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During a service check an L1011 technician working the cockpit oxygen masks inspection job card failed to 'find and fix' a broken head strap on the observer's mask.
| Attributes | |
| ACN | 698343 |
| Time | |
| Date | 200605 |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | L-1011-500 Series |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 13 |
| ASRS Report | 698343 |
| Person 2 | |
| Affiliation | government : faa |
| Function | maintenance : inspector |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | faa : investigated other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : repair |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
While working a line service work card on an L1011 aircraft; one step reads 'check flight crew and observer's oxygen masks; seat belts; and harnesses for condition; wear; and fraying.' as I performed this task; I opened the second observer's oxygen mask compartment and looked at it. Since I did not see any discrepancies with the mask; I closed the compartment and went on to the next step. However; during a ramp check by the FAA; the head strap on the mask assembly was found to be broken; which is when I received a letter of investigation from the FAA inspector. Since the card is unclr in that step; I submitted a technical publication change request form to my company's technical publication department; requesting that the step be broken down into 2 separate steps with 2 separate signoffs; as well as direct the new step to remove the masks specifically and inspect for condition and wear which will include attach points; hoses; straps; and fittings.
Original NASA ASRS Text
Title: DURING A SVC CHK AN L1011 TECHNICIAN WORKING THE COCKPIT OXYGEN MASKS INSPECTION JOB CARD FAILED TO 'FIND AND FIX' A BROKEN HEAD STRAP ON THE OBSERVER'S MASK.
Narrative: WHILE WORKING A LINE SVC WORK CARD ON AN L1011 ACFT; ONE STEP READS 'CHK FLT CREW AND OBSERVER'S OXYGEN MASKS; SEAT BELTS; AND HARNESSES FOR CONDITION; WEAR; AND FRAYING.' AS I PERFORMED THIS TASK; I OPENED THE SECOND OBSERVER'S OXYGEN MASK COMPARTMENT AND LOOKED AT IT. SINCE I DID NOT SEE ANY DISCREPANCIES WITH THE MASK; I CLOSED THE COMPARTMENT AND WENT ON TO THE NEXT STEP. HOWEVER; DURING A RAMP CHK BY THE FAA; THE HEAD STRAP ON THE MASK ASSEMBLY WAS FOUND TO BE BROKEN; WHICH IS WHEN I RECEIVED A LETTER OF INVESTIGATION FROM THE FAA INSPECTOR. SINCE THE CARD IS UNCLR IN THAT STEP; I SUBMITTED A TECHNICAL PUB CHANGE REQUEST FORM TO MY COMPANY'S TECHNICAL PUB DEPT; REQUESTING THAT THE STEP BE BROKEN DOWN INTO 2 SEPARATE STEPS WITH 2 SEPARATE SIGNOFFS; AS WELL AS DIRECT THE NEW STEP TO REMOVE THE MASKS SPECIFICALLY AND INSPECT FOR CONDITION AND WEAR WHICH WILL INCLUDE ATTACH POINTS; HOSES; STRAPS; AND FITTINGS.
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.