37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 699025 |
Time | |
Date | 200606 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : zbw.artcc |
State Reference | NH |
Altitude | msl single value : 16000 |
Environment | |
Flight Conditions | Mixed |
Weather Elements | Rain Fog Thunderstorm |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zbw.artcc |
Operator | general aviation : corporate |
Make Model Name | Learjet 60 |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | enroute airway : v489.airway |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 13800 flight time type : 1800 |
ASRS Report | 699025 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : far non adherence : company policies other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : cabin press warning other flight crewa other flight crewb |
Resolutory Action | flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
The cabin air switch was not turned on prior to takeoff. This omission wasn't caught until the 'pressurization system' caution illuminated at 8000 ca. An immediate descent to 10000 ft was requested while the crew re-pressurized the cabin. Luckily enough this was a low altitude trip and the cabin never climbed about 9500 ca. Contributing factors: 1) poor design on learjet pressurization system. The cabin air switch must be turned on prior to departure unlike most other aircraft types. Forgetting this switch is a common mistake (especially if distraction) even with experienced lear crews. 2) distrs: WX; trip route changes; radio calls; and traffic. 3) tired crew.
Original NASA ASRS Text
Title: LEAR 60 FLT CREW NEGLECTS TO TURN CABIN AIR SWITCH ON PRIOR TO DEP.
Narrative: THE CABIN AIR SWITCH WAS NOT TURNED ON PRIOR TO TKOF. THIS OMISSION WASN'T CAUGHT UNTIL THE 'PRESSURIZATION SYS' CAUTION ILLUMINATED AT 8000 CA. AN IMMEDIATE DSCNT TO 10000 FT WAS REQUESTED WHILE THE CREW RE-PRESSURIZED THE CABIN. LUCKILY ENOUGH THIS WAS A LOW ALT TRIP AND THE CABIN NEVER CLBED ABOUT 9500 CA. CONTRIBUTING FACTORS: 1) POOR DESIGN ON LEARJET PRESSURIZATION SYS. THE CABIN AIR SWITCH MUST BE TURNED ON PRIOR TO DEP UNLIKE MOST OTHER ACFT TYPES. FORGETTING THIS SWITCH IS A COMMON MISTAKE (ESPECIALLY IF DISTR) EVEN WITH EXPERIENCED LEAR CREWS. 2) DISTRS: WX; TRIP RTE CHANGES; RADIO CALLS; AND TFC. 3) TIRED CREW.
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.