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Attributes | |
ACN | 770138 |
Time | |
Date | 200712 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : iad.airport |
State Reference | DC |
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 ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 770138 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 770140 |
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 : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : training performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Beginning of shift myself and another mechanic were assigned a slide change. We installed the slide; and had it inspected. Each of us thought the other filled out the tag; however it turns out we installed a slide which had been removed earlier in the day. We did not catch the error and the plane was returned to service with a time limited slide. 'Suggested resolution provided by the submitter' if there is a discrepancy with any of the maintenance record numbers entered into maintenance system; there should be a red flag or some type of warning displayed on the screen. Supplemental information from acn 770140: beginning of shift I was assigned a slide change at aircraft main cabin entry door 1L with another mechanic. We picked up the slide at stores; installed; and had it inspected. Supplemental information from acn 770141: changed slide per maintenance manual. Normal operations. No problem with slide installation and paperwork. Callback conversation with reporter acn #770141 revealed the following information: reporter stated he removed the slide from door 2-RIGHT that ended up being installed on a different B767-300 at door 1-LEFT. The slide removed from the door 2-RIGHT aircraft had only three days left on serviceable time. Reporter stated their maintenance data system allows the mechanic to enter a part number; in this case a door slide; and 'force' the computer system to accept the part number as valid; whereas normally; the number would be rejected as belonging to another aircraft or removed for maintenance. Reporter also added that this maintenance data entry system does have some problems with accepting valid part number entries. Knowing this; mechanics tend to believe the part number entry they are inputting is valid and so they 'force' the program to accept their data entry. In this case; the maintenance data program did recognize and 'flag' the slide part number as not being valid; but the door 1-LEFT mechanics figured this was just another computer glitch; believing they had a serviceable slide; so they just 'forced' the data entry. The inspector also missed this part of the slide verification.
Original NASA ASRS Text
Title: A B767-300 CABIN DOOR 1-LEFT SLIDE WAS INADVERTENTLY REPLACED WITH A SLIDE THAT WAS ALSO REMOVED EARLIER FROM ANOTHER B767-300 ACFT FOR TIME REQUIREMENTS.
Narrative: BEGINNING OF SHIFT MYSELF AND ANOTHER MECH WERE ASSIGNED A SLIDE CHANGE. WE INSTALLED THE SLIDE; AND HAD IT INSPECTED. EACH OF US THOUGHT THE OTHER FILLED OUT THE TAG; HOWEVER IT TURNS OUT WE INSTALLED A SLIDE WHICH HAD BEEN REMOVED EARLIER IN THE DAY. WE DID NOT CATCH THE ERROR AND THE PLANE WAS RETURNED TO SVC WITH A TIME LIMITED SLIDE. 'SUGGESTED RESOLUTION PROVIDED BY THE SUBMITTER' IF THERE IS A DISCREPANCY WITH ANY OF THE MAINT RECORD NUMBERS ENTERED INTO MAINT SYS; THERE SHOULD BE A RED FLAG OR SOME TYPE OF WARNING DISPLAYED ON THE SCREEN. SUPPLEMENTAL INFO FROM ACN 770140: BEGINNING OF SHIFT I WAS ASSIGNED A SLIDE CHANGE AT ACFT MAIN CABIN ENTRY DOOR 1L WITH ANOTHER MECH. WE PICKED UP THE SLIDE AT STORES; INSTALLED; AND HAD IT INSPECTED. SUPPLEMENTAL INFO FROM ACN 770141: CHANGED SLIDE PER MAINT MANUAL. NORMAL OPS. NO PROB WITH SLIDE INSTALLATION AND PAPERWORK. CALLBACK CONVERSATION WITH RPTR ACN #770141 REVEALED THE FOLLOWING INFO: REPORTER STATED HE REMOVED THE SLIDE FROM DOOR 2-RIGHT THAT ENDED UP BEING INSTALLED ON A DIFFERENT B767-300 AT DOOR 1-LEFT. THE SLIDE REMOVED FROM THE DOOR 2-RIGHT ACFT HAD ONLY THREE DAYS LEFT ON SERVICEABLE TIME. REPORTER STATED THEIR MAINT DATA SYSTEM ALLOWS THE MECHANIC TO ENTER A PART NUMBER; IN THIS CASE A DOOR SLIDE; AND 'FORCE' THE COMPUTER SYSTEM TO ACCEPT THE PART NUMBER AS VALID; WHEREAS NORMALLY; THE NUMBER WOULD BE REJECTED AS BELONGING TO ANOTHER ACFT OR REMOVED FOR MAINT. REPORTER ALSO ADDED THAT THIS MAINT DATA ENTRY SYSTEM DOES HAVE SOME PROBLEMS WITH ACCEPTING VALID PART NUMBER ENTRIES. KNOWING THIS; MECHANICS TEND TO BELIEVE THE PART NUMBER ENTRY THEY ARE INPUTTING IS VALID AND SO THEY 'FORCE' THE PROGRAM TO ACCEPT THEIR DATA ENTRY. IN THIS CASE; THE MAINT DATA PROGRAM DID RECOGNIZE AND 'FLAG' THE SLIDE PART NUMBER AS NOT BEING VALID; BUT THE DOOR 1-LEFT MECHANICS FIGURED THIS WAS JUST ANOTHER COMPUTER GLITCH; BELIEVING THEY HAD A SERVICEABLE SLIDE; SO THEY JUST 'FORCED' THE DATA ENTRY. THE INSPECTOR ALSO MISSED THIS PART OF THE SLIDE VERIFICATION.
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.