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A B737-300 technician making a door slide special inspection was given another door slide correction job card. Believing both cards were the same, the correction to remove and replace a screw, washer and nut was not accomplished.
| Attributes | |
| ACN | 637834 |
| Time | |
| Date | 200411 |
| Day | Mon |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Aircraft 1 | |
| Controlling Facilities | tower : zzz.tower |
| 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 |
| ASRS Report | 637834 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | oversight : supervisor |
| Events | |
| Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other other : 969 |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : work cards performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On C check on aircraft, I was assigned the cabin. I was doing special inspection, inspecting girt cable routing. A crew member gave me paperwork (aircraft change order X). I did not realize it was aircraft change order and assumed it was an exemption to special inspection to verify slide serial number, cable and latch installation. I missed in bottom of signoff block to right&right screw, washer and nut. The signoff block had bold print to inspect routing of cable and small print to right&right fasteners. I verified slide serial number, cable and latch installation. I signed off the special inspection and aircraft change order, not realizing my misinterp. I assumed same next day on aircraft aft service door slide of nov/fri/04 had same cco and thought it was something new. After lunch, realized it was the same, I notified my supervisor and maintenance center.
Original NASA ASRS Text
Title: A B737-300 TECHNICIAN MAKING A DOOR SLIDE SPECIAL INSPECTION WAS GIVEN ANOTHER DOOR SLIDE CORRECTION JOB CARD. BELIEVING BOTH CARDS WERE THE SAME, THE CORRECTION TO REMOVE AND REPLACE A SCREW, WASHER AND NUT WAS NOT ACCOMPLISHED.
Narrative: ON C CHK ON ACFT, I WAS ASSIGNED THE CABIN. I WAS DOING SPECIAL INSPECTION, INSPECTING GIRT CABLE ROUTING. A CREW MEMBER GAVE ME PAPERWORK (ACFT CHANGE ORDER X). I DID NOT REALIZE IT WAS ACFT CHANGE ORDER AND ASSUMED IT WAS AN EXEMPTION TO SPECIAL INSPECTION TO VERIFY SLIDE SERIAL NUMBER, CABLE AND LATCH INSTALLATION. I MISSED IN BOTTOM OF SIGNOFF BLOCK TO R&R SCREW, WASHER AND NUT. THE SIGNOFF BLOCK HAD BOLD PRINT TO INSPECT ROUTING OF CABLE AND SMALL PRINT TO R&R FASTENERS. I VERIFIED SLIDE SERIAL NUMBER, CABLE AND LATCH INSTALLATION. I SIGNED OFF THE SPECIAL INSPECTION AND ACFT CHANGE ORDER, NOT REALIZING MY MISINTERP. I ASSUMED SAME NEXT DAY ON ACFT AFT SVC DOOR SLIDE OF NOV/FRI/04 HAD SAME CCO AND THOUGHT IT WAS SOMETHING NEW. AFTER LUNCH, REALIZED IT WAS THE SAME, I NOTIFIED MY SUPVR AND MAINT CTR.
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.