37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 990521 |
Time | |
Date | 201201 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | COS.TRACON |
State Reference | CO |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Make Model Name | Regional Jet 200 ER/LR (CRJ200) |
Operating Under FAR Part | Part 121 |
Flight Phase | Climb |
Component | |
Aircraft Component | Pneumatic Valve/Bleed Valve |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
Departed with APU deferred. Bleeds open take-off at high altitude airport. 'Cabin alt' caution message going thru 10;000 ft. Advised ATC; received revised clearance to maintain 10;000. Started QRH procedure; cross-checked ecs synoptic page and found 10th stage bleeds closed. Reset bleeds to proper configuration. Cabin pressurization returned to normal. Continued climb on ATC instruction and proceeded without incident. I had flown this aircraft with the APU deferred one leg before and performed without incident. I can only conclude; based on the evidence; that I did not select the 10th bleeds open after engine start. I've gone over the flight in my mind and cannot determine where the error occurred. Either I didn't select the 10ths to open and didn't notice or somewhere after completing checklists and viewing the EICAS they got shut off inadvertently. I find it hard to imagine; however plausible; that both crew members went through checklists and taxi without noticing the 10ths being closed. I'm usually quite diligent in taking the time to look over the EICAS and make sure the messages displayed are the ones that are supposed to be there. Ultimately; this incident is my fault. I have to presume the mistake is mine when there's no evidence to the contrary. This incident made a nice segue for a discussion with the first officer about fom... 'The pilot not performing the action called for in the checklist monitors and double checks the proper action taken'. It has been my experience that many; if not most; first officer's I fly with merely read the checklist and wait for a correct response. I encourage them to look around and make sure that what is being challenged has really been completed; per the fom and in accordance with good operating practices. Two crew members should be able to back each other up and minimize errors such as this. Other potential catches are; fob; pressurization set to destination; flight plan double check; altimeter settings; etc... I don't expect to use my crew as a crutch but I find I have to encourage them to look around and observe what is really going on. I have heard of the first officer's is being actively discouraged from looking around and being told to 'just read the checklist'... Hopefully that's not common throughout the system. This in no way excuses the error but may have provided an avenue to correcting it before it became an issue.
Original NASA ASRS Text
Title: A CRJ-200 Captain took off with APU deferred and failed to open 10th stage bleeds; resulting in a cabin altitude alert climbing through 10;000 FT. The error was trapped and the bleeds opened; allowing the flight to continue.
Narrative: Departed with APU deferred. Bleeds open take-off at high altitude airport. 'Cabin Alt' caution message going thru 10;000 FT. Advised ATC; received revised clearance to maintain 10;000. Started QRH procedure; cross-checked ECS synoptic page and found 10th stage bleeds closed. Reset bleeds to proper configuration. Cabin pressurization returned to normal. Continued climb on ATC instruction and proceeded without incident. I had flown this aircraft with the APU deferred one leg before and performed without incident. I can only conclude; based on the evidence; that I did not select the 10th bleeds open after engine start. I've gone over the flight in my mind and cannot determine where the error occurred. Either I didn't select the 10ths to open and didn't notice or somewhere after completing checklists and viewing the EICAS they got shut off inadvertently. I find it hard to imagine; however plausible; that both crew members went through checklists and taxi without noticing the 10ths being closed. I'm usually quite diligent in taking the time to look over the EICAS and make sure the messages displayed are the ones that are supposed to be there. Ultimately; this incident is my fault. I have to presume the mistake is mine when there's no evidence to the contrary. This incident made a nice segue for a discussion with the First Officer about FOM... 'The pilot not performing the action called for in the checklist monitors and double checks the proper action taken'. It has been my experience that many; if not most; First Officer's I fly with merely read the checklist and wait for a correct response. I encourage them to look around and make sure that what is being challenged has really been completed; per the FOM and IAW good operating practices. Two crew members should be able to back each other up and minimize errors such as this. Other potential catches are; FOB; pressurization set to destination; flight plan double check; altimeter settings; etc... I don't expect to use my crew as a crutch but I find I have to encourage them to look around and observe what is really going on. I have heard of the First Officer's is being actively discouraged from looking around and being told to 'Just read the checklist'... Hopefully that's not common throughout the system. This in no way excuses the error but may have provided an avenue to correcting it before it became an issue.
Data retrieved from NASA's ASRS site as of July 2013 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.