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A B737-300 aft door escape slide was removed and shipped to the slide shop in the armed condition. Lanyard wire was found attached to the pressure bottle.
| Attributes | |
| ACN | 640619 |
| Time | |
| Date | 200412 |
| Day | Wed |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Person 1 | |
| Affiliation | company : air carrier |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 640619 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Events | |
| Anomaly | maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies non adherence : far |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : inspection performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication Environmental Factor |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | Maint Manual |
Narrative:
A company rep notified me today that an aft escape slide arrived today in shop with the safety pin installed in the wrong position. I was surprised because we change so many slides here. I talked with the mechanic I was paired with that night and he recalls seeing me install the pin, signed for the installation and am the mechanic who put the slide in the box after removal and am therefore responsible. I have also made my co-workers aware so that they may be more vigilant. Callback conversation with reporter revealed the following information: the reporter admitted he removed and signed for the slide and put the slide in the shipping box, but does not remember disarming or removing the wire lanyard from the bottle pin.
Original NASA ASRS Text
Title: A B737-300 AFT DOOR ESCAPE SLIDE WAS REMOVED AND SHIPPED TO THE SLIDE SHOP IN THE ARMED CONDITION. LANYARD WIRE WAS FOUND ATTACHED TO THE PRESSURE BOTTLE.
Narrative: A COMPANY REP NOTIFIED ME TODAY THAT AN AFT ESCAPE SLIDE ARRIVED TODAY IN SHOP WITH THE SAFETY PIN INSTALLED IN THE WRONG POS. I WAS SURPRISED BECAUSE WE CHANGE SO MANY SLIDES HERE. I TALKED WITH THE MECH I WAS PAIRED WITH THAT NIGHT AND HE RECALLS SEEING ME INSTALL THE PIN, SIGNED FOR THE INSTALLATION AND AM THE MECH WHO PUT THE SLIDE IN THE BOX AFTER REMOVAL AND AM THEREFORE RESPONSIBLE. I HAVE ALSO MADE MY CO-WORKERS AWARE SO THAT THEY MAY BE MORE VIGILANT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR ADMITTED HE REMOVED AND SIGNED FOR THE SLIDE AND PUT THE SLIDE IN THE SHIPPING BOX, BUT DOES NOT REMEMBER DISARMING OR REMOVING THE WIRE LANYARD FROM THE BOTTLE PIN.
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.