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An airbus A320 mechanic describes why door 2-RIGHT evacuation slide deployed even though slide came from manufacturer with the slide bottle safety pin installed.
| Attributes | |
| ACN | 774598 |
| Time | |
| Date | 200712 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | A320 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 774598 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | performance deficiency : installation performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Company Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On aircraft X write-up; engineering order #2R evacuate/evacuation slide replacement. Accomplished door slide replacement per maintenance manual. Was unable to complete installation due to shift ending. Created maintenance write-up item to cover status of installation including position of safeties; also gave verbal pass down to on-coming shift lead who then entered aircraft. While I was completing paperwork for aircraft I heard door evacuate/evacuation slide deploy from door 2R. The status of the door was; door assist bottle was rearmed and slide bottle was still pinned as received from slide vendor. Slide vendors need to verify proper installation of slide bottle safety pin.
Original NASA ASRS Text
Title: AN AIRBUS A320 MECHANIC DESCRIBES WHY DOOR 2-RIGHT EVACUATION SLIDE DEPLOYED EVEN THOUGH SLIDE CAME FROM MANUFACTURER WITH THE SLIDE BOTTLE SAFETY PIN INSTALLED.
Narrative: ON ACFT X WRITE-UP; ENGINEERING ORDER #2R EVAC SLIDE REPLACEMENT. ACCOMPLISHED DOOR SLIDE REPLACEMENT PER MAINT MANUAL. WAS UNABLE TO COMPLETE INSTALLATION DUE TO SHIFT ENDING. CREATED MAINT WRITE-UP ITEM TO COVER STATUS OF INSTALLATION INCLUDING POS OF SAFETIES; ALSO GAVE VERBAL PASS DOWN TO ON-COMING SHIFT LEAD WHO THEN ENTERED ACFT. WHILE I WAS COMPLETING PAPERWORK FOR ACFT I HEARD DOOR EVAC SLIDE DEPLOY FROM DOOR 2R. THE STATUS OF THE DOOR WAS; DOOR ASSIST BOTTLE WAS REARMED AND SLIDE BOTTLE WAS STILL PINNED AS RECEIVED FROM SLIDE VENDOR. SLIDE VENDORS NEED TO VERIFY PROPER INSTALLATION OF SLIDE BOTTLE SAFETY PIN.
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.