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A lead mechanic signs off a log write up for replacing a used passenger oxygen bottle (pob) on a B737-700; not realizing there was a second pob written up on another log page. Discrepancy noted inflight.
| Attributes | |
| ACN | 795540 |
| Time | |
| Date | 200807 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 795540 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : briefing performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
I was asked to go help out a mechanic on a through-flight aircraft event and svced oils and went up to enter oils in logbook. The other mechanic was gone. I then noticed logbook entry for used passenger oxygen bottle. Other mechanic returned with a new passenger oxygen bottle; so I proceeded to sign item off so we could get plane out on time. Item was signed off and log page turned in to office and plane departed. Approximately 30 mins later; I was asked if I had noticed on log page that a second passenger oxygen bottle was mentioned -- that it had only 1200 PST. I said no. I then notified maintenance control and informed them that a second bottle was used (but only noted) on write-up. They informed me they would ACARS the crew to crew-defer the bottle with low psi.
Original NASA ASRS Text
Title: A LEAD MECHANIC SIGNS OFF A LOG WRITE UP FOR REPLACING A USED PASSENGER OXYGEN BOTTLE (POB) ON A B737-700; NOT REALIZING THERE WAS A SECOND POB WRITTEN UP ON ANOTHER LOG PAGE. DISCREPANCY NOTED INFLIGHT.
Narrative: I WAS ASKED TO GO HELP OUT A MECH ON A THROUGH-FLT ACFT EVENT AND SVCED OILS AND WENT UP TO ENTER OILS IN LOGBOOK. THE OTHER MECH WAS GONE. I THEN NOTICED LOGBOOK ENTRY FOR USED PAX OXYGEN BOTTLE. OTHER MECH RETURNED WITH A NEW PAX OXYGEN BOTTLE; SO I PROCEEDED TO SIGN ITEM OFF SO WE COULD GET PLANE OUT ON TIME. ITEM WAS SIGNED OFF AND LOG PAGE TURNED IN TO OFFICE AND PLANE DEPARTED. APPROX 30 MINS LATER; I WAS ASKED IF I HAD NOTICED ON LOG PAGE THAT A SECOND PAX OXYGEN BOTTLE WAS MENTIONED -- THAT IT HAD ONLY 1200 PST. I SAID NO. I THEN NOTIFIED MAINT CTL AND INFORMED THEM THAT A SECOND BOTTLE WAS USED (BUT ONLY NOTED) ON WRITE-UP. THEY INFORMED ME THEY WOULD ACARS THE CREW TO CREW-DEFER THE BOTTLE WITH LOW PSI.
Data retrieved from NASA's ASRS site as of May 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.