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A B737-700 was released for service in non compliance with the incorrect forward entry door escape slide installed. Correct slide replaced prior to dispatch.
| Attributes | |
| ACN | 593768 |
| Time | |
| Date | 200309 |
| 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 | B737-700 |
| 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 | 593768 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 593609 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : company policies non adherence : far non adherence : published procedure |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other Other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : scheduled maintenance performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance Company |
| Primary Problem | Maintenance Human Performance |
Narrative:
I was given a card to perform a deploy slide on the forward entry door slide on aircraft. The check was good. I then hung the new slide from pre-draw without thoroughly checking the part's tag. The aircraft was released and the next morning during first pushback it was discovered the wrong slide was installed. A flight delay was caused as the slide was replaced with the correct one. The primary cause of this error was my misunderstanding the slides to be universal on the B-700 aircraft. The contributing factors were: lack of communication -- I failed to communicate fully and did not get all information necessary. Conflicting maintenance document -- the non routine card and planning direction left some room for confusion on my part. Lack of resources -- proper slide was not available to me. Lack of awareness -- I failed to thoroughly check paperwork.
Original NASA ASRS Text
Title: A B737-700 WAS RELEASED FOR SVC IN NON COMPLIANCE WITH THE INCORRECT FORWARD ENTRY DOOR ESCAPE SLIDE INSTALLED. CORRECT SLIDE REPLACED PRIOR TO DISPATCH.
Narrative: I WAS GIVEN A CARD TO PERFORM A DEPLOY SLIDE ON THE FORWARD ENTRY DOOR SLIDE ON ACFT. THE CHK WAS GOOD. I THEN HUNG THE NEW SLIDE FROM PRE-DRAW WITHOUT THOROUGHLY CHKING THE PART'S TAG. THE ACFT WAS RELEASED AND THE NEXT MORNING DURING FIRST PUSHBACK IT WAS DISCOVERED THE WRONG SLIDE WAS INSTALLED. A FLT DELAY WAS CAUSED AS THE SLIDE WAS REPLACED WITH THE CORRECT ONE. THE PRIMARY CAUSE OF THIS ERROR WAS MY MISUNDERSTANDING THE SLIDES TO BE UNIVERSAL ON THE B-700 ACFT. THE CONTRIBUTING FACTORS WERE: LACK OF COM -- I FAILED TO COMMUNICATE FULLY AND DID NOT GET ALL INFO NECESSARY. CONFLICTING MAINT DOCUMENT -- THE NON ROUTINE CARD AND PLANNING DIRECTION LEFT SOME ROOM FOR CONFUSION ON MY PART. LACK OF RESOURCES -- PROPER SLIDE WAS NOT AVAILABLE TO ME. LACK OF AWARENESS -- I FAILED TO THOROUGHLY CHK PAPERWORK.
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.