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|
Attributes | |
ACN | 834473 |
Time | |
Date | 200901 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Night |
Aircraft 1 | |
Make Model Name | B777-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Escape Slide |
Person 1 | |
Function | Inspector Technician |
Qualification | Maintenance Airframe Maintenance Inspection Authority Maintenance Powerplant |
Experience | Maintenance Inspector .5 Maintenance Technician 23 |
Person 2 | |
Function | Other / Unknown |
Qualification | Maintenance Airframe Maintenance Powerplant |
Experience | Maintenance Technician 20 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural FAR Deviation - Procedural Maintenance Deviation - Procedural Published Material / Policy |
Narrative:
January 2009; I began my day as a line aviation maintenance technician (amt). Around the middle of the shift; I was called to inspect a push pull cable at door 4R; on a B777-200 aircraft located at the terminal. After installation per maintenance manual (MM) 52-11-16; I inspected installation and security and the operational check. All were normal. At this time I left to watch mandatory video on slide replacement; since slide was removed. An amt installed door slide assembly per MM 25-66-01 and I accomplished inspection and operational check of door systems. All normal. I then returned to my amt duties back on the line. Rii was then initiated for slide and using rii inspection procedure 4; I interpreted push pull cable as being an adjacent system so only 1 rii would be required for the slide and cable assembly. I believe the next day; amt realized he may have omitted 3 grommets and opened a company self discloser which opened the missed rii. Again my interpretation of the language in the procedure 4 process and made an error. I feel that some pressure from supervisors and the rush to get plane back on a revenue flight helped cause this mistake. Also my lack of experience of .5 years as an inspector and the fact that the airline fails to keep a full time inspector on shift and rather upgrade when needed. This leads to a situation where the inspector is not aware of an rii will be needed until he is called. If at the beginning of shift the company would inform the inspector of what work is being accomplished an inspector would read and be familiar with MM before he is called. Again when a plane is ready to fly and a inspector is called for an rii; more pressure exists and steps might be missed in the haste. Stations as big as this for my carrier; should always have full time inspectors on shift.
Original NASA ASRS Text
Title: A Line Mechanic who was upgraded to perform an RII inspection and a Maintenance Supervisor report on a B777-200 'ARM-Disarm'; push-pull cable installation at cabin door 4R. Line Mechanic reported on his lack of experience and mis-interpretation of the RII inspection procedure.
Narrative: January 2009; I began my day as a Line Aviation Maintenance Technician (AMT). Around the middle of the shift; I was called to inspect a push pull cable at door 4R; on a B777-200 aircraft located at the terminal. After installation per Maintenance Manual (MM) 52-11-16; I inspected installation and security and the operational check. All were normal. At this time I left to watch mandatory video on slide replacement; since slide was removed. An AMT installed door slide assembly per MM 25-66-01 and I accomplished inspection and operational check of door systems. All normal. I then returned to my AMT duties back on the line. RII was then initiated for slide and using RII inspection procedure 4; I interpreted push pull cable as being an adjacent system so only 1 RII would be required for the slide and cable assembly. I believe the next day; AMT realized he may have omitted 3 grommets and opened a company self discloser which opened the missed RII. Again my interpretation of the language in the procedure 4 process and made an error. I feel that some pressure from supervisors and the rush to get plane back on a revenue flight helped cause this mistake. Also my lack of experience of .5 years as an Inspector and the fact that the airline fails to keep a full time inspector on shift and rather upgrade when needed. This leads to a situation where the Inspector is not aware of an RII will be needed until he is called. If at the beginning of shift the company would inform the inspector of what work is being accomplished an inspector would read and be familiar with MM before he is called. Again when a plane is ready to fly and a Inspector is called for an RII; more pressure exists and steps might be missed in the haste. Stations as big as this for my carrier; should always have full time Inspectors on shift.
Data retrieved from NASA's ASRS site as of April 2012 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.