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|
Attributes | |
ACN | 513206 |
Time | |
Date | 200106 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 0.7 |
ASRS Report | 513206 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : repair performance deficiency : training performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On jun/xa/01, ship arrived in ZZZ. A deferred item was on board the aircraft with the oxygen mask door not latching. A passenger service unit was ordered to fix the deferred item. The door on the broken passenger service unit was taped closed as well as row xa seats. I removed the broken passenger service unit and installed the new one, inadvertently overlooking the reference in the maintenance manual for swapping the oxygen generator. The old passenger service units parts tag was filled out and put in the shipping box and sent to stores. Because I did not change over the oxygen generator from the old passenger service unit to the new one, stores shipped the passenger service unit with the oxygen generator still attached. Callback conversation with reporter revealed the following information: the reporter stated the passenger service unit procedure did not mention the removal and installation of the oxygen generator. The reporter said the special handling procedures for the oxygen generator were in the maintenance manual in the description and operation section. The reporter said only the passenger service unit procedure was used for the work. The reporter stated the aircraft flew 6 trips with no oxygen generator in the passenger service unit. The defective passenger service unit was sent to stores without any special handling tags to alert stores of the oxygen generator canister still installed. The reporter said his job experience is several months less than a yr. The reporter stated the FAA has made contact and was interviewed.
Original NASA ASRS Text
Title: A B767 WAS DISPATCHED IN NON COMPLIANCE WITH A PAX SVC UNIT REPLACED WITHOUT AN OXYGEN GENERATOR CANISTER INSTALLED.
Narrative: ON JUN/XA/01, SHIP ARRIVED IN ZZZ. A DEFERRED ITEM WAS ON BOARD THE ACFT WITH THE OXYGEN MASK DOOR NOT LATCHING. A PAX SVC UNIT WAS ORDERED TO FIX THE DEFERRED ITEM. THE DOOR ON THE BROKEN PAX SVC UNIT WAS TAPED CLOSED AS WELL AS ROW XA SEATS. I REMOVED THE BROKEN PAX SVC UNIT AND INSTALLED THE NEW ONE, INADVERTENTLY OVERLOOKING THE REF IN THE MAINT MANUAL FOR SWAPPING THE OXYGEN GENERATOR. THE OLD PAX SVC UNITS PARTS TAG WAS FILLED OUT AND PUT IN THE SHIPPING BOX AND SENT TO STORES. BECAUSE I DID NOT CHANGE OVER THE OXYGEN GENERATOR FROM THE OLD PAX SVC UNIT TO THE NEW ONE, STORES SHIPPED THE PAX SVC UNIT WITH THE OXYGEN GENERATOR STILL ATTACHED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE PAX SVC UNIT PROC DID NOT MENTION THE REMOVAL AND INSTALLATION OF THE OXYGEN GENERATOR. THE RPTR SAID THE SPECIAL HANDLING PROCS FOR THE OXYGEN GENERATOR WERE IN THE MAINT MANUAL IN THE DESCRIPTION AND OP SECTION. THE RPTR SAID ONLY THE PAX SVC UNIT PROC WAS USED FOR THE WORK. THE RPTR STATED THE ACFT FLEW 6 TRIPS WITH NO OXYGEN GENERATOR IN THE PAX SVC UNIT. THE DEFECTIVE PAX SVC UNIT WAS SENT TO STORES WITHOUT ANY SPECIAL HANDLING TAGS TO ALERT STORES OF THE OXYGEN GENERATOR CANISTER STILL INSTALLED. THE RPTR SAID HIS JOB EXPERIENCE IS SEVERAL MONTHS LESS THAN A YR. THE RPTR STATED THE FAA HAS MADE CONTACT AND WAS INTERVIEWED.
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.