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A B777 was dispatched with the incorrect L-3 door escape slide installed. Flight diverted to replace slide prior to overwater flight.
| Attributes | |
| ACN | 652193 |
| Time | |
| Date | 200503 |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B777-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 652193 |
| 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 : far non adherence : published procedure |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other Other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : installation |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
On mar/wed/05 at XA00; I started replacing L-3 door slide on ship X with mr Y. I checked the serial numbers of the slides removed and installed. I thought the part number order was correct for the installation. We should have verified the part number and referenced it to the air carrier X part number before installing the new slide. We picked up the slide from stores department and it was pre ordered for the aircraft. The discrepancy was discovered after the aircraft departed. The aircraft off-landed for the L-3 slide to be changed.
Original NASA ASRS Text
Title: A B777 WAS DISPATCHED WITH THE INCORRECT L-3 DOOR ESCAPE SLIDE INSTALLED. FLT DIVERTED TO REPLACE SLIDE PRIOR TO OVERWATER FLT.
Narrative: ON MAR/WED/05 AT XA00; I STARTED REPLACING L-3 DOOR SLIDE ON SHIP X WITH MR Y. I CHKED THE SERIAL NUMBERS OF THE SLIDES REMOVED AND INSTALLED. I THOUGHT THE PART NUMBER ORDER WAS CORRECT FOR THE INSTALLATION. WE SHOULD HAVE VERIFIED THE PART NUMBER AND REFERENCED IT TO THE ACR X PART NUMBER BEFORE INSTALLING THE NEW SLIDE. WE PICKED UP THE SLIDE FROM STORES DEPT AND IT WAS PRE ORDERED FOR THE ACFT. THE DISCREPANCY WAS DISCOVERED AFTER THE ACFT DEPARTED. THE ACFT OFF-LANDED FOR THE L-3 SLIDE TO BE CHANGED.
Data retrieved from NASA's ASRS site as of January 2009 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.