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Summary

Summary

During door disarming of the Boeing 747SP aircraft after landing, the cabin crew notified the flight crew that although the levers of main cabin doors L3 and L4 had been moved to the disarm position, the doors failed to disarm. The captain directed the flight attendants to remain at the doors and advised ground engineering to limit catering access. The flight engineer was directed to ensure a safe disarm. The flight engineer found the door slide girt bars still partially engaged into the girt bar receivers. He then used tools to safely disengage the girt bars and disarm both doors.

Line maintenance personnel examined the doors and, after repeated arm/disarm cycles, were unable to duplicate the anomaly. The flight crew elected to continue operations with additional precautions, referred to as "girt bar disengagement inspection", taken to ensure the operational status of the doors. That action included the flight engineer confirming arming of the doors before departure and disarming following arrival. That precaution was taken to prevent inadvertent activation of the slide during normal door opening.

Following landing at the next sector airport, the cabin crew again could not disarm main cabin doors L3/L4. The flight engineer again used tools to physically disengage the girt bars from the girt bar receivers in order to disarm both doors. A maintenance entry was made in the aircraft technical log requiring visual confirmation of the door arming/disarming during each transit. The Master Minimum Equipment List (MMEL) was reviewed and the aircraft returned to service without restrictions.

Over the next three days, the aircraft completed twelve sectors with the girt bars of main cabin doors L3/L4 requiring the girt bar disengagement inspection. Following the last of those twelve sectors, the operator's maintenance department issued an Authority To Proceed (ATP), stating a requirement that the doors not be opened from the outside or left unattended until maintenance personnel confirmed the girt bar was completely disengaged from the girt bar receiver. The ATP was applicable for two sector overwater flights only. Upon completion of those sectors, maintenance personnel corrected the girt bar discrepancy by adjusting the escape slide skirts and returned the slides and doors to normal operation.

B747SP main cabin door configuration

The aircraft's main cabin was configured with four doors per side. The doors were arranged in sequential order, with numbering starting at the nose of the aircraft. The doors were identified by lettering indicating `L' for the left side of the cabin looking towards the nose, and `R' for right.

Discrepancy history of main cabin doors L3/L4

Five days prior to girt bar disengagement inspection implementation, the technical log noted an entry that said, "L4 unable to move mode select to auto". Corrective action stated that an obstruction was found in the girt bar and had been removed, with door operations now normal.

Four days prior to disengagement inspection implementation, the technical log noted an entry, "Door L4 selector switch handle will not engage arm position or sweep seal is remaining outside the door sill". Corrective action stated that the lower skirt aft side was found fouling the girt bar, and that the skirt appeared to be distorted. The skirt was repositioned and operations reported as normal.

Two days prior to girt bar disengagement inspection implementation, the technical log noted an entry, "L4 lower bustle has skirt damage". Corrective action stated that the lower bustle sweeper seal was trimmed.

Door mounted escape slide normal operation

When the crew selected the door to the armed mode (automatic), the girt bar mechanism positioned the girt locks into the floor brackets. As the door handle was moved towards the open position (at approximately 45 degree's of rotation) it lifted the lower gate and girt lift mechanism. When the girt lift mechanism separated from the girt lock, the girt bar springs protruded, locking the girt bar to the floor brackets. The escape pack was then attached to the floor. The door was then forced open by use of an emergency pressure cylinder. That opening of the door, with the girt still attached to the aircraft, caused the slide to release from the door and initiate the inflation sequence of the slide.

Authority to proceed

The Civil Aviation Safety Authority (CASA) issued authorisation under Civil Aviation Regulation (CAR) 37 to delegates of the operator permitting those individuals to authorise continued operation of aircraft with known discrepancies. That authorisation was designed to address aircraft discrepancies not covered by the MMEL or other documentation and was subject to the conditions outlined in the ATP. Such discrepancies must not constitute a concession against an operational requirement of a CAR nor conflict with the design standard of the aircraft. An authorised delegate of the operator who annotated the discrepancy, signed the ATP. A copy of that ATP was provided to the local CASA office.

 
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