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A CRJ700 with repeated reports of pressurization discrepancies was found to have the aft cargo door seal installed backwards report cites publication confusion as a contributing factor.
| Attributes | |
| ACN | 710445 |
| Time | |
| Date | 200608 |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Regional Jet 700 ER&LR |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| ASRS Report | 710445 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| ASRS Report | 710754 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : pressurization discrepancies other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : manuals performance deficiency : logbook entry performance deficiency : testing performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Chart Or Publication Environmental Factor Aircraft Maintenance Human Performance |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | Maint Manual |
Narrative:
On (date) I was asked to look at the installation of the aft baggage door seal on aircraft (tail). I stopped what I was working on and went and verified that the seal was installed and that the seal was secure. I pulled at all the edges and looked around the door to make sure nothing was out of the ordinary and that the seal was not in danger of coming loose. I looked at the procedure to verify steps accomplished and that he signed it off to correct steps and that his documentation was correct. The mistake happened because the seal is able to be installed in more than one way and the procedure is not very clear on the correct orientation.
Original NASA ASRS Text
Title: A CRJ700 WITH REPEATED RPTS OF PRESSURIZATION DISCREPANCIES WAS FOUND TO HAVE THE AFT CARGO DOOR SEAL INSTALLED BACKWARDS RPT CITES PUB CONFUSION AS A CONTRIBUTING FACTOR.
Narrative: ON (DATE) I WAS ASKED TO LOOK AT THE INSTALLATION OF THE AFT BAGGAGE DOOR SEAL ON ACFT (TAIL). I STOPPED WHAT I WAS WORKING ON AND WENT AND VERIFIED THAT THE SEAL WAS INSTALLED AND THAT THE SEAL WAS SECURE. I PULLED AT ALL THE EDGES AND LOOKED AROUND THE DOOR TO MAKE SURE NOTHING WAS OUT OF THE ORDINARY AND THAT THE SEAL WAS NOT IN DANGER OF COMING LOOSE. I LOOKED AT THE PROC TO VERIFY STEPS ACCOMPLISHED AND THAT HE SIGNED IT OFF TO CORRECT STEPS AND THAT HIS DOCUMENTATION WAS CORRECT. THE MISTAKE HAPPENED BECAUSE THE SEAL IS ABLE TO BE INSTALLED IN MORE THAN ONE WAY AND THE PROC IS NOT VERY CLR ON THE CORRECT ORIENTATION.
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.