37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 636669 |
Time | |
Date | 200411 |
Day | Thu |
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 | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
ASRS Report | 636669 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : anomaly accepted |
Consequence | other Other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : repair performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Environmental Factor Chart Or Publication |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Maint Proc Manual |
Narrative:
In shop we service oxygen bottles. It has become normal not to use the safety tube to service the bottles. The mechanics who do this have been told to use the tube by leads, foremen, and the safety department, yet refuse to do so because 'there is nothing in the maintenance procedure manual that says I have to use it.' a sign was posted to use the tube but is not followed because nothing backs it up. We need language in the maintenance procedure manual to use the safety tube to service oxygen bottles to end this unsafe practice now. This problem has persisted for years and the company has taken no action other than an unenforceable sign. Callback conversation with reporter revealed the following information: a few technicians will avoid using the safety tube but the major problem is one technician who absolutely refuses to use the containment vessel even though a sign is displayed requiring the tube be used. The fact the maintenance procedure manual does not list the safety tube and its required use is the excuse for not following the shop practice. The reporter advised the director of safety but nothing was changed.
Original NASA ASRS Text
Title: A LEAD TECHNICIAN RPTS TECHNICIANS REFUSING TO USE THE SAFETY TUBE WHEN SERVICING OR TESTING HIGH PRESSURE OXYGEN BOTTLES.
Narrative: IN SHOP WE SERVICE OXYGEN BOTTLES. IT HAS BECOME NORMAL NOT TO USE THE SAFETY TUBE TO SERVICE THE BOTTLES. THE MECHANICS WHO DO THIS HAVE BEEN TOLD TO USE THE TUBE BY LEADS, FOREMEN, AND THE SAFETY DEPT, YET REFUSE TO DO SO BECAUSE 'THERE IS NOTHING IN THE MAINT PROC MANUAL THAT SAYS I HAVE TO USE IT.' A SIGN WAS POSTED TO USE THE TUBE BUT IS NOT FOLLOWED BECAUSE NOTHING BACKS IT UP. WE NEED LANGUAGE IN THE MAINT PROC MANUAL TO USE THE SAFETY TUBE TO SERVICE OXYGEN BOTTLES TO END THIS UNSAFE PRACTICE NOW. THIS PROB HAS PERSISTED FOR YEARS AND THE COMPANY HAS TAKEN NO ACTION OTHER THAN AN UNENFORCEABLE SIGN. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: A FEW TECHNICIANS WILL AVOID USING THE SAFETY TUBE BUT THE MAJOR PROB IS ONE TECHNICIAN WHO ABSOLUTELY REFUSES TO USE THE CONTAINMENT VESSEL EVEN THOUGH A SIGN IS DISPLAYED REQUIRING THE TUBE BE USED. THE FACT THE MAINT PROC MANUAL DOES NOT LIST THE SAFETY TUBE AND ITS REQUIRED USE IS THE EXCUSE FOR NOT FOLLOWING THE SHOP PRACTICE. THE RPTR ADVISED THE DIRECTOR OF SAFETY BUT NOTHING WAS CHANGED.
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.