37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 710854 |
Time | |
Date | 200609 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : zzz.artcc |
State Reference | US |
Altitude | msl single value : 28000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : enroute altitude change |
Route In Use | enroute airway : zzz.airway |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 262 flight time type : 3000 |
ASRS Report | 710854 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 154 |
ASRS Report | 710855 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance flight crew : exited adverse environment flight crew : declared emergency |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance ATC Human Performance |
Primary Problem | Aircraft |
Narrative:
At FL280; the cabin altitude warning horn sounded. The captain; who was the PF; requested a descent to 11000 ft. ARTCC gave us a descent to FL240; at which time the captain refused and again requested 10000 ft and declared an emergency. ARTCC gave us a descent to 11000 ft followed shortly by a descent to 10000 ft. I requested to continue the flight to ZZZ1 at 10000 ft. We accomplished the checklist; checked that all switches were in the proper position and landed uneventfully at ZZZ1. The passenger masks did not deploy and the cabin altitude went slightly above 10000 ft. This was a very puzzling situation because all switches were in the proper position with no indication of a malfunction. Both pilots accomplished all crew actions correctly except we didn't don the oxygen masks immediately as required by the QRH. This should have been our first priority.callback conversation with reporter revealed the following information: reporter stated that as the aircraft was climbing through FL280 for FL330; they heard a 'faint' horn but did not immediately identify the sound as the cabin pressurization warning. Once the horn was identified; both pilots and the jumpseater; after examining the controls and switches; decided not to change the pressurization configuration and began the descent. They reasoned that because the pressurization panel configuration was correct; the cause of the pressurization loss was somewhere else. Additionally; they were distracted by the communications with ATC and the delay in getting lower altitudes. For these reasons none of the flight station occupants donned an oxygen mask. This decision was not a conscious omission it was merely a breakdown in checklist discipline. The crew determined from air carrier maintenance that the outflow valve heater gasket and a belly drain mast failed.
Original NASA ASRS Text
Title: A B737-500 LOST CABIN PRESSURIZATION AT FL280. AN EMER WAS DECLARED; BUT OXYGEN MASKS WERE NOT USED DURING THE DSCNT TO 10000 FT.
Narrative: AT FL280; THE CABIN ALT WARNING HORN SOUNDED. THE CAPT; WHO WAS THE PF; REQUESTED A DSCNT TO 11000 FT. ARTCC GAVE US A DSCNT TO FL240; AT WHICH TIME THE CAPT REFUSED AND AGAIN REQUESTED 10000 FT AND DECLARED AN EMER. ARTCC GAVE US A DSCNT TO 11000 FT FOLLOWED SHORTLY BY A DSCNT TO 10000 FT. I REQUESTED TO CONTINUE THE FLT TO ZZZ1 AT 10000 FT. WE ACCOMPLISHED THE CHKLIST; CHKED THAT ALL SWITCHES WERE IN THE PROPER POSITION AND LANDED UNEVENTFULLY AT ZZZ1. THE PAX MASKS DID NOT DEPLOY AND THE CABIN ALT WENT SLIGHTLY ABOVE 10000 FT. THIS WAS A VERY PUZZLING SITUATION BECAUSE ALL SWITCHES WERE IN THE PROPER POSITION WITH NO INDICATION OF A MALFUNCTION. BOTH PLTS ACCOMPLISHED ALL CREW ACTIONS CORRECTLY EXCEPT WE DIDN'T DON THE OXYGEN MASKS IMMEDIATELY AS REQUIRED BY THE QRH. THIS SHOULD HAVE BEEN OUR FIRST PRIORITY.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT AS THE ACFT WAS CLBING THROUGH FL280 FOR FL330; THEY HEARD A 'FAINT' HORN BUT DID NOT IMMEDIATELY IDENTIFY THE SOUND AS THE CABIN PRESSURIZATION WARNING. ONCE THE HORN WAS IDENTIFIED; BOTH PLTS AND THE JUMPSEATER; AFTER EXAMINING THE CONTROLS AND SWITCHES; DECIDED NOT TO CHANGE THE PRESSURIZATION CONFIGURATION AND BEGAN THE DSCNT. THEY REASONED THAT BECAUSE THE PRESSURIZATION PANEL CONFIGURATION WAS CORRECT; THE CAUSE OF THE PRESSURIZATION LOSS WAS SOMEWHERE ELSE. ADDITIONALLY; THEY WERE DISTRACTED BY THE COMMUNICATIONS WITH ATC AND THE DELAY IN GETTING LOWER ALTS. FOR THESE REASONS NONE OF THE FLT STATION OCCUPANTS DONNED AN OXYGEN MASK. THIS DECISION WAS NOT A CONSCIOUS OMISSION IT WAS MERELY A BREAKDOWN IN CHKLIST DISCIPLINE. THE CREW DETERMINED FROM ACR MAINT THAT THE OUTFLOW VALVE HEATER GASKET AND A BELLY DRAIN MAST FAILED.
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.