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A B767-200 was dispatched in non compliance with the left nose gear tire and wheel assembly installed without the axle washer.
| Attributes | |
| ACN | 444809 |
| Time | |
| Date | 199907 |
| Day | Sun |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B767-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant technician : fcc |
| Experience | maintenance technician : 3 |
| ASRS Report | 444809 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : lighting performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : installation |
| Supplementary | |
| Problem Areas | Aircraft Company Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Ship xyz (boeing 767) on layover in san diego, ca, jul/xa/99. The left nose tire was found with a deep cut in the tread. During the replacement of the tire assembly, the washer (axle washer) (B767 maintenance manual reference 32-45-02-4, page 403 item #2) was inadvertently left out. This washer was found missing during a maintenance visit on jul/xe/99 in salt lake city. I was not made aware of it until jul/xf/99 at approximately XA30. The air carrier report states that the wheel spacer was missing and that is wrong. It was the axle washer that was missing.
Original NASA ASRS Text
Title: A B767-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE L NOSE GEAR TIRE AND WHEEL ASSEMBLY INSTALLED WITHOUT THE AXLE WASHER.
Narrative: SHIP XYZ (BOEING 767) ON LAYOVER IN SAN DIEGO, CA, JUL/XA/99. THE L NOSE TIRE WAS FOUND WITH A DEEP CUT IN THE TREAD. DURING THE REPLACEMENT OF THE TIRE ASSEMBLY, THE WASHER (AXLE WASHER) (B767 MAINT MANUAL REF 32-45-02-4, PAGE 403 ITEM #2) WAS INADVERTENTLY LEFT OUT. THIS WASHER WAS FOUND MISSING DURING A MAINT VISIT ON JUL/XE/99 IN SALT LAKE CITY. I WAS NOT MADE AWARE OF IT UNTIL JUL/XF/99 AT APPROX XA30. THE ACR RPT STATES THAT THE WHEEL SPACER WAS MISSING AND THAT IS WRONG. IT WAS THE AXLE WASHER THAT WAS MISSING.
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.