|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0001 To 0600|
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||B777-200|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : maintenance|
|Affiliation||company : air carrier|
|Function||maintenance : technician|
|Anomaly||aircraft equipment problem : less severe|
maintenance problem : improper maintenance
non adherence : published procedure
non adherence : far
|Independent Detector||other other : 2|
|Resolutory Action||none taken : detected after the fact|
|Maintenance||contributing factor : manuals|
contributing factor : engineering procedure
performance deficiency : non compliance with legal requirements
performance deficiency : installation
Maintenance Human Performance
Chart Or Publication
|Primary Problem||Maintenance Human Performance|
I was informed of an investigation into the battery pack for a door slide installation on aircraft X that happened a few months prior. I was told the maintenance information. I called the number given at that time but could not get hold of anyone until XA30 am the next morning. I spoke to xxxxx at that time and he told me that the slide pack was installed upside down as found on 'C' check. He also told me they had found another aircraft that way and that it was still functional installed that way. I do recall the engineering directive because it was the first time it was done in ZZZ to my knowledge and we followed the job card closely and tested it as called out. It was functional to the best of my knowledge and safety was never compromised. This is about the best I can recall after all this time. Callback conversation with reporter revealed the following information: reporter stated the original paperwork picture from engineering was very sketchy. He reinstalled the new battery pack in the same position as the old pack he just removed. They removed the slide off of the door and performed a door emergency opening with the new battery pack just to make sure the door would open. Test was successful. A new door assist bottle was installed and the slide pack re-attached to the door. The upside down battery pack was found during a 'C' check. His manager mentioned the carrier was aware of the paperwork problem and a job card change was being made to use the part number on the battery pack as a reference for the proper positioning of the pack when installed on the door. Reporter also stated that boeing will also make changes to their maintenance manual.
Original NASA ASRS Text
Title: A B777-200 MECHANIC REPORTS ON BEING TOLD HE HAD INSTALLED THE ACFT CABIN DOOR EMERGENCY ASSIST BOTTLE BATTERY PACK UPSIDE DOWN. SYSTEM CONTINUED TO BE FUNCTIONAL.
Narrative: I WAS INFORMED OF AN INVESTIGATION INTO THE BATTERY PACK FOR A DOOR SLIDE INSTALLATION ON ACFT X THAT HAPPENED A FEW MONTHS PRIOR. I WAS TOLD THE MAINT INFO. I CALLED THE NUMBER GIVEN AT THAT TIME BUT COULD NOT GET HOLD OF ANYONE UNTIL XA30 AM THE NEXT MORNING. I SPOKE TO XXXXX AT THAT TIME AND HE TOLD ME THAT THE SLIDE PACK WAS INSTALLED UPSIDE DOWN AS FOUND ON 'C' CHK. HE ALSO TOLD ME THEY HAD FOUND ANOTHER ACFT THAT WAY AND THAT IT WAS STILL FUNCTIONAL INSTALLED THAT WAY. I DO RECALL THE ENGINEERING DIRECTIVE BECAUSE IT WAS THE FIRST TIME IT WAS DONE IN ZZZ TO MY KNOWLEDGE AND WE FOLLOWED THE JOB CARD CLOSELY AND TESTED IT AS CALLED OUT. IT WAS FUNCTIONAL TO THE BEST OF MY KNOWLEDGE AND SAFETY WAS NEVER COMPROMISED. THIS IS ABOUT THE BEST I CAN RECALL AFTER ALL THIS TIME. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE ORIGINAL PAPERWORK PICTURE FROM ENGINEERING WAS VERY SKETCHY. HE REINSTALLED THE NEW BATTERY PACK IN THE SAME POSITION AS THE OLD PACK HE JUST REMOVED. THEY REMOVED THE SLIDE OFF OF THE DOOR AND PERFORMED A DOOR EMERGENCY OPENING WITH THE NEW BATTERY PACK JUST TO MAKE SURE THE DOOR WOULD OPEN. TEST WAS SUCCESSFUL. A NEW DOOR ASSIST BOTTLE WAS INSTALLED AND THE SLIDE PACK RE-ATTACHED TO THE DOOR. THE UPSIDE DOWN BATTERY PACK WAS FOUND DURING A 'C' CHECK. HIS MANAGER MENTIONED THE CARRIER WAS AWARE OF THE PAPERWORK PROBLEM AND A JOB CARD CHANGE WAS BEING MADE TO USE THE PART NUMBER ON THE BATTERY PACK AS A REFERENCE FOR THE PROPER POSITIONING OF THE PACK WHEN INSTALLED ON THE DOOR. REPORTER ALSO STATED THAT BOEING WILL ALSO MAKE CHANGES TO THEIR MAINT MANUAL.
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.