<< >> NASA ASRS Report 605725, January 2004

A B737-700 was dispatched in non compliance with a personal breathing equipment kit not installed after the wheelchair closet project.

Attributes
ACN	605725
Time
Date	200401
Day	Tue
Local Time Of Day	0601 To 1200
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	B737-700
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	605725
Person 2
Affiliation	company : air carrier
Function	maintenance : inspector
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : manuals contributing factor : work cards performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : installation
Supplementary
Problem Areas	Maintenance Human Performance Chart Or Publication Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

I was made aware around XA00 hours on jan/wed/04, that the new wheelchair closet that I had installed the previous night was missing its pbe. This was the first time for aco X to be performed at the station. I believe the oversight occurred when I removed the emergency equipment from the old windscreen. All emergency equipment is installed on the aft side except the pbe. This was compounded on the new closet -- when you open the compartment, there are no inserts installed, they are located on the door to the compartment. Also, this being the first time for this modification in ZZZ, there were a number of 'visits' by other mechanics and inspectors. I believed this to be an oversight both during the removal and installation.

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Original NASA ASRS Text

Title: A B737-700 WAS DISPATCHED IN NON COMPLIANCE WITH A PERSONAL BREATHING EQUIP KIT NOT INSTALLED AFTER THE WHEELCHAIR CLOSET PROJECT.

Narrative: I WAS MADE AWARE AROUND XA00 HRS ON JAN/WED/04, THAT THE NEW WHEELCHAIR CLOSET THAT I HAD INSTALLED THE PREVIOUS NIGHT WAS MISSING ITS PBE. THIS WAS THE FIRST TIME FOR ACO X TO BE PERFORMED AT THE STATION. I BELIEVE THE OVERSIGHT OCCURRED WHEN I REMOVED THE EMER EQUIP FROM THE OLD WINDSCREEN. ALL EMER EQUIP IS INSTALLED ON THE AFT SIDE EXCEPT THE PBE. THIS WAS COMPOUNDED ON THE NEW CLOSET -- WHEN YOU OPEN THE COMPARTMENT, THERE ARE NO INSERTS INSTALLED, THEY ARE LOCATED ON THE DOOR TO THE COMPARTMENT. ALSO, THIS BEING THE FIRST TIME FOR THIS MODIFICATION IN ZZZ, THERE WERE A NUMBER OF 'VISITS' BY OTHER MECHS AND INSPECTORS. I BELIEVED THIS TO BE AN OVERSIGHT BOTH DURING THE REMOVAL AND INSTALLATION.

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.