<< >> NASA ASRS Report 686543, February 2006

A B767-300 while working on an overwing emergency exit window shade and on completion the exit system was armed and the overwing doors and slide deployed.

Attributes
ACN	686543
Time
Date	200602
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	B767-300 and 300 ER
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 : 19
ASRS Report	686543
Person 2
Affiliation	company : air carrier
Function	maintenance : technician
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far
Independent Detector	other other : 1
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : work cards performance deficiency : repair performance deficiency : fault isolation performance deficiency : testing
Supplementary
Problem Areas	Maintenance Human Performance Chart Or Publication Company Aircraft Environmental Factor
Primary Problem	Maintenance Human Performance

Narrative:

Air carrier X right overwing emergency exit doors had their overwing slide door squibs and right side spoiler squibs blown when doors were armed after reinstalling the right overwing doors. Overwing slide also became unlaced. I was working air carrier X changing a window shade in an overwing emergency exit. We disarmed the overwing emergency exit doors; removed the doors; replaced the window shade; armed the exit system per the airline job card. Tried a final testing of the squibs but they would not test. Started troubleshooting the system and discovered that the squibs were blown on the right side. During troubleshooting of the squibs not testing found the automatic-arm and automatic-fire switches. Repositioned switches but the squibs still would not test. Later the pins for the spoiler squib were found bent. It was the first time I did this task. I was also unfamiliar with the job card. It would also have been easier if I was working with someone who had done this task before.

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Original NASA ASRS Text

Title: A B767-300 WHILE WORKING ON AN OVERWING EMER EXIT WINDOW SHADE AND ON COMPLETION THE EXIT SYS WAS ARMED AND THE OVERWING DOORS AND SLIDE DEPLOYED.

Narrative: ACR X R OVERWING EMER EXIT DOORS HAD THEIR OVERWING SLIDE DOOR SQUIBS AND R SIDE SPOILER SQUIBS BLOWN WHEN DOORS WERE ARMED AFTER REINSTALLING THE R OVERWING DOORS. OVERWING SLIDE ALSO BECAME UNLACED. I WAS WORKING ACR X CHANGING A WINDOW SHADE IN AN OVERWING EMER EXIT. WE DISARMED THE OVERWING EMER EXIT DOORS; REMOVED THE DOORS; REPLACED THE WINDOW SHADE; ARMED THE EXIT SYS PER THE AIRLINE JOB CARD. TRIED A FINAL TESTING OF THE SQUIBS BUT THEY WOULD NOT TEST. STARTED TROUBLESHOOTING THE SYS AND DISCOVERED THAT THE SQUIBS WERE BLOWN ON THE R SIDE. DURING TROUBLESHOOTING OF THE SQUIBS NOT TESTING FOUND THE AUTO-ARM AND AUTO-FIRE SWITCHES. REPOSITIONED SWITCHES BUT THE SQUIBS STILL WOULD NOT TEST. LATER THE PINS FOR THE SPOILER SQUIB WERE FOUND BENT. IT WAS THE FIRST TIME I DID THIS TASK. I WAS ALSO UNFAMILIAR WITH THE JOB CARD. IT WOULD ALSO HAVE BEEN EASIER IF I WAS WORKING WITH SOMEONE WHO HAD DONE THIS TASK BEFORE.

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.