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A B767-400 was discovered to have door 4R escape slide girt bar carrier assembly missing by a cabin attendant doing the cabin pre departure check.
| Attributes | |
| ACN | 711276 |
| Time | |
| Date | 200609 |
| 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 | B767-400 and 400 ER |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : preflight ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : fcc technician : powerplant technician : airframe |
| Experience | maintenance technician : 16 |
| ASRS Report | 711276 |
| Person 2 | |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 17 |
| ASRS Report | 711278 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other Other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Environmental Factor Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
While performing a scheduled slide deployment on an air carrier X B767-400 aircraft; a girt bar carrier assembly was removed to aid in removing the slide from the door area. The girt bar carrier assembly was never retrieved from the blown slide and reinstalled on the affected door. After slide installation the door slide was armed and the slide light illuminated as a result; thus giving the false impression that the installation had been completed correctly. The incident was discovered by a flight attendant during her preflight duties. The slide was deferred by maintenance and as a result 9 rows of seats had to be blocked off. The following day I greeted the inbound flight and installed the serviceable girt bar carrier assembly and checked the installation. The deferred slide was cleared from deferred status.
Original NASA ASRS Text
Title: A B767-400 WAS DISCOVERED TO HAVE DOOR 4R ESCAPE SLIDE GIRT BAR CARRIER ASSEMBLY MISSING BY A CABIN ATTENDANT DOING THE CABIN PRE DEP CHK.
Narrative: WHILE PERFORMING A SCHEDULED SLIDE DEPLOYMENT ON AN ACR X B767-400 ACFT; A GIRT BAR CARRIER ASSEMBLY WAS REMOVED TO AID IN REMOVING THE SLIDE FROM THE DOOR AREA. THE GIRT BAR CARRIER ASSEMBLY WAS NEVER RETRIEVED FROM THE BLOWN SLIDE AND REINSTALLED ON THE AFFECTED DOOR. AFTER SLIDE INSTALLATION THE DOOR SLIDE WAS ARMED AND THE SLIDE LIGHT ILLUMINATED AS A RESULT; THUS GIVING THE FALSE IMPRESSION THAT THE INSTALLATION HAD BEEN COMPLETED CORRECTLY. THE INCIDENT WAS DISCOVERED BY A FLT ATTENDANT DURING HER PREFLT DUTIES. THE SLIDE WAS DEFERRED BY MAINT AND AS A RESULT 9 ROWS OF SEATS HAD TO BE BLOCKED OFF. THE FOLLOWING DAY I GREETED THE INBOUND FLT AND INSTALLED THE SERVICEABLE GIRT BAR CARRIER ASSEMBLY AND CHKED THE INSTALLATION. THE DEFERRED SLIDE WAS CLRED FROM DEFERRED STATUS.
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.