 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
A B737-700 door escape slide was removed and placed in a shipping container with the shipping safety pin installed incorrectly.
| Attributes | |
| ACN | 691989 |
| Time | |
| Date | 200603 |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 691989 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : training performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
I was working line routine overnight. The task was to remove and replace front emergency slide. The error occurred on emergency slide needed to be shipped out; the shipping safety pin was in the question. After I have placed the slide in the shipping container; I noticed that hole to insert the pin is not on usual place that I was accustomed to. I checked mid-25 for slide installed on the plane -- now new slide -- that was ok. Ipc showed safety pin installation on the top of slide (upper right corner); however; slide to be shipped had 2 holes on the side just below pressure gauge in which one of those safety pins fit in. I chose shorter pin due to clearance between slide and container. Just to avoid future error; injury or damage; perhaps inspector needs to be present before closing a shipping container; or some sort of warning to mechanic of possibility of installing improper shipping-safety pin.
Original NASA ASRS Text
Title: A B737-700 DOOR ESCAPE SLIDE WAS REMOVED AND PLACED IN A SHIPPING CONTAINER WITH THE SHIPPING SAFETY PIN INSTALLED INCORRECTLY.
Narrative: I WAS WORKING LINE ROUTINE OVERNIGHT. THE TASK WAS TO REMOVE AND REPLACE FRONT EMER SLIDE. THE ERROR OCCURRED ON EMER SLIDE NEEDED TO BE SHIPPED OUT; THE SHIPPING SAFETY PIN WAS IN THE QUESTION. AFTER I HAVE PLACED THE SLIDE IN THE SHIPPING CONTAINER; I NOTICED THAT HOLE TO INSERT THE PIN IS NOT ON USUAL PLACE THAT I WAS ACCUSTOMED TO. I CHKED MID-25 FOR SLIDE INSTALLED ON THE PLANE -- NOW NEW SLIDE -- THAT WAS OK. IPC SHOWED SAFETY PIN INSTALLATION ON THE TOP OF SLIDE (UPPER R CORNER); HOWEVER; SLIDE TO BE SHIPPED HAD 2 HOLES ON THE SIDE JUST BELOW PRESSURE GAUGE IN WHICH ONE OF THOSE SAFETY PINS FIT IN. I CHOSE SHORTER PIN DUE TO CLRNC BTWN SLIDE AND CONTAINER. JUST TO AVOID FUTURE ERROR; INJURY OR DAMAGE; PERHAPS INSPECTOR NEEDS TO BE PRESENT BEFORE CLOSING A SHIPPING CONTAINER; OR SOME SORT OF WARNING TO MECH OF POSSIBILITY OF INSTALLING IMPROPER SHIPPING-SAFETY PIN.
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.