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|
Attributes | |
ACN | 456442 |
Time | |
Date | 199911 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
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 | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : airframe technician : powerplant technician : inspection authority |
Experience | maintenance technician : 8 |
ASRS Report | 456442 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : inspection performance deficiency : installation performance deficiency : repair performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On nov/xa/99 I was told by air carrier flight safety committee representative that a maintenance problem cropped up on a door I had been involved with during heavy maintenance. I was the inspector that gave an ok to install an escape slide cover on a B757 L4 door. Prior to the ok, I armed the door, verified the girt bar sweepers engaged the floor fittings, and that the door slide armed light illuminated at the L4 door. After all operations worked normally, I gave the ok to install the cover. This same operation was checked by another inspector performing a final inspection of the aft galley area per routine paperwork, with no defects noted. Apparently, 3 flts out of heavy maintenance, abc line maintenance found 1 engagement sweeper missing and 1 laying inside the slide cover, unable to get the slide to arm in this confign. All I can say is at the time of the ok to install the slide cover was given, all aspects of the slide arming system worked, all parts were installed, and no defects were noted. I spoke with the inspector who did the final in that area, and he remembers checking the arming system and getting an armed light (verifying both sweepers are in the fittings) because he had to ask someone where the armed light was before he could verify it was on.
Original NASA ASRS Text
Title: A B757-200 WAS OPERATED FOR 3 DAYS AFTER HVY MAINT AT ZZZ WHEN IT WAS RPTED DOOR 4L ESCAPE SLIDE WOULD NOT ARM. ABC LINE MAINT FOUND DOOR GIRT BAR SLIDERS DISCONNECTED.
Narrative: ON NOV/XA/99 I WAS TOLD BY ACR FLT SAFETY COMMITTEE REPRESENTATIVE THAT A MAINT PROB CROPPED UP ON A DOOR I HAD BEEN INVOLVED WITH DURING HVY MAINT. I WAS THE INSPECTOR THAT GAVE AN OK TO INSTALL AN ESCAPE SLIDE COVER ON A B757 L4 DOOR. PRIOR TO THE OK, I ARMED THE DOOR, VERIFIED THE GIRT BAR SWEEPERS ENGAGED THE FLOOR FITTINGS, AND THAT THE DOOR SLIDE ARMED LIGHT ILLUMINATED AT THE L4 DOOR. AFTER ALL OPS WORKED NORMALLY, I GAVE THE OK TO INSTALL THE COVER. THIS SAME OP WAS CHKED BY ANOTHER INSPECTOR PERFORMING A FINAL INSPECTION OF THE AFT GALLEY AREA PER ROUTINE PAPERWORK, WITH NO DEFECTS NOTED. APPARENTLY, 3 FLTS OUT OF HVY MAINT, ABC LINE MAINT FOUND 1 ENGAGEMENT SWEEPER MISSING AND 1 LAYING INSIDE THE SLIDE COVER, UNABLE TO GET THE SLIDE TO ARM IN THIS CONFIGN. ALL I CAN SAY IS AT THE TIME OF THE OK TO INSTALL THE SLIDE COVER WAS GIVEN, ALL ASPECTS OF THE SLIDE ARMING SYS WORKED, ALL PARTS WERE INSTALLED, AND NO DEFECTS WERE NOTED. I SPOKE WITH THE INSPECTOR WHO DID THE FINAL IN THAT AREA, AND HE REMEMBERS CHKING THE ARMING SYS AND GETTING AN ARMED LIGHT (VERIFYING BOTH SWEEPERS ARE IN THE FITTINGS) BECAUSE HE HAD TO ASK SOMEONE WHERE THE ARMED LIGHT WAS BEFORE HE COULD VERIFY IT WAS ON.
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.