FO OF DH8 FEELS WORKLOAD BECAME OVERWHELMING DURING FLT TO FCA WITH INOP AUTO PRESSURIZATION SYS COUPLED WITH FATIGUED AND UNCOOPERATIVE PIC.
Synopsis
FO OF DH8 FEELS WORKLOAD BECAME OVERWHELMING DURING FLT TO FCA WITH INOP AUTO PRESSURIZATION SYS COUPLED WITH FATIGUED AND UNCOOPERATIVE PIC.
Narrative
THE FLT OCCURRED ON JAN/MON/05. THE FOLLOWING ARE THE FACTS AS BEST AS I CAN RECALL: ACFT WAS A DASH 8 Q400. DISPATCHED WITH CREW OF 4 FROM SEA-MSO-FCA. FO WAS ME AT 1 YR EXPERIENCE IN PART 121 OPS AND EQUIP. CAPT WAS 4 MONTHS TO RETIREMENT. WX FORECAST FOR MSO AND FCA INCLUDED POOR VISIBILITY AND BLOWING SNOW AT OUR ETA. ACFT WAS ACCEPTED WITH AUTOMATIC PRESSURIZATION INOP PER MEL. (OP MUST BE CONDUCTED IN MANUAL MODE -- VERY HIGH WORKLOAD TO MAINTAIN PROPER DIFFERENTIAL.) I WAS CALLED OUT ON RESERVE AND WAS LATE ON ARR; ALSO THE 4TH FO TO HAVE FLOWN ON THIS 4-DAY TRIP. FURTHER FLT DELAY WAS INCURRED AT SEA AND MSO BECAUSE OF DEICING. THIS IS HOW THE FLT FROM MISSOULA TO KALISPELL UNFOLDED AS BEST AS I CAN REMEMBER: WE DEPARTED LATE FROM MISSOULA TO KALISPELL DUE TO ACFT DEICING WITH TYPE 1 AND TYPE 4 FLUIDS AS IT WAS BEGINNING TO SNOW AND FREEZING FOG WAS IN THE AREA. WE DEPARTED FROM RWY 29 AND COMPLIED WITH THE OBSTACLE CLRNC DEP. CLRED TO KALISPELL VIA VICTOR 231 AT 16000 FT MSL. DUE TO THE POOR WX AT KALISPELL; PIC ELECTED TO BE PF. HE HAD ALREADY BEEN ON DUTY FOR 12 HRS AND WAS VISIBLY FATIGUED AND READY TO GET TO THE HOTEL. ON CLBOUT; PIC ASKED FOR BLOCK ALT WITH DIRECT TO SMITH LAKE NDB TO SHORTCUT THE ARR. THE ENTIRE FLT FROM MSO-FCA WAS BLOCKED AT 21 MINS; AND AS PNF; I WAS ALREADY ENTIRELY OVERLOADED MAKING COMPANY CALLS; GETTING ATIS; PLATES; FREQS; CHKLISTS AND TRYING TO MANUALLY OPERATE THE OUTFLOW VALVE SINCE OUR AUTO-PRESSURIZATION CAPABILITY WAS INOP. THIS WAS MY FIRST TIME HAVING TO OPERATE AN ACFT IN MANUAL MODE. I DON'T BELIEVE I WAS EVER TRAINED TO MANUALLY OPERATE THAT SYS; OTHER THAN DISCUSSIONS IN GND SCHOOL. SHORTLY AFTER WE LEVELED OFF AT 16000 FT MSL; THE CABIN PRESSURIZATION MASTER WARNING WENT OFF; INDICATING THE CABIN PRESSURE HAD EXCEEDED 10000 FT. I WAS STILL IMMERSED IN READING THE DSCNT AND APCH CHKLISTS AS THE CAPT WAS TRYING TO SHORTCUT THE ARR AND START DOWN EARLY WITH THE PERMISSION OF ATC. BOTH THE PF/PNF BECAME ABSORBED IN TRYING TO EXTINGUISH THE MASTER WARNING. WE WERE GIVEN A DSCNT TO THE MVA WITH A HDG TO JOIN THE FCA LOC; APCH STILL HAD NOT BEEN BRIEFED. WX WAS RPTED AS 1500 FT OVCST AND 1 NM VISIBILITY WITH SNOW. PNF ABSORBED IN TRYING TO MAINTAIN PROPER DIFFERENTIAL AND DIDN'T NOTICE THAT THE PF WAS OVER 200 KTS; 10000 FT MSL AND ONLY 10 NM FROM THE THRESHOLD OF RWY 2 AT FCA. WE WERE ON THE LOC; GS WAS OFF THE SCALE BELOW US AROUND 5 MI OUT; LNDG CHKLIST STILL NOT COMPLETED EVEN THOUGH THE PF HAD PUT THE GEAR DOWN WHILE THE PNF WAS STILL ABSORBED IN TRYING TO MANAGE THE PRESSURIZATION. AS SOON AS THE PF ASKED ME WHAT THE DECISION ALT WAS ON FINAL; I REALIZED HOW HIGH AND FAST WE WERE. I ASKED IF HE WANTED ME TO CALL A MISSED APCH AND GET BACK UP WITH ZLC. HE DID NOT REPLY; AND SECONDS LATER WE BROKE OUT HIGH OVER THE TOUCHDOWN ZONE AT VREF +10 KTS. WE USED THE ENTIRE RWY TO COME TO A STOP. THESE ARE THE FACTORS IN CONSIDER MOST IMPORTANT IN PREVENTING FUTURE INCIDENTS LIKE THIS ONE: 1) FLT SCHEDULE: BLOCK TIMES ARE PREDICATED ON VFR DAYS; NOT ALLOWING FOR TIME TO DEICE AND OTHER WX-RELATED DELAYS -- CONSEQUENTLY PUTTING A LOT OF TIME PRESSURE ON CREW AS LEG AFTER LEG AFTER LEG IS LATE. PIC ALSO WANTED TO GET DONE WITH THE DAY; WHEN IN REALITY HE SHOULD HAVE REFUSED THE ACFT KNOWING HOW MUCH THAT INOP SYS CONTRIBUTES TO HIGH WORKLOAD IN BAD WX. 2) FATIGUE: AFTER ALREADY WORKING A 12 HR DUTY DAY; PIC WAS TIRED AND JUDGEMENT WAS IMPAIRED. 3) TECHNICAL AS WELL AS CRM INEXPERIENCE: NEW FO; RELATIVELY LOW TIME IN ACFT TYPE; NOT PROPERLY TRAINED ON HOW TO OPERATE THE PRESSURIZATION SYS MANUALLY WHILE MANAGING ALL THE OTHER DUTIES OF THE PNF. ALSO; FO DIDN'T QUESTION PIC'S JUDGEMENT ENOUGH EVEN THOUGH HE FELT UNCOMFORTABLE WITH THE SIT. THE FO SHOULD HAVE BEEN ALERT ENOUGH TO FORCE THINGS TO SLOW DOWN. 4) POOR COMMON SENSE IN DISPATCH/COMPANY MAINT: THAT ACFT SHOULD NEVER HAVE BEEN DISPATCHED FOR A NIGHT FLT INTO IMC WITH BAD WINTER WX AND UNCTLED AIRSPACE WITH THE INCREASED WORKLOAD OFTHE PRESSURIZATION SYS BEING INOP. THE MEL NEEDS TO BE CHANGED! SHOULD BE RESTR TO ALLOW MANUAL PRESSURIZATION ONLY FOR DAY VMC FLTS TO A MAINT BASE FOR IT TO BE FIXED.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.