|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0001 To 0600|
|Locale Reference||airport : zzz|
|Operator||common carrier : air carrier|
|Make Model Name||B757-200|
|Operating Under FAR Part||Part 121|
|Navigation In Use||Other |
|Flight Phase||ground : parked|
|Affiliation||company : air carrier|
|Function||other personnel other|
|Qualification||other other : other|
|Affiliation||company : air carrier|
|Function||other personnel other|
|Qualification||other other : other|
|Anomaly||aircraft equipment problem : less severe|
other anomaly other
|Independent Detector||other other : unspecified|
|Resolutory Action||none taken : detected after the fact|
|Air Traffic Incident||other|
Was assigned to do a #1 service as required and described by company policy on this overnight B757-200. I was also assigned two other mechanics to work with for this task. Arrived in at our station late due to WX on east coast. Myself and other mechanic proceeded to perform the assigned service. Well, the aircraft had very little gripes which were a&P related so all the work which we were assigned was completed in approximately 1 1/2 hours after we got the aircraft. So with still quite a bit of time left in our shift we looked and saw if there was anything else that we could work on. A change order authority/authorized which was present but not assigned to our station by system control was there on record. So the other mechanics and myself decided to do the change order authority/authorized since we were told that if we had time then we should do the change order authority/authorized. It was an easy change order authority/authorized to do but the way our company engineer wrote the change order authority/authorized, all 3 of us came up with a different interpretation of the job that was to be done. But after collaboration between the 3 of us we were able to nail down what was to be accomplished. And it boiled down to taking a measurement on a mechanism on the B757 main entry door that was located behind the door mounted slide. So we proceeded with the change order authority/authorized paperwork and company maintenance manual covering slide removal/installation of door mounted slide. The next item we tried to locate was a highlift since the aircraft was parked in the 'pea patch' and there was a narrow entry stand on the aircraft, which would be useless to help facilitate removal of door mounted slide. We could not locate a free highlift at the time, the few we have were in use. Since we could not locate a highlift which would make work on door easier from outside aircraft, we elected to do the change order authority/authorized from inside aircraft. Next minor glitch we ran into was the other two mechanics I was working with had never worked on a B757 door, much less a slide. But I did and I had been B757 door qualified when I worked our company's B757 c-chk line. I felt there would be no problem since I was familiar with the B757 door and related. With applicable paperwork in hand we proceeded to do the elected work. Since I was basically training the other two mechanics, I showed them how to remove and install the B757 door mounted slide as per the company maintenance manual. But I also gave them pointers on what to be careful of and what to watch out for to prevent injury to oneself and aircraft. Anyway we got the slide off door 1R and performed our change order authority/authorized. Aircraft was within limits as per change order authority/authorized so we then reinstalled slide on door as per company maintenance manual. I should add that though we accomplished change order authority/authorized correctly the area in front of door 1R and 1L is really tight for 3 mechanics and a B757 door mount slide. We struggled to put slide on inside aircraft due to confined space, but we did it. After we finished 1R, before putting slide bustle on, I checked slide setup as per company maintenance manual. Things were in order so we buttoned it up. We then did 1L and things went the same pretty much on that as did on 1R. Time was drawing near to take the aircraft to the gate, so we took care of paperwork. I told the 2 other mechanics I was working with I'd sign the change order authority/authorized off since I knew it was done per company maintenance manual and also since I was the resident expert on the B757 door amongst the 3 of us. Now this incident happened in march but I have been off most of april and may on training and vacation. My boss told me he needed to do an investigation on this because the aircraft took a xx time delay in XXX, for a flight attendant not being able to locate a d-ring on this particular aircraft and on the 2 doors we did the change order authority/authorized on. The only problem I have is this aircraft went (after we did change order authority/authorized) YYY-ZZZ, overnighted in ZZZ, then went ZZZ-WWW, overnighted in WWW. Incidentally that night a #2 service as described and required by company was assigned that night in WWW and incidentally on our #2 service item #11 asks to verify presence of d-ring on door #1, 2, 4, left and right on form and that item is a mechanic sign off. Then to continue, the B757 went the next day WWW-VVV then VVV-XXX where finally the d-ring could not be located, so that airplane flew 4 legs before a flight attendant said d-rings weren't present. And in the middle of the 4 legs a mechanic at another station said the rings were there by signing off #2 service assigned to aircraft? So I'm being hit by our qa department as messing up and I know I didn't. The reason they give: we were the last to do 'maintenance' on the doors. Sound like they are grabbing for straws. In addition my company made a self-disclosure to the FAA.
Original NASA ASRS Text
Title: MECH RPT REGARDING THE LACK OF D RINGS FOR THE EXIT DOOR SLIDES NOTED AFTER 4 LEGS OF FLT FOLLOWING MAINT. ACFT WAS B757-200.
Narrative: WAS ASSIGNED TO DO A #1 SVC AS REQUIRED AND DESCRIBED BY COMPANY POLICY ON THIS OVERNIGHT B757-200. I WAS ALSO ASSIGNED TWO OTHER MECHS TO WORK WITH FOR THIS TASK. ARRIVED IN AT OUR STATION LATE DUE TO WX ON EAST COAST. MYSELF AND OTHER MECH PROCEEDED TO PERFORM THE ASSIGNED SVC. WELL, THE ACFT HAD VERY LITTLE GRIPES WHICH WERE A&P RELATED SO ALL THE WORK WHICH WE WERE ASSIGNED WAS COMPLETED IN APPROX 1 1/2 HRS AFTER WE GOT THE ACFT. SO WITH STILL QUITE A BIT OF TIME LEFT IN OUR SHIFT WE LOOKED AND SAW IF THERE WAS ANYTHING ELSE THAT WE COULD WORK ON. A CHANGE ORDER AUTH WHICH WAS PRESENT BUT NOT ASSIGNED TO OUR STATION BY SYS CTL WAS THERE ON RECORD. SO THE OTHER MECHS AND MYSELF DECIDED TO DO THE CHANGE ORDER AUTH SINCE WE WERE TOLD THAT IF WE HAD TIME THEN WE SHOULD DO THE CHANGE ORDER AUTH. IT WAS AN EASY CHANGE ORDER AUTH TO DO BUT THE WAY OUR COMPANY ENGINEER WROTE THE CHANGE ORDER AUTH, ALL 3 OF US CAME UP WITH A DIFFERENT INTERP OF THE JOB THAT WAS TO BE DONE. BUT AFTER COLLABORATION BTWN THE 3 OF US WE WERE ABLE TO NAIL DOWN WHAT WAS TO BE ACCOMPLISHED. AND IT BOILED DOWN TO TAKING A MEASUREMENT ON A MECHANISM ON THE B757 MAIN ENTRY DOOR THAT WAS LOCATED BEHIND THE DOOR MOUNTED SLIDE. SO WE PROCEEDED WITH THE CHANGE ORDER AUTH PAPERWORK AND COMPANY MAINT MANUAL COVERING SLIDE REMOVAL/INSTALLATION OF DOOR MOUNTED SLIDE. THE NEXT ITEM WE TRIED TO LOCATE WAS A HIGHLIFT SINCE THE ACFT WAS PARKED IN THE 'PEA PATCH' AND THERE WAS A NARROW ENTRY STAND ON THE ACFT, WHICH WOULD BE USELESS TO HELP FACILITATE REMOVAL OF DOOR MOUNTED SLIDE. WE COULD NOT LOCATE A FREE HIGHLIFT AT THE TIME, THE FEW WE HAVE WERE IN USE. SINCE WE COULD NOT LOCATE A HIGHLIFT WHICH WOULD MAKE WORK ON DOOR EASIER FROM OUTSIDE ACFT, WE ELECTED TO DO THE CHANGE ORDER AUTH FROM INSIDE ACFT. NEXT MINOR GLITCH WE RAN INTO WAS THE OTHER TWO MECHS I WAS WORKING WITH HAD NEVER WORKED ON A B757 DOOR, MUCH LESS A SLIDE. BUT I DID AND I HAD BEEN B757 DOOR QUALIFIED WHEN I WORKED OUR COMPANY'S B757 C-CHK LINE. I FELT THERE WOULD BE NO PROB SINCE I WAS FAMILIAR WITH THE B757 DOOR AND RELATED. WITH APPLICABLE PAPERWORK IN HAND WE PROCEEDED TO DO THE ELECTED WORK. SINCE I WAS BASICALLY TRAINING THE OTHER TWO MECHS, I SHOWED THEM HOW TO REMOVE AND INSTALL THE B757 DOOR MOUNTED SLIDE AS PER THE COMPANY MAINT MANUAL. BUT I ALSO GAVE THEM POINTERS ON WHAT TO BE CAREFUL OF AND WHAT TO WATCH OUT FOR TO PREVENT INJURY TO ONESELF AND ACFT. ANYWAY WE GOT THE SLIDE OFF DOOR 1R AND PERFORMED OUR CHANGE ORDER AUTH. ACFT WAS WITHIN LIMITS AS PER CHANGE ORDER AUTH SO WE THEN REINSTALLED SLIDE ON DOOR AS PER COMPANY MAINT MANUAL. I SHOULD ADD THAT THOUGH WE ACCOMPLISHED CHANGE ORDER AUTH CORRECTLY THE AREA IN FRONT OF DOOR 1R AND 1L IS REALLY TIGHT FOR 3 MECHS AND A B757 DOOR MOUNT SLIDE. WE STRUGGLED TO PUT SLIDE ON INSIDE ACFT DUE TO CONFINED SPACE, BUT WE DID IT. AFTER WE FINISHED 1R, BEFORE PUTTING SLIDE BUSTLE ON, I CHKED SLIDE SETUP AS PER COMPANY MAINT MANUAL. THINGS WERE IN ORDER SO WE BUTTONED IT UP. WE THEN DID 1L AND THINGS WENT THE SAME PRETTY MUCH ON THAT AS DID ON 1R. TIME WAS DRAWING NEAR TO TAKE THE ACFT TO THE GATE, SO WE TOOK CARE OF PAPERWORK. I TOLD THE 2 OTHER MECHS I WAS WORKING WITH I'D SIGN THE CHANGE ORDER AUTH OFF SINCE I KNEW IT WAS DONE PER COMPANY MAINT MANUAL AND ALSO SINCE I WAS THE RESIDENT EXPERT ON THE B757 DOOR AMONGST THE 3 OF US. NOW THIS INCIDENT HAPPENED IN MARCH BUT I HAVE BEEN OFF MOST OF APRIL AND MAY ON TRAINING AND VACATION. MY BOSS TOLD ME HE NEEDED TO DO AN INVESTIGATION ON THIS BECAUSE THE ACFT TOOK A XX TIME DELAY IN XXX, FOR A FLT ATTENDANT NOT BEING ABLE TO LOCATE A D-RING ON THIS PARTICULAR ACFT AND ON THE 2 DOORS WE DID THE CHANGE ORDER AUTH ON. THE ONLY PROB I HAVE IS THIS ACFT WENT (AFTER WE DID CHANGE ORDER AUTH) YYY-ZZZ, OVERNIGHTED IN ZZZ, THEN WENT ZZZ-WWW, OVERNIGHTED IN WWW. INCIDENTALLY THAT NIGHT A #2 SVC AS DESCRIBED AND REQUIRED BY COMPANY WAS ASSIGNED THAT NIGHT IN WWW AND INCIDENTALLY ON OUR #2 SVC ITEM #11 ASKS TO VERIFY PRESENCE OF D-RING ON DOOR #1, 2, 4, L AND R ON FORM AND THAT ITEM IS A MECH SIGN OFF. THEN TO CONTINUE, THE B757 WENT THE NEXT DAY WWW-VVV THEN VVV-XXX WHERE FINALLY THE D-RING COULD NOT BE LOCATED, SO THAT AIRPLANE FLEW 4 LEGS BEFORE A FLT ATTENDANT SAID D-RINGS WEREN'T PRESENT. AND IN THE MIDDLE OF THE 4 LEGS A MECH AT ANOTHER STATION SAID THE RINGS WERE THERE BY SIGNING OFF #2 SVC ASSIGNED TO ACFT? SO I'M BEING HIT BY OUR QA DEPT AS MESSING UP AND I KNOW I DIDN'T. THE REASON THEY GIVE: WE WERE THE LAST TO DO 'MAINT' ON THE DOORS. SOUND LIKE THEY ARE GRABBING FOR STRAWS. IN ADDITION MY COMPANY MADE A SELF-DISCLOSURE TO THE FAA.
Data retrieved from NASA's ASRS site as of July 2007 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.