37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 506915 |
Time | |
Date | 200012 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 3 |
ASRS Report | 5069155 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 969 |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : engineering procedure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I had mistakenly signed off an installation of a personal breathing hood located in the aft position (which I installed) for being the mid position (which was not installed) on an engineering order, resulting in the mid personal breathing hood not being installed. The engineering order should have had pictures showing specific locations of new personal breathing hood installations. My paperwork was given to another technician after my shift. On the paperwork the aft personal breathing hood installation was left blank but in fact had already been installed, so he inspected it and signed it off. 3 1/2 months later, it was found during a preflight safety equipment inspection, possibly causing a flight delay. To my knowledge the mid personal breathing hood has been installed since.
Original NASA ASRS Text
Title: AN MD80 WAS DISPATCHED AND OPERATED WITH THE MID CABIN EMER PERSONAL BREATHING HOOD MISSING.
Narrative: I HAD MISTAKENLY SIGNED OFF AN INSTALLATION OF A PERSONAL BREATHING HOOD LOCATED IN THE AFT POS (WHICH I INSTALLED) FOR BEING THE MID POS (WHICH WAS NOT INSTALLED) ON AN ENGINEERING ORDER, RESULTING IN THE MID PERSONAL BREATHING HOOD NOT BEING INSTALLED. THE ENGINEERING ORDER SHOULD HAVE HAD PICTURES SHOWING SPECIFIC LOCATIONS OF NEW PERSONAL BREATHING HOOD INSTALLATIONS. MY PAPERWORK WAS GIVEN TO ANOTHER TECHNICIAN AFTER MY SHIFT. ON THE PAPERWORK THE AFT PERSONAL BREATHING HOOD INSTALLATION WAS LEFT BLANK BUT IN FACT HAD ALREADY BEEN INSTALLED, SO HE INSPECTED IT AND SIGNED IT OFF. 3 1/2 MONTHS LATER, IT WAS FOUND DURING A PREFLT SAFETY EQUIP INSPECTION, POSSIBLY CAUSING A FLT DELAY. TO MY KNOWLEDGE THE MID PERSONAL BREATHING HOOD HAS BEEN INSTALLED SINCE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.