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|
Attributes | |
ACN | 624988 |
Time | |
Date | 200407 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 20 maintenance technician : 4 |
ASRS Report | 624988 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 24 |
ASRS Report | 625310 |
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 |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : repair |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
A customer service agent reopened the L-2 door after being armed for departure. The exterior disarm mechanism failed to disarm the slide. The slide fell off from its housing and lay against the forward edge of the L-2 door frame facing aft. There was no sign that the door assist bottle had been triggered. The door was pulled open and not forced from the closed position. I inspected the slide for abnormalities and reinstalled the slide onto the door. The girt bar holding brackets were gummed up restricting disarming the door from the outside. The tracks were cleaned and the arm/disarm mechanism tested for proper operation. There was much commotion over who was to blame for the deployment outside the L-2 door on the jetway while installing the slide. With the focus on moving the people, I forgot to have the reinstallation of the slide inspected. The aircraft departed for ZZZ1. As soon as I realized the error, I phoned maintenance control to explain the situation. He contacted duty manager who dispatched a designated inspector and mechanic to aircraft in ZZZ1 to make the slide inspection.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH DOOR L2 ESCAPE SLIDE REINSTALLED ON DOOR AND TESTED. REQUIRED FAA INSPECTION WAS NOT ACCOMPLISHED.
Narrative: A CUSTOMER SVC AGENT REOPENED THE L-2 DOOR AFTER BEING ARMED FOR DEP. THE EXTERIOR DISARM MECHANISM FAILED TO DISARM THE SLIDE. THE SLIDE FELL OFF FROM ITS HOUSING AND LAY AGAINST THE FORWARD EDGE OF THE L-2 DOOR FRAME FACING AFT. THERE WAS NO SIGN THAT THE DOOR ASSIST BOTTLE HAD BEEN TRIGGERED. THE DOOR WAS PULLED OPEN AND NOT FORCED FROM THE CLOSED POS. I INSPECTED THE SLIDE FOR ABNORMALITIES AND REINSTALLED THE SLIDE ONTO THE DOOR. THE GIRT BAR HOLDING BRACKETS WERE GUMMED UP RESTRICTING DISARMING THE DOOR FROM THE OUTSIDE. THE TRACKS WERE CLEANED AND THE ARM/DISARM MECHANISM TESTED FOR PROPER OP. THERE WAS MUCH COMMOTION OVER WHO WAS TO BLAME FOR THE DEPLOYMENT OUTSIDE THE L-2 DOOR ON THE JETWAY WHILE INSTALLING THE SLIDE. WITH THE FOCUS ON MOVING THE PEOPLE, I FORGOT TO HAVE THE REINSTALLATION OF THE SLIDE INSPECTED. THE ACFT DEPARTED FOR ZZZ1. AS SOON AS I REALIZED THE ERROR, I PHONED MAINT CTL TO EXPLAIN THE SIT. HE CONTACTED DUTY MGR WHO DISPATCHED A DESIGNATED INSPECTOR AND MECH TO ACFT IN ZZZ1 TO MAKE THE SLIDE INSPECTION.
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.