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|
Attributes | |
ACN | 747811 |
Time | |
Date | 200707 |
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 | B777-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 25 |
ASRS Report | 747811 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
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 : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : briefing performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Engineering Directive |
Narrative:
Aircraft X arrived ZZZ for an extended layover. I began working logbook write-ups and routine maintenance items on the above aircraft. Item XXX was called out by company engineering to replace the emergency escape slide at door 1R for time; I misinterped the callout instructions; I perceived the callout as checking the part number and dash number for proper location and if found at 1R no further action other than the required computer entries were required. ZZZ maintenance management was notified the next day by maintenance control that 1R slide was signed off replaced by me however the slide at 1R was not physically replaced. I was alerted to the situation by ZZZ maintenance management where I immediately reviewed the callout in the aircraft history and after carefully reading the text realized I had misunderstood the intent of the callout. I did not however sign off the item by stating that I replaced the slide; my sign off simply stated that part number X was found to be installed in 1R position; I believed at the time that I had followed the callout instructions and complied with task as directed; I did not falsify the replacement nor sign off the item claiming to have replaced the slide; my signoff stated exactly what I accomplished. I was working 3 gates and multiple items on this day which may have contributed to my mistake and not thoroughly reading and understanding the callout and its instructions.
Original NASA ASRS Text
Title: A B777-222 ACFT REQUIRED A DOOR 1-R ESCAPE SLIDE/RAFT REPLACEMENT. CALLOUT WAS MISINTERPRETED. SLIDE NOT REPLACED.
Narrative: ACFT X ARRIVED ZZZ FOR AN EXTENDED LAYOVER. I BEGAN WORKING LOGBOOK WRITE-UPS AND ROUTINE MAINT ITEMS ON THE ABOVE ACFT. ITEM XXX WAS CALLED OUT BY COMPANY ENGINEERING TO REPLACE THE EMER ESCAPE SLIDE AT DOOR 1R FOR TIME; I MISINTERPED THE CALLOUT INSTRUCTIONS; I PERCEIVED THE CALLOUT AS CHKING THE PART NUMBER AND DASH NUMBER FOR PROPER LOCATION AND IF FOUND AT 1R NO FURTHER ACTION OTHER THAN THE REQUIRED COMPUTER ENTRIES WERE REQUIRED. ZZZ MAINT MGMNT WAS NOTIFIED THE NEXT DAY BY MAINT CTL THAT 1R SLIDE WAS SIGNED OFF REPLACED BY ME HOWEVER THE SLIDE AT 1R WAS NOT PHYSICALLY REPLACED. I WAS ALERTED TO THE SITUATION BY ZZZ MAINT MGMNT WHERE I IMMEDIATELY REVIEWED THE CALLOUT IN THE ACFT HISTORY AND AFTER CAREFULLY READING THE TEXT REALIZED I HAD MISUNDERSTOOD THE INTENT OF THE CALLOUT. I DID NOT HOWEVER SIGN OFF THE ITEM BY STATING THAT I REPLACED THE SLIDE; MY SIGN OFF SIMPLY STATED THAT PART NUMBER X WAS FOUND TO BE INSTALLED IN 1R POS; I BELIEVED AT THE TIME THAT I HAD FOLLOWED THE CALLOUT INSTRUCTIONS AND COMPLIED WITH TASK AS DIRECTED; I DID NOT FALSIFY THE REPLACEMENT NOR SIGN OFF THE ITEM CLAIMING TO HAVE REPLACED THE SLIDE; MY SIGNOFF STATED EXACTLY WHAT I ACCOMPLISHED. I WAS WORKING 3 GATES AND MULTIPLE ITEMS ON THIS DAY WHICH MAY HAVE CONTRIBUTED TO MY MISTAKE AND NOT THOROUGHLY READING AND UNDERSTANDING THE CALLOUT AND ITS INSTRUCTIONS.
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.