FLT CREW OF B734 FAILED TO TURN PRESSURIZATION BLEEDS BACK ON AFTER BLEEDS OFF NOISE ABATEMENT TKOF AT SNA. EXPERIENCED CABIN ALT WARNING HORN DUE TO EXCESSIVE CABIN ALT AFTER APU SHUT DOWN.

Date: 2003-05 · Aircraft: B737-400 · Phase: climb

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-published-material-policy

Synopsis

FLT CREW OF B734 FAILED TO TURN PRESSURIZATION BLEEDS BACK ON AFTER BLEEDS OFF NOISE ABATEMENT TKOF AT SNA. EXPERIENCED CABIN ALT WARNING HORN DUE TO EXCESSIVE CABIN ALT AFTER APU SHUT DOWN.

Narrative

WE DEPARTED SNA CONFIGURED FOR A BLEEDS OFF TKOF. AT 800 FT MSL THE FO REDUCED THE PWR; SET V2 +20 KTS; SELECTED N1 INADVERTENTLY INSTEAD OF LEVEL CHANGE AND TURNED THE R FLT DIRECTOR ON. WHEN I REALIZED I WAS NOT GETTING PITCH STEERING I CALLED FOR LEVEL CHANGE. THAT IS WHEN I REALIZED N1 WAS SELECTED. THE FO SELECTED LEVEL CHANGE AND I DISCONNECTED THE THRUST LEVERS AND REDUCED THE PWR TO CB PWR. WE CONTINUED THE DEP PROFILE. ONCE WE WERE CLEANED UP THE AFTER TKOF CHKLIST WAS CALLED FOR AND THE FLOW WAS COMPLETED BY THE FO. I DID NOT REALIZE AT THE TIME THAT THE TKOF CHKLIST HADN'T BEEN COMPLETED AND THIS MAY HAVE BEEN A RESULT OF THE WORKLOAD IN THE COCKPIT AT THE TIME AND THE CONFUSION THAT WAS CAUSED BY THE PWR SETTING. THE CONSEQUENCE OF NOT COMPLETING THE CHKLIST WAS THAT THE BLEEDS DID NOT GET REESTABLISHED. SOMETIME AFTER PASSING 10000 FT MSL AND BEFORE REACHING FL180 I TURNED OFF THE APU. THIS SET THE STAGE FOR THE NEXT EVENT. PASSING APPROX FL250 THE CABIN ALT WARNING HORN SOUNDED. THAT IS WHEN WE REALIZED THE ENG BLEEDS WERE OFF. WE SELECTED THE BLEEDS ON AND ASK FOR A DSCNT. AS WE APCHED FL240 IT WAS OBVIOUS THAT THE CABIN WAS UNDER CTL AND APCHING BACK TO 10000 FT MSL SO WE LEVELED AT FL240. DURING THE DSCNT BACK TO FL240 I CALLED BACK TO THE FLT ATTENDANTS TO ASK IF THE MASKS HAD DROPPED AND FOUND THAT THEY HAD NOT. I TOLD THEM THAT WE'D HAD A PRESSURIZATION PROB AND ASKED IF EVERYTHING WAS FINE WITH THEM AND THE PAX. THEY SAID THAT THEY HAD NOT BEEN AWARE OF ANYTHING TAKING PLACE AND THAT THE PAX WERE FINE. WE REMAINED AT FL240 UNTIL THE CABIN ALT WAS ON SCHEDULE FOR OUR PLANNED CRUISE ALT (FL350) APPROX 7200 FT MSL THEN CONTINUED OUR CLB ENRTE WITH NO FURTHER PROBS. LESSONS LEARNED: DISTRACTIONS FROM NORMAL HABIT PATTERNS CAN HAVE UNWANTED RESULTS. WHEN FLYING WITH NEW PLTS THE CAPT NEEDS TO BE MORE VIGILANT ABOUT THE FO'S DUTIES. IT IS EASY TO GET COMPLACENT WHEN YOU ARE USED TO FLYING WITH MORE EXPERIENCED PLTS. DEPARTING SNA IN A BLEEDS OFF CONFIGN IT IS IMPERATIVE TO BRIEF WHERE AND WHEN THE BLEEDS NEED TO BE REESTABLISHED. SUPPLEMENTAL INFO FROM ACN 582333: LESSONS LEARNED: THIS WAS MY FIRST FLT FROM SNA IN A B737-400 AND MY 3RD OR 4TH TOTAL. WE HAD JUST DEPARTED EARLIER THAT DAY IN A B737-700 WITHOUT EVENT. THOUGH CAPT BRIEFED THE DEP WELL AND I HAD READ THE 10-7 PAGES TWICE (THOUGH THEY DON'T MAKE MUCH REF TO BLEEDS); I CLRLY WAS NOT AS WELL PREPARED FOR THE DEP AS I SHOULD HAVE BEEN. IN THE FUTURE I WILL SPEND CONSIDERABLY MORE TIME REVIEWING AND 'CHAIR-FLYING' THE NOISE ABATEMENT PROFILE FOR THE APPROPRIATE ACFT; WITH SPECIAL EMPHASIS ON REESTABLISHING BLEEDS IN THE B737-400. DISTR CAN LEAD TO FURTHER PROBS. ONCE WE REPAIRED THE INITIAL ERROR; I SHOULD HAVE DILIGENTLY STUCK TO THE NORMAL PROCS; AS COMPLETING THE AFTER TKOF CHKLIST WOULD HAVE PREVENTED THE LATER PROB. DISCUSSION AND ANALYSIS COULD EASILY HAVE WAITED UNTIL WE REACHED CRUISE ALT.

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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.