37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 708367 |
Time | |
Date | 200608 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 3 maintenance technician : 14 |
ASRS Report | 708367 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : logbook entry performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Recovering from a severe cold with little bit of sleep with only 2 mechanics on duty that day (me and 1 mechanic) with an abnormal workload that day due to grounded aircraft and moving aircraft and working through flts with multiple issues; also researching for parts and tooling needed for the grounded aircraft. Between all this; we had an aircraft come in the morning rush with an inoperative (passenger service unit). The passenger service unit oxygen mask won't stay stowed due to 1 clip broke off; so we had to secure the oxygen mask door with tape and deferred and blocked all 3 seats at that row. After that; I ordered new passenger service unit. Later that day; 45 mins before our shift is over; the same aircraft arrived back; and the new passenger service unit became available with a svcable tag showing that passenger service unit has been bench checked and sign off by quality control; without any special notes in the comments section on the tag. After verified it has the correct part number and all other information on the tag; then due to change of aircraft routing I felt we need to change the passenger service unit to clear the deferral and gain back the 3 seats that can be used for passenger; with only 25 mins for departure. I rushed to pull up and print out the maintenance manual reference for the removal and installation. Meanwhile; the printer was jammed; so I skimmed through the maintenance manual on the computer screen and focused on the operations check after the installation; between trying not taking a delay and not disturbed the boarding of the passenger we did not notice that the new passenger service unit we installed is missing an oxygen generator canister. After we checked lights and gasper air; I sign off the item and cleared the deferral; then after 8 days it was determined that the passenger service unit we installed missing the oxygen generator canister while the aircraft in ground where the oxygen canister was ultimately replaced and the aircraft returned to service.
Original NASA ASRS Text
Title: A B737-800 WAS DISPATCHED AND OPERATED 8 DAYS WITH A PAX SVC UNIT REPLACEMENT MISSING THE REQUIRED OXYGEN CANISTER.
Narrative: RECOVERING FROM A SEVERE COLD WITH LITTLE BIT OF SLEEP WITH ONLY 2 MECHS ON DUTY THAT DAY (ME AND 1 MECH) WITH AN ABNORMAL WORKLOAD THAT DAY DUE TO GNDED ACFT AND MOVING ACFT AND WORKING THROUGH FLTS WITH MULTIPLE ISSUES; ALSO RESEARCHING FOR PARTS AND TOOLING NEEDED FOR THE GNDED ACFT. BTWN ALL THIS; WE HAD AN ACFT COME IN THE MORNING RUSH WITH AN INOP (PAX SVC UNIT). THE PAX SVC UNIT OXYGEN MASK WON'T STAY STOWED DUE TO 1 CLIP BROKE OFF; SO WE HAD TO SECURE THE OXYGEN MASK DOOR WITH TAPE AND DEFERRED AND BLOCKED ALL 3 SEATS AT THAT ROW. AFTER THAT; I ORDERED NEW PAX SVC UNIT. LATER THAT DAY; 45 MINS BEFORE OUR SHIFT IS OVER; THE SAME ACFT ARRIVED BACK; AND THE NEW PAX SVC UNIT BECAME AVAILABLE WITH A SVCABLE TAG SHOWING THAT PAX SVC UNIT HAS BEEN BENCH CHKED AND SIGN OFF BY QUALITY CTL; WITHOUT ANY SPECIAL NOTES IN THE COMMENTS SECTION ON THE TAG. AFTER VERIFIED IT HAS THE CORRECT PART NUMBER AND ALL OTHER INFO ON THE TAG; THEN DUE TO CHANGE OF ACFT ROUTING I FELT WE NEED TO CHANGE THE PAX SVC UNIT TO CLR THE DEFERRAL AND GAIN BACK THE 3 SEATS THAT CAN BE USED FOR PAX; WITH ONLY 25 MINS FOR DEP. I RUSHED TO PULL UP AND PRINT OUT THE MAINT MANUAL REF FOR THE REMOVAL AND INSTALLATION. MEANWHILE; THE PRINTER WAS JAMMED; SO I SKIMMED THROUGH THE MAINT MANUAL ON THE COMPUTER SCREEN AND FOCUSED ON THE OPS CHK AFTER THE INSTALLATION; BTWN TRYING NOT TAKING A DELAY AND NOT DISTURBED THE BOARDING OF THE PAX WE DID NOT NOTICE THAT THE NEW PAX SVC UNIT WE INSTALLED IS MISSING AN OXYGEN GENERATOR CANISTER. AFTER WE CHKED LIGHTS AND GASPER AIR; I SIGN OFF THE ITEM AND CLRED THE DEFERRAL; THEN AFTER 8 DAYS IT WAS DETERMINED THAT THE PAX SVC UNIT WE INSTALLED MISSING THE OXYGEN GENERATOR CANISTER WHILE THE ACFT IN GND WHERE THE OXYGEN CANISTER WAS ULTIMATELY REPLACED AND THE ACFT RETURNED TO SVC.
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.