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An A320 required oxygen per a job card. Technician failed to initiate a non routine job card to ensure service. After servicing; another technician failed to turn on bottle.
| Attributes | |
| ACN | 669080 |
| Time | |
| Date | 200503 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | A320 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance avionics : 22 maintenance technician : 22 |
| ASRS Report | 669080 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure non adherence : company policies |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : testing performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | 8 Day Task Card |
Narrative:
I initialed an 8 day task card for checking the cockpit. Included in that section is crew oxygen. I noticed it needed servicing and delegated the task of servicing crew oxygen. I failed to initiate a non routine form. At the gate the captain noticed a reading of 0 psi or low pressure on the oxygen. It was subsequently found that the oxygen bottle had been replaced but not turned on. Our maintenance corrected the problem by turning on the oxygen and completing the new logbook write-up. I believe some contributing factors include the initial task card not saying to initiate a non routine form if oxygen is low; and not having the crew oxygen as a separate sign off from the rest of the cockpit items. Better communication. I believe it was an inadvertent act of failing to turn on the bottle. I forgot to fill out a non routine form due to work delegation and miscom.
Original NASA ASRS Text
Title: AN A320 REQUIRED OXYGEN PER A JOB CARD. TECHNICIAN FAILED TO INITIATE A NON ROUTINE JOB CARD TO ENSURE SVC. AFTER SVCING; ANOTHER TECHNICIAN FAILED TO TURN ON BOTTLE.
Narrative: I INITIALED AN 8 DAY TASK CARD FOR CHKING THE COCKPIT. INCLUDED IN THAT SECTION IS CREW OXYGEN. I NOTICED IT NEEDED SVCING AND DELEGATED THE TASK OF SVCING CREW OXYGEN. I FAILED TO INITIATE A NON ROUTINE FORM. AT THE GATE THE CAPT NOTICED A READING OF 0 PSI OR LOW PRESSURE ON THE OXYGEN. IT WAS SUBSEQUENTLY FOUND THAT THE OXYGEN BOTTLE HAD BEEN REPLACED BUT NOT TURNED ON. OUR MAINT CORRECTED THE PROB BY TURNING ON THE OXYGEN AND COMPLETING THE NEW LOGBOOK WRITE-UP. I BELIEVE SOME CONTRIBUTING FACTORS INCLUDE THE INITIAL TASK CARD NOT SAYING TO INITIATE A NON ROUTINE FORM IF OXYGEN IS LOW; AND NOT HAVING THE CREW OXYGEN AS A SEPARATE SIGN OFF FROM THE REST OF THE COCKPIT ITEMS. BETTER COM. I BELIEVE IT WAS AN INADVERTENT ACT OF FAILING TO TURN ON THE BOTTLE. I FORGOT TO FILL OUT A NON ROUTINE FORM DUE TO WORK DELEGATION AND MISCOM.
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.