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|
Attributes | |
ACN | 648730 |
Time | |
Date | 200502 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : rno.airport |
State Reference | NV |
Altitude | msl bound lower : 10000 msl bound upper : 10500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : rno.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 145 flight time total : 9850 flight time type : 1550 |
ASRS Report | 648730 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 85 flight time total : 2115 flight time type : 295 |
ASRS Report | 648726 |
Events | |
Anomaly | non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : cabin alt warning |
Resolutory Action | flight crew : landed as precaution |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was PF and we departed out of rno. Reaching 10500 ft; the cabin altitude warning horn sounded. I leveled off at 12000 ft. Oxygen masks were put on and communications with first officer were established. Told ATC we were level at 12000 ft and we'd like to continue another 5 mins at the current altitude. ATC gave us a vector to the left due to rising terrain -- I believe it was heading 130 degrees. I called for the next memory item pressurization mode selector in manual. I was given a radar vector to heading 300 degrees and descent to 11000 ft. I came back to the memory items and the mode selector was in manual. I assumed first officer had started the memory items. I asked first officer to try to toggle the outflow valve switch closed. He said the outflow valve was closing. We were being vectored to heading 360 degrees and cleared to 9000 ft. Due to the rising terrain; compression of time; minimal required fuel to san at departure and our current location downwind abeam the airport; I decided we were going to return and land at rno. We could sort out the pressurization problem on the ground. ATC asked if we had the airport in sight and we said yes. We were then cleared for a visual approach. We verified passenger signs on and the passenger oxygen was normal (we were below 14000 ft). I asked first officer to run through the cabin altitude warning and rapid depressurization checklist in the QRH and make sure we had completed all the checklist items. He called out all the items and the checklist complete. We then completed the descent and approach checklist. I advised the passenger and crew we were returning to rno due to pressurization controller problem and would be on the ground in 5 mins. We gave ATC the souls on board; and fuel. I flew the visual approach to runway 16R and backed it up with the ILS runway 16R. Completed the landing checklist. We had an uneventful landing. The controller had the crash fire rescue equipment trucks standing by. On taxi in; I asked first officer if he had any ideas what caused the problem. He asked me if I had moved the mode selector switch to manual. I said no. He said; 'I think we departed with the mode selector switch in manual mode.' reaching the gate; I advised maintenance and dispatch that we had probably departed with the pressurization mode selector in manual mode. During the before start checklist and the after start checklist; I had noted the land altitude indicator; the cruise altitude indicator; the pack switch; isolation valve switch; and bleed air switch position (all the switches that are normally moved); but failed to note the position of the pressurization mode selector. My main concerns were the rising terrain and maintaining or reducing the cabin altitude. By the time we were stabilized and in a position to start problem solving; we were in a position to land. Supplemental information from acn 648726: I feel that this situation may be prevented in the future with a change to the before start checklist. Pressurization: packs; bleeds on; set; automatic.
Original NASA ASRS Text
Title: A B737-700 DEPARTING RNO FAILED TO PRESSURIZE BECAUSE OF THE PRESSURIZATION MODE SELECTOR'S MANUAL POS SETTING.
Narrative: I WAS PF AND WE DEPARTED OUT OF RNO. REACHING 10500 FT; THE CABIN ALT WARNING HORN SOUNDED. I LEVELED OFF AT 12000 FT. OXYGEN MASKS WERE PUT ON AND COMS WITH FO WERE ESTABLISHED. TOLD ATC WE WERE LEVEL AT 12000 FT AND WE'D LIKE TO CONTINUE ANOTHER 5 MINS AT THE CURRENT ALT. ATC GAVE US A VECTOR TO THE L DUE TO RISING TERRAIN -- I BELIEVE IT WAS HDG 130 DEGS. I CALLED FOR THE NEXT MEMORY ITEM PRESSURIZATION MODE SELECTOR IN MANUAL. I WAS GIVEN A RADAR VECTOR TO HDG 300 DEGS AND DSCNT TO 11000 FT. I CAME BACK TO THE MEMORY ITEMS AND THE MODE SELECTOR WAS IN MANUAL. I ASSUMED FO HAD STARTED THE MEMORY ITEMS. I ASKED FO TO TRY TO TOGGLE THE OUTFLOW VALVE SWITCH CLOSED. HE SAID THE OUTFLOW VALVE WAS CLOSING. WE WERE BEING VECTORED TO HDG 360 DEGS AND CLRED TO 9000 FT. DUE TO THE RISING TERRAIN; COMPRESSION OF TIME; MINIMAL REQUIRED FUEL TO SAN AT DEP AND OUR CURRENT LOCATION DOWNWIND ABEAM THE ARPT; I DECIDED WE WERE GOING TO RETURN AND LAND AT RNO. WE COULD SORT OUT THE PRESSURIZATION PROB ON THE GND. ATC ASKED IF WE HAD THE ARPT IN SIGHT AND WE SAID YES. WE WERE THEN CLRED FOR A VISUAL APCH. WE VERIFIED PAX SIGNS ON AND THE PAX OXYGEN WAS NORMAL (WE WERE BELOW 14000 FT). I ASKED FO TO RUN THROUGH THE CABIN ALT WARNING AND RAPID DEPRESSURIZATION CHKLIST IN THE QRH AND MAKE SURE WE HAD COMPLETED ALL THE CHKLIST ITEMS. HE CALLED OUT ALL THE ITEMS AND THE CHKLIST COMPLETE. WE THEN COMPLETED THE DSCNT AND APCH CHKLIST. I ADVISED THE PAX AND CREW WE WERE RETURNING TO RNO DUE TO PRESSURIZATION CONTROLLER PROB AND WOULD BE ON THE GND IN 5 MINS. WE GAVE ATC THE SOULS ON BOARD; AND FUEL. I FLEW THE VISUAL APCH TO RWY 16R AND BACKED IT UP WITH THE ILS RWY 16R. COMPLETED THE LNDG CHKLIST. WE HAD AN UNEVENTFUL LNDG. THE CTLR HAD THE CFR TRUCKS STANDING BY. ON TAXI IN; I ASKED FO IF HE HAD ANY IDEAS WHAT CAUSED THE PROB. HE ASKED ME IF I HAD MOVED THE MODE SELECTOR SWITCH TO MANUAL. I SAID NO. HE SAID; 'I THINK WE DEPARTED WITH THE MODE SELECTOR SWITCH IN MANUAL MODE.' REACHING THE GATE; I ADVISED MAINT AND DISPATCH THAT WE HAD PROBABLY DEPARTED WITH THE PRESSURIZATION MODE SELECTOR IN MANUAL MODE. DURING THE BEFORE START CHKLIST AND THE AFTER START CHKLIST; I HAD NOTED THE LAND ALT INDICATOR; THE CRUISE ALT INDICATOR; THE PACK SWITCH; ISOLATION VALVE SWITCH; AND BLEED AIR SWITCH POS (ALL THE SWITCHES THAT ARE NORMALLY MOVED); BUT FAILED TO NOTE THE POS OF THE PRESSURIZATION MODE SELECTOR. MY MAIN CONCERNS WERE THE RISING TERRAIN AND MAINTAINING OR REDUCING THE CABIN ALT. BY THE TIME WE WERE STABILIZED AND IN A POS TO START PROB SOLVING; WE WERE IN A POS TO LAND. SUPPLEMENTAL INFO FROM ACN 648726: I FEEL THAT THIS SIT MAY BE PREVENTED IN THE FUTURE WITH A CHANGE TO THE BEFORE START CHKLIST. PRESSURIZATION: PACKS; BLEEDS ON; SET; AUTO.
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.