 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Two mechanics were informed of a B737-800 requiring an air turnback due to inability to pressurize the aircraft. The #1 cargo door pressure seal had been installed backwards.
| Attributes | |
| ACN | 786215 |
| Time | |
| Date | 200805 |
| 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 | B737-800 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 19.5 |
| ASRS Report | 786215 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 19.00 |
| ASRS Report | 78624 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | flight crew : diverted to another airport |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : briefing performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : inspection performance deficiency : installation performance deficiency : repair performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
I picked up on a non routine card from the work center with a written turnover stating that the #1 cargo door seal needed completion of the remaining 24 inches at the top of the door. Installed remaining section and closed door to check for seal contact. Signed for installation of seal. Aircraft experienced air turnback on the first flight due to inability to pressurize. Upon investigation; found seal installed incorrectly. Local supervision counseled me on event. Ink stamp on seal led me to believe seal was installed correctly. Supplemental information from acn 786214: I began installing the #1 cargo door seal up to the top of the door and at the end of the shift executed a written turnover for the job to be completed and turned in to the work center. Aircraft experienced an air turnback; unable to pressurize. Upon investigation; found seal installed backwards.
Original NASA ASRS Text
Title: TWO MECHANICS WERE INFORMED OF A B737-800 REQUIRING AN AIR TURNBACK DUE TO INABILITY TO PRESSURIZE THE ACFT. THE #1 CARGO DOOR PRESSURE SEAL HAD BEEN INSTALLED BACKWARDS.
Narrative: I PICKED UP ON A NON ROUTINE CARD FROM THE WORK CTR WITH A WRITTEN TURNOVER STATING THAT THE #1 CARGO DOOR SEAL NEEDED COMPLETION OF THE REMAINING 24 INCHES AT THE TOP OF THE DOOR. INSTALLED REMAINING SECTION AND CLOSED DOOR TO CHK FOR SEAL CONTACT. SIGNED FOR INSTALLATION OF SEAL. ACFT EXPERIENCED AIR TURNBACK ON THE FIRST FLT DUE TO INABILITY TO PRESSURIZE. UPON INVESTIGATION; FOUND SEAL INSTALLED INCORRECTLY. LCL SUPERVISION COUNSELED ME ON EVENT. INK STAMP ON SEAL LED ME TO BELIEVE SEAL WAS INSTALLED CORRECTLY. SUPPLEMENTAL INFO FROM ACN 786214: I BEGAN INSTALLING THE #1 CARGO DOOR SEAL UP TO THE TOP OF THE DOOR AND AT THE END OF THE SHIFT EXECUTED A WRITTEN TURNOVER FOR THE JOB TO BE COMPLETED AND TURNED IN TO THE WORK CTR. ACFT EXPERIENCED AN AIR TURNBACK; UNABLE TO PRESSURIZE. UPON INVESTIGATION; FOUND SEAL INSTALLED BACKWARDS.
Data retrieved from NASA's ASRS site as of May 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.