37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 703557 |
Time | |
Date | 200604 |
Local Time Of Day | 0001 To 0600 |
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 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : fcc technician : airframe |
Experience | maintenance avionics : 16 maintenance technician : 1 |
ASRS Report | 703557 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : fcc technician : airframe technician : inspection authority technician : powerplant |
Experience | maintenance technician : 27 |
ASRS Report | 703556 |
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 : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure contributing factor : manuals performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was assigned to do the a-chk on aircraft in the cabin. Door 1R emergency slide inspection window of pressure gauge was found cracked and I made the write-up. This was my first time to replace the emergency slide. So; I asked my lead mechanic for help and train me to do the slide replacement along with maintenance manual. On jul/fri/06; I was notified that the regulator pin of the emergency slide at door 1R was found still installed on aircraft. Callback conversation with reporter revealed the following information: the reporter stated he recently was facing layoff at another station and exercising seniority was xferred to this station to work as an aircraft and power plant technician. Previous work experience was working in avionics for 16 yrs and although having an aircraft and power plant license had no practical work experience. This was the first escape slide installation assignment and the reporter requested the lead technician to instruct and assist with the installation using the maintenance manual. The safety pin was not removed during the installation of the slide. The reporter admits the manual is clear in one of the steps to remove the safety pin. Callback conversation with reporter from acn 703556 revealed the following information: the reporter stated the slide installation is an FAA required inspection item and the inspection is a visual overall inspection. The removal of the safety pin cannot be verified unless the slide is removed. The reporter stated the installation technician reported the pin was removed and stowed. The pin stowage cannot be confirmed as the slide would require removal. The pin problem may finally be resolved as it is rumored a new maintenance procedure and pin confign is in the works.
Original NASA ASRS Text
Title: A B737-500 WAS DISPATCHED AND OPERATED WITH DOOR 1R EMER ESCAPE SLIDE INSTALLED WITH THE SAFETY PIN STILL INSTALLED.
Narrative: I WAS ASSIGNED TO DO THE A-CHK ON ACFT IN THE CABIN. DOOR 1R EMER SLIDE INSPECTION WINDOW OF PRESSURE GAUGE WAS FOUND CRACKED AND I MADE THE WRITE-UP. THIS WAS MY FIRST TIME TO REPLACE THE EMER SLIDE. SO; I ASKED MY LEAD MECH FOR HELP AND TRAIN ME TO DO THE SLIDE REPLACEMENT ALONG WITH MAINT MANUAL. ON JUL/FRI/06; I WAS NOTIFIED THAT THE REGULATOR PIN OF THE EMER SLIDE AT DOOR 1R WAS FOUND STILL INSTALLED ON ACFT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED HE RECENTLY WAS FACING LAYOFF AT ANOTHER STATION AND EXERCISING SENIORITY WAS XFERRED TO THIS STATION TO WORK AS AN ACFT AND PWR PLANT TECHNICIAN. PREVIOUS WORK EXPERIENCE WAS WORKING IN AVIONICS FOR 16 YRS AND ALTHOUGH HAVING AN ACFT AND PWR PLANT LICENSE HAD NO PRACTICAL WORK EXPERIENCE. THIS WAS THE FIRST ESCAPE SLIDE INSTALLATION ASSIGNMENT AND THE RPTR REQUESTED THE LEAD TECHNICIAN TO INSTRUCT AND ASSIST WITH THE INSTALLATION USING THE MAINT MANUAL. THE SAFETY PIN WAS NOT REMOVED DURING THE INSTALLATION OF THE SLIDE. THE RPTR ADMITS THE MANUAL IS CLR IN ONE OF THE STEPS TO REMOVE THE SAFETY PIN. CALLBACK CONVERSATION WITH RPTR FROM ACN 703556 REVEALED THE FOLLOWING INFO: THE RPTR STATED THE SLIDE INSTALLATION IS AN FAA REQUIRED INSPECTION ITEM AND THE INSPECTION IS A VISUAL OVERALL INSPECTION. THE REMOVAL OF THE SAFETY PIN CANNOT BE VERIFIED UNLESS THE SLIDE IS REMOVED. THE RPTR STATED THE INSTALLATION TECHNICIAN REPORTED THE PIN WAS REMOVED AND STOWED. THE PIN STOWAGE CANNOT BE CONFIRMED AS THE SLIDE WOULD REQUIRE REMOVAL. THE PIN PROB MAY FINALLY BE RESOLVED AS IT IS RUMORED A NEW MAINT PROC AND PIN CONFIGN IS IN THE WORKS.
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.