Narrative:

After reprogramming numerous aed; I became confused and believed I could have misunderstood procedure #6; which states as follows; procedure #6. 'Remove and reinstall the original gray battery to run a battery insertion self test' (I personally took the meaning of this procedure as to situation on one's hands and watch). I; being aware of reality and acknowledging that this instrument could possibly save or contribute to the loss of a life; fairly or unfairly blaming/holding responsible; both the mechanic and instrument resulting in a court battle I decided to approach my foreman. I requested foreman to reprogram an aed in my presence and I collectively questioned procedure #6 revision 1; and we both agreed there was a possible issue with procedure #6; which could result in different interps. I researched aed-maintenance practices and shared the following with me. '3. Aed battery replacement; procedure B(G)' reads as follows: 'when the automatic part of the self test is successfully completed; the screen displays a message that the test passed; and then automatically starts the interactive part of the self test. The interactive part of the self test requires you to respond to the prompts in order to make sure that the display; buttons; lights; and speaker on the aed are working properly.' I feel 3.B(G) should have been written in its entirety as the final #6 procedure of this; mandating both self tests; the automatic part and the interactive part; whereby this procedure would less likely have different interps. In closing; please let me state my feelings toward this. As classified; being a 'minor alteration;' performed without an inspector's identify (second set of eyes) beside the mechanics; leaves me very concerned for reasons previously mentioned in this report. I would appreciate my considerations; following to be addressed when each of you gentlemen makes other considerations and decisions concerning this report: 1) immediately have the aed in each of the aircraft that I reprogrammed; reprogrammed. 2) changing procedure #6. 3) require an inspector's signoff as well as the mechanics. 4) when such is published in the future with the possible devastating outcomes as I believe this one could have; please have a set of seasoned eyes critiquing it additionally before it goes to press.

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Original NASA ASRS Text

Title: A B737 INSPECTOR RPTS SOME CONFUSION AND MISINTERP OF PROCS USED FOR EMER DEFIBRILLATOR PROGRAMMING.

Narrative: AFTER REPROGRAMMING NUMEROUS AED; I BECAME CONFUSED AND BELIEVED I COULD HAVE MISUNDERSTOOD PROC #6; WHICH STATES AS FOLLOWS; PROC #6. 'REMOVE AND REINSTALL THE ORIGINAL GRAY BATTERY TO RUN A BATTERY INSERTION SELF TEST' (I PERSONALLY TOOK THE MEANING OF THIS PROC AS TO SIT ON ONE'S HANDS AND WATCH). I; BEING AWARE OF REALITY AND ACKNOWLEDGING THAT THIS INST COULD POSSIBLY SAVE OR CONTRIBUTE TO THE LOSS OF A LIFE; FAIRLY OR UNFAIRLY BLAMING/HOLDING RESPONSIBLE; BOTH THE MECH AND INST RESULTING IN A COURT BATTLE I DECIDED TO APCH MY FOREMAN. I REQUESTED FOREMAN TO REPROGRAM AN AED IN MY PRESENCE AND I COLLECTIVELY QUESTIONED PROC #6 REVISION 1; AND WE BOTH AGREED THERE WAS A POSSIBLE ISSUE WITH PROC #6; WHICH COULD RESULT IN DIFFERENT INTERPS. I RESEARCHED AED-MAINT PRACTICES AND SHARED THE FOLLOWING WITH ME. '3. AED BATTERY REPLACEMENT; PROC B(G)' READS AS FOLLOWS: 'WHEN THE AUTOMATIC PART OF THE SELF TEST IS SUCCESSFULLY COMPLETED; THE SCREEN DISPLAYS A MESSAGE THAT THE TEST PASSED; AND THEN AUTOMATICALLY STARTS THE INTERACTIVE PART OF THE SELF TEST. THE INTERACTIVE PART OF THE SELF TEST REQUIRES YOU TO RESPOND TO THE PROMPTS IN ORDER TO MAKE SURE THAT THE DISPLAY; BUTTONS; LIGHTS; AND SPEAKER ON THE AED ARE WORKING PROPERLY.' I FEEL 3.B(G) SHOULD HAVE BEEN WRITTEN IN ITS ENTIRETY AS THE FINAL #6 PROC OF THIS; MANDATING BOTH SELF TESTS; THE AUTOMATIC PART AND THE INTERACTIVE PART; WHEREBY THIS PROC WOULD LESS LIKELY HAVE DIFFERENT INTERPS. IN CLOSING; PLEASE LET ME STATE MY FEELINGS TOWARD THIS. AS CLASSIFIED; BEING A 'MINOR ALTERATION;' PERFORMED WITHOUT AN INSPECTOR'S IDENT (SECOND SET OF EYES) BESIDE THE MECHS; LEAVES ME VERY CONCERNED FOR REASONS PREVIOUSLY MENTIONED IN THIS RPT. I WOULD APPRECIATE MY CONSIDERATIONS; FOLLOWING TO BE ADDRESSED WHEN EACH OF YOU GENTLEMEN MAKES OTHER CONSIDERATIONS AND DECISIONS CONCERNING THIS RPT: 1) IMMEDIATELY HAVE THE AED IN EACH OF THE ACFT THAT I REPROGRAMMED; REPROGRAMMED. 2) CHANGING PROC #6. 3) REQUIRE AN INSPECTOR'S SIGNOFF AS WELL AS THE MECHS. 4) WHEN SUCH IS PUBLISHED IN THE FUTURE WITH THE POSSIBLE DEVASTATING OUTCOMES AS I BELIEVE THIS ONE COULD HAVE; PLEASE HAVE A SET OF SEASONED EYES CRITIQUING IT ADDITIONALLY BEFORE IT GOES TO PRESS.

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.