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A B767-300 crew on preflight check found crew oxygen at zero. Found bottle shutoff valve not fully opened after replacement.
| Attributes | |
| ACN | 609844 |
| Time | |
| Date | 200402 |
| Day | Sun |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B767-300 and 300 ER |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 15 |
| ASRS Report | 609844 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance 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 : schedule pressure performance deficiency : installation performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On ship feb/sun/04, during a layover inspection crew oxygen required servicing. After servicing and reinstalling the bottle the shutoff valve was found to be not completely opened. The valve seemed to open as I turned it with my left hand until it met what I thought was sufficient resistance. After the valve was safetied I presumed it was ready for leak check. When I went to the cockpit to check for pressure on EICAS, it agreed with the bottle pressure gauge (1780 psi). When the flight crew did their preflight they found the oxygen pressure went to 0 psi when tested. Maintenance was called out and found the oxygen bottle valve was not fully open. This could have been avoided if I had gotten myself into a better position for leverage when opening the valve and then tested the mask like the flight crew does on preflight.
Original NASA ASRS Text
Title: A B767-300 CREW ON PREFLT CHK FOUND CREW OXYGEN AT ZERO. FOUND BOTTLE SHUTOFF VALVE NOT FULLY OPENED AFTER REPLACEMENT.
Narrative: ON SHIP FEB/SUN/04, DURING A LAYOVER INSPECTION CREW OXYGEN REQUIRED SVCING. AFTER SVCING AND REINSTALLING THE BOTTLE THE SHUTOFF VALVE WAS FOUND TO BE NOT COMPLETELY OPENED. THE VALVE SEEMED TO OPEN AS I TURNED IT WITH MY L HAND UNTIL IT MET WHAT I THOUGHT WAS SUFFICIENT RESISTANCE. AFTER THE VALVE WAS SAFETIED I PRESUMED IT WAS READY FOR LEAK CHK. WHEN I WENT TO THE COCKPIT TO CHK FOR PRESSURE ON EICAS, IT AGREED WITH THE BOTTLE PRESSURE GAUGE (1780 PSI). WHEN THE FLT CREW DID THEIR PREFLT THEY FOUND THE OXYGEN PRESSURE WENT TO 0 PSI WHEN TESTED. MAINT WAS CALLED OUT AND FOUND THE OXYGEN BOTTLE VALVE WAS NOT FULLY OPEN. THIS COULD HAVE BEEN AVOIDED IF I HAD GOTTEN MYSELF INTO A BETTER POS FOR LEVERAGE WHEN OPENING THE VALVE AND THEN TESTED THE MASK LIKE THE FLT CREW DOES ON PREFLT.
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.