37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 683254 |
Time | |
Date | 200601 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : elp.airport |
State Reference | TX |
Altitude | msl single value : 36000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zab.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 185 flight time total : 26500 flight time type : 22500 |
ASRS Report | 683254 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 250 flight time total : 16572 flight time type : 4195 |
ASRS Report | 683254 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : cabin alt warning horn |
Resolutory Action | flight crew : overcame equipment problem other |
Consequence | other |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Aircraft |
Narrative:
We were cruising at FL360 (if I remember right) and the cabin altitude alert horn went off. It was indicating 9700 ft in the cabin. We got our oxygen masks on; established communication; and did the procedure in the QRH checklist and got the cabin back to normal. We did the checklist; but it wasn't till we put packs to 'high' that the cabin altitude started going back down to 'normal.' during all of this; we requested lower altitude; and they gave us lower to 12000 ft (if I remember right). When everything was going fine and the cabin pressure was acting normal again; I asked the captain; 'should we let company know so they can set up for maintenance to meet us?' so we sent an ACARS message to dispatch; which we found out later dispatch never received it. On the ground; the captain talked to maintenance control for a very long time. After hearing all the details explained; maintenance control said; 'icing had prevented the outflow valve to not close all the way.' so maintenance control and dispatch gave us MEL 21.37 -- outflow valve heater gasket. So we were dispatched via MEL 21.37. We flew the next 2 legs with absolutely no problems. Next day; captain commuted on the very same plane. He looked at the logbook to see what the fix was. They found out it was the 'aft pressure APU duct bulkhead boot;' and not the 'outflow valve heater gasket' after all. He called me; and told me it was best we do a report. We did our best to do the right thing. Callback conversation with reporter revealed the following information: reporter stated that neither pilot confused this horn with the takeoff warning horn. Because the QRH procedures very quickly brought the cabin under control; they did not declare an emergency. Supplemental information from acn 683252: maybe I should have questioned the possibility of a different type of leak; but maintenance control seemed pretty matter of fact about the cause and the icing of the outflow valve seemed plausible with the existence of that MEL. In the QRH; pack switches -- automatic. Why not go to high immediately? I'm convinced that going to high was what started the cabin down and what could be harmed by immediately going to high? Seeing the cabin descend lowered the stress level immediately because we were having trouble getting an unrestr descent to a much lower altitude.
Original NASA ASRS Text
Title: AN ACR MAINT MEL'ED A B737-500 PRESSURIZATION OUTFLOW VALVE HEATER AS FAILED WHEN A RUPTURED DUCT ACTUALLY CAUSED A HIGH CABIN ALT.
Narrative: WE WERE CRUISING AT FL360 (IF I REMEMBER RIGHT) AND THE CABIN ALT ALERT HORN WENT OFF. IT WAS INDICATING 9700 FT IN THE CABIN. WE GOT OUR OXYGEN MASKS ON; ESTABLISHED COM; AND DID THE PROC IN THE QRH CHKLIST AND GOT THE CABIN BACK TO NORMAL. WE DID THE CHKLIST; BUT IT WASN'T TILL WE PUT PACKS TO 'HIGH' THAT THE CABIN ALT STARTED GOING BACK DOWN TO 'NORMAL.' DURING ALL OF THIS; WE REQUESTED LOWER ALT; AND THEY GAVE US LOWER TO 12000 FT (IF I REMEMBER RIGHT). WHEN EVERYTHING WAS GOING FINE AND THE CABIN PRESSURE WAS ACTING NORMAL AGAIN; I ASKED THE CAPT; 'SHOULD WE LET COMPANY KNOW SO THEY CAN SET UP FOR MAINT TO MEET US?' SO WE SENT AN ACARS MESSAGE TO DISPATCH; WHICH WE FOUND OUT LATER DISPATCH NEVER RECEIVED IT. ON THE GND; THE CAPT TALKED TO MAINT CTL FOR A VERY LONG TIME. AFTER HEARING ALL THE DETAILS EXPLAINED; MAINT CTL SAID; 'ICING HAD PREVENTED THE OUTFLOW VALVE TO NOT CLOSE ALL THE WAY.' SO MAINT CTL AND DISPATCH GAVE US MEL 21.37 -- OUTFLOW VALVE HEATER GASKET. SO WE WERE DISPATCHED VIA MEL 21.37. WE FLEW THE NEXT 2 LEGS WITH ABSOLUTELY NO PROBS. NEXT DAY; CAPT COMMUTED ON THE VERY SAME PLANE. HE LOOKED AT THE LOGBOOK TO SEE WHAT THE FIX WAS. THEY FOUND OUT IT WAS THE 'AFT PRESSURE APU DUCT BULKHEAD BOOT;' AND NOT THE 'OUTFLOW VALVE HEATER GASKET' AFTER ALL. HE CALLED ME; AND TOLD ME IT WAS BEST WE DO A RPT. WE DID OUR BEST TO DO THE RIGHT THING. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT NEITHER PLT CONFUSED THIS HORN WITH THE TKOF WARNING HORN. BECAUSE THE QRH PROCS VERY QUICKLY BROUGHT THE CABIN UNDER CTL; THEY DID NOT DECLARE AN EMER. SUPPLEMENTAL INFO FROM ACN 683252: MAYBE I SHOULD HAVE QUESTIONED THE POSSIBILITY OF A DIFFERENT TYPE OF LEAK; BUT MAINT CTL SEEMED PRETTY MATTER OF FACT ABOUT THE CAUSE AND THE ICING OF THE OUTFLOW VALVE SEEMED PLAUSIBLE WITH THE EXISTENCE OF THAT MEL. IN THE QRH; PACK SWITCHES -- AUTO. WHY NOT GO TO HIGH IMMEDIATELY? I'M CONVINCED THAT GOING TO HIGH WAS WHAT STARTED THE CABIN DOWN AND WHAT COULD BE HARMED BY IMMEDIATELY GOING TO HIGH? SEEING THE CABIN DSND LOWERED THE STRESS LEVEL IMMEDIATELY BECAUSE WE WERE HAVING TROUBLE GETTING AN UNRESTR DSCNT TO A MUCH LOWER ALT.
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.