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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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A BE1900D on leveloff at 17000 ft had master caution warning illuminated. Cabin pressurized to 12000 ft. Began to get multiple system failures.
| Attributes | |
| ACN | 664506 |
| Time | |
| Date | 200507 |
| Place | |
| Locale Reference | airport : zzz1.airport |
| State Reference | US |
| Altitude | msl single value : 17000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zzz2.artcc |
| Operator | common carrier : air carrier |
| Make Model Name | Beech 1900 |
| Operating Under FAR Part | Part 91 |
| Flight Phase | cruise : level |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 50 flight time total : 12000 flight time type : 1500 |
| ASRS Report | 664506 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : cabin pressure indicator other flight crewa other flight crewb |
| Resolutory Action | none taken : unable |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : briefing contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : logbook entry performance deficiency : unqualified personnel performance deficiency : testing performance deficiency : repair performance deficiency : fault isolation performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Environmental Factor Company Chart Or Publication Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Shortly after leveloff at 17000 ft; master warning illumination cabin altitude. Crew followed appropriate checklist. Cabin altitude maintained approximately 12000 ft. Continuation of flight under far part 91 for repos. First officer noticed #2 DME not working/indicating. We tried other frequencys with no change in DME status (inoperative). Shortly after that (10 mins); AC bus illumination. Followed checklist and xferred to #2 inverter. Moments later; captain dpu failure. Followed checklist xfer to all dpu #2. Now no DME indications. Upon landing in ZZZ; we wrote up: 1) captain clock inoperative. 2) left AC bus/inverter left side failure and intermittent. 3) left captain dpu intermittent. 4) cabin does not hold pressure. 5) rate controller appears not to control cabin rate. 6) first officer DME inoperative. All items above were inspected and cleaned by maintenance for the following day. (The DME on first officer side was deferred.) crew the next morning took off from ZZZ. Later investigation determined that maintenance in ZZZ1 did not install #2 DME antenna; which resulted in DME failure and pressurization problem. (Aircraft just came out of structural maintenance.) cause of problem: poor oversight by maintenance personnel. Poor pass-down during maintenance crew change.
Original NASA ASRS Text
Title: A BE1900D ON LEVELOFF AT 17000 FT HAD MASTER CAUTION WARNING ILLUMINATED. CABIN PRESSURIZED TO 12000 FT. BEGAN TO GET MULTIPLE SYS FAILURES.
Narrative: SHORTLY AFTER LEVELOFF AT 17000 FT; MASTER WARNING ILLUMINATION CABIN ALT. CREW FOLLOWED APPROPRIATE CHKLIST. CABIN ALT MAINTAINED APPROX 12000 FT. CONTINUATION OF FLT UNDER FAR PART 91 FOR REPOS. FO NOTICED #2 DME NOT WORKING/INDICATING. WE TRIED OTHER FREQS WITH NO CHANGE IN DME STATUS (INOP). SHORTLY AFTER THAT (10 MINS); AC BUS ILLUMINATION. FOLLOWED CHKLIST AND XFERRED TO #2 INVERTER. MOMENTS LATER; CAPT DPU FAILURE. FOLLOWED CHKLIST XFER TO ALL DPU #2. NOW NO DME INDICATIONS. UPON LNDG IN ZZZ; WE WROTE UP: 1) CAPT CLOCK INOP. 2) L AC BUS/INVERTER L SIDE FAILURE AND INTERMITTENT. 3) L CAPT DPU INTERMITTENT. 4) CABIN DOES NOT HOLD PRESSURE. 5) RATE CONTROLLER APPEARS NOT TO CTL CABIN RATE. 6) FO DME INOP. ALL ITEMS ABOVE WERE INSPECTED AND CLEANED BY MAINT FOR THE FOLLOWING DAY. (THE DME ON FO SIDE WAS DEFERRED.) CREW THE NEXT MORNING TOOK OFF FROM ZZZ. LATER INVESTIGATION DETERMINED THAT MAINT IN ZZZ1 DID NOT INSTALL #2 DME ANTENNA; WHICH RESULTED IN DME FAILURE AND PRESSURIZATION PROB. (ACFT JUST CAME OUT OF STRUCTURAL MAINT.) CAUSE OF PROB: POOR OVERSIGHT BY MAINT PERSONNEL. POOR PASS-DOWN DURING MAINT CREW CHANGE.
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.