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|
Attributes | |
ACN | 559951 |
Time | |
Date | 200207 |
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 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 13 |
ASRS Report | 559951 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : unqualified personnel performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
While working a B767 aircraft, on walkaround I found tire #1F worn beyond limits. I made a write-up to replace the tire. I printed a copy of the relevant maintenance manual reference and began to replace the tire and wheel assembly. I had another mechanic working with me. Even though I had never changed a tire on this model aircraft, I took the lead and this other mechanic basically followed me. The old tire came off without any problems. We had a little trouble aligning the new wheel assembly on the axle, but once lined-up, the assembly slid into place without problem. The first indication that there was something wrong came after we had applied initial torque and were applying the final torque. The holes for the locking bolts didn't align and, per the maintenance manual, we continued to torque the nut to bring the holes into alignment. It appeared to me that too much torque was required, but we didn't exceed the 15 degrees additional rotation on the axle nut as allowed by the maintenance manual, so I dismissed this as normal. We also had difficulty installing the hub cap. The clamp seemed too tight, but again I dismissed this. Once the wheel assembly was installed, it spun normally on the axle with no abnormal indications. I conferred with the other mechanic and we both agreed that the tire was installed properly. When the aircraft landed at its next destination, the brake on this wheel assembly overheated and the tire deflated. On inspection, it was noted that the inboard spacer was missing from the assembly. To the best of my recollection, this is my first experience changing a wheel assembly on this model aircraft and, for that matter, any model aircraft that has an inboard spacer. I've changed many wheels on B757 aircraft and assumed that the process was similar on the B767. While I had a copy of the maintenance manual, I referred to it only for torque values. I didn't look for this inboard spacer because I wasn't aware of it.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH #1 FRONT WHEEL AND TIRE ASSEMBLY MISSING THE INBOARD WHEEL SPACER.
Narrative: WHILE WORKING A B767 ACFT, ON WALKAROUND I FOUND TIRE #1F WORN BEYOND LIMITS. I MADE A WRITE-UP TO REPLACE THE TIRE. I PRINTED A COPY OF THE RELEVANT MAINT MANUAL REF AND BEGAN TO REPLACE THE TIRE AND WHEEL ASSEMBLY. I HAD ANOTHER MECH WORKING WITH ME. EVEN THOUGH I HAD NEVER CHANGED A TIRE ON THIS MODEL ACFT, I TOOK THE LEAD AND THIS OTHER MECH BASICALLY FOLLOWED ME. THE OLD TIRE CAME OFF WITHOUT ANY PROBS. WE HAD A LITTLE TROUBLE ALIGNING THE NEW WHEEL ASSEMBLY ON THE AXLE, BUT ONCE LINED-UP, THE ASSEMBLY SLID INTO PLACE WITHOUT PROB. THE FIRST INDICATION THAT THERE WAS SOMETHING WRONG CAME AFTER WE HAD APPLIED INITIAL TORQUE AND WERE APPLYING THE FINAL TORQUE. THE HOLES FOR THE LOCKING BOLTS DIDN'T ALIGN AND, PER THE MAINT MANUAL, WE CONTINUED TO TORQUE THE NUT TO BRING THE HOLES INTO ALIGNMENT. IT APPEARED TO ME THAT TOO MUCH TORQUE WAS REQUIRED, BUT WE DIDN'T EXCEED THE 15 DEGS ADDITIONAL ROTATION ON THE AXLE NUT AS ALLOWED BY THE MAINT MANUAL, SO I DISMISSED THIS AS NORMAL. WE ALSO HAD DIFFICULTY INSTALLING THE HUB CAP. THE CLAMP SEEMED TOO TIGHT, BUT AGAIN I DISMISSED THIS. ONCE THE WHEEL ASSEMBLY WAS INSTALLED, IT SPUN NORMALLY ON THE AXLE WITH NO ABNORMAL INDICATIONS. I CONFERRED WITH THE OTHER MECH AND WE BOTH AGREED THAT THE TIRE WAS INSTALLED PROPERLY. WHEN THE ACFT LANDED AT ITS NEXT DEST, THE BRAKE ON THIS WHEEL ASSEMBLY OVERHEATED AND THE TIRE DEFLATED. ON INSPECTION, IT WAS NOTED THAT THE INBOARD SPACER WAS MISSING FROM THE ASSEMBLY. TO THE BEST OF MY RECOLLECTION, THIS IS MY FIRST EXPERIENCE CHANGING A WHEEL ASSEMBLY ON THIS MODEL ACFT AND, FOR THAT MATTER, ANY MODEL ACFT THAT HAS AN INBOARD SPACER. I'VE CHANGED MANY WHEELS ON B757 ACFT AND ASSUMED THAT THE PROCESS WAS SIMILAR ON THE B767. WHILE I HAD A COPY OF THE MAINT MANUAL, I REFERRED TO IT ONLY FOR TORQUE VALUES. I DIDN'T LOOK FOR THIS INBOARD SPACER BECAUSE I WASN'T AWARE OF IT.
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.