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A B737-300 was dispatched in non compliance with the forward entrance door snubber installed incorrectly.
| Attributes | |
| ACN | 604268 |
| Time | |
| Date | 200401 |
| Day | Mon |
| Local Time Of Day | 0001 To 0600 |
| 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 | B737-300 |
| 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 | 604268 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Qualification | technician : inspection authority technician : airframe technician : powerplant |
| ASRS Report | 604626 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
During 'C' check, inspection found the snubber on the forward entry door weak. I changed the snubber and installed it with the servicing port in an accessible area. It would only go on one way for this to happen. After the installation, I operations checked the door and checked to see if the snubber was clear of the door frame and aircraft structure. There was no binding and the door had full travel. Perceptions: the fact that there is a servicing port on the snubber would indicate that it could be svced, that is the way I installed it. Poor judgement was used on my part by not following the maintenance manual. If the snubber port was marked with an installation placard to indicate what position it should be installed. This should help in preventing this from happening again.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE FORWARD ENTRANCE DOOR SNUBBER INSTALLED INCORRECTLY.
Narrative: DURING 'C' CHK, INSPECTION FOUND THE SNUBBER ON THE FORWARD ENTRY DOOR WEAK. I CHANGED THE SNUBBER AND INSTALLED IT WITH THE SVCING PORT IN AN ACCESSIBLE AREA. IT WOULD ONLY GO ON ONE WAY FOR THIS TO HAPPEN. AFTER THE INSTALLATION, I OPS CHKED THE DOOR AND CHKED TO SEE IF THE SNUBBER WAS CLR OF THE DOOR FRAME AND ACFT STRUCTURE. THERE WAS NO BINDING AND THE DOOR HAD FULL TRAVEL. PERCEPTIONS: THE FACT THAT THERE IS A SVCING PORT ON THE SNUBBER WOULD INDICATE THAT IT COULD BE SVCED, THAT IS THE WAY I INSTALLED IT. POOR JUDGEMENT WAS USED ON MY PART BY NOT FOLLOWING THE MAINT MANUAL. IF THE SNUBBER PORT WAS MARKED WITH AN INSTALLATION PLACARD TO INDICATE WHAT POS IT SHOULD BE INSTALLED. THIS SHOULD HELP IN PREVENTING THIS FROM HAPPENING AGAIN.
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.