Date: 201603
Local time of day: 1201-1800
Flight conditions: VMC
Light: Daylight
Aircraft: B737-700
Operator: Air Carrier
Operating under: Part 91
Flight plan: IFR
Mission: Ferry / Re-Positioning
Flight phase: Parked
Aircraft component: Pressurization System
Component problem: Improperly Operated
Reporter organization: Air Carrier
Reporter function: Captain
Human factors: Situational Awareness
Anomaly: Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy
Detector: Person Flight Crew
When detected: In-flight
Result: General Maintenance Action
Contributing factors: Human Factors
Primary problem: Human Factors

Narrative: This was to be an unpressurized Maintenance ferry at 10;000'. While I was not disappointed that the procedures for this flight would be completely screwed up; (they exceeded even my wildest expectations) what I found wrong with the aircraft made my blood boil.On arrival at the gate; I was told the aircraft did an air return due to a Cabin Altitude Warning light and Warning horn; and it was so documented in the aircraft logbook. As I entered the cockpit the first thing that jumped out at me was the fact that BOTH Engine Bleed switches were OFF and the APU Bleed switch was ON. I assumed that Contract Maintenance had been troubleshooting. Due to conflicts between the Dispatch Release notes; MEL requirements and the Maintenance Procedures Manual; there was the obligatory extended period of time while abject confusion reigned amongst all the various groups involved.While sitting in the back of the aircraft waiting for the confusion to subside; I asked the First Officer if she had moved the bleed switches to their current configuration. She replied she hadn't touched any controls or switches in the cockpit as of yet. I then told her about the bleed configuration as a matter of curiosity. Shortly after this; two Contract Maintenance Technicians came into the cockpit to disable the Passenger Oxygen Auto Deployment system.I asked the AMT if he had worked on the aircraft; and he replied he was the first one at the aircraft that morning. I asked him if he had reconfigured the bleed switches and he said; 'I turned the Engine Bleeds ON to trouble-shoot the problem; but I then put them back to OFF as I found them. They were both OFF when I first looked at them.' He then looked into the cockpit and said; 'That's the way they were right there.' He also stated that he did a BITE check and both pressurization controllers showed no faults.Later; when I parked the aircraft at the hangar; the two AMTs who took the aircraft from me stated they had done a 'remote download' of flight data and it showed the Crew had; in fact; taken off with the bleeds OFF.The WARNING HORN or WARNING LIGHT - CABIN ALTITUDE QRH Checklist says to put on your mask; etc.; go to the CABIN ALTITUDE WARNING or Rapid Depressurization QRH Checklist which says to put on your mask; then put the Pressurization Mode Selector in MAN and then close the Outflow Valve; then go to yet ANOTHER QRH Checklist for emergency descent. Great.Our previous QRH was a custom designed checklist to address several obvious short-comings and omissions of the Boeing QRH; and there were several. The BIGGEST change made was the addition of the 'CABIN ALTITUDE WARNING/Abnormal Pressurization Checklist.' This checklist was implemented due to the fact that 99 percent of all pressurization problems were attributed directly to the Crew taking off with the bleeds and/or the pack switches OFF (as well as the pressurization controller being left in manual.) To quote the current Flight Standards mantra - this was DATA DRIVEN. Indeed; a previous airline crash was caused; in part; due to the engine and APU bleed switches being OFF (see AAIASB report; page 50; section 1.12.2.2) Had the Crew followed the Boeing QRH; they would have put the Pressurization Mode selector into manual and closed the outflow valve; which would have done nothing. As it turns out; they actually took off with the mode controller in manual; and the accident report stated if they had just put the mode selector back in AUTO they would have been fine. But; that's not true since the bleed switches were OFF. However; the point remains - there was a specific need to VERIFY the packs and bleed switches were ON at some point in the cabin depressurization evolution to avoid decreasing safety margins for the Passengers and the Crew. THAT was the main reason; as I recall; for the custom QRH Checklist here. While it is very hard not to fault the Crew; in my case; if they did in fact; takeoff with the bleeds OFF (that'sNOT confirmed; just to be clear) it is still an example of Flight Operations ignoring a known problem documented with 'DATA;' no less; and then incredibly deleting a solution that had been implemented for more than 10 years. And; by the way; this was done ostensibly (according to Flight Standards) to save money; make QRH updates easier; and; as I was just told in recurrent training; to reduce liability. Really. As if Company won't be liable? That statement borders on asinine.I ask you; why execute an emergency descent into crowded airspace from possibly high altitude (loss of separation); in high terrain (CFIT; etc.); putting Passenger well-being at risk (perforated eardrums; etc.); not to mention creating mass panic; if all you need to do is turn the flamin' packs and bleeds back on?By the way; this ferry flight departed about three hours late due to me not rushing and making sure all parties were on the same page and all paperwork was in order. You NEVER want to rush in this business. It simply isn't worth it.Assuming the Crew was at fault:1)  Flt Ops needs to start STRESSING and POUNDING it repeatedly into Pilots' heads to STOP RUSHING. Make it the new mantra - STOP RUSHING! Pilots rushing around; trying to push as quick as they can to make up time is the biggest problem that I observed when I started flying the line. It virtually leads directly to Pilots not doing the checklists in a slow; methodical manner. Doing ALL checklists in a slow; methodical manner will reduce or even eliminate 'expectation bias' on a checklist.  My Passengers are expecting me to get them there safely; and I intend to do just that. Assuming Flight Ops is trying to 'save money' and have an 'easier time with updates' and avoid worrying about not being 'liable' as they have stated in videos and training:2) Modify the 'CABIN ALTITUDE WARNING or Rapid Depressurization' Checklist to include; at some point; turning the bleeds and packs back ON to at least give the Pilots a shot at not doing a 'high dive' in a perfectly performing aircraft.And for the experts:3) Demand that Boeing modify the QRH in the Aircraft Flight Manual (AFM) to include verifying that the packs and bleeds are ON during a pressurization event/malfunction. It's not rocket science; it's just common sense.  Conclusion:Not all pressurization problems are due to packs and bleed configurations. I am fully aware of that. In fact; I have several colleagues I know personally that have had an outflow valve suddenly open in flight due to system malfunctions. But; it happens enough that these suggestions should be implemented and implemented quickly.It is hard for me to imagine that our current Leadership thinks that if a serious incident or; heaven forbid; accident happens due to a packs and bleeds configuration problem; that we won't be liable. Especially when it is discovered that we KNEW not turning the packs and bleeds on could be a problem;  and even had a procedure to mitigate that particular circumstance; but that; to 'save money' and make things 'easier' we took it out.'




Synopsis: B737 Captain believes that the current QRH procedures for pressurization anomalies is convoluted and does not address the primary cause of most failures. Namely; takeoff with engine bleed and or pack switches in the off position.