 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
A B767-300 aircraft door 4-LEFT door slide was inadvertently replaced with a slide configured for door 2-LEFT. Correct slide was installed at down line station.
| Attributes | |
| ACN | 755509 |
| Time | |
| Date | 200709 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B767-300 and 300 ER |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | other |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance lead technician : 1 maintenance technician : 19 |
| ASRS Report | 755509 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : briefing contributing factor : manuals performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : training performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | MM Door Location Inadequate |
Narrative:
Myself and an air carrier X rep/mechanic were to install a slide for time change on aircraft X in ZZZ. I replaced the slide while the air carrier X rep accomplished the rii. Due to the different door configns in the fleet we inadvertently installed a L2 slide in the L4 position. The aircraft departed to ZZZ1. When it arrived the slide was removed and replaced with the correct one. Callback conversation with reporter revealed the following information: reporter stated he is a contract maintenance group working with a carrier rep for overnight maintenance. There was confusion with the carrier's MM for indicating cabin entry door location numbering system. As a result; both the reporter and the company rep; acting as the rii; just misinterpreted the slide position. The slide was being changed for time.
Original NASA ASRS Text
Title: A B767-300 ACFT DOOR 4-LEFT DOOR SLIDE WAS INADVERTENTLY REPLACED WITH A SLIDE CONFIGURED FOR DOOR 2-LEFT. CORRECT SLIDE WAS INSTALLED AT DOWN LINE STATION.
Narrative: MYSELF AND AN ACR X REP/MECH WERE TO INSTALL A SLIDE FOR TIME CHANGE ON ACFT X IN ZZZ. I REPLACED THE SLIDE WHILE THE ACR X REP ACCOMPLISHED THE RII. DUE TO THE DIFFERENT DOOR CONFIGNS IN THE FLEET WE INADVERTENTLY INSTALLED A L2 SLIDE IN THE L4 POS. THE ACFT DEPARTED TO ZZZ1. WHEN IT ARRIVED THE SLIDE WAS REMOVED AND REPLACED WITH THE CORRECT ONE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED HE IS A CONTRACT MAINT GROUP WORKING WITH A CARRIER REP FOR OVERNIGHT MAINT. THERE WAS CONFUSION WITH THE CARRIER'S MM FOR INDICATING CABIN ENTRY DOOR LOCATION NUMBERING SYSTEM. AS A RESULT; BOTH THE REPORTER AND THE COMPANY REP; ACTING AS THE RII; JUST MISINTERPRETED THE SLIDE POSITION. THE SLIDE WAS BEING CHANGED FOR TIME.
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.