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|
Attributes | |
ACN | 652653 |
Time | |
Date | 200502 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 652653 |
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 : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : door bottle press indicator other other : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On feb/sun/05 an aircraft technician inadvertently deployed an escape slide on an airbus A320 during a maintenance visit at ZZZ which included some maintenance on the same door #1 lh. A non routine write-up was created and a mechanic replaced the slide pack. I inspected the installation of the slide assembly and the aircraft went into service the following day. On feb/thu/05 this aft went through a #3 service check at ZZZ1 at which time the #1 lh door assist bottle pressure read zero. Replacing the bottle diaphragm and servicing this bottle cleared this discrepancy. The assist bottle aids the flight attendant in opening the door in an emergency and thus expedites the process of deploying the slide. The assist bottle was not svced in ZZZ when the slide was replaced. The following factors contributed: the lead-in charge of processing the write-up processed the write-up only to replace the slide pack. The separately mounted assist bottle should have its own document to be svced or replaced. This document would show the replacement parts ordered to service the bottle such as the diaphragm and shear pin. The mechanic installing the slide pack per maintenance manual also would have to replace or service the assist bottle then document it on the write-up as work accomplished. I am an inspector and my function is to inspect the work performed. In this case the only work performed was the slide replacement. As such; this is what I did. The problem thus lies with the servicing of the assist bottle. Even though the maintenance manual states to service the assist bottle; the policy of who is responsible for completion of this task is not clear. The lead states he processed the write-up per maintenance manual reference; however; he was not precise enough to state all steps required. The mechanic missed the same item and the inspector only inspected that which was processed and worked (replaced).
Original NASA ASRS Text
Title: AN A320 HAD DOOR 1L SLIDE INSTALLED; HOWEVER THE DOOR ASSIST BOTTLE WAS FOUND WITH ZERO PRESSURE. SLIDE REPLACEMENT PROCS REQUIRE DOOR BOTTLE SVCING.
Narrative: ON FEB/SUN/05 AN ACFT TECHNICIAN INADVERTENTLY DEPLOYED AN ESCAPE SLIDE ON AN AIRBUS A320 DURING A MAINT VISIT AT ZZZ WHICH INCLUDED SOME MAINT ON THE SAME DOOR #1 LH. A NON ROUTINE WRITE-UP WAS CREATED AND A MECH REPLACED THE SLIDE PACK. I INSPECTED THE INSTALLATION OF THE SLIDE ASSEMBLY AND THE ACFT WENT INTO SVC THE FOLLOWING DAY. ON FEB/THU/05 THIS AFT WENT THROUGH A #3 SVC CHK AT ZZZ1 AT WHICH TIME THE #1 LH DOOR ASSIST BOTTLE PRESSURE READ ZERO. REPLACING THE BOTTLE DIAPHRAGM AND SVCING THIS BOTTLE CLRED THIS DISCREPANCY. THE ASSIST BOTTLE AIDS THE FLT ATTENDANT IN OPENING THE DOOR IN AN EMER AND THUS EXPEDITES THE PROCESS OF DEPLOYING THE SLIDE. THE ASSIST BOTTLE WAS NOT SVCED IN ZZZ WHEN THE SLIDE WAS REPLACED. THE FOLLOWING FACTORS CONTRIBUTED: THE LEAD-IN CHARGE OF PROCESSING THE WRITE-UP PROCESSED THE WRITE-UP ONLY TO REPLACE THE SLIDE PACK. THE SEPARATELY MOUNTED ASSIST BOTTLE SHOULD HAVE ITS OWN DOCUMENT TO BE SVCED OR REPLACED. THIS DOCUMENT WOULD SHOW THE REPLACEMENT PARTS ORDERED TO SVC THE BOTTLE SUCH AS THE DIAPHRAGM AND SHEAR PIN. THE MECH INSTALLING THE SLIDE PACK PER MAINT MANUAL ALSO WOULD HAVE TO REPLACE OR SVC THE ASSIST BOTTLE THEN DOCUMENT IT ON THE WRITE-UP AS WORK ACCOMPLISHED. I AM AN INSPECTOR AND MY FUNCTION IS TO INSPECT THE WORK PERFORMED. IN THIS CASE THE ONLY WORK PERFORMED WAS THE SLIDE REPLACEMENT. AS SUCH; THIS IS WHAT I DID. THE PROB THUS LIES WITH THE SVCING OF THE ASSIST BOTTLE. EVEN THOUGH THE MAINT MANUAL STATES TO SVC THE ASSIST BOTTLE; THE POLICY OF WHO IS RESPONSIBLE FOR COMPLETION OF THIS TASK IS NOT CLR. THE LEAD STATES HE PROCESSED THE WRITE-UP PER MAINT MANUAL REF; HOWEVER; HE WAS NOT PRECISE ENOUGH TO STATE ALL STEPS REQUIRED. THE MECH MISSED THE SAME ITEM AND THE INSPECTOR ONLY INSPECTED THAT WHICH WAS PROCESSED AND WORKED (REPLACED).
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.