Narrative:

Upon takeoff; climb out; and departure aircraft failed to pressurize adequately and a forward cargo door caution message appeared on EICAS screen accompanied by a cabin altitude caution message. Also appearing briefly on EICAS was a cargo door warning message which displayed only for a few seconds before disappearing. All appropriate checklists were run in sequence; including cabin altitude check; forward cargo door check; and manual pressurization check in company flight manual all to no avail. Dispatch was contacted through SELCAL and advised to continue to flight destination. However; through running our cfm checklists we were advised to land at nearest suitable airport. At that time departure was advised of our intentions to return and we were sequenced back to land uneventfully. Upon arrival back at the gate; ground crew advised us that the forward cargo door was indeed entirely open; but with all bags still present. Some contributing factors to the incident include issues with MEL items and their corresponding procedures. Upon arrival at aircraft all standard checklists were run in sequence followed by a captain brief which included all MEL items pertaining to the flight. Of which; included a #1 pack inoperative; observer headset inoperative and most importantly; a proximity system fault #2 with associated status message and an associated forward cargo door caution message. The captain referenced the procedure in the MEL book and mention was made that forward cargo door caution message was allowable as long as the ground crew could verify that the door was stowed and locked as per the MEL procedure. However; the nature of the proximity system fault was such that the only way to verify that the forward cargo door was closed was to have the ground crew verify as such. Human performance considerations: some issues that were brought to my attention are the sole reliance; according to the MEL procedure; on behalf of the ground crew to verify that the forward cargo door has been and is closed properly. Otherwise; in this instance there is no way of knowing if the cargo door is properly closed or actually open. The procedure does not seem to provide much redundancy if at all. Another issue pertaining to this incident was I; as the first officer was off communication with ground crew while I was contacting ramp tower for pushback clearance during the time the captain verified with ground crew that the door was indeed closed. So in actuality I did not hear the ground crew verify the forward cargo door was closed. However; the captain had said he verified that it was; so I went on his word. I believe in future instances I will reaffirm confirmation with the captain and ground crews on such issues. Another instance that might have contributed to the incident was the conditions at hand that being early morning; night conditions. In such conditions it could have been a possibility that the ground crew did not recognize that the forward cargo door was not closed properly. Supplemental information from acn 777824: our canadair regional jet was dispatched with 3 MEL's. The pertinent one was the proximity sensor for the forward cargo door. The MEL procedure is to visually check the door handle and flapper position before each flight. I; as captain; briefed one specific ramp agent prior to loading passenger that the door system was MEL'ed and arranged for him to doublechk it after closing and provide me with a visual signal that it was in fact closed. This signal was received prior to pushback. Upon takeoff; our aircraft pressurization obviously was not working with associated vibration and loud air stream noise in the forward cabin. We coordination with departure control that we had an abnormal condition and requested 10000 ft (rather than 14000 ft which they started to issue us). We referenced our company flight manual for appropriate checklists; cabin altitude checklist; and manual cabin pressure. These procedures did not seem to help; so we followed the guidance for cargo door ajar -- land as soon as possible. We attempted to SELCAL our company which took far too long and get a phone patch to dispatch. Feeling that we needed to get back on the ground very soon -- in complying with land as soon as possible -- we abandoned the call and utilized ACARS to text them a quick message. Their response: reference the cfm and proceed to your destination. We responded that: we believe the forward cargo door was open. We also notified departure that we needed to return to ZZZ for landing and required no special services. A call to operations at ZZZ was made to notify our intentions to return and requested they contact company to let them know. Upon landing and taxiing to our original gate; we shut down the engines and opened the main cabin door. The same ramper that I coordination with prior to flight approached the aircraft as I came down the stairs. The forward bin door was wide open. He swore to me profusely that the door was verified shut prior to pushback. I notified our company maintenance department; made a write-up; and filled out a company report. Contract maintenance personnel inspected the door and signed off the discrepancy. We were sent new dispatch paperwork; refueled; and loaded passenger again. Later; upon reaching our base; I submitted to a drug and alcohol test.

Related reports:

Google
 

Original NASA ASRS Text

Title: A CRJ200 DEPARTED WITH THE FWD CARGO DOOR OPEN AFTER THE GND CREW VERIFIED IT CLOSED. A MEL'ED DOOR PROXIMITY SWITCH ALLOWED FOR AN OPEN CARGO DOOR LIGHT.

Narrative: UPON TKOF; CLBOUT; AND DEP ACFT FAILED TO PRESSURIZE ADEQUATELY AND A FORWARD CARGO DOOR CAUTION MESSAGE APPEARED ON EICAS SCREEN ACCOMPANIED BY A CABIN ALT CAUTION MESSAGE. ALSO APPEARING BRIEFLY ON EICAS WAS A CARGO DOOR WARNING MESSAGE WHICH DISPLAYED ONLY FOR A FEW SECONDS BEFORE DISAPPEARING. ALL APPROPRIATE CHKLISTS WERE RUN IN SEQUENCE; INCLUDING CABIN ALT CHK; FORWARD CARGO DOOR CHK; AND MANUAL PRESSURIZATION CHK IN COMPANY FLT MANUAL ALL TO NO AVAIL. DISPATCH WAS CONTACTED THROUGH SELCAL AND ADVISED TO CONTINUE TO FLT DEST. HOWEVER; THROUGH RUNNING OUR CFM CHKLISTS WE WERE ADVISED TO LAND AT NEAREST SUITABLE ARPT. AT THAT TIME DEP WAS ADVISED OF OUR INTENTIONS TO RETURN AND WE WERE SEQUENCED BACK TO LAND UNEVENTFULLY. UPON ARR BACK AT THE GATE; GND CREW ADVISED US THAT THE FORWARD CARGO DOOR WAS INDEED ENTIRELY OPEN; BUT WITH ALL BAGS STILL PRESENT. SOME CONTRIBUTING FACTORS TO THE INCIDENT INCLUDE ISSUES WITH MEL ITEMS AND THEIR CORRESPONDING PROCS. UPON ARR AT ACFT ALL STANDARD CHKLISTS WERE RUN IN SEQUENCE FOLLOWED BY A CAPT BRIEF WHICH INCLUDED ALL MEL ITEMS PERTAINING TO THE FLT. OF WHICH; INCLUDED A #1 PACK INOP; OBSERVER HEADSET INOP AND MOST IMPORTANTLY; A PROX SYS FAULT #2 WITH ASSOCIATED STATUS MESSAGE AND AN ASSOCIATED FORWARD CARGO DOOR CAUTION MESSAGE. THE CAPT REFED THE PROC IN THE MEL BOOK AND MENTION WAS MADE THAT FORWARD CARGO DOOR CAUTION MESSAGE WAS ALLOWABLE AS LONG AS THE GND CREW COULD VERIFY THAT THE DOOR WAS STOWED AND LOCKED AS PER THE MEL PROC. HOWEVER; THE NATURE OF THE PROX SYS FAULT WAS SUCH THAT THE ONLY WAY TO VERIFY THAT THE FORWARD CARGO DOOR WAS CLOSED WAS TO HAVE THE GND CREW VERIFY AS SUCH. HUMAN PERFORMANCE CONSIDERATIONS: SOME ISSUES THAT WERE BROUGHT TO MY ATTN ARE THE SOLE RELIANCE; ACCORDING TO THE MEL PROC; ON BEHALF OF THE GND CREW TO VERIFY THAT THE FORWARD CARGO DOOR HAS BEEN AND IS CLOSED PROPERLY. OTHERWISE; IN THIS INSTANCE THERE IS NO WAY OF KNOWING IF THE CARGO DOOR IS PROPERLY CLOSED OR ACTUALLY OPEN. THE PROC DOES NOT SEEM TO PROVIDE MUCH REDUNDANCY IF AT ALL. ANOTHER ISSUE PERTAINING TO THIS INCIDENT WAS I; AS THE FO WAS OFF COM WITH GND CREW WHILE I WAS CONTACTING RAMP TWR FOR PUSHBACK CLRNC DURING THE TIME THE CAPT VERIFIED WITH GND CREW THAT THE DOOR WAS INDEED CLOSED. SO IN ACTUALITY I DID NOT HEAR THE GND CREW VERIFY THE FORWARD CARGO DOOR WAS CLOSED. HOWEVER; THE CAPT HAD SAID HE VERIFIED THAT IT WAS; SO I WENT ON HIS WORD. I BELIEVE IN FUTURE INSTANCES I WILL REAFFIRM CONFIRMATION WITH THE CAPT AND GND CREWS ON SUCH ISSUES. ANOTHER INSTANCE THAT MIGHT HAVE CONTRIBUTED TO THE INCIDENT WAS THE CONDITIONS AT HAND THAT BEING EARLY MORNING; NIGHT CONDITIONS. IN SUCH CONDITIONS IT COULD HAVE BEEN A POSSIBILITY THAT THE GND CREW DID NOT RECOGNIZE THAT THE FORWARD CARGO DOOR WAS NOT CLOSED PROPERLY. SUPPLEMENTAL INFO FROM ACN 777824: OUR CANADAIR REGIONAL JET WAS DISPATCHED WITH 3 MEL'S. THE PERTINENT ONE WAS THE PROX SENSOR FOR THE FORWARD CARGO DOOR. THE MEL PROC IS TO VISUALLY CHK THE DOOR HANDLE AND FLAPPER POS BEFORE EACH FLT. I; AS CAPT; BRIEFED ONE SPECIFIC RAMP AGENT PRIOR TO LOADING PAX THAT THE DOOR SYS WAS MEL'ED AND ARRANGED FOR HIM TO DOUBLECHK IT AFTER CLOSING AND PROVIDE ME WITH A VISUAL SIGNAL THAT IT WAS IN FACT CLOSED. THIS SIGNAL WAS RECEIVED PRIOR TO PUSHBACK. UPON TKOF; OUR ACFT PRESSURIZATION OBVIOUSLY WAS NOT WORKING WITH ASSOCIATED VIBRATION AND LOUD AIR STREAM NOISE IN THE FORWARD CABIN. WE COORD WITH DEP CTL THAT WE HAD AN ABNORMAL CONDITION AND REQUESTED 10000 FT (RATHER THAN 14000 FT WHICH THEY STARTED TO ISSUE US). WE REFED OUR COMPANY FLT MANUAL FOR APPROPRIATE CHKLISTS; CABIN ALT CHKLIST; AND MANUAL CABIN PRESSURE. THESE PROCS DID NOT SEEM TO HELP; SO WE FOLLOWED THE GUIDANCE FOR CARGO DOOR AJAR -- LAND ASAP. WE ATTEMPTED TO SELCAL OUR COMPANY WHICH TOOK FAR TOO LONG AND GET A PHONE PATCH TO DISPATCH. FEELING THAT WE NEEDED TO GET BACK ON THE GND VERY SOON -- IN COMPLYING WITH LAND ASAP -- WE ABANDONED THE CALL AND UTILIZED ACARS TO TEXT THEM A QUICK MESSAGE. THEIR RESPONSE: REF THE CFM AND PROCEED TO YOUR DEST. WE RESPONDED THAT: WE BELIEVE THE FORWARD CARGO DOOR WAS OPEN. WE ALSO NOTIFIED DEP THAT WE NEEDED TO RETURN TO ZZZ FOR LNDG AND REQUIRED NO SPECIAL SVCS. A CALL TO OPS AT ZZZ WAS MADE TO NOTIFY OUR INTENTIONS TO RETURN AND REQUESTED THEY CONTACT COMPANY TO LET THEM KNOW. UPON LNDG AND TAXIING TO OUR ORIGINAL GATE; WE SHUT DOWN THE ENGS AND OPENED THE MAIN CABIN DOOR. THE SAME RAMPER THAT I COORD WITH PRIOR TO FLT APCHED THE ACFT AS I CAME DOWN THE STAIRS. THE FORWARD BIN DOOR WAS WIDE OPEN. HE SWORE TO ME PROFUSELY THAT THE DOOR WAS VERIFIED SHUT PRIOR TO PUSHBACK. I NOTIFIED OUR COMPANY MAINT DEPT; MADE A WRITE-UP; AND FILLED OUT A COMPANY RPT. CONTRACT MAINT PERSONNEL INSPECTED THE DOOR AND SIGNED OFF THE DISCREPANCY. WE WERE SENT NEW DISPATCH PAPERWORK; REFUELED; AND LOADED PAX AGAIN. LATER; UPON REACHING OUR BASE; I SUBMITTED TO A DRUG AND ALCOHOL TEST.

Data retrieved from NASA's ASRS site as of May 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.