37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 797319 |
Time | |
Date | 200807 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 18000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc artcc : zny.artcc |
Operator | general aviation : personal |
Make Model Name | Learjet 25 |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 18600 flight time type : 900 |
ASRS Report | 797319 |
Person 2 | |
Affiliation | other |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine pilot : private |
Experience | flight time last 90 days : 85 flight time total : 500 flight time type : 85 |
ASRS Report | 797325 |
Events | |
Anomaly | non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : became reoriented |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
During the before takeoff checklist; I omitted turning the air bleed switch on in an effort to cool the cockpit. We did not have an operable fan in the cockpit. On the after takeoff checklist the switch was somehow overlooked by both crew members. Aural warning misidented as overspeed warning. I do not remember hearing the horn below 18000 ft. The last flight we had in this same aircraft a few days before did have a false aural trim in motion warning. My initial thought was that we again had a false alarm. Finally the sic discovered the problem and turned on the air bleed switch. I do not remember flying above 18000 ft; however we did climb to approximately 30000 ft before problem idented. As I was having difficulty controling the aircraft; I declared an emergency and we were assigned a lower altitude. During this process we had difficulty controling the cabin altitude in either automatic or manual mode with cherry picker. My first look at the cabin altitude shown the cabin at 10000 ft. That cannot be true as all masks had deployed. My next recollection is flying at 8000 ft and having a heightened sense of awareness. I was unable to perceive the symptoms of hypoxia at any time during the flight. My lack of action in donning the oxygen mask could have easily resulted in catastrophe. Some of the contributing factors were an XA00 am wake up in ZZZ1. High heat and humidity in ZZZ and ZZZ2.
Original NASA ASRS Text
Title: A LR25 CREW EXPERIENCED HYPOXIA AT FL300 AFTER FAILING TO OPEN THE ENG BLEED VALVES BEFORE TKOF; NOT IDENTIFYING THE CABIN ALT WARNING HORN; AND NOT DONNING OXYGEN MASKS.
Narrative: DURING THE BEFORE TKOF CHKLIST; I OMITTED TURNING THE AIR BLEED SWITCH ON IN AN EFFORT TO COOL THE COCKPIT. WE DID NOT HAVE AN OPERABLE FAN IN THE COCKPIT. ON THE AFTER TKOF CHKLIST THE SWITCH WAS SOMEHOW OVERLOOKED BY BOTH CREW MEMBERS. AURAL WARNING MISIDENTED AS OVERSPEED WARNING. I DO NOT REMEMBER HEARING THE HORN BELOW 18000 FT. THE LAST FLT WE HAD IN THIS SAME ACFT A FEW DAYS BEFORE DID HAVE A FALSE AURAL TRIM IN MOTION WARNING. MY INITIAL THOUGHT WAS THAT WE AGAIN HAD A FALSE ALARM. FINALLY THE SIC DISCOVERED THE PROB AND TURNED ON THE AIR BLEED SWITCH. I DO NOT REMEMBER FLYING ABOVE 18000 FT; HOWEVER WE DID CLB TO APPROX 30000 FT BEFORE PROB IDENTED. AS I WAS HAVING DIFFICULTY CTLING THE ACFT; I DECLARED AN EMER AND WE WERE ASSIGNED A LOWER ALT. DURING THIS PROCESS WE HAD DIFFICULTY CTLING THE CABIN ALT IN EITHER AUTO OR MANUAL MODE WITH CHERRY PICKER. MY FIRST LOOK AT THE CABIN ALT SHOWN THE CABIN AT 10000 FT. THAT CANNOT BE TRUE AS ALL MASKS HAD DEPLOYED. MY NEXT RECOLLECTION IS FLYING AT 8000 FT AND HAVING A HEIGHTENED SENSE OF AWARENESS. I WAS UNABLE TO PERCEIVE THE SYMPTOMS OF HYPOXIA AT ANY TIME DURING THE FLT. MY LACK OF ACTION IN DONNING THE OXYGEN MASK COULD HAVE EASILY RESULTED IN CATASTROPHE. SOME OF THE CONTRIBUTING FACTORS WERE AN XA00 AM WAKE UP IN ZZZ1. HIGH HEAT AND HUMIDITY IN ZZZ AND ZZZ2.
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.