37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 673299 |
Time | |
Date | 200509 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : oak.airport |
State Reference | CA |
Altitude | msl single value : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : nct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial climbout : intermediate altitude |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 180 flight time total : 8000 flight time type : 4000 |
ASRS Report | 673299 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was PF departing oak. Passing 10000 ft when the cabin altitude warning horn went off. I looked at the cabin altitude and saw that it was the same as our aircraft altitude. I was hand flying; so I attempted to level off and look at the pressurization panel. When I looked at the panel; everything looked normal. I eventually engaged the autoplt and began to analyze the problem. The pressure did not stabilize; so I directed the first officer to don his mask and I donned mine. I was a bit confused because everything looked right but the cabin was still at 10000 ft. To make matters worse; I couldn't find the warning horn cutout switch. I finally found it and silenced the horn. We then ran the checklist. After running the checklist; the first officer told me he had left the mode selector switch in manual during his preflight (which I missed also) and that he had returned it to normal while I leveled the aircraft. We placed the switch to 'altitude' then normal and the cabin finally came down. We continued on. That is when I noticed the amber confign lights on the left main fuel gauge. I looked up at the fuel panel to find that I had left the xfeed open during my preflight. I balanced the fuel and we continued the trip uneventfully (believe it or not). I had a short night the night before because I was on reserve and had to be in oak early. I was able to get a 2 hour nap before the flight; so I did feel refreshed. I had been off for about 1 week before the flight; but didn't feel rusty. My first officer was in his first full month; but seemed to be doing ok. We pushed about 25 mins late due to the late arrival of the aircraft; but I didn't feel rushed. So; I have no real excuse for the mistakes other than lack of attention to detail.
Original NASA ASRS Text
Title: POOR COCKPIT PREFLTS BY B737 FLT CREW RESULT IN PRESSURIZATION LOSS AND FUEL CONFIGN OUT OF LIMITS DUE TO XFEED LEFT OPEN.
Narrative: I WAS PF DEPARTING OAK. PASSING 10000 FT WHEN THE CABIN ALT WARNING HORN WENT OFF. I LOOKED AT THE CABIN ALT AND SAW THAT IT WAS THE SAME AS OUR ACFT ALT. I WAS HAND FLYING; SO I ATTEMPTED TO LEVEL OFF AND LOOK AT THE PRESSURIZATION PANEL. WHEN I LOOKED AT THE PANEL; EVERYTHING LOOKED NORMAL. I EVENTUALLY ENGAGED THE AUTOPLT AND BEGAN TO ANALYZE THE PROB. THE PRESSURE DID NOT STABILIZE; SO I DIRECTED THE FO TO DON HIS MASK AND I DONNED MINE. I WAS A BIT CONFUSED BECAUSE EVERYTHING LOOKED RIGHT BUT THE CABIN WAS STILL AT 10000 FT. TO MAKE MATTERS WORSE; I COULDN'T FIND THE WARNING HORN CUTOUT SWITCH. I FINALLY FOUND IT AND SILENCED THE HORN. WE THEN RAN THE CHKLIST. AFTER RUNNING THE CHKLIST; THE FO TOLD ME HE HAD LEFT THE MODE SELECTOR SWITCH IN MANUAL DURING HIS PREFLT (WHICH I MISSED ALSO) AND THAT HE HAD RETURNED IT TO NORMAL WHILE I LEVELED THE ACFT. WE PLACED THE SWITCH TO 'ALT' THEN NORMAL AND THE CABIN FINALLY CAME DOWN. WE CONTINUED ON. THAT IS WHEN I NOTICED THE AMBER CONFIGN LIGHTS ON THE L MAIN FUEL GAUGE. I LOOKED UP AT THE FUEL PANEL TO FIND THAT I HAD LEFT THE XFEED OPEN DURING MY PREFLT. I BALANCED THE FUEL AND WE CONTINUED THE TRIP UNEVENTFULLY (BELIEVE IT OR NOT). I HAD A SHORT NIGHT THE NIGHT BEFORE BECAUSE I WAS ON RESERVE AND HAD TO BE IN OAK EARLY. I WAS ABLE TO GET A 2 HR NAP BEFORE THE FLT; SO I DID FEEL REFRESHED. I HAD BEEN OFF FOR ABOUT 1 WK BEFORE THE FLT; BUT DIDN'T FEEL RUSTY. MY FO WAS IN HIS FIRST FULL MONTH; BUT SEEMED TO BE DOING OK. WE PUSHED ABOUT 25 MINS LATE DUE TO THE LATE ARR OF THE ACFT; BUT I DIDN'T FEEL RUSHED. SO; I HAVE NO REAL EXCUSE FOR THE MISTAKES OTHER THAN LACK OF ATTN TO DETAIL.
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.