Narrative:

My partner and I were doing a door slide change; and per MM you can use a specific pin for the door bottle or 2 bolts. Since pins are hard to find; we decided to use the bolts to pin the bottle; but we did not put the streamers on the bolts because we normally finished the whole job. And because the bottle is located in the ceiling near the main entrance; I closed the panel after we pinned the bottle to prevent anybody from hitting their head on the panel. And whoever finished the job did not pull the pins. The plane ended up flying around until it went to c-check and they found the bolts still in the bottle. Supplemental information from acn 810965: I was given the turnover from previous shift aircraft X door 1R slide change; that the door girt bar would not arm easy and the new slide was already installed by previous shift. XXXX and I adjusted the girt; sold the work we performed to inspector. We removed the bottle pin from the slide and stowed it. Opened the ceiling panel and verified no streamer present on the door assist bottle. Then taxied to the gate on a delay. Used proper deactivation procedures.supplemental information from acn 810967: the door assist bottle safety pin was not removed but was also not installed correctly due to it not having a safety streamer as per MM advises to use. I witnessed my partner look to see if the safety pin and streamer was installed but did not view it myself. I heard him say it was not installed. Use the correct safety pin not a bolt with no streamer.supplemental information from acn 810966: aircraft door 1R emergency power reservoir was found with 2 bolts installed as safety pins (no streamers attached) when aircraft came in docks for 'C' check.supplemental information from acn 804234: 2 amts began replacing a slide at door 1R at XA00. The amts used bolts instead of lockout pins to keep from having the 1R door bottle operate unintentionally. The pins are okay to use per B757 amm; however they did not tag them with streamers. Techs did not finish the job and left the girt bar adjust for next shift techs. The next shift amts and the inspector who bought the rii of the slide installation did not see the bolts installed on the bottle which is installed above the ceiling panel aft of the cockpit door and inboard of the forward lavatory. The safety pin on the slide was removed. It was an irregular installation on the 1R bottle and they were not looking for it. The bolts were left on aircraft X for 103 flight cycles before being found during the c-check. I was the area supervisor that day and cleared an item stating 'amm followed;' reference: maintenance control pages for the following. Were all safety devices removed? Was the rii done? I answered 'yes' after speaking with the amts and being told we were good. I believe the usage of bolts instead of a pin and streamer should not be allowed and any lockout left on an emergency system needs to be documented. Also; the warnings at the end of the amm need expansion. Human factors include complacency; pressure; communication; resources; and consistency. Changes to the amm procedures are being suggested to engineering as I write this report.

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Original NASA ASRS Text

Title: MECHANICS; AN INSPECTOR AND SUPERVISOR DESCRIBE THEIR INVOLVEMENT WITH A B757-200 OPERATING WITH THE CABIN DOOR 1R EMERGENCY ASSIST BOTTLE DEACTIVATED BY LOCKOUT BOLTS; AND THAT DID NOT HAVE STREAMERS ATTACHED.

Narrative: MY PARTNER AND I WERE DOING A DOOR SLIDE CHANGE; AND PER MM YOU CAN USE A SPECIFIC PIN FOR THE DOOR BOTTLE OR 2 BOLTS. SINCE PINS ARE HARD TO FIND; WE DECIDED TO USE THE BOLTS TO PIN THE BOTTLE; BUT WE DID NOT PUT THE STREAMERS ON THE BOLTS BECAUSE WE NORMALLY FINISHED THE WHOLE JOB. AND BECAUSE THE BOTTLE IS LOCATED IN THE CEILING NEAR THE MAIN ENTRANCE; I CLOSED THE PANEL AFTER WE PINNED THE BOTTLE TO PREVENT ANYBODY FROM HITTING THEIR HEAD ON THE PANEL. AND WHOEVER FINISHED THE JOB DID NOT PULL THE PINS. THE PLANE ENDED UP FLYING AROUND UNTIL IT WENT TO C-CHECK AND THEY FOUND THE BOLTS STILL IN THE BOTTLE. SUPPLEMENTAL INFO FROM ACN 810965: I WAS GIVEN THE TURNOVER FROM PREVIOUS SHIFT ACFT X DOOR 1R SLIDE CHANGE; THAT THE DOOR GIRT BAR WOULD NOT ARM EASY AND THE NEW SLIDE WAS ALREADY INSTALLED BY PREVIOUS SHIFT. XXXX AND I ADJUSTED THE GIRT; SOLD THE WORK WE PERFORMED TO INSPECTOR. WE REMOVED THE BOTTLE PIN FROM THE SLIDE AND STOWED IT. OPENED THE CEILING PANEL AND VERIFIED NO STREAMER PRESENT ON THE DOOR ASSIST BOTTLE. THEN TAXIED TO THE GATE ON A DELAY. USED PROPER DEACTIVATION PROCS.SUPPLEMENTAL INFO FROM ACN 810967: THE DOOR ASSIST BOTTLE SAFETY PIN WAS NOT REMOVED BUT WAS ALSO NOT INSTALLED CORRECTLY DUE TO IT NOT HAVING A SAFETY STREAMER AS PER MM ADVISES TO USE. I WITNESSED MY PARTNER LOOK TO SEE IF THE SAFETY PIN AND STREAMER WAS INSTALLED BUT DID NOT VIEW IT MYSELF. I HEARD HIM SAY IT WAS NOT INSTALLED. USE THE CORRECT SAFETY PIN NOT A BOLT WITH NO STREAMER.SUPPLEMENTAL INFO FROM ACN 810966: ACFT DOOR 1R EMER POWER RESERVOIR WAS FOUND WITH 2 BOLTS INSTALLED AS SAFETY PINS (NO STREAMERS ATTACHED) WHEN ACFT CAME IN DOCKS FOR 'C' CHECK.SUPPLEMENTAL INFO FROM ACN 804234: 2 AMTS BEGAN REPLACING A SLIDE AT DOOR 1R AT XA00. THE AMTS USED BOLTS INSTEAD OF LOCKOUT PINS TO KEEP FROM HAVING THE 1R DOOR BOTTLE OPERATE UNINTENTIONALLY. THE PINS ARE OKAY TO USE PER B757 AMM; HOWEVER THEY DID NOT TAG THEM WITH STREAMERS. TECHS DID NOT FINISH THE JOB AND LEFT THE GIRT BAR ADJUST FOR NEXT SHIFT TECHS. THE NEXT SHIFT AMTS AND THE INSPECTOR WHO BOUGHT THE RII OF THE SLIDE INSTALLATION DID NOT SEE THE BOLTS INSTALLED ON THE BOTTLE WHICH IS INSTALLED ABOVE THE CEILING PANEL AFT OF THE COCKPIT DOOR AND INBOARD OF THE FORWARD LAVATORY. THE SAFETY PIN ON THE SLIDE WAS REMOVED. IT WAS AN IRREGULAR INSTALLATION ON THE 1R BOTTLE AND THEY WERE NOT LOOKING FOR IT. THE BOLTS WERE LEFT ON ACFT X FOR 103 FLT CYCLES BEFORE BEING FOUND DURING THE C-CHECK. I WAS THE AREA SUPVR THAT DAY AND CLEARED AN ITEM STATING 'AMM FOLLOWED;' REF: MAINT CTL PAGES FOR THE FOLLOWING. WERE ALL SAFETY DEVICES REMOVED? WAS THE RII DONE? I ANSWERED 'YES' AFTER SPEAKING WITH THE AMTS AND BEING TOLD WE WERE GOOD. I BELIEVE THE USAGE OF BOLTS INSTEAD OF A PIN AND STREAMER SHOULD NOT BE ALLOWED AND ANY LOCKOUT LEFT ON AN EMERGENCY SYSTEM NEEDS TO BE DOCUMENTED. ALSO; THE WARNINGS AT THE END OF THE AMM NEED EXPANSION. HUMAN FACTORS INCLUDE COMPLACENCY; PRESSURE; COM; RESOURCES; AND CONSISTENCY. CHANGES TO THE AMM PROCS ARE BEING SUGGESTED TO ENGINEERING AS I WRITE THIS RPT.

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.