37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 646738 |
Time | |
Date | 200502 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : cvg.airport |
State Reference | OH |
Altitude | msl single value : 10000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Ice |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : cvg.tracon |
Operator | common carrier : air carrier |
Make Model Name | MD-88 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 190 flight time total : 8731 flight time type : 4293 |
ASRS Report | 646738 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : multi engine pilot : instrument pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 5000 flight time type : 1500 |
ASRS Report | 647406 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : cabin alt warning other other : 3 |
Resolutory Action | flight crew : landed as precaution other |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Company Aircraft |
Primary Problem | Company |
Narrative:
I was captain and the PNF on a flight from cvg. We were delayed in boarding the aircraft because maintenance was on board. Normal preflight was conducted and before takeoff checklist was completed. Conditions were light rain; visibility approximately 2 mi; 2 degrees celsius with possible icing conditions. The reduced thrust takeoff was runway heading to 6000 ft. As we were climbing to 6000 ft; I noticed light rime icing. The engine anti-ice had been on for takeoff; so I turned on air foil anti-icing. For that reason; the after takeoff checklist had not yet been completed. We were then cleared to climb to 13000 ft. As the aircraft began to climb; the aft flight attendant called to report a loud squeal around the aft galley. I told the first officer to level off. At about the same time; we were passing 10000 ft and the cabin altitude aural vocal sounded. I instructed the first officer to begin a gradual descent. In the descent to 8000 ft; we noticed the cabin altitude control selector was in the manual position. The cabin altitude control selector was placed in automatic to try to get control of the cabin pressurization. The cabin followed our descent and did not pressurize in the automatic mode. I decided to return to cvg and have maintenance check the aircraft rather than continue. No emergency was declared. Landing and taxi to the gate were uneventful. We subsequently changed aircraft and proceeded to pwm. Contributing factors: 1) fatigue: a reduced layover in atl the night before into a long day of dealing with WX. This was a factor in missing the check of the controller during preflight. 2) the pressure to stay on schedule after receiving the aircraft late during preflight. 3) set up by maintenance; the aircraft had been pressurized for a maintenance check. The controller was left in the manual mode full open. Night looking at the controller the position of the valve is the same as you would normally find in automatic mode. Supplemental information from acn 647406: the PNF was overly concerned about icing and failed to notice the cabin pressure climbing.
Original NASA ASRS Text
Title: FLT CREW OF MD88 FAIL TO PLACE PRESSURIZATION SYS IN AUTO PER CHKLIST AND ENCOUNTER PRESSURIZATION ANOMALIES DURING CLB WHICH FORCE A RETURN TO DEP STATION. INCOMPLETE LAST MIN MAINT CONTRIBUTED.
Narrative: I WAS CAPT AND THE PNF ON A FLT FROM CVG. WE WERE DELAYED IN BOARDING THE ACFT BECAUSE MAINT WAS ON BOARD. NORMAL PREFLT WAS CONDUCTED AND BEFORE TKOF CHKLIST WAS COMPLETED. CONDITIONS WERE LIGHT RAIN; VISIBILITY APPROX 2 MI; 2 DEGS CELSIUS WITH POSSIBLE ICING CONDITIONS. THE REDUCED THRUST TKOF WAS RWY HDG TO 6000 FT. AS WE WERE CLBING TO 6000 FT; I NOTICED LIGHT RIME ICING. THE ENG ANTI-ICE HAD BEEN ON FOR TKOF; SO I TURNED ON AIR FOIL ANTI-ICING. FOR THAT REASON; THE AFTER TKOF CHKLIST HAD NOT YET BEEN COMPLETED. WE WERE THEN CLRED TO CLB TO 13000 FT. AS THE ACFT BEGAN TO CLB; THE AFT FLT ATTENDANT CALLED TO RPT A LOUD SQUEAL AROUND THE AFT GALLEY. I TOLD THE FO TO LEVEL OFF. AT ABOUT THE SAME TIME; WE WERE PASSING 10000 FT AND THE CABIN ALT AURAL VOCAL SOUNDED. I INSTRUCTED THE FO TO BEGIN A GRADUAL DSCNT. IN THE DSCNT TO 8000 FT; WE NOTICED THE CABIN ALT CTL SELECTOR WAS IN THE MANUAL POS. THE CABIN ALT CTL SELECTOR WAS PLACED IN AUTO TO TRY TO GET CTL OF THE CABIN PRESSURIZATION. THE CABIN FOLLOWED OUR DSCNT AND DID NOT PRESSURIZE IN THE AUTO MODE. I DECIDED TO RETURN TO CVG AND HAVE MAINT CHK THE ACFT RATHER THAN CONTINUE. NO EMER WAS DECLARED. LNDG AND TAXI TO THE GATE WERE UNEVENTFUL. WE SUBSEQUENTLY CHANGED ACFT AND PROCEEDED TO PWM. CONTRIBUTING FACTORS: 1) FATIGUE: A REDUCED LAYOVER IN ATL THE NIGHT BEFORE INTO A LONG DAY OF DEALING WITH WX. THIS WAS A FACTOR IN MISSING THE CHK OF THE CTLR DURING PREFLT. 2) THE PRESSURE TO STAY ON SCHEDULE AFTER RECEIVING THE ACFT LATE DURING PREFLT. 3) SET UP BY MAINT; THE ACFT HAD BEEN PRESSURIZED FOR A MAINT CHK. THE CTLR WAS LEFT IN THE MANUAL MODE FULL OPEN. NIGHT LOOKING AT THE CTLR THE POS OF THE VALVE IS THE SAME AS YOU WOULD NORMALLY FIND IN AUTO MODE. SUPPLEMENTAL INFO FROM ACN 647406: THE PNF WAS OVERLY CONCERNED ABOUT ICING AND FAILED TO NOTICE THE CABIN PRESSURE CLBING.
Data retrieved from NASA's ASRS site as of January 2009 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.