37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 338858 |
Time | |
Date | 199606 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dfw |
State Reference | TX |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 11000 flight time type : 1200 |
ASRS Report | 338858 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | conflict : ground less severe non adherence : far other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
Maintenance changed both nose tires due to a vibration problem. Only one mechanic was available to do this work and the flight was already 30 mins past departure when the job was completed. As the mechanic was signing off the paperwork, I personally inspected the tires for proper installation of axle nuts and cotter pins. However, I failed to notice that the jack adaptor was still attached to the nose gear strut. Fortunately, it fell off during taxi. Unfortunately, it was run over by an MD80 with some damage to that aircraft's spray deflector. When the adaptor is attached to the strut, it very much looks as if it is a part of the strut assembly, being of the same color and construction. I believe if this, and other similar hardware, were painted a bright color (ie, red, orange, yellow) I might have noticed it, the mechanic might have noticed it, the ramp person who pulled the chocks might have noticed it, and the MD80 crew might have been able to avoid it. Also, mechanics working in pairs (much like cockpit crews) might have prevented this type of human error.
Original NASA ASRS Text
Title: BOTH AN ACFT EQUIP PROB AND FLC VIGILANCE. AFTER CHANGING NOSE TIRES, THE JACK ADAPTOR WAS LEFT ATTACHED TO THE NOSE GEAR. IT WAS NOT SEEN BY EITHER THE MECH OR THE RPTR FLC. CONSEQUENTLY, AS THEY TAXIED, THE ADAPTOR FELL OFF AND CAUSED DAMAGE TO AN ACFT TAXIING BEHIND.
Narrative: MAINT CHANGED BOTH NOSE TIRES DUE TO A VIBRATION PROB. ONLY ONE MECH WAS AVAILABLE TO DO THIS WORK AND THE FLT WAS ALREADY 30 MINS PAST DEP WHEN THE JOB WAS COMPLETED. AS THE MECH WAS SIGNING OFF THE PAPERWORK, I PERSONALLY INSPECTED THE TIRES FOR PROPER INSTALLATION OF AXLE NUTS AND COTTER PINS. HOWEVER, I FAILED TO NOTICE THAT THE JACK ADAPTOR WAS STILL ATTACHED TO THE NOSE GEAR STRUT. FORTUNATELY, IT FELL OFF DURING TAXI. UNFORTUNATELY, IT WAS RUN OVER BY AN MD80 WITH SOME DAMAGE TO THAT ACFT'S SPRAY DEFLECTOR. WHEN THE ADAPTOR IS ATTACHED TO THE STRUT, IT VERY MUCH LOOKS AS IF IT IS A PART OF THE STRUT ASSEMBLY, BEING OF THE SAME COLOR AND CONSTRUCTION. I BELIEVE IF THIS, AND OTHER SIMILAR HARDWARE, WERE PAINTED A BRIGHT COLOR (IE, RED, ORANGE, YELLOW) I MIGHT HAVE NOTICED IT, THE MECH MIGHT HAVE NOTICED IT, THE RAMP PERSON WHO PULLED THE CHOCKS MIGHT HAVE NOTICED IT, AND THE MD80 CREW MIGHT HAVE BEEN ABLE TO AVOID IT. ALSO, MECHS WORKING IN PAIRS (MUCH LIKE COCKPIT CREWS) MIGHT HAVE PREVENTED THIS TYPE OF HUMAN ERROR.
Data retrieved from NASA's ASRS site as of July 2007 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.