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In climb at FL190 cabin altitude rose to 10000 ft. Flight crew made descent to 10000 to catch cabin altitude.
| Attributes | |
| ACN | 193921 |
| Time | |
| Date | 199111 |
| Day | Fri |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : clt |
| State Reference | NC |
| Altitude | msl bound lower : 10000 msl bound upper : 19000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : ztl |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Flight Phase | climbout : intermediate altitude descent other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : commercial pilot : instrument |
| Experience | flight time last 90 days : 220 flight time total : 13000 flight time type : 135 |
| ASRS Report | 193921 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : flight engineer pilot : atp pilot : commercial pilot : cfi pilot : instrument |
| Experience | flight time last 90 days : 125 flight time total : 8500 flight time type : 20 |
| ASRS Report | 194060 |
| Events | |
| Anomaly | aircraft equipment problem : less severe altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : far non adherence : published procedure |
| Independent Detector | other controllera other flight crewa |
| Resolutory Action | flight crew : overcame equipment problem |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
While climbing to FL220, cabin altitude exceeded 10000 ft and emergency alert activated. Pilots executed rapid descent to 10000 ft, following all emergency descent procedures. High cabin altitude cause was pilot forgetting to turn on both packs after start, and climbing unpressurized. Normally packs come on automatically on this aircraft, however, due to abnormal start procedure (due to low APU bleed pressure), packs were manually selected off by PIC and never turned back on. Human performance: previous flight that same night was a diversion to charlotte, with subsequent aircraft change due to mechanical problem. This caused considerable extra workload, late at night, and I was very tired after not sleeping for 48 hours.
Original NASA ASRS Text
Title: IN CLB AT FL190 CABIN ALT ROSE TO 10000 FT. FLC MADE DSCNT TO 10000 TO CATCH CABIN ALT.
Narrative: WHILE CLBING TO FL220, CABIN ALT EXCEEDED 10000 FT AND EMER ALERT ACTIVATED. PLTS EXECUTED RAPID DSCNT TO 10000 FT, FOLLOWING ALL EMER DSCNT PROCS. HIGH CABIN ALT CAUSE WAS PLT FORGETTING TO TURN ON BOTH PACKS AFTER START, AND CLBING UNPRESSURIZED. NORMALLY PACKS COME ON AUTOMATICALLY ON THIS ACFT, HOWEVER, DUE TO ABNORMAL START PROC (DUE TO LOW APU BLEED PRESSURE), PACKS WERE MANUALLY SELECTED OFF BY PIC AND NEVER TURNED BACK ON. HUMAN PERFORMANCE: PREVIOUS FLT THAT SAME NIGHT WAS A DIVERSION TO CHARLOTTE, WITH SUBSEQUENT ACFT CHANGE DUE TO MECHANICAL PROBLEM. THIS CAUSED CONSIDERABLE EXTRA WORKLOAD, LATE AT NIGHT, AND I WAS VERY TIRED AFTER NOT SLEEPING FOR 48 HRS.
Data retrieved from NASA's ASRS site as of July 2007 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.