Narrative:

When accomplishing a time change on a tail cone evacuate/evacuation slide, an inspection item was inadvertently omitted. Replacement of the tail slide was assigned on sep/xa/99 as part of a work package which made no reference to following a job procedure card which was available, although at the time I was unaware of this availability. (Job procedure cards are referenced as part of work packages on other items on which no inspection is required, such as autoland checks, oil filter changes, and coalescer bag replacement.) the lack of this reference on this item in the work package, combined with my lack of knowledge that such a card existed, led directly to the inadvertent omission of the inspection. The omission was discovered during casual conversation in the shop area, and local management was promptly notified of the error/omission. Local management initiated action to rectify the situation. Possible steps to prevent recurrence of the situation include placing reference to job cards in all work items to be accomplished when such cards exist, and placing notes/alerts in with parts when shipped out of shops.

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Original NASA ASRS Text

Title: A DC9-30 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH THE TAIL CONE ESCAPE SLIDE INSTALLED BUT INSTALLATION WAS NOT INSPECTED.

Narrative: WHEN ACCOMPLISHING A TIME CHANGE ON A TAIL CONE EVAC SLIDE, AN INSPECTION ITEM WAS INADVERTENTLY OMITTED. REPLACEMENT OF THE TAIL SLIDE WAS ASSIGNED ON SEP/XA/99 AS PART OF A WORK PACKAGE WHICH MADE NO REF TO FOLLOWING A JOB PROC CARD WHICH WAS AVAILABLE, ALTHOUGH AT THE TIME I WAS UNAWARE OF THIS AVAILABILITY. (JOB PROC CARDS ARE REFED AS PART OF WORK PACKAGES ON OTHER ITEMS ON WHICH NO INSPECTION IS REQUIRED, SUCH AS AUTOLAND CHKS, OIL FILTER CHANGES, AND COALESCER BAG REPLACEMENT.) THE LACK OF THIS REF ON THIS ITEM IN THE WORK PACKAGE, COMBINED WITH MY LACK OF KNOWLEDGE THAT SUCH A CARD EXISTED, LED DIRECTLY TO THE INADVERTENT OMISSION OF THE INSPECTION. THE OMISSION WAS DISCOVERED DURING CASUAL CONVERSATION IN THE SHOP AREA, AND LCL MGMNT WAS PROMPTLY NOTIFIED OF THE ERROR/OMISSION. LCL MGMNT INITIATED ACTION TO RECTIFY THE SIT. POSSIBLE STEPS TO PREVENT RECURRENCE OF THE SIT INCLUDE PLACING REF TO JOB CARDS IN ALL WORK ITEMS TO BE ACCOMPLISHED WHEN SUCH CARDS EXIST, AND PLACING NOTES/ALERTS IN WITH PARTS WHEN SHIPPED OUT OF SHOPS.

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.