<< >> NASA ASRS Report 592355, August 2003

A B737-300 was dispatched in non compliance with the forward entry door snubber installed incorrectly causing door seal damage.

Attributes
ACN	592355
Time
Date	200308
Day	Fri
Local Time Of Day	0001 To 0600
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Environment
Light	Night
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B737-300
Operating Under FAR Part	Part 121
Flight Phase	ground : maintenance
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
Qualification	technician : powerplant technician : airframe
ASRS Report	592355
Person 2
Affiliation	company : air carrier
Function	maintenance : inspector
Qualification	technician : airframe technician : inspection authority technician : powerplant
ASRS Report	592556
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : schedule pressure contributing factor : engineering procedure performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : repair
Supplementary
Problem Areas	Chart Or Publication Maintenance Human Performance Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

On aug/fri/03, aircraft X was in the maintenance station at X airlines. During the inspection of the aircraft cabin, the forward entry door was found to be weak in its snubbing action of the door. Upon the finding of the above discrepancy, I removed and replaced the forward entry door snubber. This action was done incorrectly due to my putting the snubber in backwards. This action was due to a mental error due to complacency on my part. Supplemental information from acn 592556: I wrote up the L1 door snubber as being inoperative on the 'C' check as part of my routine inspection. This was one of over 100 write-ups in the cabin. The mechanic who installed the new door snubber installed it backwards, causing the lower hinge seal plate to be bent and causing a pressurization leak when the aircraft was pressurized on the first flight of the morning, causing an air turn back. I should have taken more time and done a more complete inspection of the door snubber installation.

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Original NASA ASRS Text

Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE FORWARD ENTRY DOOR SNUBBER INSTALLED INCORRECTLY CAUSING DOOR SEAL DAMAGE.

Narrative: ON AUG/FRI/03, ACFT X WAS IN THE MAINT STATION AT X AIRLINES. DURING THE INSPECTION OF THE ACFT CABIN, THE FORWARD ENTRY DOOR WAS FOUND TO BE WEAK IN ITS SNUBBING ACTION OF THE DOOR. UPON THE FINDING OF THE ABOVE DISCREPANCY, I REMOVED AND REPLACED THE FORWARD ENTRY DOOR SNUBBER. THIS ACTION WAS DONE INCORRECTLY DUE TO MY PUTTING THE SNUBBER IN BACKWARDS. THIS ACTION WAS DUE TO A MENTAL ERROR DUE TO COMPLACENCY ON MY PART. SUPPLEMENTAL INFO FROM ACN 592556: I WROTE UP THE L1 DOOR SNUBBER AS BEING INOP ON THE 'C' CHK AS PART OF MY ROUTINE INSPECTION. THIS WAS ONE OF OVER 100 WRITE-UPS IN THE CABIN. THE MECH WHO INSTALLED THE NEW DOOR SNUBBER INSTALLED IT BACKWARDS, CAUSING THE LOWER HINGE SEAL PLATE TO BE BENT AND CAUSING A PRESSURIZATION LEAK WHEN THE ACFT WAS PRESSURIZED ON THE FIRST FLT OF THE MORNING, CAUSING AN AIR TURN BACK. I SHOULD HAVE TAKEN MORE TIME AND DONE A MORE COMPLETE INSPECTION OF THE DOOR SNUBBER INSTALLATION.

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.