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A B737-300 was found to have passenger emergency oxygen generators installed incorrectly with the release pin installed in the shipping hole.
| Attributes | |
| ACN | 490836 |
| Time | |
| Date | 200008 |
| Day | Mon |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 18 |
| ASRS Report | 490836 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : powerplant technician : airframe |
| Events | |
| Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : far |
| Independent Detector | other other : person 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : training performance deficiency : logbook entry performance deficiency : inspection performance deficiency : installation |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance Company |
| Primary Problem | Maintenance Human Performance |
Narrative:
I feel that I may have incorrectly interpreted the manual and job card in reference to the replacement of oxygen generators. I may have installed the release pin into the shipping pin hole instead of the release pin hole in the ________ pin. I believe the manual has subsequently been revised to better indicate the situation. Also I have received no training to perform this task and no inspection was required on this safety related task to ensure this task was completed correctly.
Original NASA ASRS Text
Title: A B737-300 WAS FOUND TO HAVE PAX EMER OXYGEN GENERATORS INSTALLED INCORRECTLY WITH THE RELEASE PIN INSTALLED IN THE SHIPPING HOLE.
Narrative: I FEEL THAT I MAY HAVE INCORRECTLY INTERPRETED THE MANUAL AND JOB CARD IN REF TO THE REPLACEMENT OF OXYGEN GENERATORS. I MAY HAVE INSTALLED THE RELEASE PIN INTO THE SHIPPING PIN HOLE INSTEAD OF THE RELEASE PIN HOLE IN THE ________ PIN. I BELIEVE THE MANUAL HAS SUBSEQUENTLY BEEN REVISED TO BETTER INDICATE THE SIT. ALSO I HAVE RECEIVED NO TRAINING TO PERFORM THIS TASK AND NO INSPECTION WAS REQUIRED ON THIS SAFETY RELATED TASK TO ENSURE THIS TASK WAS COMPLETED CORRECTLY.
Data retrieved from NASA's ASRS site as of July 2007 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.