37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 756598 |
Time | |
Date | 200710 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 10000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : vacating altitude |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : private pilot : multi engine pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 136 flight time total : 6500 flight time type : 686 |
ASRS Report | 756598 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 143 flight time total : 10000 flight time type : 320 |
ASRS Report | 756687 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : cabin alt warning other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : overcame equipment problem flight crew : landed as precaution |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Taxied out from ramp area with 1 engine running. During taxi out we were given a runway change which requires redoing the taxi checklist. We accomplished these items and shortly thereafter I call for the delayed engine start which the first officer accomplishes and then we do the before takeoff check while holding short of runway. We are then cleared on to hold then almost immediately cleared for takeoff on that runway. I xfer control of the aircraft to first officer and he commences the takeoff. Uneventful takeoff roll and lift-off. After initiating left turn to 260 degrees at 400 ft AGL; and passing approximately 2500 ft AGL; the after takeoff checklist is initiated. During this process we are switched to departure frequency and check in. I then observe traffic at left 10 O'clock position and inform departure of this. Shortly thereafter we get a TCAS TA showing traffic at right 2 O'clock position for a couple of mi on downwind. Departure control confirms this. As we are passing 8000 ft MSL; I start looking for the TCAS advisory traffic and monitoring our altitude as I am concerned about the traffic on downwind and the TCAS advisory; I make the 9000 ft for 10000 ft call and confirm that the first officer is leveling off. While this is occurring; departure control states that traffic is no factor and continue climb to FL230. I inquire about deleting the 250 KT speed restr and departure gives us normal speed and tells us to turn left on a heading to intercept the departure. I wait for the aircraft to roll out on the assigned heading and engage LNAV for the first officer. Almost immediately after LNAV is engaged; the intermittent cabin warning horn starts to go off. At this time we notice the cabin altitude climbing above 10000 ft. We put on our oxygen masks; perform the recall items and establish cockpit communications. Very shortly after this I tell the first officer to level off and I talk to ATC; stating we need to descend back down to 10000 ft. ATC advises his MVA is 11000 ft and I request a turn and descent. ATC clears us north and down to 11000 ft. During this whole process; the lead flight attendant is attempting to call me and inform me the passenger oxygen masks have deployed. Also during this process; I told the first officer to take all communications with ATC while I accomplish the QRH procedure for cabin altitude warning horn. As we are coordinating for return I initiate the descent and approach checklist. It is at this time I notice that both engine bleed switches are off. I then turn on the left engine bleed switch; paused for a few moments and then turn on the right engine bleed switch. As we complete the approach check; and with the pressurization panel operating in manual with the valve closed per QRH cabin altitude warning horn procedure; I manually open the outflow valve to reduce differential pressure to zero prior to landing. Landing and rollout were uneventful. Observations: due to the higher elevation of the airport; and our fairly light weight/higher rate of climb coupled with frequency change; TCAS TA distraction and looking for traffic; intermediate leveloff; and subsequent instructions/clearance from departure control; I had not yet finished the after takeoff check prior to aircraft climbing above 10000 ft MSL. Thus had not yet confirmed the pressurization/engine bleed confign prior to cabin altitude warning horn going off.
Original NASA ASRS Text
Title: B737 FLT CREW REPORTS CABIN ALTITUDE WARNING PASSING 10000 FEET MSL AND QUICKLY LEVELS OFF; BUT NOT BEFORE PAX OXYGEN MASKS DEPLOY. CAPTAIN DISCOVERS BLEED SWITCHES OFF DURING RETURN TO DEPARTURE ARPT.
Narrative: TAXIED OUT FROM RAMP AREA WITH 1 ENG RUNNING. DURING TAXI OUT WE WERE GIVEN A RWY CHANGE WHICH REQUIRES REDOING THE TAXI CHKLIST. WE ACCOMPLISHED THESE ITEMS AND SHORTLY THEREAFTER I CALL FOR THE DELAYED ENG START WHICH THE FO ACCOMPLISHES AND THEN WE DO THE BEFORE TKOF CHK WHILE HOLDING SHORT OF RWY. WE ARE THEN CLRED ON TO HOLD THEN ALMOST IMMEDIATELY CLRED FOR TKOF ON THAT RWY. I XFER CTL OF THE ACFT TO FO AND HE COMMENCES THE TKOF. UNEVENTFUL TKOF ROLL AND LIFT-OFF. AFTER INITIATING L TURN TO 260 DEGS AT 400 FT AGL; AND PASSING APPROX 2500 FT AGL; THE AFTER TKOF CHKLIST IS INITIATED. DURING THIS PROCESS WE ARE SWITCHED TO DEP FREQ AND CHK IN. I THEN OBSERVE TFC AT L 10 O'CLOCK POS AND INFORM DEP OF THIS. SHORTLY THEREAFTER WE GET A TCAS TA SHOWING TFC AT R 2 O'CLOCK POS FOR A COUPLE OF MI ON DOWNWIND. DEP CTL CONFIRMS THIS. AS WE ARE PASSING 8000 FT MSL; I START LOOKING FOR THE TCAS ADVISORY TFC AND MONITORING OUR ALT AS I AM CONCERNED ABOUT THE TFC ON DOWNWIND AND THE TCAS ADVISORY; I MAKE THE 9000 FT FOR 10000 FT CALL AND CONFIRM THAT THE FO IS LEVELING OFF. WHILE THIS IS OCCURRING; DEP CTL STATES THAT TFC IS NO FACTOR AND CONTINUE CLB TO FL230. I INQUIRE ABOUT DELETING THE 250 KT SPD RESTR AND DEP GIVES US NORMAL SPD AND TELLS US TO TURN L ON A HDG TO INTERCEPT THE DEP. I WAIT FOR THE ACFT TO ROLL OUT ON THE ASSIGNED HDG AND ENGAGE LNAV FOR THE FO. ALMOST IMMEDIATELY AFTER LNAV IS ENGAGED; THE INTERMITTENT CABIN WARNING HORN STARTS TO GO OFF. AT THIS TIME WE NOTICE THE CABIN ALT CLBING ABOVE 10000 FT. WE PUT ON OUR OXYGEN MASKS; PERFORM THE RECALL ITEMS AND ESTABLISH COCKPIT COMS. VERY SHORTLY AFTER THIS I TELL THE FO TO LEVEL OFF AND I TALK TO ATC; STATING WE NEED TO DSND BACK DOWN TO 10000 FT. ATC ADVISES HIS MVA IS 11000 FT AND I REQUEST A TURN AND DSCNT. ATC CLRS US N AND DOWN TO 11000 FT. DURING THIS WHOLE PROCESS; THE LEAD FLT ATTENDANT IS ATTEMPTING TO CALL ME AND INFORM ME THE PAX OXYGEN MASKS HAVE DEPLOYED. ALSO DURING THIS PROCESS; I TOLD THE FO TO TAKE ALL COMS WITH ATC WHILE I ACCOMPLISH THE QRH PROC FOR CABIN ALT WARNING HORN. AS WE ARE COORDINATING FOR RETURN I INITIATE THE DSCNT AND APCH CHKLIST. IT IS AT THIS TIME I NOTICE THAT BOTH ENG BLEED SWITCHES ARE OFF. I THEN TURN ON THE L ENG BLEED SWITCH; PAUSED FOR A FEW MOMENTS AND THEN TURN ON THE R ENG BLEED SWITCH. AS WE COMPLETE THE APCH CHK; AND WITH THE PRESSURIZATION PANEL OPERATING IN MANUAL WITH THE VALVE CLOSED PER QRH CABIN ALT WARNING HORN PROC; I MANUALLY OPEN THE OUTFLOW VALVE TO REDUCE DIFFERENTIAL PRESSURE TO ZERO PRIOR TO LNDG. LNDG AND ROLLOUT WERE UNEVENTFUL. OBSERVATIONS: DUE TO THE HIGHER ELEVATION OF THE ARPT; AND OUR FAIRLY LIGHT WT/HIGHER RATE OF CLB COUPLED WITH FREQ CHANGE; TCAS TA DISTR AND LOOKING FOR TFC; INTERMEDIATE LEVELOFF; AND SUBSEQUENT INSTRUCTIONS/CLRNC FROM DEP CTL; I HAD NOT YET FINISHED THE AFTER TKOF CHK PRIOR TO ACFT CLBING ABOVE 10000 FT MSL. THUS HAD NOT YET CONFIRMED THE PRESSURIZATION/ENG BLEED CONFIGN PRIOR TO CABIN ALT WARNING HORN GOING OFF.
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.