|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0601 To 1200|
|Locale Reference||airport : zzz.airport|
|Altitude||msl single value : 35000|
|Controlling Facilities||artcc : zzz.artcc|
|Operator||common carrier : air carrier|
|Make Model Name||B737-300|
|Operating Under FAR Part||Part 121|
|Flight Phase||cruise : level|
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Experience||flight time last 90 days : 181|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Experience||flight time last 90 days : 236|
|Anomaly||aircraft equipment problem : critical|
|Independent Detector||aircraft equipment other aircraft equipment : cabin alt warning|
|Resolutory Action||controller : issued new clearance|
flight crew : exited adverse environment
flight crew : landed as precaution
flight crew : diverted to another airport
Flight Crew Human Performance
Approximately 40 minutes into our flight at 35000 ft; the cabin altitude warning horn went off. Looking up at the pressurization panel and cabin altitude panel all switches were in the correct positions. The cabin altitude was 10500 ft and climbing. I determined the aircraft was losing pressurization at about 2000 FPM. I asked the captain to get us a descent lower. ATC immediately answered with a descent from 35000 ft to 24000 ft. The captain and I donned our oxygen and established communications. Once this was complete I extended the speed brakes and started a descent on or close to vmmo/mmo. The captain established communications with the flight attendants. After starting the descent I could still see the cabin climbing at about 2000 FPM. I asked the captain for lower and handed him the QRH. ATC initially gave us 24000 ft; then we asked for lower and we got 12000 ft. He went through the checklist items while I concentrated on the descent. We considered declaring an emergency but at the time we were in the mid-teens on our way down and it seemed like the emergency was over. I believe that the cabin altitude made it up to 16000 ft before the aircraft descent equalized the pressure. Passing somewhere through the teens; I started looking for the closest company city. We had no delays in our descent all the way down to 12000 ft. After a brief call to ATC; ZZZ1 was determined to be the closest field and a vector was assigned 180 degrees from our current course back to ZZZ. I asked the captain for below 10000 ft and he got us 9000 ft direct to ZZZ. I sent an ACARS message to dispatch about a diversion for pressurization. The captain coordinated with the flight attendants. Along the way down I exceeded some of our altitude restrictions in an effort to get the cabin below 10000 ft. All checklist items were completed and all normal checklist items were completed on our short flight to ZZZ. We landed from a visual approach uneventfully. After touchdown; the cabin started to pressurize below sea level. Both the captain and I could feel a large pressure differential. While approaching the gate; I shut down the level. Once the aircraft was parked; I had to open my window to break the pressure seal. I think we started down the right path with the emergency but got sidetracked into not declaring an emergency. As with any real time emergency; crew coordination could have been better. But overall; I think this situation was handled in a professional safe way.callback conversation with reporter 705505 revealed the following information: reporter stated that other than the door seal failing; maintenance did not identify any other failed component.supplemental information from 705507: at FL350 cruise; the altitude warning horn sounded and the cabin pressurization appeared to be stable at 10000 ft. All other indications were normal. We requested and received dscnts to FL240; 12000 ft and finally 9000 ft. I thought initially this would be precautionary only. We donned our oxygen masks and established communications. In an approximately 3000 ft to 4000 ft descent and around 18000 ft MSL; I talked to the 'a' flight attendant and asked if the masks dropped in the back. She said they had and I saw that the cabin altitude was now 14000 ft. We had accomplished the cabin altitude warning horn/abnormal pressurization checklist with no change in the system. We coordinated with ATC to land at the nearest suitable field. We were unable to communicate with dispatch on frequency and we never heard from them when we asked operations to ask them to come up to frequency. The first officer acar'd them and received the response; 'did the masks drop' and 'did you declare an emergency?' everything was stable at 9000 ft; the flight attendants said the customers were ok; so we acar'd 'yes and no.' I interviewed the operations agent who had talked to the passenger. The passenger were ok. I interviewed the flight attendants and; other than some sinus stress; they were ready to go. Everybody was loaded; the release WX was good and I assumed we could work it out later. So we launched for our destination and had the three-way there and finished the day in another city. I did not see the quick rise in cabin altitude when we gotthe clearance to FL240; 12000 ft and 9000 ft. I should have declared an emergency. I thought it was slowly rising. The checklist was accomplished like an emergency; so even if ATC had already given us everything as quickly as we could do it and the passenger were ok as per my check with them; declaring an emergency and canceling it later with no rush would have been better. I should not have departed without talking with a chief pilot and dispatch. I tried; then got distracted in a go mode and I thought I could complete it later.callback conversation with reporter 705507 revealed the following information: captain stated that this crew had no difficulty identifying the cabin altitude warning horn because each had just completed a training session that included a pressurization problem. What was disconcerting for them was lack of secondary indications on the pressurization controller. There was no 'automatic fail' or 'stby on' light. After the aircraft was on the ground; the crew had trouble depressurizing the aircraft and considered closing the bleeds and shutting down the engines. In the end; opening the first officer's window depressurized the aircraft. Maintenance said the controller malfunctioned and also the fwd cargo door seal was leaking.
Original NASA ASRS Text
Title: A B737-300 FLT CREW PERFORMED A RAPID DSCNT FOLLOWING A SLOW CABIN PRESSURIZATION LOSS WITH A WARNING HORN. AN EMER WAS NOT DECLARED.
Narrative: APPROX 40 MINUTES INTO OUR FLT AT 35000 FT; THE CABIN ALT WARNING HORN WENT OFF. LOOKING UP AT THE PRESSURIZATION PANEL AND CABIN ALT PANEL ALL SWITCHES WERE IN THE CORRECT POSITIONS. THE CABIN ALT WAS 10500 FT AND CLBING. I DETERMINED THE ACFT WAS LOSING PRESSURIZATION AT ABOUT 2000 FPM. I ASKED THE CAPT TO GET US A DSCNT LOWER. ATC IMMEDIATELY ANSWERED WITH A DSCNT FROM 35000 FT TO 24000 FT. THE CAPT AND I DONNED OUR OXYGEN AND ESTABLISHED COMMUNICATIONS. ONCE THIS WAS COMPLETE I EXTENDED THE SPD BRAKES AND STARTED A DSCNT ON OR CLOSE TO VMMO/MMO. THE CAPT ESTABLISHED COMMUNICATIONS WITH THE FLT ATTENDANTS. AFTER STARTING THE DSCNT I COULD STILL SEE THE CABIN CLBING AT ABOUT 2000 FPM. I ASKED THE CAPT FOR LOWER AND HANDED HIM THE QRH. ATC INITIALLY GAVE US 24000 FT; THEN WE ASKED FOR LOWER AND WE GOT 12000 FT. HE WENT THROUGH THE CHKLIST ITEMS WHILE I CONCENTRATED ON THE DSCNT. WE CONSIDERED DECLARING AN EMER BUT AT THE TIME WE WERE IN THE MID-TEENS ON OUR WAY DOWN AND IT SEEMED LIKE THE EMER WAS OVER. I BELIEVE THAT THE CABIN ALT MADE IT UP TO 16000 FT BEFORE THE ACFT DSCNT EQUALIZED THE PRESSURE. PASSING SOMEWHERE THROUGH THE TEENS; I STARTED LOOKING FOR THE CLOSEST COMPANY CITY. WE HAD NO DELAYS IN OUR DSCNT ALL THE WAY DOWN TO 12000 FT. AFTER A BRIEF CALL TO ATC; ZZZ1 WAS DETERMINED TO BE THE CLOSEST FIELD AND A VECTOR WAS ASSIGNED 180 DEGS FROM OUR CURRENT COURSE BACK TO ZZZ. I ASKED THE CAPT FOR BELOW 10000 FT AND HE GOT US 9000 FT DIRECT TO ZZZ. I SENT AN ACARS MESSAGE TO DISPATCH ABOUT A DIVERSION FOR PRESSURIZATION. THE CAPT COORDINATED WITH THE FLT ATTENDANTS. ALONG THE WAY DOWN I EXCEEDED SOME OF OUR ALT RESTRICTIONS IN AN EFFORT TO GET THE CABIN BELOW 10000 FT. ALL CHKLIST ITEMS WERE COMPLETED AND ALL NORMAL CHKLIST ITEMS WERE COMPLETED ON OUR SHORT FLT TO ZZZ. WE LANDED FROM A VISUAL APCH UNEVENTFULLY. AFTER TOUCHDOWN; THE CABIN STARTED TO PRESSURIZE BELOW SEA LEVEL. BOTH THE CAPT AND I COULD FEEL A LARGE PRESSURE DIFFERENTIAL. WHILE APCHING THE GATE; I SHUT DOWN THE LEVEL. ONCE THE ACFT WAS PARKED; I HAD TO OPEN MY WINDOW TO BREAK THE PRESSURE SEAL. I THINK WE STARTED DOWN THE RIGHT PATH WITH THE EMER BUT GOT SIDETRACKED INTO NOT DECLARING AN EMER. AS WITH ANY REAL TIME EMER; CREW COORDINATION COULD HAVE BEEN BETTER. BUT OVERALL; I THINK THIS SITUATION WAS HANDLED IN A PROFESSIONAL SAFE WAY.CALLBACK CONVERSATION WITH RPTR 705505 REVEALED THE FOLLOWING INFO: RPTR STATED THAT OTHER THAN THE DOOR SEAL FAILING; MAINT DID NOT IDENTIFY ANY OTHER FAILED COMPONENT.SUPPLEMENTAL INFO FROM 705507: AT FL350 CRUISE; THE ALT WARNING HORN SOUNDED AND THE CABIN PRESSURIZATION APPEARED TO BE STABLE AT 10000 FT. ALL OTHER INDICATIONS WERE NORMAL. WE REQUESTED AND RECEIVED DSCNTS TO FL240; 12000 FT AND FINALLY 9000 FT. I THOUGHT INITIALLY THIS WOULD BE PRECAUTIONARY ONLY. WE DONNED OUR OXYGEN MASKS AND ESTABLISHED COMMUNICATIONS. IN AN APPROX 3000 FT TO 4000 FT DSCNT AND AROUND 18000 FT MSL; I TALKED TO THE 'A' FLT ATTENDANT AND ASKED IF THE MASKS DROPPED IN THE BACK. SHE SAID THEY HAD AND I SAW THAT THE CABIN ALT WAS NOW 14000 FT. WE HAD ACCOMPLISHED THE CABIN ALT WARNING HORN/ABNORMAL PRESSURIZATION CHKLIST WITH NO CHANGE IN THE SYSTEM. WE COORDINATED WITH ATC TO LAND AT THE NEAREST SUITABLE FIELD. WE WERE UNABLE TO COMMUNICATE WITH DISPATCH ON FREQ AND WE NEVER HEARD FROM THEM WHEN WE ASKED OPS TO ASK THEM TO COME UP TO FREQ. THE FO ACAR'D THEM AND RECEIVED THE RESPONSE; 'DID THE MASKS DROP' AND 'DID YOU DECLARE AN EMER?' EVERYTHING WAS STABLE AT 9000 FT; THE FLT ATTENDANTS SAID THE CUSTOMERS WERE OK; SO WE ACAR'D 'YES AND NO.' I INTERVIEWED THE OPS AGENT WHO HAD TALKED TO THE PAX. THE PAX WERE OK. I INTERVIEWED THE FLT ATTENDANTS AND; OTHER THAN SOME SINUS STRESS; THEY WERE READY TO GO. EVERYBODY WAS LOADED; THE RELEASE WX WAS GOOD AND I ASSUMED WE COULD WORK IT OUT LATER. SO WE LAUNCHED FOR OUR DEST AND HAD THE THREE-WAY THERE AND FINISHED THE DAY IN ANOTHER CITY. I DID NOT SEE THE QUICK RISE IN CABIN ALT WHEN WE GOTTHE CLRNC TO FL240; 12000 FT AND 9000 FT. I SHOULD HAVE DECLARED AN EMER. I THOUGHT IT WAS SLOWLY RISING. THE CHKLIST WAS ACCOMPLISHED LIKE AN EMER; SO EVEN IF ATC HAD ALREADY GIVEN US EVERYTHING AS QUICKLY AS WE COULD DO IT AND THE PAX WERE OK AS PER MY CHECK WITH THEM; DECLARING AN EMER AND CANCELING IT LATER WITH NO RUSH WOULD HAVE BEEN BETTER. I SHOULD NOT HAVE DEPARTED WITHOUT TALKING WITH A CHIEF PLT AND DISPATCH. I TRIED; THEN GOT DISTRACTED IN A GO MODE AND I THOUGHT I COULD COMPLETE IT LATER.CALLBACK CONVERSATION WITH RPTR 705507 REVEALED THE FOLLOWING INFO: CAPT STATED THAT THIS CREW HAD NO DIFFICULTY IDENTIFYING THE CABIN ALT WARNING HORN BECAUSE EACH HAD JUST COMPLETED A TRAINING SESSION THAT INCLUDED A PRESSURIZATION PROB. WHAT WAS DISCONCERTING FOR THEM WAS LACK OF SECONDARY INDICATIONS ON THE PRESSURIZATION CTLR. THERE WAS NO 'AUTO FAIL' OR 'STBY ON' LIGHT. AFTER THE ACFT WAS ON THE GND; THE CREW HAD TROUBLE DEPRESSURIZING THE ACFT AND CONSIDERED CLOSING THE BLEEDS AND SHUTTING DOWN THE ENGS. IN THE END; OPENING THE FO'S WINDOW DEPRESSURIZED THE ACFT. MAINT SAID THE CTLR MALFUNCTIONED AND ALSO THE FWD CARGO DOOR SEAL WAS LEAKING.
Data retrieved from NASA's ASRS site as of January 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.