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Attributes | |
ACN | 634403 |
Time | |
Date | 200410 |
Day | Tue |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 634403 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 634404 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : testing performance deficiency : repair |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Previous shift started the troubleshooting and repair work, during which they replaced the snubber. Previous shift inspection was not notified by the technicians of the rii requirement and turned it over to next shift, the first inspector available for any assistance was lead inspector, mr X. I was currently at the line for an aircraft callout there. Upon my return, mr X asked if I would take over on aircraft X and proceeded to give me a verbal turnover on what he saw while operating the door. When the technicians got to what they felt was the problem, they came into the office and said they found the upper hinge bolt (7) (reference maintenance manual 52-11-00 page 404, figure 401, sheet 3) was loose and when they tightened it up the door operation improved, so with the exception of the snubber change that previous shift did, next shift concentrated on the upper hinge and since previous shift missed the rii for the snubber I looked it over and found it was installed incorrectly and had the next shift technician install it in accordance with maintenance manual 52-11-71, once that was done, the technician was holding the lower hinge seal open as I looked over their install and the flexible cosmetic covering pulled loose from the seal plate which he re-secured. At the time of the final look over there was no obvious signs of damage or problems in operation with L1 door. Callback conversation with reporter revealed the following information: the reporter stated this door repair went on for several shifts and the first problem was a previous technician installed the door snubber incorrectly and this required removal and correct reinstallation. The door was rigged and inspected and the airplane was released for service. The reporter does not recall inspecting the lower door seal.
Original NASA ASRS Text
Title: B737-400 WAS DISPATCHED AFTER REPAIR TO DOOR 1L FOR 'HARD TO CLOSE' RPT. AIRPLANE RETURNED TO THE FIELD WITH DOOR 1L PRESSURE LEAK.
Narrative: PREVIOUS SHIFT STARTED THE TROUBLESHOOTING AND REPAIR WORK, DURING WHICH THEY REPLACED THE SNUBBER. PREVIOUS SHIFT INSPECTION WAS NOT NOTIFIED BY THE TECHNICIANS OF THE RII REQUIREMENT AND TURNED IT OVER TO NEXT SHIFT, THE FIRST INSPECTOR AVAILABLE FOR ANY ASSISTANCE WAS LEAD INSPECTOR, MR X. I WAS CURRENTLY AT THE LINE FOR AN ACFT CALLOUT THERE. UPON MY RETURN, MR X ASKED IF I WOULD TAKE OVER ON ACFT X AND PROCEEDED TO GIVE ME A VERBAL TURNOVER ON WHAT HE SAW WHILE OPERATING THE DOOR. WHEN THE TECHNICIANS GOT TO WHAT THEY FELT WAS THE PROB, THEY CAME INTO THE OFFICE AND SAID THEY FOUND THE UPPER HINGE BOLT (7) (REF MAINT MANUAL 52-11-00 PAGE 404, FIGURE 401, SHEET 3) WAS LOOSE AND WHEN THEY TIGHTENED IT UP THE DOOR OP IMPROVED, SO WITH THE EXCEPTION OF THE SNUBBER CHANGE THAT PREVIOUS SHIFT DID, NEXT SHIFT CONCENTRATED ON THE UPPER HINGE AND SINCE PREVIOUS SHIFT MISSED THE RII FOR THE SNUBBER I LOOKED IT OVER AND FOUND IT WAS INSTALLED INCORRECTLY AND HAD THE NEXT SHIFT TECHNICIAN INSTALL IT IN ACCORDANCE WITH MAINT MANUAL 52-11-71, ONCE THAT WAS DONE, THE TECHNICIAN WAS HOLDING THE LOWER HINGE SEAL OPEN AS I LOOKED OVER THEIR INSTALL AND THE FLEXIBLE COSMETIC COVERING PULLED LOOSE FROM THE SEAL PLATE WHICH HE RE-SECURED. AT THE TIME OF THE FINAL LOOK OVER THERE WAS NO OBVIOUS SIGNS OF DAMAGE OR PROBS IN OP WITH L1 DOOR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THIS DOOR REPAIR WENT ON FOR SEVERAL SHIFTS AND THE FIRST PROB WAS A PREVIOUS TECHNICIAN INSTALLED THE DOOR SNUBBER INCORRECTLY AND THIS REQUIRED REMOVAL AND CORRECT REINSTALLATION. THE DOOR WAS RIGGED AND INSPECTED AND THE AIRPLANE WAS RELEASED FOR SVC. THE RPTR DOES NOT RECALL INSPECTING THE LOWER DOOR SEAL.
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.