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A dehavilland 8-300 was in maintenance when the underwing emergency exit ditching dam deployed. Caused by emergency exit door job card deficiency.
| Attributes | |
| ACN | 557570 |
| Time | |
| Date | 200208 |
| Day | Thu |
| 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 | Dash 8-100 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 18 |
| ASRS Report | 557570 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far |
| Independent Detector | other other : person 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other other Other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Company Chart Or Publication Maintenance Human Performance |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | MAINT MANUAL |
Narrative:
While performing work card 53-11-10B, on aircraft X, the right ditching dam was accidentally deployed. The work card does not give any notes, cautions, or warnings about dam deployment or disconnecting the lanyard from the exit door. Then respectively the card does not call for the lanyard to be reinstalled. It was determined that the aircraft was in a pre-modified 8/1690 confign. The nitrogen bottle was replaced to accommodate the rupture and subsequent replacement of the neoprene diaphragm. Callback conversation with reporter revealed the following information: the reporter stated the ditching dam is deployed to prevent water from entering the cabin when the underwing class 11 emergency exit door is opened. The reporter said several modifications were accomplished to this door but the door removal and installation job card has never been revised to indicate these changes.
Original NASA ASRS Text
Title: A DEHAVILLAND 8-300 WAS IN MAINT WHEN THE UNDERWING EMER EXIT DITCHING DAM DEPLOYED. CAUSED BY EMER EXIT DOOR JOB CARD DEFICIENCY.
Narrative: WHILE PERFORMING WORK CARD 53-11-10B, ON ACFT X, THE R DITCHING DAM WAS ACCIDENTALLY DEPLOYED. THE WORK CARD DOES NOT GIVE ANY NOTES, CAUTIONS, OR WARNINGS ABOUT DAM DEPLOYMENT OR DISCONNECTING THE LANYARD FROM THE EXIT DOOR. THEN RESPECTIVELY THE CARD DOES NOT CALL FOR THE LANYARD TO BE REINSTALLED. IT WAS DETERMINED THAT THE ACFT WAS IN A PRE-MODIFIED 8/1690 CONFIGN. THE NITROGEN BOTTLE WAS REPLACED TO ACCOMMODATE THE RUPTURE AND SUBSEQUENT REPLACEMENT OF THE NEOPRENE DIAPHRAGM. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE DITCHING DAM IS DEPLOYED TO PREVENT WATER FROM ENTERING THE CABIN WHEN THE UNDERWING CLASS 11 EMER EXIT DOOR IS OPENED. THE RPTR SAID SEVERAL MODIFICATIONS WERE ACCOMPLISHED TO THIS DOOR BUT THE DOOR REMOVAL AND INSTALLATION JOB CARD HAS NEVER BEEN REVISED TO INDICATE THESE CHANGES.
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.