37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 745763 |
Time | |
Date | 200707 |
Place | |
Locale Reference | airport : skbo.airport |
State Reference | FO |
Altitude | agl single value : 500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain |
Experience | flight time last 90 days : 51 flight time total : 15000 flight time type : 3000 |
ASRS Report | 745763 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 90 flight time total : 12000 flight time type : 60 |
ASRS Report | 745760 |
Events | |
Anomaly | non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : eicas cabin alt warning other flight crewa other flight crewb |
Resolutory Action | aircraft : equipment problem dissipated flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We planned a heavy-weight departure from bogota on a B767 aircraft. The takeoff weight and temperature required that we perform a packs-off takeoff from runway 13L; and we discussed this procedure in the blocks before taxi out. We also loaded the ZIP1H SID into the FMS in route #1; and the engine-out procedure for runway 13L in route #2. During taxi out; the first officer inadvertently configured the bleed air system for an APU to packs takeoff instead of the proper packs off takeoff. I was paying more attention to taxiing because some of the txwys were closed; and failed to confirm the proper confign. Our takeoff was normal until approximately 500 ft AGL. I had already called for gear retraction; and just called for 'LNAV;' when the EICAS gave us a 'C hydraulic pressure' warning; followed shortly by a 'gear disagreement' warning. The first officer also observed that the center hydraulic pressure lights on the overhead panel were illuminated. He then opened the left bleed air valve to re-establish air conditioning and pressurization. I elected to continue on the SID; and discussed leveling off at 12000 ft MSL; and turn back toward the bog VOR to work the problem. To further add to the confusion; the cabin altitude warning activated. The first officer established the normal bleed air confign for flight; and announced that the hydraulic warnings had extinguished and the gear had retracted normally. The cabin altitude warning ceased shortly thereafter. I elected to continue the flight towards destination. During cruise; when we were discussing the earlier problem and how to write it up in the logbook; we realized that the improper bleed air confign at takeoff had removed bleed air from the center duct; and the center adp had not activated to aid gear retraction as it is supposed to. This; in turn; had caused the center hydraulic warnings. In other words; our improper confign of the bleed air system; had caused the problem. The vast majority of high altitude departures that I have performed have been in the B757; using the APU to packs takeoff procedure. In the future; I need to pay greater attention to the type aircraft; and correct procedure; both in briefing and in practice. I hope this episode will serve as an example and reminder to other flight crews operation in a high altitude environment.
Original NASA ASRS Text
Title: B767-300 FLT CREW MISCONFIGURED ACFT FOR PACKS OFF TKOF RESULTING IN VARIOUS UNWANTED ANOMALIES AFTER TKOF.
Narrative: WE PLANNED A HVY-WT DEP FROM BOGOTA ON A B767 ACFT. THE TKOF WT AND TEMP REQUIRED THAT WE PERFORM A PACKS-OFF TKOF FROM RWY 13L; AND WE DISCUSSED THIS PROC IN THE BLOCKS BEFORE TAXI OUT. WE ALSO LOADED THE ZIP1H SID INTO THE FMS IN RTE #1; AND THE ENG-OUT PROC FOR RWY 13L IN RTE #2. DURING TAXI OUT; THE FO INADVERTENTLY CONFIGURED THE BLEED AIR SYS FOR AN APU TO PACKS TKOF INSTEAD OF THE PROPER PACKS OFF TKOF. I WAS PAYING MORE ATTN TO TAXIING BECAUSE SOME OF THE TXWYS WERE CLOSED; AND FAILED TO CONFIRM THE PROPER CONFIGN. OUR TKOF WAS NORMAL UNTIL APPROX 500 FT AGL. I HAD ALREADY CALLED FOR GEAR RETRACTION; AND JUST CALLED FOR 'LNAV;' WHEN THE EICAS GAVE US A 'C HYD PRESSURE' WARNING; FOLLOWED SHORTLY BY A 'GEAR DISAGREEMENT' WARNING. THE FO ALSO OBSERVED THAT THE CTR HYD PRESSURE LIGHTS ON THE OVERHEAD PANEL WERE ILLUMINATED. HE THEN OPENED THE L BLEED AIR VALVE TO RE-ESTABLISH AIR CONDITIONING AND PRESSURIZATION. I ELECTED TO CONTINUE ON THE SID; AND DISCUSSED LEVELING OFF AT 12000 FT MSL; AND TURN BACK TOWARD THE BOG VOR TO WORK THE PROB. TO FURTHER ADD TO THE CONFUSION; THE CABIN ALT WARNING ACTIVATED. THE FO ESTABLISHED THE NORMAL BLEED AIR CONFIGN FOR FLT; AND ANNOUNCED THAT THE HYD WARNINGS HAD EXTINGUISHED AND THE GEAR HAD RETRACTED NORMALLY. THE CABIN ALT WARNING CEASED SHORTLY THEREAFTER. I ELECTED TO CONTINUE THE FLT TOWARDS DEST. DURING CRUISE; WHEN WE WERE DISCUSSING THE EARLIER PROB AND HOW TO WRITE IT UP IN THE LOGBOOK; WE REALIZED THAT THE IMPROPER BLEED AIR CONFIGN AT TKOF HAD REMOVED BLEED AIR FROM THE CTR DUCT; AND THE CTR ADP HAD NOT ACTIVATED TO AID GEAR RETRACTION AS IT IS SUPPOSED TO. THIS; IN TURN; HAD CAUSED THE CTR HYD WARNINGS. IN OTHER WORDS; OUR IMPROPER CONFIGN OF THE BLEED AIR SYS; HAD CAUSED THE PROB. THE VAST MAJORITY OF HIGH ALT DEPS THAT I HAVE PERFORMED HAVE BEEN IN THE B757; USING THE APU TO PACKS TKOF PROC. IN THE FUTURE; I NEED TO PAY GREATER ATTN TO THE TYPE ACFT; AND CORRECT PROC; BOTH IN BRIEFING AND IN PRACTICE. I HOPE THIS EPISODE WILL SERVE AS AN EXAMPLE AND REMINDER TO OTHER FLT CREWS OP IN A HIGH ALT ENVIRONMENT.
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.