37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 701189 |
Time | |
Date | 200606 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl bound lower : 14000 msl bound upper : 15000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | general aviation : corporate |
Make Model Name | Gulfstream II |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 25 flight time total : 11500 flight time type : 2500 |
ASRS Report | 701189 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : provided flight assist flight crew : declared emergency other |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Preflight Inspection Proc |
Narrative:
Climbing out on radar vectors to SID; passenger noted smoke in the cabin. It was verified visually by both pilots. Ram air and emergency pressurization were selected; ATC was notified; and follow-up checklist was accomplished for smoke removal; and the aircraft returned to ZZZ for an uneventful landing. The smoke immediately dissipated with no further inflow. Maintenance investigated and discovered both manual temperature control valves; in the aft baggage compartment; were set to full hot. These control valves override the inputs in the remainder of the system; so the pilots had no control of the air being sent through the duct system; and the ducts had overheated and were creating the smoke. No damage was discovered; the valves were reset to their center/off position; the system was ground checked; and a subsequent flight was accomplished with no problems. Callback conversation with reporter revealed the following information: the reporter stated the following; these aft cargo compartment's mechanically operated valves are only installed in the gulfstream 11 and normally set to center/off position. This airplane had just been released from maintenance and was on its first flight. The valves' settings are not included in the preflight inspections and it is believed the setting of these two valves to full hot was done while in maintenance. These valves when set in the full hot position will override the temperature inputs to the air conditioning system. While set to full hot; the ducting overheated creating the smell and smoke. The reporter has never experienced these valves set to full hot and they were not aware of the possibility of duct overheating.
Original NASA ASRS Text
Title: A GULFSTREAM 11 IN CLB AT 14000 FT DECLARED AN EMER AND RETURNED TO THE DEP ARPT DUE TO PAX RPTING SMOKE IN THE CABIN.
Narrative: CLBING OUT ON RADAR VECTORS TO SID; PAX NOTED SMOKE IN THE CABIN. IT WAS VERIFIED VISUALLY BY BOTH PLTS. RAM AIR AND EMER PRESSURIZATION WERE SELECTED; ATC WAS NOTIFIED; AND FOLLOW-UP CHKLIST WAS ACCOMPLISHED FOR SMOKE REMOVAL; AND THE ACFT RETURNED TO ZZZ FOR AN UNEVENTFUL LNDG. THE SMOKE IMMEDIATELY DISSIPATED WITH NO FURTHER INFLOW. MAINT INVESTIGATED AND DISCOVERED BOTH MANUAL TEMPERATURE CONTROL VALVES; IN THE AFT BAGGAGE COMPARTMENT; WERE SET TO FULL HOT. THESE CONTROL VALVES OVERRIDE THE INPUTS IN THE REMAINDER OF THE SYSTEM; SO THE PLTS HAD NO CTL OF THE AIR BEING SENT THROUGH THE DUCT SYSTEM; AND THE DUCTS HAD OVERHEATED AND WERE CREATING THE SMOKE. NO DAMAGE WAS DISCOVERED; THE VALVES WERE RESET TO THEIR CTR/OFF POSITION; THE SYSTEM WAS GND CHKED; AND A SUBSEQUENT FLT WAS ACCOMPLISHED WITH NO PROBS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE FOLLOWING; THESE AFT CARGO COMPARTMENT'S MECHANICALLY OPERATED VALVES ARE ONLY INSTALLED IN THE GULFSTREAM 11 AND NORMALLY SET TO CTR/OFF POSITION. THIS AIRPLANE HAD JUST BEEN RELEASED FROM MAINT AND WAS ON ITS FIRST FLT. THE VALVES' SETTINGS ARE NOT INCLUDED IN THE PREFLT INSPECTIONS AND IT IS BELIEVED THE SETTING OF THESE TWO VALVES TO FULL HOT WAS DONE WHILE IN MAINT. THESE VALVES WHEN SET IN THE FULL HOT POSITION WILL OVERRIDE THE TEMP INPUTS TO THE AIR CONDITIONING SYSTEM. WHILE SET TO FULL HOT; THE DUCTING OVERHEATED CREATING THE SMELL AND SMOKE. THE RPTR HAS NEVER EXPERIENCED THESE VALVES SET TO FULL HOT AND THEY WERE NOT AWARE OF THE POSSIBILITY OF DUCT OVERHEATING.
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.