENDED TO 10000 FT MSL. WE THEN INFORMED OUR PASSENGERS OF THE NATURE OF THE PROBLEM, AND COMPLETED A NORMAL LNDG AT ZZZ ARPT APPROX 15 MINS LATER. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THIS AIRPLANE HAD FOUR SERIOUS INCIDENTS OF RAPID DEPRESSURIZATION WITHIN A PERIOD OF ONE MONTH. THE RPTR SAID TWO OF THE INCIDENTS OCCURRED WHILE HE WAS FLYING THE AIRPLANE AND THIS RPT COVERS THE THIRD INCIDENT. THE RPTR STATED THE FIRST AND SECOND INCIDENT OF RAPID DEPRESSURIZATION WERE CORRECTED BY COMPANY MAINT WITH THE REPLACEMENT OF THE CABIN PRESSURE CTLRS. THE RPTR SAID IN THIS THIRD EVENT AN EMER WAS DECLARED AND DSCNT TO 10000 FT WITH NO INJURIES TO CREW OR PASSENGERS. THE RPTR STATED THE DIVERSION ARPT JUST HAPPENED TO BE A AUTHORIZED MANUFACTURERS SVC CENTER AND THE AIRPLANE WAS TURNED OVER TO THEM FOR A POSITIVE FIX. THE RPTR SAID AT THIS MAINT FACILITY CLAMPS WERE TIGHTENED, CONNECTIONS AND HOSES WERE REPLACED AND THE AIRPLANE WAS RETURNED TO SVC. THE RPTR STATED AFTER DEPARTING THE AUTHORIZED MANUFACTURERS REPAIR FACILITY AND CRUISING AT FL350 THE FOURTH INCIDENT OF CAB DEPRESSURIZATION OCCURRED. THE RPTR SAID THE AIRPLANE WAS FLOWN DEPRESSURIZED TO THE COMPANY BASE WERE MAINT FOUND A DEFECTIVE INTERMITTENT SQUAT SWITCH THAT WOULD FAIL IN THE GND MODE CAUSING THE OUTFLOW VALVE TO GO TO THE FULL OPEN POSITION IN FLT.
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.