B737 CREW EXPERIENCES CABIN ALT WARNING HORN AND INITIATES AN EMER DSCNT.

Date: 2006-10 · Aircraft: B737-300 · Phase: climb

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

Synopsis

B737 CREW EXPERIENCES CABIN ALT WARNING HORN AND INITIATES AN EMER DSCNT.

Narrative

WHILE CLBING THROUGH FL300 FOR FINAL CRUISE ALT OF FL330; THE CABIN PRESSURIZATION WARNING HORN SOUNDED. THE CAPT NOTED THE CABIN PRESSURE BTWN 10000 FT AND 11000 FT AND INITIATED AN IMMEDIATE DSCNT WHILE INSTRUCTING THE FO TO ACCOMPLISH THE QRH MEMORY ITEMS FOR 'CABIN ALT WARNING HORN/ABNORMAL PRESSURIZATION' AND EMER DSCNT CHKLIST ITEMS. BOTH THE CAPT AND FO DONNED EMER OXYGEN MASKS AND ESTABLISHED CREW COMS WHILE REQUESTING AN IMMEDIATE DSCNT TO 14000 FT OR BELOW FROM ARTCC. THE CAPT INSTRUCTED THE FO TO NOTIFY THE FLT ATTENDANTS. THE CAPT DECLARED AN EMER WITH ARTCC; WHO FACILITATED A VMMO DSCNT TO 9000 FT MSL. ONCE LEVEL AT 9000 FT MSL; THE CAPT AND FO REMOVED THEIR OXYGEN MASKS AND COMPLETED ALL QRH CHKLIST ITEMS. THE FO NOTICED THE ALT SET IN THE 'LAND ALT' AND THE 'CAB ALT' INDICTOR WINDOWS WERE BOTH SET INCORRECTLY. THE FO INTENDED TO SELECT 1118 FT. HOWEVER; THE FO INADVERTENTLY SET 11080 FT IN THE 'LAND ALT' AND 'CAB ALT' ANALOG INDICATORS. THESE ENTRIES LIKELY CAUSED THE ABNORMAL PRESSURIZATION; WHICH RESULTED IN A MAX CABIN ALT BTWN 10000 FT AND 11000 FT. THE CAPT ELECTED TO SWITCH THE PRESSURIZATION FROM MANUAL TO THE AUTO MODE WITH THE CORRECT 'LAND ALT' AND 'CAB ALT' ENTRIES IN THE INDICATOR WINDOWS. UPON THIS ACTION; THE ACFT PRESSURIZED NORMALLY. THE CAPT INSTRUCTED THE FO TO COMPLETE ALL QRH AND NORMAL DSCNT CHKLIST ITEMS; AND TO EVALUATE THE REQUIRED FUEL TO COMPLETE THE FLT. AFTER ASSESSING ALL PARAMETERS; THE CAPT ELECTED TO CONTINUE AT 9000 FT AND 250. ENRTE COMPANY MAINT AND OPS WERE NOTIFIED OF AN ABNORMAL CABIN PRESSURIZATION EVENT AND WERE REQUESTED TO MEET THE ACFT ON ARR. COMPANY MAINT COMPLETED A FULL TEST OF THE PRESSURIZATION SYS OF THE ACFT AND CONCLUDED THAT THE INCORRECT SETTINGS IN THE 'LAND ALT' AND 'CAB ALT' INDICATORS LIKELY CAUSED AN OFF-SCHEDULED CABIN PRESSURIZATION EVENT. THE ACFT WAS RECERTIFIED TO CONTINUE FLT AFTER PASSING ALL PRESSURIZATION CHKS. THE CAPT AND FO FLEW THE ACFT UNEVENTFULLY TO OUR NEXT CITY; AS SCHEDULED; WITH NO FURTHER PRESSURIZATION ISSUES. LESSONS LEARNED: 1) FO MUST ENSURE THE CORRECT DEST ARPT ALT IS ENTERED INTO THE ACFT SYS. 2) THERE IS SIGNIFICANT VALUE IN PRACTICING DONNING EMER MASKS AND ESTABLISHING CREW COMS. THE AMBIENT NOISE DURING AN EMER DSCNT IS SIGNIFICANT AND COMS BTWN CREW MEMBERS CAN BE DIFFICULT. ADDITIONALLY; BOOM MIKES; HEADSETS; AND GLASSES CAN BE IMPEDIMENTS TO RAPIDLY DONNING THE MASKS. LASTLY; THE FO HAD RECENTLY COMPLETED A SIMILAR TRAINING EVENT DURING HIS INITIAL TRAINING AS A NEW HIRE. THIS RECENCY OF TRAINING AND EXPOSURE TO A RAPID DSCNT WAS VALUABLE TRAINING. 3) AT CERTAIN SEAT HEIGHTS; IT IS DIFFICULT TO PROPERLY READ THE PRESSURIZATION READOUTS AND THERE ARE KNOBS THAT CAN OBSTRUCT THE CAPT'S AND FO XCHK OF THE PRESSURIZATION WINDOW. THERE IS NO SUBSTITUTE FOR ACFT SYS KNOWLEDGE. THIS EVENT APPEARED TO BE A RESULT OF IMPROPER 'LAND ALT' AND 'CAB ALT' INDICATOR ENTRIES; BUT THE POSSIBILITY OF SUCH AN EVENT; OR ITS CONSEQUENCES; IS NOT ADDRESSED IN THE ACFT MANUAL. 5) THERE IS NO SUBSTITUTE FOR XCHK; CHK; AND RECHKING EVEN WHEN ONE ASSUMES ALL CHKLISTS HAVE BEEN CONFIRMED.

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