37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 543155 |
Time | |
Date | 200203 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : foa.airport |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | L-1011 Tri-Star All Series |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 543155 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other other : 969 |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure contributing factor : manuals performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
During a brake change on an L1011 wheel, an inner spacer was inadvertently not reinstalled during change. Myself and 2 other mechanics worked a grounded L1011 in ZZZ. We worked an oil consumption problem, daily service and line service check. The brake was the last job. Numerous hours were worked by the 3 of us, 19 hours per day for 3 days personally. A new wheel/tire assembly, new brake were changed to correct the problem. I have submitted a change to company suggesting the spacer be an rii item. Thank you for your attention. No injuries to personnel and the plane was not on a revenue flight.
Original NASA ASRS Text
Title: AN L1011 WAS DISPATCHED IN NON COMPLIANCE WITH A MAIN LNDG GEAR TIRE AND WHEEL ASSEMBLY REPLACED OMITTING THE INNER WHEEL SPACER.
Narrative: DURING A BRAKE CHANGE ON AN L1011 WHEEL, AN INNER SPACER WAS INADVERTENTLY NOT REINSTALLED DURING CHANGE. MYSELF AND 2 OTHER MECHS WORKED A GNDED L1011 IN ZZZ. WE WORKED AN OIL CONSUMPTION PROB, DAILY SVC AND LINE SVC CHK. THE BRAKE WAS THE LAST JOB. NUMEROUS HRS WERE WORKED BY THE 3 OF US, 19 HRS PER DAY FOR 3 DAYS PERSONALLY. A NEW WHEEL/TIRE ASSEMBLY, NEW BRAKE WERE CHANGED TO CORRECT THE PROB. I HAVE SUBMITTED A CHANGE TO COMPANY SUGGESTING THE SPACER BE AN RII ITEM. THANK YOU FOR YOUR ATTN. NO INJURIES TO PERSONNEL AND THE PLANE WAS NOT ON A REVENUE FLT.
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.