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Attributes | |
ACN | 765020 |
Time | |
Date | 200711 |
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 | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 21 |
ASRS Report | 765020 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 21 |
ASRS Report | 764805 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure contributing factor : briefing performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Beginning of shift; I was assigned a slide change at door 1L for time limit. Myself and another mechanic picked up what we presumed was a new slide. We installed the slide and had the installation inspected. Each of us thought the other had filled out the part tag. It turned out we had installed a used slide removed for time earlier in the day. We entered work performed and slide part numbers and released the aircraft. Neither one of us verified this was an airworthy slide prior to installation. Aircraft flew 6 legs with an out of time slide. Callback conversation with reporter revealed the following information: reporter states the events started when they were pulled off of another aircraft they were working to replace the fwd entry door 1-LEFT escape slide on what was supposed to be a 'hot' aircraft; with departure time approaching. They picked-up the replacement slide in their stores; parts staging area allocated for new; serviceable slides. However; the parts employee was fairly new and not familiar with the positioning of serviceable and unserviceable slide containers. Reporter further stated; they just assumed the slide in the 'normal' serviceable holding area was a 'good' slide. Just having what was assumed to be a 'good' slide available was surprising; because of the constant shortage of parts. Any aircraft pulled out of service is sure to have parts 'robbed' or cannibalized for some other aircraft that needs a part. After installing the replacement slide; both he; his fellow mechanic and their inspector verified the slide part # and serial # was accepted into their company's maintenance data computer system. Reporter also noted; this replacement escape slide part # and serial numbers should not have been accepted into their maintenance computer system; if in fact; it had already been removed from another aircraft for time; and that was according to his company's own procedures manual. But; the numbers were accepted and all three of them believed the installation record requirement was satisfied. Since this incident; company changes have been; and are being implemented; to address the slide staging areas; their maintenance computer data entry acceptance criteria; emphasis on mechanics' use of parts tags and verifying serviceable slides.
Original NASA ASRS Text
Title: A B767-300 FWD CABIN ENTRY DOOR 1-LEFT ESCAPE SLIDE WAS REPLACED FOR TIME. AFTER SIX FLIGHTS; THE REPLACEMENT SLIDE WAS FOUND TO HAVE BEEN USED; NOT SERVICEABLE SLIDE AND REMOVED EARLIER; ALSO FOR TIME; FROM A DIFFERENT ACFT.
Narrative: BEGINNING OF SHIFT; I WAS ASSIGNED A SLIDE CHANGE AT DOOR 1L FOR TIME LIMIT. MYSELF AND ANOTHER MECH PICKED UP WHAT WE PRESUMED WAS A NEW SLIDE. WE INSTALLED THE SLIDE AND HAD THE INSTALLATION INSPECTED. EACH OF US THOUGHT THE OTHER HAD FILLED OUT THE PART TAG. IT TURNED OUT WE HAD INSTALLED A USED SLIDE REMOVED FOR TIME EARLIER IN THE DAY. WE ENTERED WORK PERFORMED AND SLIDE PART NUMBERS AND RELEASED THE ACFT. NEITHER ONE OF US VERIFIED THIS WAS AN AIRWORTHY SLIDE PRIOR TO INSTALLATION. ACFT FLEW 6 LEGS WITH AN OUT OF TIME SLIDE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATES THE EVENTS STARTED WHEN THEY WERE PULLED OFF OF ANOTHER ACFT THEY WERE WORKING TO REPLACE THE FWD ENTRY DOOR 1-LEFT ESCAPE SLIDE ON WHAT WAS SUPPOSED TO BE A 'HOT' ACFT; WITH DEPARTURE TIME APPROACHING. THEY PICKED-UP THE REPLACEMENT SLIDE IN THEIR STORES; PARTS STAGING AREA ALLOCATED FOR NEW; SERVICEABLE SLIDES. HOWEVER; THE PARTS EMPLOYEE WAS FAIRLY NEW AND NOT FAMILIAR WITH THE POSITIONING OF SERVICEABLE AND UNSERVICEABLE SLIDE CONTAINERS. REPORTER FURTHER STATED; THEY JUST ASSUMED THE SLIDE IN THE 'NORMAL' SERVICEABLE HOLDING AREA WAS A 'GOOD' SLIDE. JUST HAVING WHAT WAS ASSUMED TO BE A 'GOOD' SLIDE AVAILABLE WAS SURPRISING; BECAUSE OF THE CONSTANT SHORTAGE OF PARTS. ANY ACFT PULLED OUT OF SERVICE IS SURE TO HAVE PARTS 'ROBBED' OR CANNIBALIZED FOR SOME OTHER ACFT THAT NEEDS A PART. AFTER INSTALLING THE REPLACEMENT SLIDE; BOTH HE; HIS FELLOW MECHANIC AND THEIR INSPECTOR VERIFIED THE SLIDE PART # AND SERIAL # WAS ACCEPTED INTO THEIR COMPANY'S MAINT DATA COMPUTER SYSTEM. REPORTER ALSO NOTED; THIS REPLACEMENT ESCAPE SLIDE PART # AND SERIAL NUMBERS SHOULD NOT HAVE BEEN ACCEPTED INTO THEIR MAINT COMPUTER SYSTEM; IF IN FACT; IT HAD ALREADY BEEN REMOVED FROM ANOTHER ACFT FOR TIME; AND THAT WAS ACCORDING TO HIS COMPANY'S OWN PROCEDURES MANUAL. BUT; THE NUMBERS WERE ACCEPTED AND ALL THREE OF THEM BELIEVED THE INSTALLATION RECORD REQUIREMENT WAS SATISFIED. SINCE THIS INCIDENT; COMPANY CHANGES HAVE BEEN; AND ARE BEING IMPLEMENTED; TO ADDRESS THE SLIDE STAGING AREAS; THEIR MAINT COMPUTER DATA ENTRY ACCEPTANCE CRITERIA; EMPHASIS ON MECHANICS' USE OF PARTS TAGS AND VERIFYING SERVICEABLE SLIDES.
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.