37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 640194 |
Time | |
Date | 200412 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : atl.airport |
State Reference | GA |
Altitude | msl bound lower : 23000 msl bound upper : 26000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : ztl.artcc |
Operator | common carrier : air carrier |
Make Model Name | MD-88 |
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 : flight engineer pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 36 flight time total : 4000 flight time type : 500 |
ASRS Report | 640196 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : multi engine pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 180 flight time total : 17000 flight time type : 6000 |
ASRS Report | 640820 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : cabin alt warning |
Resolutory Action | flight crew : declared emergency flight crew : diverted to another airport |
Consequence | other |
Supplementary | |
Problem Areas | Chart Or Publication Company Aircraft |
Primary Problem | Aircraft |
Narrative:
Departed with left pack automatic temperature controller inoperative. On climb out, altitude approximately 10000 ft, entered icing conditions, turned airfoil and engine anti-ice on. Received 'left/right ice protection temperature high' after about 2 mins of engine and wing anti-ice being on. Completed 'ice protection temperature high' checklist. Messages extinguished. Received 'flow' light warning on pressurization panel, ran 'flow light' checklist. Unable to maintain cabin pressurization (cabin climbing), 'cabin altitude warning' went off. Ran 'rapid decompression/cabin altitude warning' checklist. Captain initiated emergency descent at FL270, cabin continued to climb while aircraft descended. Maximum cabin altitude reached was 15500 ft. Passenger oxygen masks deployed above 10000 ft cabin altitude for approximately 2 1/2 mins. None of the checklists referenced directed looking at pack pressures. This should be a required step in the 'flow light' checklist. Very busy time for both of us from approximately 10000 ft to FL270 and then down to 6000 ft. Numerous communications with ATC, flight attendants and other pilot. Initially captain flew aircraft, talked on radio and communicated with flight attendants. After checklist completion, I flew aircraft and communicated with ATC. Emergency descent complete when I began flying. Bottom line: passenger and crew all ok. Only distraction was that pack pressures were not specifically referenced in any of the checklists run. Pack pressures were probably low to zero -- checklist(south) should address pack pressures early on. This may have aided in our ability to recover pressure in the cabin. Callback conversation with reporter revealed the following information: reporter stated that because of the 'flow light' indication at about 8000 ft cabin altitude, the crew was ready for the aural annunciation 'cabin altitude' and the warning horn. They were in the process of executing the loss of pressure checklist and initiating a descent with ATC when the masks dropped. The cabin was ascending at about 1500 FPM. Reporter feels that the airline's system knowledge requirement is too low and that while more knowledge would not have helped them overcome or manage in this situation, system knowledge in general may have helped them understand what was occurring. A known anomaly with the MD88 is a pack overheat with normal pressure indications. The key to system operation in the event of an overheat is the flow indication. The crew did not determine nor did maintenance inform them what caused the problem.
Original NASA ASRS Text
Title: AN MD80 CREW CONDUCTED AN EMER DSCNT FOLLOWING A GRADUAL CABIN DEPRESSURIZATION.
Narrative: DEPARTED WITH L PACK AUTO TEMP CONTROLLER INOP. ON CLBOUT, ALT APPROX 10000 FT, ENTERED ICING CONDITIONS, TURNED AIRFOIL AND ENG ANTI-ICE ON. RECEIVED 'L/R ICE PROTECTION TEMP HIGH' AFTER ABOUT 2 MINS OF ENG AND WING ANTI-ICE BEING ON. COMPLETED 'ICE PROTECTION TEMP HIGH' CHKLIST. MESSAGES EXTINGUISHED. RECEIVED 'FLOW' LIGHT WARNING ON PRESSURIZATION PANEL, RAN 'FLOW LIGHT' CHKLIST. UNABLE TO MAINTAIN CABIN PRESSURIZATION (CABIN CLBING), 'CABIN ALT WARNING' WENT OFF. RAN 'RAPID DECOMPRESSION/CABIN ALT WARNING' CHKLIST. CAPT INITIATED EMER DSCNT AT FL270, CABIN CONTINUED TO CLB WHILE ACFT DSNDED. MAX CABIN ALT REACHED WAS 15500 FT. PAX OXYGEN MASKS DEPLOYED ABOVE 10000 FT CABIN ALT FOR APPROX 2 1/2 MINS. NONE OF THE CHKLISTS REFED DIRECTED LOOKING AT PACK PRESSURES. THIS SHOULD BE A REQUIRED STEP IN THE 'FLOW LIGHT' CHKLIST. VERY BUSY TIME FOR BOTH OF US FROM APPROX 10000 FT TO FL270 AND THEN DOWN TO 6000 FT. NUMEROUS COMS WITH ATC, FLT ATTENDANTS AND OTHER PLT. INITIALLY CAPT FLEW ACFT, TALKED ON RADIO AND COMMUNICATED WITH FLT ATTENDANTS. AFTER CHKLIST COMPLETION, I FLEW ACFT AND COMMUNICATED WITH ATC. EMER DSCNT COMPLETE WHEN I BEGAN FLYING. BOTTOM LINE: PAX AND CREW ALL OK. ONLY DISTR WAS THAT PACK PRESSURES WERE NOT SPECIFICALLY REFED IN ANY OF THE CHKLISTS RUN. PACK PRESSURES WERE PROBABLY LOW TO ZERO -- CHKLIST(S) SHOULD ADDRESS PACK PRESSURES EARLY ON. THIS MAY HAVE AIDED IN OUR ABILITY TO RECOVER PRESSURE IN THE CABIN. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT BECAUSE OF THE 'FLOW LIGHT' INDICATION AT ABOUT 8000 FT CABIN ALT, THE CREW WAS READY FOR THE AURAL ANNUNCIATION 'CABIN ALT' AND THE WARNING HORN. THEY WERE IN THE PROCESS OF EXECUTING THE LOSS OF PRESSURE CHKLIST AND INITIATING A DSCNT WITH ATC WHEN THE MASKS DROPPED. THE CABIN WAS ASCENDING AT ABOUT 1500 FPM. RPTR FEELS THAT THE AIRLINE'S SYS KNOWLEDGE REQUIREMENT IS TOO LOW AND THAT WHILE MORE KNOWLEDGE WOULD NOT HAVE HELPED THEM OVERCOME OR MANAGE IN THIS SIT, SYS KNOWLEDGE IN GENERAL MAY HAVE HELPED THEM UNDERSTAND WHAT WAS OCCURRING. A KNOWN ANOMALY WITH THE MD88 IS A PACK OVERHEAT WITH NORMAL PRESSURE INDICATIONS. THE KEY TO SYS OP IN THE EVENT OF AN OVERHEAT IS THE FLOW INDICATION. THE CREW DID NOT DETERMINE NOR DID MAINT INFORM THEM WHAT CAUSED THE PROB.
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.