Bleeds off takeoff

[pelmet]

It is a frequent technique where I work to check the pressurization display, when time permits during climb every once in a while as things can get missed. Whenever your ears pop in the climb, it is a good idea to check the cabin rate of climb.

Occurrence No.: A15O0018 Occurrence Type: INCIDENT NONREPORTABLE
Class: CLASS 5 Reportable Type:
Date: 2015-02-28 Time: 16:30:00
Region of Responsibility: ONTARIO
Location: HAMILTON
Ground Injuries: Fatal: 0 Minor: 0
Serious: 0 Unknown: 0
---------- Aircraft 1 ----------
Registration: F-GZHA
Manufacturer: BOEING Operator Type: COMMERCIAL
Model: 737-800 CARs Info: 705 - AIRLINER
Injuries: Fatal: 0 Minor: 0
Serious: 0 Unknown: 0
Occurrence Summary:
The Air Transat Boeing 737-800 aircraft (TSC832, F-GZHA) was on route from CYHM to MUVR.
While climbing through 15000 feet asl when the cabin altitude warning horn sounded. The crew
initiated emergency procedures but determined cabin pressurization was not controllable. ATC was
advised and the aircraft was cleared to a lower altitude. The crew did not declare an emergency
but returned to the departure airport. The landing was uneventful and there were no reported
injuries. Examination of the aircraft determined that both engine bleed air switches were in the off
position. Normally, these switches are selected off for engine start.

[Meatservo]

So, the emergency checklist for the cabin altitude warning doesn't include checking the engine bleed air switches are on? Isn't that like wondering why it's so cold in your house, after you're done fiddling with the thermostat with no joy, you go to the basement to check if the furnace is still running?

What do I know. I don't operate anything nearly as complex as a 737.

[fish4life]

I'm with meat I can't believe the bleeds aren't part of the checklist for pressurization. Is the Airbus like this at transat where the bleeds are turned off for takeoff manually or is it automatic and perhaps the new type caused a few issues ?

[FICU]

Engine bleeds are checked in the after start and after takeoff checklists. Pressurization is checked in the 10,000 foot checklist. In an engine on de-ice checklist the APU is shut off unless required for a bleeds off take-off so if the APU was off they would have not pressurized at all. After de-ice you run the after start checklist. After a bleeds off take-off you turn the engine bleeds back on at 1000 feet AGL followed by the after take-off checklist.

A lot of redundancy to ensure engine bleeds are on if SOPs are followed and switches are actually looked at rather than just responding to the checklists.

This was a big bummer.

http://avherald.com/h?article=4831338e&opt=0

[Illya Kuryakin]

A perfect example of blind faith in a written checlist. Monkey doesn't see, monkey doesn't do.
Illya

[switchflicker]

Well, at least they didn't declare an emergency. Give them some credit.

Can you imagine the do-do that the 'professionals' would bestow upon them if they had done so.

How does it go? "Send money, Send guns, Call the lawyers and tell Mom I love her"

Baa Humbug

[Eric Janson]

Normally, these switches are selected off for engine start.

When I flew the 737 (-300) the Engine Bleed switches were turned on as part of the cockpit preparation flow.

Only the packs were turned off for Engine start. The Engine Bleed switches were always kept on.

That's the problem with the 1950's cockpit design of the 737 - plenty of things that can easily catch you out.

[FICU]

A mistake in the reporting. Engine bleed switches should never be off unless de-iceing with engines on or when doing a bleeds off take-off.

[CFM Symphony]

With the 737 being fairly new to TS, I can see how this could happen. It happened to me too, albeit in the comfortable confines of the sim during my initial. Still learning the flows, I neglected the packs, and they were not caught during the checklist reading.

There are many little mistakes one can make, most of which will be non-events when caught, for example switching the "B" pumps off instead of Engine Anti-Ice (never done that...). Unfortunately however, if the packs are missed things could get a little ugly. I am glad I made the mistake in the sim instead of the plane.

[Eric Janson]

There are many little mistakes one can make, most of which will be non-events when caught, for example switching the "B" pumps off instead of Engine Anti-Ice (never done that...).

I had my F/O do this to me on a Line Training flight. As he moved the 'B' Electric pump switch off he realised his mistake and immediately turned the switch back on.

There was a loud "clunk" as the resulting electrical spike tripped off the left generator - followed by the autopilot disconnect warning. I lost the primary flight instruments on my side so I had to transfer control to him.

The generator wouldn't reset - I had to start the APU and connect that to restore everything. After a few minutes the left generator reset normally and things went back to normal.

It was very quiet in the cockpit after that....

There's no rush to flip a switch - take the extra 0.5 sec to mentally confirm that the switch is the correct one.

If you're doing something you don't do every day (de-icing/crossbleed start) - keep the relevant supplementary checklist open and make sure all the steps in the procedure have been completed.

At a convenient point in the climb and at top of climb check the overhead panel to see if everything is in the correct position. Things do get missed (I've missed things as well).

[Liquid Charlie]

reminds me of that old saying -- "worst thing you can do is fuk with it" -- because then it's gone --

[Illya Kuryakin]

Well, at least they didn't declare an emergency. Give them some credit.

Can you imagine the do-do that the 'professionals' would bestow upon them if they had done so.

How does it go? "Send money, Send guns, Call the lawyers and tell Mom I love her"

Baa Humbug

It's "Send lawyers, guns, and money. The shit has hit the fan."
They didn't declare an emergency, because it wasn't one. Finger trouble never (almost) is.
They just cost the company several thousand dollars, and pissed off all their passengers. No big. Right?
Illya

[Gannet167]

Any reason to not just turn the bleeds on, let the pressurization start, and resume the climb?

[BBQ Chips]

Any reason to not just turn the bleeds on, let the pressurization start, and resume the climb?

Rubber jungle automatically deploys at a cabin altitude of 14000 feet if my memory serves me correctly.

[Gannet167]

Ahh, that's right, that'll do it. Hard to talk your way out of that.

[Gilles Hudicourt]

What is the source of the incident report? I checked CADORS and this incident isn't listed. Is there another place they can be found ?

[7ECA]

What is the source of the incident report? I checked CADORS and this incident isn't listed. Is there another place they can be found ?

Search CADORS number: 2015O0407, or by flight number TSC832.

[ahramin]

http://wwwapps.tc.gc.ca/Saf-Sec-Sur/2/c ... d2015O0407

[ahramin]

So, the emergency checklist for the cabin altitude warning doesn't include checking the engine bleed air switches are on?

No. Emergency and abnormal checklists assume the normal checklists have been accomplished and are written do deal with aircraft failures, not crew failures. If there is discretionary time, part of managing any abnormal situation should be a review of the relevant normal checklists. Doesn't sound applicable in this case as the decision to return had already been made, which changes the goals and priorities of the crew.

When it comes to checklists the order should be emergency, normal, then abnormal.

[Gilles Hudicourt]

What is the source of the incident report? I checked CADORS and this incident isn't listed. Is there another place they can be found ?

Search CADORS number: 2015O0407, or by flight number TSC832.

I hadn't found it because I searched under Air Transat. This one is recorded under Transavia, the registered owner......

[Illya Kuryakin]

So, the emergency checklist for the cabin altitude warning doesn't include checking the engine bleed air switches are on?

No. Emergency and abnormal checklists assume the normal checklists have been accomplished and are written do deal with aircraft failures, not crew failures. If there is discretionary time, part of managing any abnormal situation should be a review of the relevant normal checklists. Doesn't sound applicable in this case as the decision to return had already been made, which changes the goals and priorities of the crew.

When it comes to checklists the order should be emergency, normal, then abnormal.

There's that word again. "ASSUME".
So, you're suggesting the crew should rerun the normal checklist, discover any errors, then rerun the abnormal checklists using the new found knowledge that they've missed something in the aforementioned normal checklist? Why would anybody with even half a brain not put "check bleed air on" on an abnormal checklist regarding pressurization??
The house suddenly got cold. "Check door is closed".
ASS U ME.
Illya

[FICU]

That's the way Boeing designed it. For example if you do a bleeds off take-off and have a pack or bleed issue you reconfigure back to bleeds on before you run the non-normal checklist.

Boeing expects you to follow SOPs and run normal checklists properly. They can't hold your hand.

This issue should have been caught at 10,000 feet where the crew could have checked the pressurization panel and realized the bleeds were off before the masks dropped 4000 feet later.

[Illya Kuryakin]

That's the way Boeing designed it. For example if you do a bleeds off take-off and have a pack or bleed issue you reconfigure back to bleeds on before you run the non-normal checklist.

Boeing expects you to follow SOPs and run normal checklists properly. They can't hold your hand.

This issue should have been caught at 10,000 feet where the crew could have checked the pressurization panel and realized the bleeds were off before the masks dropped 4000 feet later.

Is a 10000 foot check a flow, or is there a checklist for it?
Illya

[monkey]

Probably just a silent check although the after takeoff checklist does have bleed and pack check on it. Guess that got missed as well. Amazing how different Boeing and Airbus products are with that overhead panel.

[FICU]

Is a 10000 foot check a flow, or is there a checklist for it?

It's a flow along with turning landing lights off and shutting the APU off if a bleeds off take-off was performed.