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A B757-200 engineering change order to relocate the passenger service units wording and the number of technicians involved caused doubt as to the correct installation of oxygen generator heat shield tape.
| Attributes | |
| ACN | 605602 |
| Time | |
| Date | 200401 |
| Day | Sat |
| 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 | B757 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 605602 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 606478 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far non adherence : company policies |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : schedule pressure contributing factor : engineering procedure performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | ENGINEERING CHANGE ORDER |
Narrative:
Putting 'psu relocation,' X card, #0001 on page 6 item C. The second note: requires relocation of heat shield tape on the bottom of overhead bin, above oxygen generators. Due to the number of employees involved in relocation of psu overhead panels, there is some confusion as to whether or not all psu's have the proper heat shield location in the proper position. Corrective action: notification of company supervisor and crew chief as well as fellow employees.
Original NASA ASRS Text
Title: A B757-200 ENGINEERING CHANGE ORDER TO RELOCATE THE PAX SVC UNITS WORDING AND THE NUMBER OF TECHNICIANS INVOLVED CAUSED DOUBT AS TO THE CORRECT INSTALLATION OF OXYGEN GENERATOR HEAT SHIELD TAPE.
Narrative: PUTTING 'PSU RELOCATION,' X CARD, #0001 ON PAGE 6 ITEM C. THE SECOND NOTE: REQUIRES RELOCATION OF HEAT SHIELD TAPE ON THE BOTTOM OF OVERHEAD BIN, ABOVE OXYGEN GENERATORS. DUE TO THE NUMBER OF EMPLOYEES INVOLVED IN RELOCATION OF PSU OVERHEAD PANELS, THERE IS SOME CONFUSION AS TO WHETHER OR NOT ALL PSU'S HAVE THE PROPER HEAT SHIELD LOCATION IN THE PROPER POS. CORRECTIVE ACTION: NOTIFICATION OF COMPANY SUPVR AND CREW CHIEF AS WELL AS FELLOW EMPLOYEES.
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.