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A B737-300 had a door mounted escape slide installed at door 2R. At a later 'a' check; it was discovered the safety pin in the regulator was still installed. Pin rendered slide inoperative.
| Attributes | |
| ACN | 645261 |
| Time | |
| Date | 200501 |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : airframe technician : inspection authority technician : powerplant |
| Experience | maintenance technician : 26 |
| ASRS Report | 645261 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : installation performance deficiency : logbook entry performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Aircraft Environmental Factor Maintenance Human Performance Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
I work as a lead mechanic. I assigned an experienced mechanic under my charge to replace a door mounted slide located in the door #2 r-hand position. It was to be replaced due to a company callout for time. Both the mechanic assigned the task and I had previously accomplished this task. I went about my normal tasks of overseeing maintenance and mechanics on the other aircraft at the terminal; usually about 10-12. When the job was complete; I went to inspect the slide installation. From outward appearances; everything looked good. Unknown to me; the mechanic installing the slide failed to remove the safety pin in the regulator. This is not visible with the slide installed. With the pin installed; the slide would not deploy in an emergency. To prevent this from happening again; the pin should protrude through the slide cover; or a window in the slide cover should be incorporated; or the inspector should be available to witness installation.
Original NASA ASRS Text
Title: A B737-300 HAD A DOOR MOUNTED ESCAPE SLIDE INSTALLED AT DOOR 2R. AT A LATER 'A' CHK; IT WAS DISCOVERED THE SAFETY PIN IN THE REGULATOR WAS STILL INSTALLED. PIN RENDERED SLIDE INOP.
Narrative: I WORK AS A LEAD MECH. I ASSIGNED AN EXPERIENCED MECH UNDER MY CHARGE TO REPLACE A DOOR MOUNTED SLIDE LOCATED IN THE DOOR #2 R-HAND POS. IT WAS TO BE REPLACED DUE TO A COMPANY CALLOUT FOR TIME. BOTH THE MECH ASSIGNED THE TASK AND I HAD PREVIOUSLY ACCOMPLISHED THIS TASK. I WENT ABOUT MY NORMAL TASKS OF OVERSEEING MAINT AND MECHS ON THE OTHER ACFT AT THE TERMINAL; USUALLY ABOUT 10-12. WHEN THE JOB WAS COMPLETE; I WENT TO INSPECT THE SLIDE INSTALLATION. FROM OUTWARD APPEARANCES; EVERYTHING LOOKED GOOD. UNKNOWN TO ME; THE MECH INSTALLING THE SLIDE FAILED TO REMOVE THE SAFETY PIN IN THE REGULATOR. THIS IS NOT VISIBLE WITH THE SLIDE INSTALLED. WITH THE PIN INSTALLED; THE SLIDE WOULD NOT DEPLOY IN AN EMER. TO PREVENT THIS FROM HAPPENING AGAIN; THE PIN SHOULD PROTRUDE THROUGH THE SLIDE COVER; OR A WINDOW IN THE SLIDE COVER SHOULD BE INCORPORATED; OR THE INSPECTOR SHOULD BE AVAILABLE TO WITNESS INSTALLATION.
Data retrieved from NASA's ASRS site as of January 2009 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.