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A B757-200 was dispatched in non compliance with door 1L incorrect emergency power reservoir installed. Door 1R unit installed.
| Attributes | |
| ACN | 578363 |
| Time | |
| Date | 200304 |
| Day | Sat |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Dawn |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 578363 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 578364 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies non adherence : far |
| Independent Detector | other other : person 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other Other |
| Factors | |
| Maintenance | contributing factor : weather performance deficiency : inspection performance deficiency : unqualified personnel performance deficiency : training performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Weather Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Found L1 door pressure gauge at zero psi on emergency power reservoir. Replaced EPR with opposite side part number RES5033 when RES1031 is required at the L1 position. Later that morning, stores noted wrong part on part tag. Aircraft was grounded and correct part was installed at that time. I know at least 1 leg was flown. Supplemental information from acn 578364: I watched technician X remove r-hand side reservoir assembly for L1 door and I filled out the rotatable tag for RES5033 when RES1031 should have been removed and replaced.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH DOOR 1L INCORRECT EMER PWR RESERVOIR INSTALLED. DOOR 1R UNIT INSTALLED.
Narrative: FOUND L1 DOOR PRESSURE GAUGE AT ZERO PSI ON EMER PWR RESERVOIR. REPLACED EPR WITH OPPOSITE SIDE PART NUMBER RES5033 WHEN RES1031 IS REQUIRED AT THE L1 POS. LATER THAT MORNING, STORES NOTED WRONG PART ON PART TAG. ACFT WAS GNDED AND CORRECT PART WAS INSTALLED AT THAT TIME. I KNOW AT LEAST 1 LEG WAS FLOWN. SUPPLEMENTAL INFO FROM ACN 578364: I WATCHED TECHNICIAN X REMOVE R-HAND SIDE RESERVOIR ASSEMBLY FOR L1 DOOR AND I FILLED OUT THE ROTATABLE TAG FOR RES5033 WHEN RES1031 SHOULD HAVE BEEN REMOVED AND REPLACED.
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.