37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 708539 |
Time | |
Date | 200608 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl bound lower : 0 msl bound upper : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi pilot : commercial pilot : multi engine pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 10250 flight time type : 3500 |
ASRS Report | 708239 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : company policies |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : declared emergency flight crew : landed in emergency condition |
Consequence | other |
Supplementary | |
Problem Areas | Company Aircraft |
Primary Problem | Company |
Narrative:
On takeoff I noticed a loud low rumble and noticed that the aircraft was not pressurizing. I leveled off at 2000 ft and began a turn to the north. I had my first officer check the ecs page and couldn't determine why we were not pressurizing and where the noise was coming from. I turned for a downwind and told ATC that we needed to return to the airport and declared the emergency. I had the first officer notify the flight attendants that we were returning to the airport and would not evacuate/evacuation the aircraft. I made a normal base to final landing. I returned to the gate and shut the aircraft down. When I went outside I noticed that the aft; forward cargo door was open. I had the passenger get off and did not have time to talk with them about the emergency. I told everyone not to touch the door and then contacted operations. Recommendations to prevent this from happening in the future: 1)change MEL and weight and balance manifest to reflect same door terminology. This was a major factor in causing confusion in this event. 2) change MEL procedure to reflect same procedure in emb MEL. Adding the language that requires flight crew and ground crew to 'carefully check that all doors are closed and locked before each takeoff' would minimize the risk of future occurrences. Callback conversation with reporter revealed the following information: reporter stated that the crew was confused by the MEL because the forward aft cargo door (center door of 3 cargo doors) had an amber EICAS annunciation prior to their previous departure but was closed. The crew assumed that was the MEL'ed door because the MEL'ed door (aft) actually had a green (closed) indication. Furthermore; the weight and balance does not reflect the door confign on this aircraft and that led to further confusion when the door closed report was given. The reporter does not understand how the person reporting closed and locked could visually miss an open door because the door actually drops out and down; clearly visible beneath the aircraft.
Original NASA ASRS Text
Title: A CRJ900 PLT RPTS DECLARING AN EMER AND RETURNING TO LAND BECAUSE A FORWARD CARGO DOOR WAS NOT CLOSED BEFORE TKOF.
Narrative: ON TKOF I NOTICED A LOUD LOW RUMBLE AND NOTICED THAT THE ACFT WAS NOT PRESSURIZING. I LEVELED OFF AT 2000 FT AND BEGAN A TURN TO THE N. I HAD MY FO CHK THE ECS PAGE AND COULDN'T DETERMINE WHY WE WERE NOT PRESSURIZING AND WHERE THE NOISE WAS COMING FROM. I TURNED FOR A DOWNWIND AND TOLD ATC THAT WE NEEDED TO RETURN TO THE ARPT AND DECLARED THE EMER. I HAD THE FO NOTIFY THE FLT ATTENDANTS THAT WE WERE RETURNING TO THE ARPT AND WOULD NOT EVAC THE ACFT. I MADE A NORMAL BASE TO FINAL LNDG. I RETURNED TO THE GATE AND SHUT THE ACFT DOWN. WHEN I WENT OUTSIDE I NOTICED THAT THE AFT; FORWARD CARGO DOOR WAS OPEN. I HAD THE PAX GET OFF AND DID NOT HAVE TIME TO TALK WITH THEM ABOUT THE EMER. I TOLD EVERYONE NOT TO TOUCH THE DOOR AND THEN CONTACTED OPS. RECOMMENDATIONS TO PREVENT THIS FROM HAPPENING IN THE FUTURE: 1)CHANGE MEL AND WT AND BAL MANIFEST TO REFLECT SAME DOOR TERMINOLOGY. THIS WAS A MAJOR FACTOR IN CAUSING CONFUSION IN THIS EVENT. 2) CHANGE MEL PROC TO REFLECT SAME PROC IN EMB MEL. ADDING THE LANGUAGE THAT REQUIRES FLT CREW AND GND CREW TO 'CAREFULLY CHK THAT ALL DOORS ARE CLOSED AND LOCKED BEFORE EACH TKOF' WOULD MINIMIZE THE RISK OF FUTURE OCCURRENCES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE CREW WAS CONFUSED BY THE MEL BECAUSE THE FORWARD AFT CARGO DOOR (CTR DOOR OF 3 CARGO DOORS) HAD AN AMBER EICAS ANNUNCIATION PRIOR TO THEIR PREVIOUS DEP BUT WAS CLOSED. THE CREW ASSUMED THAT WAS THE MEL'ED DOOR BECAUSE THE MEL'ED DOOR (AFT) ACTUALLY HAD A GREEN (CLOSED) INDICATION. FURTHERMORE; THE WT AND BAL DOES NOT REFLECT THE DOOR CONFIGN ON THIS ACFT AND THAT LED TO FURTHER CONFUSION WHEN THE DOOR CLOSED RPT WAS GIVEN. THE RPTR DOES NOT UNDERSTAND HOW THE PERSON RPTING CLOSED AND LOCKED COULD VISUALLY MISS AN OPEN DOOR BECAUSE THE DOOR ACTUALLY DROPS OUT AND DOWN; CLRLY VISIBLE BENEATH THE ACFT.
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.