37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 527267 |
Time | |
Date | 200110 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 1 |
ASRS Report | 527267 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : person 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : lighting performance deficiency : inspection performance deficiency : installation performance deficiency : training |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On or about oct/xa/01, I was assigned to work aircraft X at the terminal. This particular airplane came in with a log write-up stating the aircraft steered to the left while taxiing. It was decided by my lead that both nose landing gear tires were to be changed to see if this would resolve the problem since there was no history of this happening previously. Another mechanic and myself removed and replaced both nose landing gear tires in accordance with B757 maintenance manual 32-45-02. The log item was signed off. Upon returning to work on oct/xd/01, it was brought to my attention by a fellow mechanic that he had worked said aircraft on oct/xc/01 regarding low pressure in the right nose tire. A look through the history indicated that this same tire had previously been replaced twice in as many days. It was also brought to my attention that a job callout concerning the proper installation of the nose landing gear tires had been initiated. The mechanic who replaced the tires the second time stated that both nose tire washers and snap rings were found to be missing upon inspection. I thought I recalled both being present on each tire assembly at the time I had changed the tires. I think it should be noted that the aircraft suffered no damage nor was there any personal injury to anyone. I think one of the contributing causes was a general lack of knowledge on my part. This was the first time I had to change the nose landing gear tires on a B757. Another factor was the fact that I was very fatigued. Also, the lighting at the terminal is fair at best. In order to prevent a recurrence, more training needs to be given to relatively new mechanics, more lighting needs to be used when working at night and people need to be less fatigued on the job.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE R NOSE TIRE INSTALLED INCORRECTLY. AXLE WASHER AND SNAP RING NOT INSTALLED.
Narrative: ON OR ABOUT OCT/XA/01, I WAS ASSIGNED TO WORK ACFT X AT THE TERMINAL. THIS PARTICULAR AIRPLANE CAME IN WITH A LOG WRITE-UP STATING THE ACFT STEERED TO THE L WHILE TAXIING. IT WAS DECIDED BY MY LEAD THAT BOTH NOSE LNDG GEAR TIRES WERE TO BE CHANGED TO SEE IF THIS WOULD RESOLVE THE PROB SINCE THERE WAS NO HISTORY OF THIS HAPPENING PREVIOUSLY. ANOTHER MECH AND MYSELF REMOVED AND REPLACED BOTH NOSE LNDG GEAR TIRES IN ACCORDANCE WITH B757 MAINT MANUAL 32-45-02. THE LOG ITEM WAS SIGNED OFF. UPON RETURNING TO WORK ON OCT/XD/01, IT WAS BROUGHT TO MY ATTN BY A FELLOW MECH THAT HE HAD WORKED SAID ACFT ON OCT/XC/01 REGARDING LOW PRESSURE IN THE R NOSE TIRE. A LOOK THROUGH THE HISTORY INDICATED THAT THIS SAME TIRE HAD PREVIOUSLY BEEN REPLACED TWICE IN AS MANY DAYS. IT WAS ALSO BROUGHT TO MY ATTN THAT A JOB CALLOUT CONCERNING THE PROPER INSTALLATION OF THE NOSE LNDG GEAR TIRES HAD BEEN INITIATED. THE MECH WHO REPLACED THE TIRES THE SECOND TIME STATED THAT BOTH NOSE TIRE WASHERS AND SNAP RINGS WERE FOUND TO BE MISSING UPON INSPECTION. I THOUGHT I RECALLED BOTH BEING PRESENT ON EACH TIRE ASSEMBLY AT THE TIME I HAD CHANGED THE TIRES. I THINK IT SHOULD BE NOTED THAT THE ACFT SUFFERED NO DAMAGE NOR WAS THERE ANY PERSONAL INJURY TO ANYONE. I THINK ONE OF THE CONTRIBUTING CAUSES WAS A GENERAL LACK OF KNOWLEDGE ON MY PART. THIS WAS THE FIRST TIME I HAD TO CHANGE THE NOSE LNDG GEAR TIRES ON A B757. ANOTHER FACTOR WAS THE FACT THAT I WAS VERY FATIGUED. ALSO, THE LIGHTING AT THE TERMINAL IS FAIR AT BEST. IN ORDER TO PREVENT A RECURRENCE, MORE TRAINING NEEDS TO BE GIVEN TO RELATIVELY NEW MECHS, MORE LIGHTING NEEDS TO BE USED WHEN WORKING AT NIGHT AND PEOPLE NEED TO BE LESS FATIGUED ON THE JOB.
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.