AN A319 PORTABLE PAX OXYGEN BOTTLE WAS USED DURING A MEDICAL EMER. BOTTLE WAS REFILLED AND RETURNED TO AIRPLANE.

Date: 2006-11

Anomalies: aircraft-equipment-problem-less-severe|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-maintenance|deviation-discrepancy-procedural-far

Synopsis

AN A319 PORTABLE PAX OXYGEN BOTTLE WAS USED DURING A MEDICAL EMER. BOTTLE WAS REFILLED AND RETURNED TO AIRPLANE.

Narrative

FLIGHT DEPARTED ZZZ1 BOUND FOR ZZZ2. MIDWAY ENRTE; THE ACFT DID A MEDICAL DIVERSION INTO ZZZ3. A PAX PORTABLE OXYGEN BOTTLE WAS USED DURING THE MEDICAL EMER. STATION STOCK HAD A REPLACEMENT BOTTLE IN STOCK. MEL PROCS ALLOW FOR DEFERRAL. ZZZ3 MAINT CHOSE TO 'PERFORM MAINT' BY REFILLING THE EXISTING POB. THE BOTTLE WAS REFILLED AND RETURNED TO THE ACFT. ZZZ3 MAINT CALLED MAINT CTL FOR A MANUAL REFERENCE FOR LOGBOOK SIGN OFF. ONE COULD NOT BE FOUND. THE MAINT CTL SUPVR WAS SIMULTANEOUSLY NOTIFIED AND HE MADE AN ATTEMPT TO LOCATE A VALID SIGN OFF REFERENCE. NONE COULD BE READILY LOCATED AND ZZZ3 MAINT WAS CALLED TO SEE IF THE ACFT HAD DEPARTED. MAINT CTL WAS INFORMED THAT IT HAD ALREADY DEPARTED AND THE 'ITEM' SIGNED OFF. BASICALLY; A 'GENERIC' LOGBOOK ENTRY WAS MADE BY ZZZ3 MAINT. MAINT CTL SUPVR ALERTED THE DIRECTOR OF MAINT CTL AND THE ISSUE WAS LOOKED INTO. PRESENTLY; ONLY A TRAINING NOTICE IS SUPPOSEDLY BEING WRITTEN TO INFORM MAINT PERSONNEL OF THIS ISSUE. HOWEVER; A SIMILAR SITUATION OCCURRED A FEW DAYS LATER; DIFFERENT ACFT; IN A DIFFERENT LOCATION; AND WHEN A MAINT MANAGER WAS INFORMED TO HAVE THE POB ADDRESSED; HE SAID HE WOULD HAVE IT SERVICED USING THE ROUTINE MANNER. WHEN INFORMED THERE WAS NO VALID MAINT MANUAL REFERENCE AVAILABLE HE SAID HE WOULD USE THE TRAINING NOTICE WHICH WAS JUST PUBLISHED. I INFORMED HIM THAT A TRAINING NOTICE WAS NOT A VALID MAINT MANUAL REFERENCE EITHER; AND HAD NOT BEEN ISSUED AS YET. UPON RETURNING TO WORK; I NOTICED A MAINT NOTICE (NOT A TRAINING NOTICE) HAD BEEN APPROVED BY QUALITY CTL GUIDING THE UNKNOWING MAINT PERSONNEL TO A SPECIFIC PROCEDURE FOR SERVICING CREW OXYGEN CYLINDERS. THE REFERENCED PROCEDURE ONLY APPLIES TO A SPECIFIC SERIES OF CYLINDERS WHILE THE FLEET HAS TWO TYPES OF CREW OXYGEN CYLINDERS. THE MAINT NOTICE DOES NOT APPLY TO POB'S AT ALL. THIS MAINT NOTICE MISLEADS THE MAINT PERSONNEL TO USE THIS PROCEDURE FOR ALL OXYGEN SERVICING. THIS TYPE OF IRRESPONSIBLE DISSEMINATION OF MISLEADING DATA MUST CEASE. IT WAS ALSO NOTED THAT THE ITEM AS SIGNED OFF IN THE ACFT MAINT LOGBOOK WAS NOT ENTERED (OR WAS REMOVED THEREAFTER) FROM THE COMPANY'S; FAA APPROVED; COMPUTER DATABASE. IF PURPOSELY DONE; THIS IS A VIOLATION. THIS AIRLINE; BY NOT PROVIDING THE MAINT MECHANIC WITH THE NECESSARY METHODS; TECHNIQUES; AND PRACTICES; IS KNOWINGLY SETTING UP THE A&P MECHANIC WORKING THE ACFT FOR A LICENSE VIOLATION. THIS AIRLINE IS KNOWINGLY VIOLATING OSHA REQUIREMENTS FOR SERVICING OXYGEN CYLINDERS. THIS AIRLINE IS KNOWINGLY REFILLING POB'S AND CREW OXYGEN CYLINDERS (BOTTLES) WITHOUT VALID ACFT MAINT MANUAL REFERENCES; A PRACTICE AND UNWRITTEN POLICY WHICH IS CONTRARY TO FAR'S AND OSHA'S CFR'S. THIS AIRLINE IS KNOWINGLY PUTTING THEIR EMPLOYEES AND PAX IN EXTREME DANGER WHICH MAY RESULT IN IMMEDIATE OR LATENT CATASTROPHIC EVENTS. SEVERE INJURY; DEATH; OR EVEN SUBSEQUENT AIR DISASTER MAY RESULT DUE TO IMPROPER SERVICING OF ACFT INSTALLED OXYGEN CYLINDERS.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE FOLLOWING: TWO INCIDENTS HAVE OCCURRED WHERE EMER PORTABLE PAX OXYGEN BOTTLES HAVE BEEN USED AND WERE REFILLED AT LOCAL STATIONS. THE REFILLING OF THESE PORTABLE PAX AND CREW BOTTLES IS NOT APPROVED AS THE BOTTLES MUST BE RETURNED TO AN APPROVED PRESSURE VESSEL SHOP WITH AN APPROVED MAINT PROGRAM. THE REFILLING OF THE SECOND BOTTLE WAS ACCOMPLISHED AT A MAINT STATION THAT HAD NO SPARE BOTTLE IN STOCK AND USED THE MAINT NOTICE SENT OUT BY MANAGEMENT AND APPROVED BY QUALITY CTL AS REFERENCE FOR REFILLING THE BOTTLE. THIS MAINT NOTICE DID NOT ADDRESS THE PORTABLE OXYGEN BOTTLES AT ALL AND AMOUNTED TO MISLEADING INFO FOR ALL OXYGEN SERVICING. THE RPTR RESTATED THIS CARRIER HAS ENDANGERED PAX AND EMPLOYEES BY ALLOWING IMPROPER SERVICING OF INSTALLED OXYGEN CYLINDERS.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.