37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 712301 |
Time | |
Date | 200608 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 700 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 712301 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead 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 indications other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : engineering procedure contributing factor : manuals performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft Environmental Factor |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Maint Manual Chap 52 |
Narrative:
Cargo door seal was installed backwards. I was installing a new cargo door seal and was following the amm up to the follow-up steps. The amm was not clear and the way the seal was labeled was wrong. I was confused so I asked a co-worker. He said he had not replaced the seal before; so I went to my lead tech. He looked at the seal and the amm and we decided to put the seal on opposite of the way it was labeled. The seal was labeled wrong and the amm is not clear and that can confuse a new mechanic like me. The amm does not say improper installation could cause pressurization problems.callback conversation with reporter revealed the following information: the reporter stated the seal was marked incorrectly 'fwd' was 'aft' and 'top' was 'bottom.' the seal was actually installed correctly in the original installation but noting the seal markings; the reporter requested lead technician help. The lead technician and the reporter checked the maintenance manual pictorials and text and found little help. The lead technician advised removing the seal and reinstall using the seal markings as a guide. The seal was removed and installed according with the markings. The next shift made the operational pressurization check and released the airplane for service. First flight the airplane came back with pressurization problems.
Original NASA ASRS Text
Title: A CRJ700 WAS RELEASED FOR SVC AFTER THE AFT CARGO DOOR SEAL WAS REPLACED. FLT CREW EXPERIENCED PRESSURIZATION PROBS. RETURNED TO DEP ARPT. THE DOOR SEAL LABELING WAS ALLEGEDLY REVERSED.
Narrative: CARGO DOOR SEAL WAS INSTALLED BACKWARDS. I WAS INSTALLING A NEW CARGO DOOR SEAL AND WAS FOLLOWING THE AMM UP TO THE FOLLOW-UP STEPS. THE AMM WAS NOT CLEAR AND THE WAY THE SEAL WAS LABELED WAS WRONG. I WAS CONFUSED SO I ASKED A CO-WORKER. HE SAID HE HAD NOT REPLACED THE SEAL BEFORE; SO I WENT TO MY LEAD TECH. HE LOOKED AT THE SEAL AND THE AMM AND WE DECIDED TO PUT THE SEAL ON OPPOSITE OF THE WAY IT WAS LABELED. THE SEAL WAS LABELED WRONG AND THE AMM IS NOT CLEAR AND THAT CAN CONFUSE A NEW MECHANIC LIKE ME. THE AMM DOES NOT SAY IMPROPER INSTALLATION COULD CAUSE PRESSURIZATION PROBS.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE SEAL WAS MARKED INCORRECTLY 'FWD' WAS 'AFT' AND 'TOP' WAS 'BOTTOM.' THE SEAL WAS ACTUALLY INSTALLED CORRECTLY IN THE ORIGINAL INSTALLATION BUT NOTING THE SEAL MARKINGS; THE RPTR REQUESTED LEAD TECHNICIAN HELP. THE LEAD TECHNICIAN AND THE RPTR CHKED THE MAINT MANUAL PICTORIALS AND TEXT AND FOUND LITTLE HELP. THE LEAD TECHNICIAN ADVISED REMOVING THE SEAL AND REINSTALL USING THE SEAL MARKINGS AS A GUIDE. THE SEAL WAS REMOVED AND INSTALLED ACCORDING WITH THE MARKINGS. THE NEXT SHIFT MADE THE OPERATIONAL PRESSURIZATION CHK AND RELEASED THE AIRPLANE FOR SVC. FIRST FLT THE AIRPLANE CAME BACK WITH PRESSURIZATION PROBS.
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.