Narrative:

During flight attendant training, a mini-evacuate/evacuation drill was performed. On the first attempt, a flight attendant opened a door marked 'fire,' making a repeat of the drill necessary. The maintenance support crew was given about 2 1/2 hours to replace the 5 slides, restow the emergency equipment used, police the cabin, and prepare the aircraft for the second test. The aircraft was in a non air conditioned hangar, and the cabin was about 95 degrees F. When the #1 left slide was replaced, the girt bar was left stowed on the slide pack, rather than properly installed on the girt bar carrier. There were 4 or 5 people involved in the installation, and none noticed. The replacement was performed using amm procedures, and was entered in the aircraft logbook. During the second drill, the #1L door was opened, and the slide did not operate, so this drill was also ruled a 'fail' by the FAA. The slide was made svcable by placing the girt bar into the carrier. The added pressure of time, temperature, and feeling 'under the gun' all were major factors in the failure to notice the girt bar position. If the slide replacement had been performed on job-instruction cards, there would have been a quality control inspector involved. The on-site FAA personnel gave the individuals involved a 'severe talking to' regarding possible financial penalties as well as loss of life, etc. I am sure the individuals involved will never make that particular mistake again. The third drill was also a failure, due to a flight attendant opening the door marked 'fire' (again!). I should note that each flight attendant crew had been sequestered and did not know what the other crews had done.

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Original NASA ASRS Text

Title: A B767-400 DURING A EMER TRAINING DRILL AN EMER ESCAPE SLIDE FAILED TO DEPLOY DUE TO INCORRECT INSTALLATION.

Narrative: DURING FLT ATTENDANT TRAINING, A MINI-EVAC DRILL WAS PERFORMED. ON THE FIRST ATTEMPT, A FLT ATTENDANT OPENED A DOOR MARKED 'FIRE,' MAKING A REPEAT OF THE DRILL NECESSARY. THE MAINT SUPPORT CREW WAS GIVEN ABOUT 2 1/2 HRS TO REPLACE THE 5 SLIDES, RESTOW THE EMER EQUIP USED, POLICE THE CABIN, AND PREPARE THE ACFT FOR THE SECOND TEST. THE ACFT WAS IN A NON AIR CONDITIONED HANGAR, AND THE CABIN WAS ABOUT 95 DEGS F. WHEN THE #1 L SLIDE WAS REPLACED, THE GIRT BAR WAS LEFT STOWED ON THE SLIDE PACK, RATHER THAN PROPERLY INSTALLED ON THE GIRT BAR CARRIER. THERE WERE 4 OR 5 PEOPLE INVOLVED IN THE INSTALLATION, AND NONE NOTICED. THE REPLACEMENT WAS PERFORMED USING AMM PROCS, AND WAS ENTERED IN THE ACFT LOGBOOK. DURING THE SECOND DRILL, THE #1L DOOR WAS OPENED, AND THE SLIDE DID NOT OPERATE, SO THIS DRILL WAS ALSO RULED A 'FAIL' BY THE FAA. THE SLIDE WAS MADE SVCABLE BY PLACING THE GIRT BAR INTO THE CARRIER. THE ADDED PRESSURE OF TIME, TEMP, AND FEELING 'UNDER THE GUN' ALL WERE MAJOR FACTORS IN THE FAILURE TO NOTICE THE GIRT BAR POS. IF THE SLIDE REPLACEMENT HAD BEEN PERFORMED ON JOB-INSTRUCTION CARDS, THERE WOULD HAVE BEEN A QUALITY CTL INSPECTOR INVOLVED. THE ON-SITE FAA PERSONNEL GAVE THE INDIVIDUALS INVOLVED A 'SEVERE TALKING TO' REGARDING POSSIBLE FINANCIAL PENALTIES AS WELL AS LOSS OF LIFE, ETC. I AM SURE THE INDIVIDUALS INVOLVED WILL NEVER MAKE THAT PARTICULAR MISTAKE AGAIN. THE THIRD DRILL WAS ALSO A FAILURE, DUE TO A FLT ATTENDANT OPENING THE DOOR MARKED 'FIRE' (AGAIN!). I SHOULD NOTE THAT EACH FLT ATTENDANT CREW HAD BEEN SEQUESTERED AND DID NOT KNOW WHAT THE OTHER CREWS HAD DONE.

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.