37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 658389 |
Time | |
Date | 200502 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | other |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : fcc technician : airframe technician : inspection authority |
Experience | maintenance lead technician : 8 maintenance technician : 30 |
ASRS Report | 658389 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure non adherence : far |
Independent Detector | other other : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On feb/thu/05 when company X performed a 'C' check on aircraft X; it was discovered that the aft right slide had 2 discrepancies. One was the electrical harness to remain in place for a left slide installation. I didn't understand how this would effect the deployment of the slide. The emergency lights and warning system operated correctly. An oversight on my part was the reason for the discrepancy. Upon review of the training slide and close review of the job card JC25-62-01; the incorrect position wouldn't cause a deployment failure. At the time of maintenance being performed; the maintenance department was under a great deal of stress due to labor layoffs and contract negotiations. This is not an excuse; but a factor causing distrs. The second discrepancy involved the quick disconnect. I am sure this was performed in accordance with ja 25-62-01. How it became loose is of concern to me. I always paid particular attention to warning flags and streamers and the proper installation of the quick disconnect. There may have been an inadvertent action unknown to me. I can't recall a problem in this area of the job card procedures. Again; I reviewed and participated in slide training and participated in photographing the slide for future training updates. At the time of maintenance being performed; a high stress level was present.
Original NASA ASRS Text
Title: AN A319 ENTERED A CONTRACT MAINT FACILITY FOR A 'C' CHK. DURING THE CHK IT WAS DISCOVERED THE R AFT ESCAPE SLIDE WAS INSTALLED INCORRECTLY.
Narrative: ON FEB/THU/05 WHEN COMPANY X PERFORMED A 'C' CHK ON ACFT X; IT WAS DISCOVERED THAT THE AFT R SLIDE HAD 2 DISCREPANCIES. ONE WAS THE ELECTRICAL HARNESS TO REMAIN IN PLACE FOR A L SLIDE INSTALLATION. I DIDN'T UNDERSTAND HOW THIS WOULD EFFECT THE DEPLOYMENT OF THE SLIDE. THE EMER LIGHTS AND WARNING SYS OPERATED CORRECTLY. AN OVERSIGHT ON MY PART WAS THE REASON FOR THE DISCREPANCY. UPON REVIEW OF THE TRAINING SLIDE AND CLOSE REVIEW OF THE JOB CARD JC25-62-01; THE INCORRECT POS WOULDN'T CAUSE A DEPLOYMENT FAILURE. AT THE TIME OF MAINT BEING PERFORMED; THE MAINT DEPT WAS UNDER A GREAT DEAL OF STRESS DUE TO LABOR LAYOFFS AND CONTRACT NEGOTIATIONS. THIS IS NOT AN EXCUSE; BUT A FACTOR CAUSING DISTRS. THE SECOND DISCREPANCY INVOLVED THE QUICK DISCONNECT. I AM SURE THIS WAS PERFORMED IN ACCORDANCE WITH JA 25-62-01. HOW IT BECAME LOOSE IS OF CONCERN TO ME. I ALWAYS PAID PARTICULAR ATTN TO WARNING FLAGS AND STREAMERS AND THE PROPER INSTALLATION OF THE QUICK DISCONNECT. THERE MAY HAVE BEEN AN INADVERTENT ACTION UNKNOWN TO ME. I CAN'T RECALL A PROB IN THIS AREA OF THE JOB CARD PROCS. AGAIN; I REVIEWED AND PARTICIPATED IN SLIDE TRAINING AND PARTICIPATED IN PHOTOGRAPHING THE SLIDE FOR FUTURE TRAINING UPDATES. AT THE TIME OF MAINT BEING PERFORMED; A HIGH STRESS LEVEL WAS PRESENT.
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.