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A B737-300 during maintenance a door escape slide pressure bottle was found pinned. Maintenance manual revision to add pin to door bottle and location of pin flag major cause of failure to remove pin.
| Attributes | |
| ACN | 668095 |
| Time | |
| Date | 200504 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 18 |
| ASRS Report | 668095 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Qualification | technician : airframe technician : inspection authority technician : powerplant |
| ASRS Report | 667183 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : manuals performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Company Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | Maint Manual Revisions |
Narrative:
On apr/xa/05; I was asked to replace a door slide at position 1R. Replacing the slide consisted of removing 2 screws holding the slide pack to the door. For the past 15 yrs that I have changed these slides; the assist bottle was never pinned and the slide was just hung. As of jan/05; the procedure was changed and the slide is now pinned with a streamer attached. The problem is that the streamer is not exposed -- it is packed under the bustle out of sight. I was not aware of the procedure to have the new slide pinned for shipping and I did not see the streamer. My opinion is that the streamer to the pin should be exposed. Maintenance personnel were never notified of the change to the maintenance manual stating to remove the bottle pin after installation. This could have been prevented if there was a longer streamer and made more visible.
Original NASA ASRS Text
Title: A B737-300 DURING MAINT A DOOR ESCAPE SLIDE PRESSURE BOTTLE WAS FOUND PINNED. MAINT MANUAL REVISION TO ADD PIN TO DOOR BOTTLE AND LOCATION OF PIN FLAG MAJOR CAUSE OF FAILURE TO REMOVE PIN.
Narrative: ON APR/XA/05; I WAS ASKED TO REPLACE A DOOR SLIDE AT POS 1R. REPLACING THE SLIDE CONSISTED OF REMOVING 2 SCREWS HOLDING THE SLIDE PACK TO THE DOOR. FOR THE PAST 15 YRS THAT I HAVE CHANGED THESE SLIDES; THE ASSIST BOTTLE WAS NEVER PINNED AND THE SLIDE WAS JUST HUNG. AS OF JAN/05; THE PROC WAS CHANGED AND THE SLIDE IS NOW PINNED WITH A STREAMER ATTACHED. THE PROB IS THAT THE STREAMER IS NOT EXPOSED -- IT IS PACKED UNDER THE BUSTLE OUT OF SIGHT. I WAS NOT AWARE OF THE PROC TO HAVE THE NEW SLIDE PINNED FOR SHIPPING AND I DID NOT SEE THE STREAMER. MY OPINION IS THAT THE STREAMER TO THE PIN SHOULD BE EXPOSED. MAINT PERSONNEL WERE NEVER NOTIFIED OF THE CHANGE TO THE MAINT MANUAL STATING TO REMOVE THE BOTTLE PIN AFTER INSTALLATION. THIS COULD HAVE BEEN PREVENTED IF THERE WAS A LONGER STREAMER AND MADE MORE VISIBLE.
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.