Narrative:

There was a callout to change overwing slide. I performed inspection after mechanics completed job. After 4 legs of flight; overwing compartment door opened on landing. Maintenance manual states that door is known to have a false latch dilemma. Unfortunately; this was not discovered; so I am not sure if that was the actual problem. I believe some contributing factors in the chain of events are: 1) no clear cut directives/procedures or sign-offs for the inspector to perform; called out in the maintenance manual procedures. 2) no clear cut procedures on what to specifically check; after mechanics install slide assembly; called out in the required inspection items (rii) list. 3) as this is a faulty system; known for false latching; lack of management/engineering to take a proactive role to prevent reoccurrence other than discipline.callback conversation with reporter revealed the following information: the reporter stated the maintenance manual and the rii list have no clear steps on what to inspect during and after the overwing slide installation. The maintenance manual makes clear this door and slide assembly has a false latch problem but has no inspection task procedure or steps to assure positive door locking. Reporter stated this system has a known fault and feels management and engineering must take a proactive role to prevent another incident.

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Original NASA ASRS Text

Title: A B757-200; FOUR FLTS AFTER INSTALLATION OF AN ESCAPE SLIDE; HAD THE SLIDE DOOR OPEN UPON LNDG.

Narrative: THERE WAS A CALLOUT TO CHANGE OVERWING SLIDE. I PERFORMED INSPECTION AFTER MECHANICS COMPLETED JOB. AFTER 4 LEGS OF FLT; OVERWING COMPARTMENT DOOR OPENED ON LNDG. MAINT MANUAL STATES THAT DOOR IS KNOWN TO HAVE A FALSE LATCH DILEMMA. UNFORTUNATELY; THIS WAS NOT DISCOVERED; SO I AM NOT SURE IF THAT WAS THE ACTUAL PROB. I BELIEVE SOME CONTRIBUTING FACTORS IN THE CHAIN OF EVENTS ARE: 1) NO CLEAR CUT DIRECTIVES/PROCS OR SIGN-OFFS FOR THE INSPECTOR TO PERFORM; CALLED OUT IN THE MAINT MANUAL PROCS. 2) NO CLEAR CUT PROCS ON WHAT TO SPECIFICALLY CHECK; AFTER MECHANICS INSTALL SLIDE ASSEMBLY; CALLED OUT IN THE REQUIRED INSPECTION ITEMS (RII) LIST. 3) AS THIS IS A FAULTY SYSTEM; KNOWN FOR FALSE LATCHING; LACK OF MANAGEMENT/ENGINEERING TO TAKE A PROACTIVE ROLE TO PREVENT REOCCURRENCE OTHER THAN DISCIPLINE.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE MAINT MANUAL AND THE RII LIST HAVE NO CLEAR STEPS ON WHAT TO INSPECT DURING AND AFTER THE OVERWING SLIDE INSTALLATION. THE MAINT MANUAL MAKES CLEAR THIS DOOR AND SLIDE ASSEMBLY HAS A FALSE LATCH PROB BUT HAS NO INSPECTION TASK PROC OR STEPS TO ASSURE POSITIVE DOOR LOCKING. RPTR STATED THIS SYSTEM HAS A KNOWN FAULT AND FEELS MANAGEMENT AND ENGINEERING MUST TAKE A PROACTIVE ROLE TO PREVENT ANOTHER INCIDENT.

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.