2010-07 · NASA ASRS report 902979
A Lead stock clerk describes the force and damage resulting from a B737-700 Emergency Evacuation slide that deployed at their Maintenance Stores Receiving dock in ZZZ1 while being unloaded from a freight cart. Another stock clerk in ZZZ reports the slide pack had been dropped prior to loading onto a B737 and shipped to ZZZ1 where it deployed. Bottle safety pin could not be found.
[I'm] a stock clerk in ZZZ [and] brought two unserviceable aircraft slides planeside for flight. At gate I asked the Gate Lead which bin [cargo pit] he wanted them to be loaded. He advised me that he wanted them loaded in the aft bin. I brought the tailgate down on the pickup and pulled the slides to about one inch from the edge of the tailgate. I got in the pickup and as I accelerated to go forward to line up with the belt loader; one of the slides fell off the back of the pickup approximately three inches. With assistant; I picked up the slide and carried it to the belt loader. There was no visible damage noted to the outside of the case. I did not accelerate at a high rate of speed. I then backed up the pickup to the belt loader and loaded the other slide. The paperwork was signed and I left without further incident. Regretfully; I did not think to inspect the inside of the slide after it fell to the ground. The following morning I was informed that the slide had inflated on the cargo dock. The name they got from the paperwork was from one of my co-workers; which was from the slides I shipped.
I was the Lead Stock clerk on evening shift in the Maintenance Stores department. The Receiving dock stock clerk 'X' was walking towards me and told me a slide (an emergency evacuation slide) had blown just as he was unloading it from the freight cart onto a small; flat push cart in the Stock room. The emergency evacuation slide was prepared for shipment by an Aircraft Maintenance Technician at ZZZ. The Hazardous Material paperwork for the emergency evacuation slide was prepared by stock clerk 'Y'. The emergency slide was shipped from ZZZ to ZZZ1. The slide was unloaded by and deployed by stock clerk 'X' in ZZZ1. I telephoned the company hotline that same evening. After I made a brief statement and description of the accident; I lastly stated that there was a concern that the emergency evacuation slide had been shipped on our aircraft without having the slide bottle properly secured with the slide pin installed.When the emergency evacuation slide deployed; the force of the deploying emergency evacuation slide blew back 15-20 feet with the slide somehow hitting the gas line and the gas heater just above the dock doors; ripping off the electrical cover panel on the back of the gas heater and ripping loose the electrical wiring and twisting the gas heater to a 40 degree or so angle. The force of the emergency evacuation slide deploying in the slide case bent the left front hinge pin on the case; popping the latch completely off. The latch on the front left side simply ripped the catch 'tongue' in a downward angle until; I assume; the latch did not hold anymore and popped loose. The back piano hinge on the slide case seemed to be fully intact; but some rivets seemed as if they were somewhat pulled out by the force of the deploying slide. Also; though it does not seem like it would have made much difference; it appears no 'safety strap' had ever been installed inside the slide case. According to stock clerk Mr 'X'; the only other individuals present on the Receiving dock at the time the emergency evacuation slide deployed were stock clerks 'Z' and 'A;' and the Receiving Inspector Mr 'X'. The other Receiving Inspector on duty was not present on the receiving dock at the time the slide deployed. As I walked to the receiving dock; numerous people were standing around the deployed emergency evacuation slide that was laid out on the Receiving dock floor. Most of the employees present; at one time or another; seemed to have looked around on the floor for something and several moments later I was told they were searching for the slide bottle pin that was not present with or around the slide bottle. Two of the Inspectors who examined the slide; Mr 'X' and Mr 'Y'; both said at one time or another while examining the emergency evacuation slide; that the slide bottle did not have a pin installed because if the slide bottle had a pin; the pin would have been somewhere in the immediate vicinity of the slide bottle. I asked stock clerk 'X' if he or 'Z' had searched for the slide bottle pin. Stock clerk 'X' said he and stock clerk 'Z' had looked for the slide bottle pin and that they had also searched the outside ramp leading up to the Receiving dock door as well as the baggage carts that ramp had pulled the slide boxes in; but could not find one. Several of the aircraft maintenance technicians present began asking if anyone knew how to contact the Aircraft Maintenance Technician in ZZZ who prepared the 'Unserviceable' slide for shipment and signed off on the 'Unserviceable' Tag. The Aircraft Maintenance Technician who signed the tag [in ZZZ] is Mr 'X'. Since the mechanics present at the accident scene [in ZZZ1] were going to contact Mechanic 'X'; I; as a stock clerk; decided to contact the ZZZ stock clerk who had signed-off on the company Air Bill. According to the initial ZZZ stock clerk I spoke with; stock clerk 'Y' was off-work for the next several days. I explained the accident to him and asked to have 'Y' call me if he could contact her. Sometime later that evening; stock clerk 'Y' called me. Clerk 'Y' sounded upset; or at least very annoyed that she was somehow being implicated in this accident. As clerk 'Y' explained to me; a number of aircraft maintenance technicians had called her and asked her if she had verified that the slide bottle had the pin installed before she shipped it. As clerk 'Y' told me; she told the various aircraft maintenance technicians who called her that all she checked was the color of the slide bottle; because that is all we; as stock clerks had been instructed to do. It seems some; or all of the aircraft maintenance technicians somehow gave her the idea that she; as a stock clerk; was responsible for ensuring that the Aircraft Maintenance Technician had properly installed the slide bottle pin before she shipped it. This in fact is not the case. The only thing we as Stock clerks have been instructed to check; on emergency evacuation slides is the color of the slide bottle in this case. Though I have not shipped an emergency evacuation slide in quite some time; several of my co-workers told me that quite some time ago; company officials apparently distributed a memo to all stock clerks instructing us to open the slide case and check the color of the slide bottle; but there was no mention of checking the slide bottle pins. I myself even question this procedure. Also none of the company Hazardous Materials Training classes have ever; to my recollection; covered any material; or had any instructions that stock clerks are to verify that aircraft maintenance technicians have installed the pins correctly. This situation is almost exactly like the 'Unserviceable' MEC (Main Engine Control Unit) fiasco we have had for many; many years at our carrier.Aircraft maintenance technicians would bring the 'Unserviceable' [MEC] units to stock clerks. We; as stock clerks; were told by officials to assume that enough fuel was drained from the MEC by the Aircraft Technician so that the MEC could be legally shipped by air (per 49 CFR); when in reality; stock clerks had no way of knowing how much residual fuel remained in the 'Unserviceable' MEC. Just as with the earlier shipment of MECs; stock clerks have assumed the aircraft maintenance technicians have prepared the emergency evacuation slides for shipments properly; including installing the pin in the slide bottle; and until we receive written instruction otherwise; I am sure this is what we will continue to do. I briefly explained company reporting to her as I understood it. I suggested that she note that she simply checked the color of the slide bottle; but not the slide bottle pin since we never have been instructed to [do so]. Unbelievably; unless I somehow misunderstood our telephone conversation; I have heard company officials are claiming that stock clerk 'Y' did check the slide bottle pin and verified it was installed before it was shipped when she clearly told me she only checked the color of the slide bottle; not the pin. Is it that company could neither confirm nor deny that the slide bottle pin was installed and company officials are intentionally misconstruing her statement to say that she verified the slide bottle pin was installed; when in fact; it had not? Also I find it interesting that later that evening; two employees from Engineering; and 'Z' the Receiving Inspector (the inspector who was not present on the dock when the side deployed); walked through the stock room at the far end of the building from the Receiving dock and were looking all around and under the Lead desk for something. I asked them if they needed help finding something and they said no; they were looking for the missing slide pin. I laughed and told them the slide pin; if one had been installed (but was clearly not installed) would not be found on this end of the building. They said they were instructed to look through the whole Stock room for the missing slide pin. After searching for the missing slide pin; Inspectors 'X' and 'Z' rolled the slide up and placed it in a large; grey plastic push cart with a lid. The slide case was set on top. Even as of yesterday evening; one of my co-workers said some employees were still searching throughout the stock room for the missing slide pin. This is; of course; ridiculous. If a slide pin has been installed on the slide bottle; even though I am not an Aircraft Maintenance Technician; I am fairly sure; based on what was said by the Inspectors at the accident scene; the slide bottle pin would have been found almost immediately in the vicinity of the slide bottle. Based on the issues above; simply as a stock clerk I would find it highly suspicious if anyone claims to have found the missing emergency evacuation side bottle pin regardless of their title or position.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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