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A B767-300 technician working a report of door R4 not arming corrected the problem but inadvertently deployed the slide. Failed to pin the slide bottle.
| Attributes | |
| ACN | 603934 |
| Time | |
| Date | 200312 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B767 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 603934 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : person 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : repair performance deficiency : fault isolation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
On dec/fri/03, I was assigned to aircraft X, a B767, to address a PIREP regarding the R4 door slide not arming. I began troubleshooting the R4 door and was unable to get the slide to arm. At that point, I called the maintenance routing office for assistance from a technical crew chief. He decided we should remove the cover that the yellow armed flag guides threw to alert that the door is armed because in the past history, the arming flag binds in the cover not allowing you to arm the slide. So we removed the cover and lubricated the arming handle and mechanism which netted no results. We then raised the R4 door and noticed that the exterior handle was not completely stowed. We stowed the exterior handle and closed the door. We were now able to arm the door slide, however, when the slide armed, the yellow armed flag went behind the door handle because we had previously removed the cover/guide in our troubleshooting. At this point the job was complete. We then proceeded to put the cover/guide back on but were unable to because the door handle has to be in the up position to reinstall the cover. Due to the fact that the yellow armed flag went behind the door handle, we did not realize that the door was armed and lifted the door handle to reinstall the cover/guide at which point the door slide deployed when the handle was lifted. After reviewing the maintenance manual it showed that I should have deactivated the slide bottle before performing any maintenance on the slide.
Original NASA ASRS Text
Title: A B767-300 TECHNICIAN WORKING A RPT OF DOOR R4 NOT ARMING CORRECTED THE PROB BUT INADVERTENTLY DEPLOYED THE SLIDE. FAILED TO PIN THE SLIDE BOTTLE.
Narrative: ON DEC/FRI/03, I WAS ASSIGNED TO ACFT X, A B767, TO ADDRESS A PIREP REGARDING THE R4 DOOR SLIDE NOT ARMING. I BEGAN TROUBLESHOOTING THE R4 DOOR AND WAS UNABLE TO GET THE SLIDE TO ARM. AT THAT POINT, I CALLED THE MAINT ROUTING OFFICE FOR ASSISTANCE FROM A TECHNICAL CREW CHIEF. HE DECIDED WE SHOULD REMOVE THE COVER THAT THE YELLOW ARMED FLAG GUIDES THREW TO ALERT THAT THE DOOR IS ARMED BECAUSE IN THE PAST HISTORY, THE ARMING FLAG BINDS IN THE COVER NOT ALLOWING YOU TO ARM THE SLIDE. SO WE REMOVED THE COVER AND LUBRICATED THE ARMING HANDLE AND MECHANISM WHICH NETTED NO RESULTS. WE THEN RAISED THE R4 DOOR AND NOTICED THAT THE EXTERIOR HANDLE WAS NOT COMPLETELY STOWED. WE STOWED THE EXTERIOR HANDLE AND CLOSED THE DOOR. WE WERE NOW ABLE TO ARM THE DOOR SLIDE, HOWEVER, WHEN THE SLIDE ARMED, THE YELLOW ARMED FLAG WENT BEHIND THE DOOR HANDLE BECAUSE WE HAD PREVIOUSLY REMOVED THE COVER/GUIDE IN OUR TROUBLESHOOTING. AT THIS POINT THE JOB WAS COMPLETE. WE THEN PROCEEDED TO PUT THE COVER/GUIDE BACK ON BUT WERE UNABLE TO BECAUSE THE DOOR HANDLE HAS TO BE IN THE UP POS TO REINSTALL THE COVER. DUE TO THE FACT THAT THE YELLOW ARMED FLAG WENT BEHIND THE DOOR HANDLE, WE DID NOT REALIZE THAT THE DOOR WAS ARMED AND LIFTED THE DOOR HANDLE TO REINSTALL THE COVER/GUIDE AT WHICH POINT THE DOOR SLIDE DEPLOYED WHEN THE HANDLE WAS LIFTED. AFTER REVIEWING THE MAINT MANUAL IT SHOWED THAT I SHOULD HAVE DEACTIVATED THE SLIDE BOTTLE BEFORE PERFORMING ANY MAINT ON THE SLIDE.
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.