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A B757-200 escape slide technician working overwing escape slides reports installing one-way check valves backwards in the air hoses.
| Attributes | |
| ACN | 618416 |
| Time | |
| Date | 200405 |
| Day | Tue |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| 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 |
| ASRS Report | 618416 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure non adherence : far |
| Independent Detector | other other : person1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other Other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : engineering procedure contributing factor : manuals performance deficiency : training performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : installation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | Engineerign Service Order |
Narrative:
Installed the one-way valves on the air hoses backwards. Callback conversation with reporter revealed the following information: the reporter stated he was assigned to the escape slide shop and worked only overwing slides for the B757-200. The reporter said the work was to install check valves in the air hoses. The reporter stated the paperwork for the job did not have any pictorial diagrams which would indicate airflow and therefore check valve direction. The reporter said the only diagram of the hoses and check valves was in the parts catalog which is not normally used for installation. The reporter stated he believed he knew how the hose assembly went together and never realized the check valve error until later. The reporter said so far three slides have been recovered and corrected, but checking and recovery continues.
Original NASA ASRS Text
Title: A B757-200 ESCAPE SLIDE TECHNICIAN WORKING OVERWING ESCAPE SLIDES RPTS INSTALLING ONE-WAY CHK VALVES BACKWARDS IN THE AIR HOSES.
Narrative: INSTALLED THE ONE-WAY VALVES ON THE AIR HOSES BACKWARDS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED HE WAS ASSIGNED TO THE ESCAPE SLIDE SHOP AND WORKED ONLY OVERWING SLIDES FOR THE B757-200. THE RPTR SAID THE WORK WAS TO INSTALL CHK VALVES IN THE AIR HOSES. THE RPTR STATED THE PAPERWORK FOR THE JOB DID NOT HAVE ANY PICTORIAL DIAGRAMS WHICH WOULD INDICATE AIRFLOW AND THEREFORE CHK VALVE DIRECTION. THE RPTR SAID THE ONLY DIAGRAM OF THE HOSES AND CHK VALVES WAS IN THE PARTS CATALOG WHICH IS NOT NORMALLY USED FOR INSTALLATION. THE RPTR STATED HE BELIEVED HE KNEW HOW THE HOSE ASSEMBLY WENT TOGETHER AND NEVER REALIZED THE CHK VALVE ERROR UNTIL LATER. THE RPTR SAID SO FAR THREE SLIDES HAVE BEEN RECOVERED AND CORRECTED, BUT CHKING AND RECOVERY CONTINUES.
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.