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B737-300 right #1 entrance door snubber was replaced incorrectly; damaging the door seal and resulting in a noisy pressure leak.
| Attributes | |
| ACN | 679705 |
| Time | |
| Date | 200511 |
| Local Time Of Day | 1801 To 2400 |
| 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 |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : fcc technician : airframe technician : powerplant |
| Experience | maintenance lead technician : 2 maintenance technician : 15 |
| ASRS Report | 679705 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure non adherence : company policies |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | flight crew : diverted to another airport none taken : detected after the fact |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : lighting contributing factor : weather performance deficiency : installation performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Environmental Factor Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
On nov/sat/05; I was assigned to work on aircraft X on door 1R snubber. I replaced the snubber per maintenance manual; but I didn't install it correctly with the fitting towards the outboard side. That resulted in damaging the door seal and the aircraft had a squeal noise and pressure leak the next morning. It was a very cold and dark night. And I did not see that the snubber came in contact with the door seal; causing it to tear. I believe that this type of work needs to be accomplished in the hangar with sufficient lighting and work platforms. In addition; the snubber should be modified so it can be installed one way only (without damaging the door seal).
Original NASA ASRS Text
Title: B737-300 R #1 ENTRANCE DOOR SNUBBER WAS REPLACED INCORRECTLY; DAMAGING THE DOOR SEAL AND RESULTING IN A NOISY PRESSURE LEAK.
Narrative: ON NOV/SAT/05; I WAS ASSIGNED TO WORK ON ACFT X ON DOOR 1R SNUBBER. I REPLACED THE SNUBBER PER MAINT MANUAL; BUT I DIDN'T INSTALL IT CORRECTLY WITH THE FITTING TOWARDS THE OUTBOARD SIDE. THAT RESULTED IN DAMAGING THE DOOR SEAL AND THE ACFT HAD A SQUEAL NOISE AND PRESSURE LEAK THE NEXT MORNING. IT WAS A VERY COLD AND DARK NIGHT. AND I DID NOT SEE THAT THE SNUBBER CAME IN CONTACT WITH THE DOOR SEAL; CAUSING IT TO TEAR. I BELIEVE THAT THIS TYPE OF WORK NEEDS TO BE ACCOMPLISHED IN THE HANGAR WITH SUFFICIENT LIGHTING AND WORK PLATFORMS. IN ADDITION; THE SNUBBER SHOULD BE MODIFIED SO IT CAN BE INSTALLED ONE WAY ONLY (WITHOUT DAMAGING THE DOOR SEAL).
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.