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|
Attributes | |
ACN | 549620 |
Time | |
Date | 200206 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : zzz.artcc |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight attendant : on duty |
Qualification | flight attendant : currently qualified |
Experience | flight attendant time airline total : 17 flight attendant time total : 17 flight attendant time type : 90 |
ASRS Report | 549620 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight attendant : on duty |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : inspection performance deficiency : testing performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Cabin Crew Human Performance Flight Crew Human Performance Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MAINT MANUAL DOOR SLIDE INSTL. |
Narrative:
This incident is regarding a slide pack/girt bar being the wrong size, installed by maintenance previous to flight abc's departure. Upon door closure and hearing the announcement 'flight attendants prepare doors for departure and xchk,' flight attendant C armed doors 2L&right not noticing anything unusual. I walked from the forward cabin to the back galley and crosschecked doors 2L&right and perceived them to be armed. After takeoff (30 mins to 1 hour) flight attendant C came forward and asked the flight deck if she could come up and talk to them. Soon after she and the captain came out and the captain went to the aft galley to look at the doors. Flight attendant C explained to me that the girt bar on 2L would not click fully into the locked position on its left side. She felt it had armed fine and even heard the clicking sound it makes when she armed it. The captain determined that slide was the wrong slide/girt bar for that door, and in fact was a girt bar/slide for doors 1L&right and therefore was difficult to fully install into the floor brackets when armed. After I went back to look again at door 2L, I saw one side of the bar completely and firmly installed in the floor bracket but the left side was not seated completely and firmly in the bracket. The captain called ahead to maintenance to inform them we would need the correct slide installed and maintenance said they would send one up on the next flight. Callback conversation with reporter revealed the following information: the reporter stated door 2L was not her station and the door was armed by another cabin attendant. The reporter said after takeoff and when walking back to the galley, door 2L and door 2R were crosschecked and perceived them to be armed.
Original NASA ASRS Text
Title: A B737-700 WAS DISPATCHED IN NON COMPLIANCE WITH THE IMPROPER GIRT BAR ON DOOR 2L. DISCOVERED AFTER DEP BY CABIN ATTENDANT.
Narrative: THIS INCIDENT IS REGARDING A SLIDE PACK/GIRT BAR BEING THE WRONG SIZE, INSTALLED BY MAINT PREVIOUS TO FLT ABC'S DEP. UPON DOOR CLOSURE AND HEARING THE ANNOUNCEMENT 'FLT ATTENDANTS PREPARE DOORS FOR DEP AND XCHK,' FLT ATTENDANT C ARMED DOORS 2L&R NOT NOTICING ANYTHING UNUSUAL. I WALKED FROM THE FORWARD CABIN TO THE BACK GALLEY AND XCHKED DOORS 2L&R AND PERCEIVED THEM TO BE ARMED. AFTER TKOF (30 MINS TO 1 HR) FLT ATTENDANT C CAME FORWARD AND ASKED THE FLT DECK IF SHE COULD COME UP AND TALK TO THEM. SOON AFTER SHE AND THE CAPT CAME OUT AND THE CAPT WENT TO THE AFT GALLEY TO LOOK AT THE DOORS. FLT ATTENDANT C EXPLAINED TO ME THAT THE GIRT BAR ON 2L WOULD NOT CLICK FULLY INTO THE LOCKED POS ON ITS L SIDE. SHE FELT IT HAD ARMED FINE AND EVEN HEARD THE CLICKING SOUND IT MAKES WHEN SHE ARMED IT. THE CAPT DETERMINED THAT SLIDE WAS THE WRONG SLIDE/GIRT BAR FOR THAT DOOR, AND IN FACT WAS A GIRT BAR/SLIDE FOR DOORS 1L&R AND THEREFORE WAS DIFFICULT TO FULLY INSTALL INTO THE FLOOR BRACKETS WHEN ARMED. AFTER I WENT BACK TO LOOK AGAIN AT DOOR 2L, I SAW ONE SIDE OF THE BAR COMPLETELY AND FIRMLY INSTALLED IN THE FLOOR BRACKET BUT THE L SIDE WAS NOT SEATED COMPLETELY AND FIRMLY IN THE BRACKET. THE CAPT CALLED AHEAD TO MAINT TO INFORM THEM WE WOULD NEED THE CORRECT SLIDE INSTALLED AND MAINT SAID THEY WOULD SEND ONE UP ON THE NEXT FLT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED DOOR 2L WAS NOT HER STATION AND THE DOOR WAS ARMED BY ANOTHER CABIN ATTENDANT. THE RPTR SAID AFTER TKOF AND WHEN WALKING BACK TO THE GALLEY, DOOR 2L AND DOOR 2R WERE XCHKED AND PERCEIVED THEM TO BE ARMED.
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.