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A B757-200 service door escape slide was replaced for falling out. Slide replaced per maintenance manual. Technicians failed to service door bottle.
| Attributes | |
| ACN | 725387 |
| Time | |
| Date | 200701 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 7 |
| ASRS Report | 725387 |
| Person 2 | |
| Affiliation | company : air carrier |
| Qualification | technician : powerplant technician : inspection authority technician : airframe |
| Experience | maintenance technician : 3 |
| ASRS Report | 725388 |
| 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 : door bottle presss indicator other other : 4 |
| Resolutory Action | other |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
I was working overtime; when I was sent to gate X for an R-1 door slide change. We changed the slide per the maintenance manual; all the way to the last page; which shows the installation of the d-ring strap. At that point; maybe because we were being rushed and the plane was already boarding; we mistakenly did not check the emergency power (reservoir). This was perhaps easy for us to overlook because the slide had not deployed. It had just fallen off the door. I believed we were changing it as (precautionary). Also the fact that when I arrived the slide was in the jetway and the R-1 door was closed. Something like the emergency power reservoir would blow the door open and deploy the slide.
Original NASA ASRS Text
Title: A B757-200 SVC DOOR ESCAPE SLIDE WAS REPLACED FOR FALLING OUT. SLIDE REPLACED PER MAINT MANUAL. TECHNICIANS FAILED TO SVC DOOR BOTTLE.
Narrative: I WAS WORKING OVERTIME; WHEN I WAS SENT TO GATE X FOR AN R-1 DOOR SLIDE CHANGE. WE CHANGED THE SLIDE PER THE MAINT MANUAL; ALL THE WAY TO THE LAST PAGE; WHICH SHOWS THE INSTALLATION OF THE D-RING STRAP. AT THAT POINT; MAYBE BECAUSE WE WERE BEING RUSHED AND THE PLANE WAS ALREADY BOARDING; WE MISTAKENLY DID NOT CHK THE EMER PWR (RESERVOIR). THIS WAS PERHAPS EASY FOR US TO OVERLOOK BECAUSE THE SLIDE HAD NOT DEPLOYED. IT HAD JUST FALLEN OFF THE DOOR. I BELIEVED WE WERE CHANGING IT AS (PRECAUTIONARY). ALSO THE FACT THAT WHEN I ARRIVED THE SLIDE WAS IN THE JETWAY AND THE R-1 DOOR WAS CLOSED. SOMETHING LIKE THE EMER PWR RESERVOIR WOULD BLOW THE DOOR OPEN AND DEPLOY THE SLIDE.
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.