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An MD80 required a security seal on a lavatory ceiling panel. Technician inadvertently installed seal on overhead emergency oxygen door.
| Attributes | |
| ACN | 666334 |
| Time | |
| Date | 200507 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| 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 |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 666334 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : logbook entry performance deficiency : training performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
On jul/sat/05 I was called out to check an oxygen compartment seal broken on aircraft X. When I inspected the oxygen compartment; there was a broken security seal on the door. So I inspected the compartment carefully not to drop the masks and installed the seal. In hindsight; I realize that this was the wrong compartment. I believe I made this mistake because there was a previous seal installed in the same location; and the maintenance manual supplement 25-40-00 wasn't very clear. At the time I thought I did the right thing. It was my first time I had to install a seal. Callback conversation with reporter revealed the following information: the panel that required sealing was the ceiling access panel and not the emergency oxygen compartment. Reporter observed the broken seal on the emergency oxygen compartment door and replaced the sea. Reporter stated that he understands the serious situation that can develop if the masks were needed.
Original NASA ASRS Text
Title: AN MD80 REQUIRED A SECURITY SEAL ON A LAVATORY CEILING PANEL. TECHNICIAN INADVERTENTLY INSTALLED SEAL ON OVERHEAD EMER OXYGEN DOOR.
Narrative: ON JUL/SAT/05 I WAS CALLED OUT TO CHK AN OXYGEN COMPARTMENT SEAL BROKEN ON ACFT X. WHEN I INSPECTED THE OXYGEN COMPARTMENT; THERE WAS A BROKEN SECURITY SEAL ON THE DOOR. SO I INSPECTED THE COMPARTMENT CAREFULLY NOT TO DROP THE MASKS AND INSTALLED THE SEAL. IN HINDSIGHT; I REALIZE THAT THIS WAS THE WRONG COMPARTMENT. I BELIEVE I MADE THIS MISTAKE BECAUSE THERE WAS A PREVIOUS SEAL INSTALLED IN THE SAME LOCATION; AND THE MAINT MANUAL SUPPLEMENT 25-40-00 WASN'T VERY CLR. AT THE TIME I THOUGHT I DID THE RIGHT THING. IT WAS MY FIRST TIME I HAD TO INSTALL A SEAL. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE PANEL THAT REQUIRED SEALING WAS THE CEILING ACCESS PANEL AND NOT THE EMER OXYGEN COMPARTMENT. RPTR OBSERVED THE BROKEN SEAL ON THE EMER OXYGEN COMPARTMENT DOOR AND REPLACED THE SEA. RPTR STATED THAT HE UNDERSTANDS THE SERIOUS SITUATION THAT CAN DEVELOP IF THE MASKS WERE NEEDED.
Data retrieved from NASA's ASRS site as of January 2009 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.