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Captain of a CL65 made an error when executing the door emergency QRH procedure resulting in inadvertent cabin depressurization at 10000 ft.
| Attributes | |
| ACN | 461041 |
| Time | |
| Date | 200001 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : cvg.airport |
| State Reference | OH |
| Altitude | msl single value : 10000 |
| Environment | |
| Flight Conditions | Mixed |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tracon : cvg.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other other vortac |
| Flight Phase | climbout : intermediate altitude |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : cfi pilot : commercial pilot : instrument pilot : multi engine |
| Experience | flight time last 90 days : 160 flight time total : 2540 flight time type : 425 |
| ASRS Report | 461041 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : company policies non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : door warning other flight crewa other flight crewb |
| Resolutory Action | none taken : detected after the fact |
| Supplementary | |
| Problem Areas | Aircraft Flight Crew Human Performance |
| Primary Problem | Aircraft |
Narrative:
PNF incorrectly performed checklist items causing the cabin to depressurize in-flight (10000 ft MSL). This checklist was being performed in response to a 'passenger door' red warning message. The error can primarily be attributed to poor crew rest (trip report time XA00 jan/thu/00, flight to day, oh, then a morning report at XA00 jan/fri/00, flight to cvg, oh. The rest period allowed the crew a total of less than 3.5 hours of rest. This type of trip is defined as a continuous duty.) in addition, inadequate training on a recent checklist revision, and lack of attention to detail by the PNF.
Original NASA ASRS Text
Title: CAPT OF A CL65 MADE AN ERROR WHEN EXECUTING THE DOOR EMER QRH PROC RESULTING IN INADVERTENT CABIN DEPRESSURIZATION AT 10000 FT.
Narrative: PNF INCORRECTLY PERFORMED CHKLIST ITEMS CAUSING THE CABIN TO DEPRESSURIZE INFLT (10000 FT MSL). THIS CHKLIST WAS BEING PERFORMED IN RESPONSE TO A 'PAX DOOR' RED WARNING MESSAGE. THE ERROR CAN PRIMARILY BE ATTRIBUTED TO POOR CREW REST (TRIP RPT TIME XA00 JAN/THU/00, FLT TO DAY, OH, THEN A MORNING RPT AT XA00 JAN/FRI/00, FLT TO CVG, OH. THE REST PERIOD ALLOWED THE CREW A TOTAL OF LESS THAN 3.5 HRS OF REST. THIS TYPE OF TRIP IS DEFINED AS A CONTINUOUS DUTY.) IN ADDITION, INADEQUATE TRAINING ON A RECENT CHKLIST REVISION, AND LACK OF ATTN TO DETAIL BY THE PNF.
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.