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Attributes | |
ACN | 579600 |
Time | |
Date | 200304 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 3 |
ASRS Report | 579600 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure non adherence : company policies |
Independent Detector | aircraft equipment other aircraft equipment : slide failed to inflate other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Manual |
Narrative:
On apr/sun/03, at approximately XA30 hours, I was working as an aviation line maintenance technician for air carrier X at ZZZ. Aircraft X arrived at gate on its regularly scheduled flight from ZZZ1. The airplane was scheduled to depart within 30 mins for a return flight to ZZZ1. During the cleaning between flts while the aircraft was at the gate, the contract cleaner personnel hit the housing of the emergency evacuate/evacuation slide attached to the right door. Subsequently, the right door was opened to allow access to the galley for catering personnel. At that time or very soon after the slide fell to the ground from the door, without inflating (as it had been disarmed upon landing). Air carrier X amt's, mr X, mr Y and myself were called out to the plane and found the emergency slide on the ground below the R7 door. The slide was not inflated, however part of the slide had come loose from its packing. Mr X, mr Y and myself replaced the slide from ZZZ stock and I signed the procedure off on the logbook of the aircraft. The time available for the replacement was very short, and the process of replacing the slide caused the plane to delay its departure to ZZZ1 approximately 25 mins. On apr/sat/03, I was working again at ZZZ with mr X and mr Z, another air carrier X mechanic. A phone call was received from air carrier X aircraft maintenance at ZZZ1, who informed us that the door slide on aircraft X on the right door had been inadvertently activated by ground personnel, and the slide came out of its housing, but did not inflate. Investigation showed that the safety pin used for shipping the slide had not been pulled when it was installed on the aircraft on apr/sat/03. I take full responsibility for not pulling the shipping pin when we installed the slide at ZZZ on apr/sat/03.
Original NASA ASRS Text
Title: A B737-300 PARKED ON GATE. GND PERSONNEL INADVERTENTLY DEPLOYED R #1 SVC DOOR ESCAPE SLIDE. SLIDE DID NOT INFLATE DUE TO SHIPPING PIN NOT REMOVED ON INSTALLATION.
Narrative: ON APR/SUN/03, AT APPROX XA30 HRS, I WAS WORKING AS AN AVIATION LINE MAINT TECHNICIAN FOR ACR X AT ZZZ. ACFT X ARRIVED AT GATE ON ITS REGULARLY SCHEDULED FLT FROM ZZZ1. THE AIRPLANE WAS SCHEDULED TO DEPART WITHIN 30 MINS FOR A RETURN FLT TO ZZZ1. DURING THE CLEANING BTWN FLTS WHILE THE ACFT WAS AT THE GATE, THE CONTRACT CLEANER PERSONNEL HIT THE HOUSING OF THE EMER EVAC SLIDE ATTACHED TO THE R DOOR. SUBSEQUENTLY, THE R DOOR WAS OPENED TO ALLOW ACCESS TO THE GALLEY FOR CATERING PERSONNEL. AT THAT TIME OR VERY SOON AFTER THE SLIDE FELL TO THE GND FROM THE DOOR, WITHOUT INFLATING (AS IT HAD BEEN DISARMED UPON LNDG). ACR X AMT'S, MR X, MR Y AND MYSELF WERE CALLED OUT TO THE PLANE AND FOUND THE EMER SLIDE ON THE GND BELOW THE R7 DOOR. THE SLIDE WAS NOT INFLATED, HOWEVER PART OF THE SLIDE HAD COME LOOSE FROM ITS PACKING. MR X, MR Y AND MYSELF REPLACED THE SLIDE FROM ZZZ STOCK AND I SIGNED THE PROC OFF ON THE LOGBOOK OF THE ACFT. THE TIME AVAILABLE FOR THE REPLACEMENT WAS VERY SHORT, AND THE PROCESS OF REPLACING THE SLIDE CAUSED THE PLANE TO DELAY ITS DEP TO ZZZ1 APPROX 25 MINS. ON APR/SAT/03, I WAS WORKING AGAIN AT ZZZ WITH MR X AND MR Z, ANOTHER ACR X MECH. A PHONE CALL WAS RECEIVED FROM ACR X ACFT MAINT AT ZZZ1, WHO INFORMED US THAT THE DOOR SLIDE ON ACFT X ON THE R DOOR HAD BEEN INADVERTENTLY ACTIVATED BY GND PERSONNEL, AND THE SLIDE CAME OUT OF ITS HOUSING, BUT DID NOT INFLATE. INVESTIGATION SHOWED THAT THE SAFETY PIN USED FOR SHIPPING THE SLIDE HAD NOT BEEN PULLED WHEN IT WAS INSTALLED ON THE ACFT ON APR/SAT/03. I TAKE FULL RESPONSIBILITY FOR NOT PULLING THE SHIPPING PIN WHEN WE INSTALLED THE SLIDE AT ZZZ ON APR/SAT/03.
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.