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A B737-700 was released from a maintenance check and operated 14 days with the R-1 door escape slide floor brackets installed incorrectly.
| Attributes | |
| ACN | 685991 |
| Time | |
| Date | 200601 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 14 |
| ASRS Report | 685991 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance lead technician : 20 |
| ASRS Report | 685990 |
| 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 |
| Factors | |
| Maintenance | contributing factor : engineering procedure contributing factor : schedule pressure contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | Engineering Order |
Narrative:
On jan/fri/2006; I was assigned to install a girt bar assembly on R-1 door on aircraft X. I completed this task per work card and in accordance to aircraft maintenance manual procedures. It was reported to me by local management that 14 days after the aircraft left the hangar in ZZZ; one of the girt bar's attachments was backwards. To the best of my knowledge; I installed the part correctly.callback conversation with reporter revealed the following information: the reporter stated the job card had no pictorial on how a correct installation appears; adding; these brackets are not 'murphy proof' and can be installed incorrectly and still allow the girt bar to be attached. The reporter noted that the lead technician and the inspector both separately installed or viewed the girt bar attachment and approved the installation.
Original NASA ASRS Text
Title: A B737-700 WAS RELEASED FROM A MAINT CHK AND OPERATED 14 DAYS WITH THE R-1 DOOR ESCAPE SLIDE FLOOR BRACKETS INSTALLED INCORRECTLY.
Narrative: ON JAN/FRI/2006; I WAS ASSIGNED TO INSTALL A GIRT BAR ASSEMBLY ON R-1 DOOR ON ACFT X. I COMPLETED THIS TASK PER WORK CARD AND IN ACCORDANCE TO ACFT MAINT MANUAL PROCS. IT WAS RPTED TO ME BY LOCAL MANAGEMENT THAT 14 DAYS AFTER THE ACFT LEFT THE HANGAR IN ZZZ; ONE OF THE GIRT BAR'S ATTACHMENTS WAS BACKWARDS. TO THE BEST OF MY KNOWLEDGE; I INSTALLED THE PART CORRECTLY.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE JOB CARD HAD NO PICTORIAL ON HOW A CORRECT INSTALLATION APPEARS; ADDING; THESE BRACKETS ARE NOT 'MURPHY PROOF' AND CAN BE INSTALLED INCORRECTLY AND STILL ALLOW THE GIRT BAR TO BE ATTACHED. THE RPTR NOTED THAT THE LEAD TECHNICIAN AND THE INSPECTOR BOTH SEPARATELY INSTALLED OR VIEWED THE GIRT BAR ATTACHMENT AND APPROVED THE 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.