37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 633962 |
Time | |
Date | 200410 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 37000 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | artcc : zzzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level cruise : enroute altitude change descent : vacating altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 210 flight time total : 15000 flight time type : 1400 |
ASRS Report | 633962 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 264 flight time total : 9000 flight time type : 2528 |
ASRS Report | 633963 |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | aircraft equipment other aircraft equipment : cabin alt warning horn |
Resolutory Action | flight crew : declared emergency flight crew : diverted to another airport |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft |
Primary Problem | Aircraft |
Narrative:
The first indication of a problem was when the autothrottle disengaged and would not re-engage. We sent company maintenance a message and then didnT think too much of it. Shortly thereafter, ATC reported that they were not receiving our transponder. We switched to the 'right' transponder and ATC reported they were now receiving it ok. The captain began thinking that the autothrottle and transponder issues were related somehow and might have to do with an air-ground sensing problem. Both the captain and first officer got out their flight manuals to start researching the power sources for these two items. The next thing the crew heard was an intermittent horn sounding in the cockpit which we interpreted to be the takeoff warning horn. In our minds we were dealing with an air/ground sensing problem and the takeoff warning horn sounding would not have been an unusual thing to happen in that situation. After approximately a few minutes the first officer remembered that the takeoff warning horn also doubles as the cabin altitude warning horn. He checked the cabin altimeter and saw that it was above 10000 ft. This is when we realized the cabin was slowly losing pressure. We donned our oxygen masks and established crew communications and completed the appropriate qrc. Clearance was received from ATC to descend from FL370 to 10000 ft and a rapid descent was initiated. The cabin altitude never reached 14000 ft, so the passenger oxygen masks were not deployed either manually or automatically. Upon reaching 10000 ft we leveled and completed the reference actions for the checklist. The captain contacted dispatch and maintenance to report the situation. Captain's emergency authority was used to pull and reset circuit breakers per instructions from maintenance. Upon resetting the landing gear air/ground relay circuit breaker, all systems returned to normal. After consultation with dispatch, maintenance, the flight duty officer, and the first officer, and captain made the decision to divert the flight and land in ZZZ due to a lack of fuel to safely continue to our original destination. The flight attendants and passenger were briefed on the situation and a normal, uneventful landing was accomplished in ZZZ. A safety issue I would like to raise awareness about based on my experience, is the lack of wisdom in having the takeoff warning horn double as the altitude warning horn. Because the cabin was losing pressure slowly, we did not feel any pressure changes in our ears that would have normally served to alert us to a pressurization problem. If the first officer had not happened to remember that the horn also serves as a cabin altitude warning horn, we may have continued trying to troubleshoot the air/ground problem until passing out from lack of oxygen. Flight crews are not accustomed to associating an intermittent horn with the cabin altitude warning system. During the captain's cockpit setup the intermittent horn is tested by advancing a throttle to check the takeoff warning system. Like pavlov's dogs, this forms the habit pattern of only associating that sound with that system. There is no test performed on the cabin altitude warning system and as a result there is no particular sound flight crews are trained to associate with that system. Hearing the intermittent horn only served to reinforce in our minds that we are dealing with an air/ground sensing, takeoff warning horn problem and distracted us from the more serious problem of losing cabin pressure. Something as important as the cabin altitude should have a warning system with its own unique sound that cannot be associated with any other problem. I would suggest a voice that says 'cabin altitude.' pilots can be trained that hearing that sound only means one thing, 'put your mask on now!' callback conversation with reporter revealed the following information: the captain stated again that the 'pavlov effect' caused both crew members to focus in the wrong area for a horn cause. The first officer happened to remember about the cabin altitude warning. This crew member stated that from his perspective a verbal alert such as 'cabin altitude' would be preferential. There are too many aural sounds now and many of them do have unique causes.
Original NASA ASRS Text
Title: A B737-300 FLC PERFORMED A RAPID DSCNT FOLLOWING DELAYED RECOGNITION OF A SLOW CABIN PRESSURIZATION LOSS INDICATED BY A DUAL PURPOSE AURAL WARNING HORN.
Narrative: THE FIRST INDICATION OF A PROB WAS WHEN THE AUTOTHROTTLE DISENGAGED AND WOULD NOT RE-ENGAGE. WE SENT COMPANY MAINT A MESSAGE AND THEN DIDNT THINK TOO MUCH OF IT. SHORTLY THEREAFTER, ATC RPTED THAT THEY WERE NOT RECEIVING OUR TRANSPONDER. WE SWITCHED TO THE 'R' TRANSPONDER AND ATC RPTED THEY WERE NOW RECEIVING IT OK. THE CAPT BEGAN THINKING THAT THE AUTOTHROTTLE AND TRANSPONDER ISSUES WERE RELATED SOMEHOW AND MIGHT HAVE TO DO WITH AN AIR-GROUND SENSING PROB. BOTH THE CAPT AND FO GOT OUT THEIR FLT MANUALS TO START RESEARCHING THE POWER SOURCES FOR THESE TWO ITEMS. THE NEXT THING THE CREW HEARD WAS AN INTERMITTENT HORN SOUNDING IN THE COCKPIT WHICH WE INTERPRETED TO BE THE TKOF WARNING HORN. IN OUR MINDS WE WERE DEALING WITH AN AIR/GROUND SENSING PROB AND THE TKOF WARNING HORN SOUNDING WOULD NOT HAVE BEEN AN UNUSUAL THING TO HAPPEN IN THAT SIT. AFTER APPROX A FEW MINUTES THE FO REMEMBERED THAT THE TKOF WARNING HORN ALSO DOUBLES AS THE CABIN ALT WARNING HORN. HE CHECKED THE CABIN ALTIMETER AND SAW THAT IT WAS ABOVE 10000 FT. THIS IS WHEN WE REALIZED THE CABIN WAS SLOWLY LOSING PRESSURE. WE DONNED OUR OXYGEN MASKS AND ESTABLISHED CREW COMS AND COMPLETED THE APPROPRIATE QRC. CLRNC WAS RECEIVED FROM ATC TO DSND FROM FL370 TO 10000 FT AND A RAPID DSCNT WAS INITIATED. THE CABIN ALT NEVER REACHED 14000 FT, SO THE PAX OXYGEN MASKS WERE NOT DEPLOYED EITHER MANUALLY OR AUTOMATICALLY. UPON REACHING 10000 FT WE LEVELED AND COMPLETED THE REFERENCE ACTIONS FOR THE CHKLIST. THE CAPT CONTACTED DISPATCH AND MAINT TO RPT THE SIT. CAPT'S EMER AUTHORITY WAS USED TO PULL AND RESET CIRCUIT BREAKERS PER INSTRUCTIONS FROM MAINT. UPON RESETTING THE LANDING GEAR AIR/GROUND RELAY CIRCUIT BREAKER, ALL SYSTEMS RETURNED TO NORMAL. AFTER CONSULTATION WITH DISPATCH, MAINT, THE FLT DUTY OFFICER, AND THE FO, AND CAPT MADE THE DECISION TO DIVERT THE FLT AND LAND IN ZZZ DUE TO A LACK OF FUEL TO SAFELY CONTINUE TO OUR ORIGINAL DEST. THE FLT ATTENDANTS AND PAX WERE BRIEFED ON THE SIT AND A NORMAL, UNEVENTFUL LNDG WAS ACCOMPLISHED IN ZZZ. A SAFETY ISSUE I WOULD LIKE TO RAISE AWARENESS ABOUT BASED ON MY EXPERIENCE, IS THE LACK OF WISDOM IN HAVING THE TKOF WARNING HORN DOUBLE AS THE ALT WARNING HORN. BECAUSE THE CABIN WAS LOSING PRESSURE SLOWLY, WE DID NOT FEEL ANY PRESSURE CHANGES IN OUR EARS THAT WOULD HAVE NORMALLY SERVED TO ALERT US TO A PRESSURIZATION PROB. IF THE FO HAD NOT HAPPENED TO REMEMBER THAT THE HORN ALSO SERVES AS A CABIN ALT WARNING HORN, WE MAY HAVE CONTINUED TRYING TO TROUBLESHOOT THE AIR/GROUND PROB UNTIL PASSING OUT FROM LACK OF OXYGEN. FLT CREWS ARE NOT ACCUSTOMED TO ASSOCIATING AN INTERMITTENT HORN WITH THE CABIN ALT WARNING SYSTEM. DURING THE CAPT'S COCKPIT SETUP THE INTERMITTENT HORN IS TESTED BY ADVANCING A THROTTLE TO CHECK THE TKOF WARNING SYSTEM. LIKE PAVLOV'S DOGS, THIS FORMS THE HABIT PATTERN OF ONLY ASSOCIATING THAT SOUND WITH THAT SYSTEM. THERE IS NO TEST PERFORMED ON THE CABIN ALT WARNING SYSTEM AND AS A RESULT THERE IS NO PARTICULAR SOUND FLT CREWS ARE TRAINED TO ASSOCIATE WITH THAT SYSTEM. HEARING THE INTERMITTENT HORN ONLY SERVED TO REINFORCE IN OUR MINDS THAT WE ARE DEALING WITH AN AIR/GROUND SENSING, TKOF WARNING HORN PROB AND DISTRACTED US FROM THE MORE SERIOUS PROB OF LOSING CABIN PRESSURE. SOMETHING AS IMPORTANT AS THE CABIN ALT SHOULD HAVE A WARNING SYSTEM WITH ITS OWN UNIQUE SOUND THAT CANNOT BE ASSOCIATED WITH ANY OTHER PROB. I WOULD SUGGEST A VOICE THAT SAYS 'CABIN ALT.' PLTS CAN BE TRAINED THAT HEARING THAT SOUND ONLY MEANS ONE THING, 'PUT YOUR MASK ON NOW!' CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT STATED AGAIN THAT THE 'PAVLOV EFFECT' CAUSED BOTH CREW MEMBERS TO FOCUS IN THE WRONG AREA FOR A HORN CAUSE. THE FO HAPPENED TO REMEMBER ABOUT THE CABIN ALT WARNING. THIS CREW MEMBER STATED THAT FROM HIS PERSPECTIVE A VERBAL ALERT SUCH AS 'CABIN ALT' WOULD BE PREFERENTIAL. THERE ARE TOO MANY AURAL SOUNDS NOW AND MANY OF THEM DO HAVE UNIQUE CAUSES.
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.