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B737-700 during a heavy maintenance check the emergency escape slides were removed for cleaning and dry lubing. Slides were reinstalled in incorrect positions.
| Attributes | |
| ACN | 716930 |
| Time | |
| Date | 200611 |
| 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 | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 716930 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 716920 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Independent Detector | other other : 4 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
During 'back course' check; I was assigned to do the doors and water checks. We had 4 cards to remove; clean; lube and reinstall the emergency slides. We had marked the shrouds with tape as to where they came from; but the slides were not marked. We thought we had laid them on the table in the correct position and installed them in the shrouds in that order. Somehow; we ended up installing the aft slides in the forward shrouds and vice versa. This mistake was found by the flight attendants before the first flight in the morning.
Original NASA ASRS Text
Title: B737-700 DURING A HVY MAINT CHK THE EMER ESCAPE SLIDES WERE REMOVED FOR CLEANING AND DRY LUBING. SLIDES WERE REINSTALLED IN INCORRECT POSITIONS.
Narrative: DURING 'BC' CHK; I WAS ASSIGNED TO DO THE DOORS AND WATER CHKS. WE HAD 4 CARDS TO REMOVE; CLEAN; LUBE AND REINSTALL THE EMER SLIDES. WE HAD MARKED THE SHROUDS WITH TAPE AS TO WHERE THEY CAME FROM; BUT THE SLIDES WERE NOT MARKED. WE THOUGHT WE HAD LAID THEM ON THE TABLE IN THE CORRECT POS AND INSTALLED THEM IN THE SHROUDS IN THAT ORDER. SOMEHOW; WE ENDED UP INSTALLING THE AFT SLIDES IN THE FORWARD SHROUDS AND VICE VERSA. THIS MISTAKE WAS FOUND BY THE FLT ATTENDANTS BEFORE THE FIRST FLT IN THE MORNING.
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.