Embarrassing Oops

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trey kule
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Re: Embarrassing Oops

#26 Post by trey kule » Thu Jan 19, 2017 10:01 am


gimmepars wrote:
pelmet wrote:

"As the flight crew levelled the aircraft at the cruising altitude of FL240, the check pressurization light illuminated."


How'd they get to FL240 before the light came on if the bleeds were never turned on after takeoff?
There is the assumption being made that that the warning light was noticed immediately when it was illuminated. That is not always the case, and it may have just been noticed when they were doing a check. Might be an honest belief as that is when they noticed it so they made the same assumption.

Think of all the pilots, every year, that do not hear the gear warning horn and flop the plane in gear up.

Two crew and checklists go a long way to resolving these kinds of issues.....or should. Unfortunately humans do not always follow rules ( not speculating at all about this incident..generic).
And basic flight training instills in too many pilots the belief that they must take action, and quickly.
Getting pilots to slow down is a training challenge. Add to that the hours and hours of flying without a glitch. Time since the last training when pilots reviewed abnormal situations, and intangables like crew familiarity and familiarity with the aircraft. SOPs, checklists, crew priorities all can be ignored, and the habit can set in fast.
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Re: Embarrassing Oops

#27 Post by bobcaygeon » Thu Jan 19, 2017 10:56 am

UPDATE from National Flight Operations: A Civil Aviation Safety Inspector (CASI) looked into this occurrence. The aircraft returned due to a flight crew error as the engine bleed switches were placed in the incorrect position following de-icing in CYHZ. This was discovered after having completed the rapid depressurization Quick Reference Card (QRC) when the cabin pressure warning light illuminated at FL240 and the subsequent Quick Reference Handbook (QRH) procedure at 10000 ft. The crew returned to the airport of departure (CYHZ).

Something just a little different than the routine ie deicing can cause things start down that path.
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Re: Embarrassing Oops

#28 Post by oldtimer » Thu Jan 19, 2017 2:05 pm

Drawing on past experience where the right seater forgot the blower switch, there is a lesson to be learned here. A pressurization fault where cabin pressure differential increases and the cabin descends will be felt quite quickly by inner ear discomfort but where cabin altitude is increased by a lack of pressurization, it may not always be felt in the inner ears so it can creap up on a pilot.
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Re: Embarrassing Oops

#29 Post by Heliian » Thu Jan 19, 2017 3:52 pm

This is not an "embarrassing oops", this was a human error caused by a chain of events that had a positive outcome. The pilots entered into to a situation that required them to take immediate action. Their decision to discontinue the flight may have not been the most efficient but they did land safely.

Much to be analyzed after the fact, a good educational lesson.
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Re: Embarrassing Oops

#30 Post by The Hammer » Fri Jan 20, 2017 8:31 am

Heliian wrote:This is not an "embarrassing oops", this was a human error caused by a chain of events that had a positive outcome. The pilots entered into to a situation that required them to take immediate action. Their decision to discontinue the flight may have not been the most efficient but they did land safely.

Much to be analyzed after the fact, a good educational lesson.

Human error is a stretch. Miss the same check once or twice, ok. You're not supposed to miss the initial check (Bleeds), then Multiple pressurization checks, and then also incorrectly complete the QRH procedures. This wasn't a complicate or long QRH procedure like smoke in the cockpit (I hate those). Sorry it's an embarrassing oops.
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Re: Embarrassing Oops

#31 Post by trey kule » Fri Jan 20, 2017 8:33 am

Double post
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Last edited by trey kule on Fri Jan 20, 2017 6:24 pm, edited 1 time in total.

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Re: Embarrassing Oops

#32 Post by trey kule » Fri Jan 20, 2017 8:34 am

You are trying to minimize it Helian. It might have been a simple human error if some procedures or whatnot can be changed to avoid in the future.


Or...it was a crew that was screwing the pooch, screwed up by ignoring SOPs and checklists, forgot to turn the the switches on, and then , instead of following the proper emergency/abnormal procedures went into hyper reaction mode. Its all about safety...right?

We do not have the complete facts, but the fact they forgot to turn on the bleed air is a big and fairly clear signal to me that the crew was not doing their job. The response to their error? A bit over the top I think, and I again suspect that once on the ground standing red faced, they would swear they followed all the proper procedures...

In any event, we will never probably have all the pertitant facts, so your claim that it was simple error is in dispute.
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Re: Embarrassing Oops

#33 Post by Rookie50 » Fri Jan 20, 2017 4:57 pm

crazyaviator wrote:
A bit over the top I think, and I again suspect that once on the ground standing red faced, they would swear they followed all the proper procedures..
That's what I meant by old boys club ( cover-up if possible )
Ok I'll bite. Yeah they clearly messed up. However --

Where is the clear, hard proof of an attempted "cover up"?

Both here and on the other accident thread you seem to be willing to speculate to trash pilots reputations, in incidents, without a shred of evidence, assuming they are all "cowboys".

The Ken Borek thread is totally ridiculous in that regard as well.

I'd suggest in future if you have hard facts report them. Do not speculate.
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Re: Embarrassing Oops

#34 Post by Go Guns » Fri Jan 20, 2017 5:59 pm

Donald wrote:
frog wrote:TSB typo ?

On engines start, bleed air switches are on on the 738, packs switches are off.

No typo.

Think about the configuration for an engines running de-ice.

The Transat crew didn't re-configure properly after the de-ice, missed it in the after takeoff checklist, missed it in 10,000 checks, and didn't catch it with the QRH when the horn went off.
Had it on the little RJ once that they didn't properly connected the cannon plugs on the back of the pressurization controller, and the plane didn't pressurize. I was PF, Noticed it immediately after takeoff, before the gear was up. Could easily feel the difference in my ears, and with the sound. Can't imagine not noticing that on the 737.
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Re: Embarrassing Oops

#35 Post by crazyaviator » Fri Jan 20, 2017 6:11 pm

If 2 pilots were landing a dash 8 and got waived off by tower for not having their gear down, then said pilots, realizing they forgot the gear, went ahead and put the gear down on downwind,,,,would they then thereafter have maintenance inspect the landing gear system and release the aircraft ??

From the report:
The operator’s maintenance determined that no faults were present. The aircraft was returned to service."
Maybe the pilots said there appeared to be a switch fault ? lol
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Re: Embarrassing Oops

#36 Post by crazyaviator » Fri Jan 20, 2017 6:15 pm

How much pressurization is still available at 24000 feet with the switches off OR was the cabin so well sealed that it took that long to reach cabin warning altitude ? ( kudos to Bombardier/ maint if that is the case ) I worked on the dash at city express tooooo long ago :D
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Re: Embarrassing Oops

#37 Post by Rookie50 » Fri Jan 20, 2017 6:24 pm

crazyaviator wrote:
From the report:
The operator’s maintenance determined that no faults were present. The aircraft was returned to service."
This proves -- not speculates -- exactly what?
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Re: Embarrassing Oops

#38 Post by crazyaviator » Fri Jan 20, 2017 10:51 pm

IF the pilots reported to ops that the failure was due to finger trouble, would they have any need to go to Maint ? I suspect that it was more of an immediate cover-up so that it could be reported to the pax/media etc that it was checked by maintenance and a professional with a licence signed off the aircraft as serviceable ( returned to service) to buy them time until when the truth came out no one would care anyways !

After declaring an emergency and returning/ descending to 5000 feet,their goose was cooked and they could not resume their flight to Ottawa right ?

Wouldn't it be soooo terrible if the truth were told to the passengers, absolute panic and stocks would hit the basement, No one would fly for that airline ever again !!! :lol:

Pilots would complain of fatigue and the fault of the deicer and get some remedial training on how to use a checklist and all is A okay ! :?
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Re: Embarrassing Oops

#39 Post by crazyaviator » Fri Jan 20, 2017 11:00 pm

I can hear it now ( passing through 4000 feet on the emergency descent back to Halifax )

" Attention passengers, we, ah, had a simple failure of the crew, well, the pilot and co-pilot failed to turn a switch on and , ah '' well, we didn't have pressurization and that could have killed us all, but the good news is that we operated the switch and pressurization is available now, the bad news is that we cannot continue onto our planned destination, but the good news is you get to spend more time in Halifax and us pilots get to do our laundry before our next flight over and out " :P

SHit HAppens !
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Re: Embarrassing Oops

#40 Post by pelmet » Sun Sep 10, 2017 7:58 am

This one is obviously a different sort of situation but if one pack is inop for departure, I suggest checking the pressurization during the initial climb, even if it is not official SOP to do so. Especially, if you have O2 generators, it could save a lot of further headache. Best to monitor closely while enroute as well.

"C-FLSW, a Boeing 737-800 aircraft operated by Sunwing, was conducting flight SWG803 from Toronto/Lester B. Pearson Intl, ON (CYYZ) to Vancouver Intl, BC (CYVR). While climbing through 10 000 feet after the departure from CYYZ, the flight crew noticed that the cabin altitude was also climbing to 10 000 feet. When the cabin altitude reached 11 000 feet, the Cabin Altitude Warning
activated. QRH procedures were executed, the flight crew requested to return to CYYZ with a descend. ARFF was also requested to be available to check the brakes due to the overweight landing. The aircraft landed without further event and, after ARFF checked the brake temperatures, the aircraft was authorized to taxi to the gate. The aircraft had been released for the flight with the number 1 Air Conditioning Pack on MEL. The number 2 pack became unserviceable during the climb due to a loose connector causing an
intermittent electrical power supply to the pack. The connector was secured and the aircraft was returned to service."
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Re: Embarrassing Oops

#41 Post by goingnowherefast » Sun Sep 10, 2017 12:33 pm

Is the procedure really to land overweight? I can't imagine a pressurisation issue would prevent an airplane from flying around at 5000' burning gas until under max landing weight. If that's what the procedure is, then that's it. I just find it surprising.
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Re: Embarrassing Oops

#42 Post by nohojob » Sun Sep 10, 2017 12:42 pm

Yes the 737-800 can land overweight without causing any major issues. It is what you would do after an engine failure for instance. You wouldn't be turning during several hours with an engine on fire would you ?
All it takes after an overweight landing is an inspection.
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Re: Embarrassing Oops

#43 Post by goingnowherefast » Sun Sep 10, 2017 5:31 pm

Engine fire and pressurization problem are vastly different levels of severity and urgency. You can safely fly around all day with the cabin unpressurized. There's no safety reason to land ASAP, purely economic.
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Re: Embarrassing Oops

#44 Post by oldtimer » Sun Sep 10, 2017 8:31 pm

In the Beech 350,the Bleed Air switches have 3 positions, Off, Low and High. We use Off for normal shutdown and of course for smoke but the Low position reduces bleed air flow from the packs for improved take-off performance and I have gotten to a high altitude with max pressure diff with the bleeds Low.
With the newer models, they will hold the normal 6.5 psid pressure diff to the high flight levels in Bleeds Low but the people in the back get a bit cold. Solution is to turn the bleed High and it warms up.
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Re: Embarrassing Oops

#45 Post by J31 » Mon Sep 11, 2017 12:52 am

goingnowherefast wrote:Is the procedure really to land overweight? I can't imagine a pressurisation issue would prevent an airplane from flying around at 5000' burning gas until under max landing weight. If that's what the procedure is, then that's it. I just find it surprising.
With no air flow from the packs I'm sure the cabin temperature would be climbing. Depending on the passenger/fuel load on the YYZ-YVR route you could be flying around for 2-3 hours burning fuel to get to landing weight.

Not an emergency but would you want to fly around for hours with hot, cranky passengers?

If you have the landing distance numbers it is not unsafe to land a 737-800 over max landing weight. At 165000 lbs (20000 lbs over landing weight) you can easily stop in 7000 ft.
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Re: Embarrassing Oops

#46 Post by nohojob » Mon Sep 11, 2017 1:07 am

Coming back on a long runway is no big deal for an overweight landing with this aircraft. Again , just an inspection is required. Just don't slam the brakes and don't do a hard landing. I suppose you'd be able to dump fuel if overweight landing was a big deal with the 737/800.
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Re: Embarrassing Oops

#47 Post by justwork » Mon Sep 11, 2017 5:14 am

When I used to fly the Q I had on 2 separate occasions the FO forget the bleeds in the after take off check. The plane climbs like a raped ape, by 6000' you can tell something is going on. Turn one bleed on and wait a thousand feet before turning on the other, this will help your ears out.
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Re: Embarrassing Oops

#48 Post by Maynard » Mon Sep 11, 2017 1:03 pm

How do you even get to FL240 without your ears telling you something is wrong? That seems crazy. "Gee my ears sure are popping more than normal, especially way up here at 13,000'" "Oh well, look at this climb performance!"
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Re: Embarrassing Oops

#49 Post by confusedalot » Mon Sep 11, 2017 7:27 pm

nohojob wrote:Coming back on a long runway is no big deal for an overweight landing with this aircraft. Again , just an inspection is required. Just don't slam the brakes and don't do a hard landing. I suppose you'd be able to dump fuel if overweight landing was a big deal with the 737/800.
No fuel dump on a 737. Need to get into bigger Boeings for that.

As far as forgetting switches, it's a two man crew and I suppose the Encore checklists are challenge and response, so it is inappropriate to blame the other guy.

Short and pressured turns bring their own characteristics which may have been a contributing factor to this incident, especially when a crew change is involved.
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Re: Embarrassing Oops

#50 Post by Eric Janson » Tue Sep 12, 2017 8:47 am

I've been taught to always check that critical systems are operating normally during the climb.

I've also been taught to check all the switch positions when reaching cruise altitude.

This is basic Airmanship imho.

Sadly Airmanship is something that seems to have almost completely disappeared.
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