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A B737-400 was dispatched in non compliance with the crew oxygen bottle valve not fully opened after replacement and leak checked.
| Attributes | |
| ACN | 580897 |
| Time | |
| Date | 200304 |
| Day | Fri |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 20 |
| ASRS Report | 580897 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : company policies non adherence : far non adherence : published procedure |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : lighting performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : testing |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Maintenance Human Performance Environmental Factor Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X on ZZZ, apr/sat/03. Reference log pages a and B 'a' check requires servicing of crew oxygen. Upon installation I opened bottle valve slowly to prevent high pressure oxygen into the system all at once. Then the bottle valve is opened all the way immediately after, followed by a leak check. It was claimed that the bottle valve was not fully opened. I do not recall any interruptions that would have taken me away from the servicing/installation procedure. Aircraft departed ZZZ with no maintenance problem. Same scenario was duplicated on aircraft Y on may/sun/03, with the crew oxygen bottle just cracked off its seat. Log page B could not be duplicated with 2 maintenance personnel using captain's and first officer's oxygen stations.
Original NASA ASRS Text
Title: A B737-400 WAS DISPATCHED IN NON COMPLIANCE WITH THE CREW OXYGEN BOTTLE VALVE NOT FULLY OPENED AFTER REPLACEMENT AND LEAK CHKED.
Narrative: ACFT X ON ZZZ, APR/SAT/03. REF LOG PAGES A AND B 'A' CHK REQUIRES SVCING OF CREW OXYGEN. UPON INSTALLATION I OPENED BOTTLE VALVE SLOWLY TO PREVENT HIGH PRESSURE OXYGEN INTO THE SYS ALL AT ONCE. THEN THE BOTTLE VALVE IS OPENED ALL THE WAY IMMEDIATELY AFTER, FOLLOWED BY A LEAK CHK. IT WAS CLAIMED THAT THE BOTTLE VALVE WAS NOT FULLY OPENED. I DO NOT RECALL ANY INTERRUPTIONS THAT WOULD HAVE TAKEN ME AWAY FROM THE SVCING/INSTALLATION PROC. ACFT DEPARTED ZZZ WITH NO MAINT PROB. SAME SCENARIO WAS DUPLICATED ON ACFT Y ON MAY/SUN/03, WITH THE CREW OXYGEN BOTTLE JUST CRACKED OFF ITS SEAT. LOG PAGE B COULD NOT BE DUPLICATED WITH 2 MAINT PERSONNEL USING CAPT'S AND FO'S OXYGEN STATIONS.
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.