B737-700 FAILS TO PRESSURIZE WHEN FLIGHT CREW DOES NOT NOTE ENGINE BLEEDS WERE CLOSED.

2008-12 · NASA ASRS report 814232

Date: 2008-12 · Aircraft: B737-700 · Phase: climb

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

Synopsis

B737-700 FAILS TO PRESSURIZE WHEN FLIGHT CREW DOES NOT NOTE ENGINE BLEEDS WERE CLOSED.

Narrative

WE WERE DEPARTING ZZZ AND HAD A LAST MIN CAPT CHANGE DUE TO SCHEDULING ISSUES AND WE STARTED OFF BEHIND THE TIME LINE. WE PUSHED 14 MINS LATE AND WERE HUSTLING TO GET THINGS DONE. THE WX IN ZZZ WAS POOR. THE VISIBILITY WAS DOWN DUE TO FOG AND WAS RIGHT AT MINIMUMS FOR TKOF. THE TWR COULD NOT SEE THE RAMP AND ISSUED A CLRNC AROUND CONSTRUCTION AREAS TO RWY XXR. WE HAD PLANNED FOR RWY XXL. THE GND CTLR ALSO ASKED US TO RPT SEVERAL LOCATIONS ALONG OUR TAXI RTE SO THAT HE COULD CONFIRM OUR LOCATION. OTHER ACFT WERE ALSO TAXIING BUT COULD NOT BE SEEN BY THE TWR OR US. THE TAXI WAS SLOW; WITH BOTH PLTS STRAINING TO SEE CONSTRUCTION AREAS AND ARPT SIGNAGE AND TO FOLLOW THE CTLR'S DIRECTIONS. WE WERE ALSO MAKING TAXI POSITION RPTS AND LOOKING FOR THE OTHER ACFT THAT WE KNEW WERE OUT THERE. WHEN WE FINALLY ARRIVED AT THE END OF RWY XXR; WE CAME UP ON ANOTHER CARRIER. WE WERE UNAWARE OF HIS PRESENCE DURING THE TAXI AND WERE SURPRISED TO SEE HIM. WE WERE GIVEN AN IMMEDIATE TKOF CLRNC; COMPLETED THE CHKLIST; AND DEPARTED. AT 10000 FT MSL; I CALLED FOR THE CLB CHKLIST. ALMOST SIMULTANEOUSLY; WE GOT THE CABIN ALT WARNING HORN. BOTH PLTS IMMEDIATELY PERFORMED THE BOXED PROCS. SIMULTANEOUSLY; I LEVELED OFF (ABOUT 11000 FT MSL) AND NOTED THE CABIN ALT WAS AT 10000 FT. WE IMMEDIATELY ASKED FOR AND RECEIVED A CLRNC DOWN TO 10000 FT AND THEN GOT A SUBSEQUENT CLRNC DOWN TO 9000 FT MSL. WE ASKED FOR A VECTOR TO WORK THE ISSUE. THE CAPT RAN THE CHKLIST AND IMMEDIATELY NOTICED THAT THE ENG BLEED SWITCHES WERE OFF. HE TURNED THEM ON IN ACCORDANCE WITH THE CHKLIST AND THE ACFT PRESSURIZED NORMALLY. THE MASKS IN THE BACK DID NOT DROP AND THE CABIN ALT DID NOT GO MUCH ABOVE 10000 FT. WE BRIEFED THE FLT ATTENDANTS THAT EVERYTHING WAS BACK TO NORMAL AND TOLD ATC THE SAME. WE CONTINUED ON OUR RTE OF FLT AT PLANNED CRUISE ALT. THE REMAINDER OF THE FLT WAS UNEVENTFUL. THIS SITUATION WAS AVOIDABLE. WE WERE DEALING WITH SEVERAL DISTRS DURING THE MORNING THAT SHOULD HAVE NOT LEFT BLEED SWITCHES 'OFF' THE NIGHT BEFORE AND GONE UNNOTICED. WE ARE SO ACCUSTOMED TO THEM ALWAYS BEING 'ON' THAT IT WAS MISTAKENLY OVERLOOKED. THE CAPT CHANGE; BEING LATE; THE RWY CHANGE AFTER PUSH; THE LOW VISIBILITY TAXI; POSITION RPTING; AND OTHER ACFT THAT WE COULD NOT SEE; ALL WERE VERY DISTRACTING AND LED US TO MISS THIS ITEM ON THE BEFORE TKOF CHKLIST. WE WERE SO FOCUSED ON THE TAXI CONCERNS AND EXTERNAL THREATS THAT THE CHKLIST WAS NOT PROPERLY RUN. SIMPLY PUT; STRICT CHKLIST DISCIPLINE WOULD HAVE PREVENTED THIS ISSUE. WE CLEARLY NEEDED TO SLOW THINGS DOWN EVEN MORE TO ENSURE THAT EVERYTHING WAS SET PROPERLY. ANOTHER FACTOR WAS THAT THE BLEED SWITCHES WERE LEFT OFF. AFTER LITERALLY HUNDREDS OF ACFT STARTUPS; I HAVE NEVER SEEN THIS ISSUE. I HAVE NEVER HAD TO TURN ON THE ENG BLEEDS WHEN PREFLTING BEFORE. AGAIN; PREFLT DISCIPLINE WOULD HAVE CAUGHT THIS. NOTHING CAN BE TAKEN FOR GRANTED. WHEN DISTRS ARE PULLING YOU AWAY FROM NORMAL HABIT PATTERNS AND PROCS -- STOP! SLOW DOWN AND MAKE THINGS RIGHT!

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

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