Narrative:

Miscom between mechanics and inspectors; possible training; air carrier's task cards with poor communication between maintenance and inspection need improved turn-over for maintenance personnel. Aircraft was parked in hangar for passenger psu replacement and maintenance personnel informed to accomplish the inspection. All passenger generator psu were replaced with no inspection buy off; and the lead maintenance informed; the maintenance personnel waiting for inspection; but I asked to verify all part numbers for the new oxygen generators replaced and how many oxygen generators were replaced. I noted all psu panels were deployed. After that; I performed the inspection for the proper firing pin installation and release pin installation; and general condition for components I noted was installed properly. After accomplishing the test; I verified proper drop of the psu per maintenance manual -- but for the oxygen generator activated system. I no-stamped on partial work of the maintenance write-up for the pins on rows xyz. Do not have inspection stamp on partial work of the maintenance write-up. I believe this was an error. Maintenance personnel did not remove the pins and there was a miscom with the inspection department. Supplemental information from acn 754084: I installed approximately 28 oxygen generators on aircraft X with shipping safety pins installed. I verbally verified it to the next shift; informing them that all oxygen generators that I installed were deactivated with the safety pins installed. Partial work was documented on a maintenance write-up. Supplemental information from acn 753806: maintenance met new crew in jetway. Notified us that while fixing a previous crew's first class overhead reading light write-up; he noticed a red flag attached to the safety pin of the oxygen generator. It was still installed. Maintenance then opened all of the overhead oxygen panels; finding 3 more flags with the pins still installed on the generators. We swapped to another aircraft. Callback conversation with reporter acn 753806 revealed the following information: reporter; who was the inspector; stated that the passenger oxygen generators found with the red tags and safety pins still installed were not those stamped off (signed off) by him during the rii inspection. The miscom appears to be the result of shift change and more oxygen generators having been changed than what the inspectors were asked to verify for correct part numbers and safety pins removed. Paperwork and a clear understanding of all the work initiated prior to inspection verification has been a problem. Reporter also stated that since this incident; his carrier has made procedural changes to their maintenance manuals in an effort to improve accountability of work on the aircraft; including the aircraft status at shift turnovers.

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Original NASA ASRS Text

Title: A B737-400 OUTBOUND PLT RPTS OF LINE MAINT FINDING PAX OXYGEN GENERATORS WITH RED FLAGS AND SAFETY PINS STILL INSTALLED.

Narrative: MISCOM BTWN MECHS AND INSPECTORS; POSSIBLE TRAINING; ACR'S TASK CARDS WITH POOR COM BTWN MAINT AND INSPECTION NEED IMPROVED TURN-OVER FOR MAINT PERSONNEL. ACFT WAS PARKED IN HANGAR FOR PAX PSU REPLACEMENT AND MAINT PERSONNEL INFORMED TO ACCOMPLISH THE INSPECTION. ALL PAX GENERATOR PSU WERE REPLACED WITH NO INSPECTION BUY OFF; AND THE LEAD MAINT INFORMED; THE MAINT PERSONNEL WAITING FOR INSPECTION; BUT I ASKED TO VERIFY ALL PART NUMBERS FOR THE NEW OXYGEN GENERATORS REPLACED AND HOW MANY OXYGEN GENERATORS WERE REPLACED. I NOTED ALL PSU PANELS WERE DEPLOYED. AFTER THAT; I PERFORMED THE INSPECTION FOR THE PROPER FIRING PIN INSTALLATION AND RELEASE PIN INSTALLATION; AND GENERAL CONDITION FOR COMPONENTS I NOTED WAS INSTALLED PROPERLY. AFTER ACCOMPLISHING THE TEST; I VERIFIED PROPER DROP OF THE PSU PER MAINT MANUAL -- BUT FOR THE OXYGEN GENERATOR ACTIVATED SYS. I NO-STAMPED ON PARTIAL WORK OF THE MAINT WRITE-UP FOR THE PINS ON ROWS XYZ. DO NOT HAVE INSPECTION STAMP ON PARTIAL WORK OF THE MAINT WRITE-UP. I BELIEVE THIS WAS AN ERROR. MAINT PERSONNEL DID NOT REMOVE THE PINS AND THERE WAS A MISCOM WITH THE INSPECTION DEPT. SUPPLEMENTAL INFO FROM ACN 754084: I INSTALLED APPROX 28 OXYGEN GENERATORS ON ACFT X WITH SHIPPING SAFETY PINS INSTALLED. I VERBALLY VERIFIED IT TO THE NEXT SHIFT; INFORMING THEM THAT ALL OXYGEN GENERATORS THAT I INSTALLED WERE DEACTIVATED WITH THE SAFETY PINS INSTALLED. PARTIAL WORK WAS DOCUMENTED ON A MAINT WRITE-UP. SUPPLEMENTAL INFO FROM ACN 753806: MAINT MET NEW CREW IN JETWAY. NOTIFIED US THAT WHILE FIXING A PREVIOUS CREW'S FIRST CLASS OVERHEAD READING LIGHT WRITE-UP; HE NOTICED A RED FLAG ATTACHED TO THE SAFETY PIN OF THE OXYGEN GENERATOR. IT WAS STILL INSTALLED. MAINT THEN OPENED ALL OF THE OVERHEAD OXYGEN PANELS; FINDING 3 MORE FLAGS WITH THE PINS STILL INSTALLED ON THE GENERATORS. WE SWAPPED TO ANOTHER ACFT. CALLBACK CONVERSATION WITH RPTR ACN 753806 REVEALED THE FOLLOWING INFO: RPTR; WHO WAS THE INSPECTOR; STATED THAT THE PAX OXYGEN GENERATORS FOUND WITH THE RED TAGS AND SAFETY PINS STILL INSTALLED WERE NOT THOSE STAMPED OFF (SIGNED OFF) BY HIM DURING THE RII INSPECTION. THE MISCOM APPEARS TO BE THE RESULT OF SHIFT CHANGE AND MORE OXYGEN GENERATORS HAVING BEEN CHANGED THAN WHAT THE INSPECTORS WERE ASKED TO VERIFY FOR CORRECT PART NUMBERS AND SAFETY PINS REMOVED. PAPERWORK AND A CLR UNDERSTANDING OF ALL THE WORK INITIATED PRIOR TO INSPECTION VERIFICATION HAS BEEN A PROB. RPTR ALSO STATED THAT SINCE THIS INCIDENT; HIS CARRIER HAS MADE PROCEDURAL CHANGES TO THEIR MAINT MANUALS IN AN EFFORT TO IMPROVE ACCOUNTABILITY OF WORK ON THE ACFT; INCLUDING THE ACFT STATUS AT SHIFT TURNOVERS.

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.