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|
Attributes | |
ACN | 465440 |
Time | |
Date | 200003 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : pbi.tower |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
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 : powerplant technician : airframe |
Experience | maintenance technician : 16 |
ASRS Report | 465440 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 10 |
ASRS Report | 465739 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : lighting performance deficiency : inspection performance deficiency : repair performance deficiency : training performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Early in the morning in the dark with a dimly lit head lamp, I was changing the left nose tire of this B767-322. Everything seemed to be going well. I read our maintenance manual very carefully because this was the first time for me changing a tire on this type of aircraft. There was a caution in the maintenance manual noting to check for the anti rotation washer. I did so. It appeared as if the washer was on the axle. With the combination of the dimly lit head lamp and the buildup of fresh grease, I continued on with the job. After torque of the axle nut, I was able to put the safety bolts in with no problem. I grasped the tire and tried to shimmy it as usual to check for a firmness. Later I was told by the mechanic who reworks these wheels that my washer was stuck to the bearing. When the aircraft landed in den, it was grounded while waiting for a replacement washer. I believe now that I may have been able to prevent this again from happening if I took the time to replace my batteries in my head lamp and if I wiped clean the axle of excess grease.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE L NOSE GEAR WHEEL ANTI-ROTATION WASHER NOT INSTALLED AFTER WHEEL AND TIRE REPLACEMENT.
Narrative: EARLY IN THE MORNING IN THE DARK WITH A DIMLY LIT HEAD LAMP, I WAS CHANGING THE L NOSE TIRE OF THIS B767-322. EVERYTHING SEEMED TO BE GOING WELL. I READ OUR MAINT MANUAL VERY CAREFULLY BECAUSE THIS WAS THE FIRST TIME FOR ME CHANGING A TIRE ON THIS TYPE OF ACFT. THERE WAS A CAUTION IN THE MAINT MANUAL NOTING TO CHK FOR THE ANTI ROTATION WASHER. I DID SO. IT APPEARED AS IF THE WASHER WAS ON THE AXLE. WITH THE COMBINATION OF THE DIMLY LIT HEAD LAMP AND THE BUILDUP OF FRESH GREASE, I CONTINUED ON WITH THE JOB. AFTER TORQUE OF THE AXLE NUT, I WAS ABLE TO PUT THE SAFETY BOLTS IN WITH NO PROB. I GRASPED THE TIRE AND TRIED TO SHIMMY IT AS USUAL TO CHK FOR A FIRMNESS. LATER I WAS TOLD BY THE MECH WHO REWORKS THESE WHEELS THAT MY WASHER WAS STUCK TO THE BEARING. WHEN THE ACFT LANDED IN DEN, IT WAS GNDED WHILE WAITING FOR A REPLACEMENT WASHER. I BELIEVE NOW THAT I MAY HAVE BEEN ABLE TO PREVENT THIS AGAIN FROM HAPPENING IF I TOOK THE TIME TO REPLACE MY BATTERIES IN MY HEAD LAMP AND IF I WIPED CLEAN THE AXLE OF EXCESS GREASE.
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.