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|
Attributes | |
ACN | 933493 |
Time | |
Date | 201102 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Escape Slide |
Person 1 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy Deviation - Procedural Maintenance |
Narrative:
I was working overtime on line routine overnight (ron) aircraft and was given two planes to work; with two other mechanics that night. One aircraft was the wash bird [wash rack] with maintenance visits levels one and two and multiple special inspections; including a time change of the (left) L-1 and L-2 door slides. During the change process of the slides; I inadvertently mixed the girt bars and failed to catch my error. I had both slides removed and in the jet way at the same time and our lead brought up the two new slides (all identical) into the jet way for us and the confusion in the jet ways must have contributed to the confusing of the forward and aft girt bars during the change-over process.I was working with one other mechanic at the time and followed the paperwork during the whole process of changing over the slides and closing of the slide enclosures. I failed to notice the subtask [procedure] of trial fitting of the girt bars into the floor clips and mistakenly assumed that I had kept the parts (slides) separated during the change-over process and that they would fit as they had before the changing of the slides. There were cleaners at work on the aircraft at the time and we were in a rush to get down to the wash rack to finish the other plane before the end of our shift. At push time that morning; the mistake was found by the flight attendants when they pushed back from the gate and couldn't engage the girt bars in the floor fittings.several factors contributed to this event including time; fatigue; confusion in the jet way; lack of warnings in the paperwork specifically towards this issue. While it is mentioned in the procedures to test fit the girt bars; we wrongly assumed that since the slides were all the same so were the girt bars.
Original NASA ASRS Text
Title: A Line Mechanic reports he failed to notice a subtask in the door slide change maintenance procedures to 'trial fit' the new slide girt bar into the floor clips at cabin doors (left) L-1 and L-2. Flight Attendant noticed the B737-700 girt bars would not engage in floor clips during the pushback. Fatigue; rushing; assumptions and confusion in jetway were noted as contributors.
Narrative: I was working overtime on Line Routine Overnight (RON) aircraft and was given two planes to work; with two other mechanics that night. One aircraft was the wash bird [wash rack] with maintenance visits levels one and two and multiple special inspections; including a time change of the (left) L-1 and L-2 door slides. During the change process of the slides; I inadvertently mixed the girt bars and failed to catch my error. I had both slides removed and in the jet way at the same time and our Lead brought up the two new slides (all identical) into the jet way for us and the confusion in the jet ways must have contributed to the confusing of the forward and aft girt bars during the change-over process.I was working with one other Mechanic at the time and followed the paperwork during the whole process of changing over the slides and closing of the slide enclosures. I failed to notice the subtask [procedure] of trial fitting of the girt bars into the floor clips and mistakenly assumed that I had kept the parts (slides) separated during the change-over process and that they would fit as they had before the changing of the slides. There were cleaners at work on the aircraft at the time and we were in a rush to get down to the wash rack to finish the other plane before the end of our shift. At push time that morning; the mistake was found by the flight attendants when they pushed back from the gate and couldn't engage the girt bars in the floor fittings.Several factors contributed to this event including time; fatigue; confusion in the jet way; lack of warnings in the paperwork specifically towards this issue. While it is mentioned in the procedures to test fit the girt bars; we wrongly assumed that since the slides were all the same so were the girt bars.
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.