37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 675203 |
Time | |
Date | 200510 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 5 maintenance technician : 20 |
ASRS Report | 675203 |
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 | aircraft equipment other aircraft equipment : cabin pressure indicator other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to another airport |
Factors | |
Maintenance | contributing factor : weather contributing factor : non availability of parts contributing factor : lighting performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
Upon arriving to work and getting my job assignment; this was replacing the cargo door seals (both doors forward and aft) on aircraft X. I found both seals had been removed and discarded. So there was no example to see before starting the job. There was 1 seal in an airbus parts box and it matched the effectivity for this A319. The box was already open; so I tried to verify it was the correct part. I found the part number written on it with a ballpoint pen; not stamped. There was no other marking on the seal at all. I was informed that there would be another seal coming later that night for the other cargo door. Both cargo doors took the same seal part number. I pulled the amm and printed it. After reading it; I looked for the other markings on it; like the amm stated. It stated that the seal should say 'lower door' on it. This marking could not be located on the seal. I proceeded to go and install the seal that I had with the inflation holes on the inside of the door for the aft cargo door. After completing this; I had about a 2 hour wait for the other seal to arrive. When it arrived; I installed it in the forward cargo door. I did not see a marking on it stating 'lower door' either. After installing it; I finished the paperwork and released the aircraft for service. The next day; I heard there had been a problem with pressurization and they could not pressurize the cabin above 9000 ft on their flight. I could not remember checking the placement of the inflation holes as stated in the AMM52-31-18-410. I notified the mechanics on field service working the aircraft and suggested them to verify where the inflation holes were on the forward door. I asked that they also verify the aft door seal inflation holes location. I didn't hear back until oct/thu/05. There were a lot of human factors that led up to this. The most disturbing part that the seal; I didn't think was marked correctly. The lighting in doing the job was less than adequate and the WX was becoming an issue (cold). In reality; these are all excuses; but contributing factors when they are put on one another.
Original NASA ASRS Text
Title: AN A319 DIVERTED DUE TO INABILITY TO PRESSURIZE CABIN ABOVE 9000 FT. FOUND LOWER CARGO DOOR SEALS IMPROPERLY INSTALLED.
Narrative: UPON ARRIVING TO WORK AND GETTING MY JOB ASSIGNMENT; THIS WAS REPLACING THE CARGO DOOR SEALS (BOTH DOORS FORWARD AND AFT) ON ACFT X. I FOUND BOTH SEALS HAD BEEN REMOVED AND DISCARDED. SO THERE WAS NO EXAMPLE TO SEE BEFORE STARTING THE JOB. THERE WAS 1 SEAL IN AN AIRBUS PARTS BOX AND IT MATCHED THE EFFECTIVITY FOR THIS A319. THE BOX WAS ALREADY OPEN; SO I TRIED TO VERIFY IT WAS THE CORRECT PART. I FOUND THE PART NUMBER WRITTEN ON IT WITH A BALLPOINT PEN; NOT STAMPED. THERE WAS NO OTHER MARKING ON THE SEAL AT ALL. I WAS INFORMED THAT THERE WOULD BE ANOTHER SEAL COMING LATER THAT NIGHT FOR THE OTHER CARGO DOOR. BOTH CARGO DOORS TOOK THE SAME SEAL PART NUMBER. I PULLED THE AMM AND PRINTED IT. AFTER READING IT; I LOOKED FOR THE OTHER MARKINGS ON IT; LIKE THE AMM STATED. IT STATED THAT THE SEAL SHOULD SAY 'LOWER DOOR' ON IT. THIS MARKING COULD NOT BE LOCATED ON THE SEAL. I PROCEEDED TO GO AND INSTALL THE SEAL THAT I HAD WITH THE INFLATION HOLES ON THE INSIDE OF THE DOOR FOR THE AFT CARGO DOOR. AFTER COMPLETING THIS; I HAD ABOUT A 2 HR WAIT FOR THE OTHER SEAL TO ARRIVE. WHEN IT ARRIVED; I INSTALLED IT IN THE FORWARD CARGO DOOR. I DID NOT SEE A MARKING ON IT STATING 'LOWER DOOR' EITHER. AFTER INSTALLING IT; I FINISHED THE PAPERWORK AND RELEASED THE ACFT FOR SVC. THE NEXT DAY; I HEARD THERE HAD BEEN A PROB WITH PRESSURIZATION AND THEY COULD NOT PRESSURIZE THE CABIN ABOVE 9000 FT ON THEIR FLT. I COULD NOT REMEMBER CHKING THE PLACEMENT OF THE INFLATION HOLES AS STATED IN THE AMM52-31-18-410. I NOTIFIED THE MECHS ON FIELD SVC WORKING THE ACFT AND SUGGESTED THEM TO VERIFY WHERE THE INFLATION HOLES WERE ON THE FORWARD DOOR. I ASKED THAT THEY ALSO VERIFY THE AFT DOOR SEAL INFLATION HOLES LOCATION. I DIDN'T HEAR BACK UNTIL OCT/THU/05. THERE WERE A LOT OF HUMAN FACTORS THAT LED UP TO THIS. THE MOST DISTURBING PART THAT THE SEAL; I DIDN'T THINK WAS MARKED CORRECTLY. THE LIGHTING IN DOING THE JOB WAS LESS THAN ADEQUATE AND THE WX WAS BECOMING AN ISSUE (COLD). IN REALITY; THESE ARE ALL EXCUSES; BUT CONTRIBUTING FACTORS WHEN THEY ARE PUT ON ONE ANOTHER.
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.