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A B737-500 special inspection job card to inspect escape slide cable latch routing has illustrations that can cause confusion on cable routing.
| Attributes | |
| ACN | 636488 |
| Time | |
| Date | 200411 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| 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 | B737-500 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 636488 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other Other |
| Factors | |
| Maintenance | contributing factor : engineering procedure contributing factor : work cards performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | Escape Slide Publication |
Narrative:
The special item issued for aircraft to inspect escape slide cable latch. Eventually, the cables were correctly installed, however, when you go through each step and the pictures, the pictures led me to rerte the cables incorrectly. When the escape slide bar latches to the door, the cables seem incorrectly installed according to the pictures shown, and correctly installed in opposite way. Therefore, these pictures led me to the wrong direction. However, when the picture is shown for direction reference, the whole view should be shown for more specific details for this situation.
Original NASA ASRS Text
Title: A B737-500 SPECIAL INSPECTION JOB CARD TO INSPECT ESCAPE SLIDE CABLE LATCH ROUTING HAS ILLUSTRATIONS THAT CAN CAUSE CONFUSION ON CABLE ROUTING.
Narrative: THE SPECIAL ITEM ISSUED FOR ACFT TO INSPECT ESCAPE SLIDE CABLE LATCH. EVENTUALLY, THE CABLES WERE CORRECTLY INSTALLED, HOWEVER, WHEN YOU GO THROUGH EACH STEP AND THE PICTURES, THE PICTURES LED ME TO RERTE THE CABLES INCORRECTLY. WHEN THE ESCAPE SLIDE BAR LATCHES TO THE DOOR, THE CABLES SEEM INCORRECTLY INSTALLED ACCORDING TO THE PICTURES SHOWN, AND CORRECTLY INSTALLED IN OPPOSITE WAY. THEREFORE, THESE PICTURES LED ME TO THE WRONG DIRECTION. HOWEVER, WHEN THE PICTURE IS SHOWN FOR DIRECTION REF, THE WHOLE VIEW SHOULD BE SHOWN FOR MORE SPECIFIC DETAILS FOR THIS SIT.
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.