EMER DSCNT INITIATED IN ACR MLG AFTER LOSS OF CABIN PRESSURE. RETURN LAND IN A DIVERSION TO ALTERNATE.
Synopsis
EMER DSCNT INITIATED IN ACR MLG AFTER LOSS OF CABIN PRESSURE. RETURN LAND IN A DIVERSION TO ALTERNATE.
Narrative
ENCLOSED ATTACHED IS A RPT SUBMITTED TO ACR. ADDITIONAL INFO IS AS FOLLOWS. BOTH CREW MEMBERS HAD FLOWN TOGETHER FOR THE PREVIOUS 4 WKS. FLT SCHEDULE WAS HVY DURING THIS TIME. BOTH CREW MEMBERS REMARKED ON LEG PRIOR TO THIS LEG THAT THEY WERE TIRED. IN FACT; THEY WERE BOTH EXHAUSTED. CREW HAD A 30 HR IN 7 DAYS LEGALITY CONFLICT. SO THEY WERE DEADHEADED ON FIRST LEG OF DAY TO REDUCE BLOCK TIME AND STAY UNDER THE 30 IN 7 LEGAL LIMIT. THIS ACTION BY COMPANY COMPLIED WITH THE LETTER OF THE LAW; BUT NOT THE INTENT (TO PROVIDE ADEQUATE REST TO CREW MEMBERS). FO FAILED TO TURN ON PACK SWITCHES TO PRESSURIZE ACFT AND CAPT FAILED TO NOTICE THIS OMISSION ON HIS AFTER TKOF CHKLIST. ACFT WAS VERY AIR TIGHT SO THE CABIN ONLY CLBED AT APPROX HALF THE RATE OF CLB OF THE ACFT. CREW ATTN WAS INTERRUPTED SEVERAL TIMES DURING PUSHBACK; START-UP; AND TAXI PHASES OF FLT. CREW'S ATTN WAS FURTHER DIVERTED TO WORK WITH A FAULTY INDICATION IN A GAUGE FOR ANOTHER SYS. APCHING 31000 FT THE CABIN ALT WARNING HORN WENT OFF AND SHORTLY THEREAFTER CABIN ALT CLBED FROM 10000 FT (HORN) TO 13500 FT AND CABIN OXYGEN MASKS DEPLOYED. UPON GETTING THE CABIN WARNING HORN; BOTH CREW MEMBERS CHKED THE PRESSURIZATION CTLR BUT STILL DID NOT NOTICE THE PACK SWITCHES IN THE OFF POS. AN EMER DSCNT WAS INITIATED; ACFT LEVELED OFF AT 10000 FT AND RETURNED TO ORIGINATING STATION. BOTH CREW MEMBERS AGREE THAT THE BOTTOM LINE CAUSE OF THIS INCIDENT IS CREW MEMBER FATIGUE. COMPANY IS UNWILLING TO ADMIT THEIR SCHEDULING PRACTICES ARE CONTRIBUTORY IN ANY WAY.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.