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A B757-200 left door escape slide was replaced but the technician failed to remove the safety pin from the door assist bottle and to ch pressure.
| Attributes | |
| ACN | 627124 |
| Time | |
| Date | 200407 |
| Day | Mon |
| 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 | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance lead technician : 1 maintenance technician : 19 |
| ASRS Report | 627124 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| 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 : manuals performance deficiency : logbook entry performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Environmental Factor Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
On jul/mon/04, at approximately XA30, air carrier aircraft, a B757-200, arrived in ZZZ. On a reposition ferry permit from ZZZ1 with the L-4 door slide deployed and stowed in the aircraft's aft cargo bin. The original log page was closed for a ferry permit. I obtained a serviceable door slide, and proceeded to install it using boeing maintenance manual 25-66-01. Since the slide was already removed, I only printed the installation portion of the maintenance manual. Forgetting the B757 has a door assist bottle to help with slide deployment, I inadvertently forgot to service it. Had I pulled up the removal of the slide I would have read the first steps were to install safety pins in the slide and door assist bottle. Also I missed the very last step in the installation portion in returning the aircraft to original condition, to remove the safety pin in the door assist bottle and verify pressure. Log page for slide installation was Y. On jul/wed/04, on a routine ch the L4 door assist bottle was found empty and was replaced in ZZZ2, log page Z. This event was an oversight on my part. I should have read the maintenance manual more closely.
Original NASA ASRS Text
Title: A B757-200 L DOOR ESCAPE SLIDE WAS REPLACED BUT THE TECHNICIAN FAILED TO REMOVE THE SAFETY PIN FROM THE DOOR ASSIST BOTTLE AND TO CH PRESSURE.
Narrative: ON JUL/MON/04, AT APPROX XA30, ACR ACFT, A B757-200, ARRIVED IN ZZZ. ON A REPOSITION FERRY PERMIT FROM ZZZ1 WITH THE L-4 DOOR SLIDE DEPLOYED AND STOWED IN THE ACFT'S AFT CARGO BIN. THE ORIGINAL LOG PAGE WAS CLOSED FOR A FERRY PERMIT. I OBTAINED A SERVICEABLE DOOR SLIDE, AND PROCEEDED TO INSTALL IT USING BOEING MAINT MANUAL 25-66-01. SINCE THE SLIDE WAS ALREADY REMOVED, I ONLY PRINTED THE INSTALLATION PORTION OF THE MAINT MANUAL. FORGETTING THE B757 HAS A DOOR ASSIST BOTTLE TO HELP WITH SLIDE DEPLOYMENT, I INADVERTENTLY FORGOT TO SVC IT. HAD I PULLED UP THE REMOVAL OF THE SLIDE I WOULD HAVE READ THE FIRST STEPS WERE TO INSTALL SAFETY PINS IN THE SLIDE AND DOOR ASSIST BOTTLE. ALSO I MISSED THE VERY LAST STEP IN THE INSTALLATION PORTION IN RETURNING THE ACFT TO ORIGINAL CONDITION, TO REMOVE THE SAFETY PIN IN THE DOOR ASSIST BOTTLE AND VERIFY PRESSURE. LOG PAGE FOR SLIDE INSTALLATION WAS Y. ON JUL/WED/04, ON A ROUTINE CH THE L4 DOOR ASSIST BOTTLE WAS FOUND EMPTY AND WAS REPLACED IN ZZZ2, LOG PAGE Z. THIS EVENT WAS AN OVERSIGHT ON MY PART. I SHOULD HAVE READ THE MAINT MANUAL MORE CLOSELY.
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.