Narrative:

On sept/mon/2002 a mistake was made that has had an impact on me. I was assigned a 1 service on aircraft X. My partner amt did the initial exterior walk around and found the #1 fwd medium large transport tire worn beyond limits. He wrote the tire up per company regulations, and printed a copy of the company maintenance manual for replacing the tire. While he did that, I gathered all the equipment necessary to do the job. Since B767's are not used too much at ZZZ, I had not changed a B767 tire in about 2 yrs. My partner was changing his first one. This is a very important factor that led to the mistake. As we pulled the bad tire off the axle, unknown to us, the inner spacer came off with the bad tire. The MM mentioned the spacer but we mistook the MM thinking it was the front spacer that is behind the nut. We installed the new tire without a rear spacer. I had a feeling something was wrong but the tire torqued to proper setting, and turned normal. The next day it flew to ZZZ2 and upon arrival ZZZ2 mechanic's found a blown tire and locked up brake. The flight crew had brake temperature of 9. Callback conversation with reporter revealed the following information: the reporter stated the maintenance manual was used to replace the wheel and tire assembly and the procedure did not have any pictorial or illustration of the wheel spacer. The reporter said the only pictorial showing the wheel spacer is in the maintenance manual procedure for the brake replacement. Supplemental information from acn 560272: on mon, sept, I was assigned to take over a brake and tire change on aircraft at gate. When I arrived there, the day shift technician, day shift lead technician, and day shift team leader were standing by the left main landing gear. They told me that the #1 forward brake assembly had overheated and blown the fuse plugs on the wheel assembly. Hence, they were in the process of replacing both the brake assembly and wheel assembly. The wheel assembly had been removed so far and I was to continue from this point. The day shift foreman asked me what a good estimated time to complete the task would be and I told him xb:30 pm. The afternoon shift lead and gate tech arrived to help me with the removal of the brake assembly. While we were standing next to the landing gear waiting for the brake to cool down before we could remove it safely, the day shift foreman told us that a spacer he was alluding to. He showed us the spacer that is installed between the wheel assembly and axle nut and stated it was not there when the aircraft arrival. This meant to me that the spacer had been left out the previous night in ZZZ. He believed this to be the cause of the problem when the aircraft arrived in ZZZ2. The gate technician and myself questioned him as to what spacer we had in our possession was the one that was left out in ZZZ. We proceeded to continue with the job, with many interruptions to look up the proper ipc and MM references to see if everything we needed was there, keeping in mind that when the wheel and brake assemblies were removed there were pieces of broken parts all over the ramp. At one point we also asked the day shift foreman if a bearing-looking piece was to be installed between the brake and wheel assemblies to which he responded that it was the wheel bearing off of the old wheel assembly. I was asked to go to another gate to see if I could be of some help because there was a B777 that had a maintenance discrepancy at departure time. When I arrived back at gate the wheel assembly had been installed while I was away. Feeling pressured and rushed to finish a job I had never done previous because the aircraft had been delayed at least three hours, I did not feel comfortable with the way the entire process had been carried out and had no intentions of signing off the discrepancy. The question arose as to if additional procedures were necessary because the fuse plugs had blown and we were told don't worry about it. I helped return all of the equipment that was used for the job and the aircraft departed. Second callback conversation from acn # 560272 revealed the following information: the reporter stated whendisassembling the damaged wheel and brake many small pieces fell of the axle. The reporter said the supervisor advised the reporter and the technician assisting in the job that a down line station reports not installing the wheel spacer on the axle. The reporter stated the supervisor was questioned on what spacer was not installed and was shown the axle nut washer. The reporter said prior to completing the job he was sent to another gate and on returning found the installation of the brake and wheel assembly complete. The reporter stated because of the way the work was rushed and the interruption he would not sign off the work. The reporter said the supervisor took it upon himself to sign off the work in the computer improperly.

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Original NASA ASRS Text

Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE MAIN LNDG GEAR #1 FRONT WHEEL AND TIRE ASSEMBLY MISSING THE WHEEL SPACER. INCURRED DAMAGE TO THE BRAKE, WHEEL AND TIRE ASSEMBLY. SPACER OMITTED AT BRAKE CHANGE.

Narrative: ON SEPT/MON/2002 A MISTAKE WAS MADE THAT HAS HAD AN IMPACT ON ME. I WAS ASSIGNED A 1 SVC ON ACFT X. MY PARTNER AMT DID THE INITIAL EXTERIOR WALK AROUND AND FOUND THE #1 FWD MLG TIRE WORN BEYOND LIMITS. HE WROTE THE TIRE UP PER COMPANY REGS, AND PRINTED A COPY OF THE COMPANY MAINT MANUAL FOR REPLACING THE TIRE. WHILE HE DID THAT, I GATHERED ALL THE EQUIPMENT NECESSARY TO DO THE JOB. SINCE B767'S ARE NOT USED TOO MUCH AT ZZZ, I HAD NOT CHANGED A B767 TIRE IN ABOUT 2 YRS. MY PARTNER WAS CHANGING HIS FIRST ONE. THIS IS A VERY IMPORTANT FACTOR THAT LED TO THE MISTAKE. AS WE PULLED THE BAD TIRE OFF THE AXLE, UNKNOWN TO US, THE INNER SPACER CAME OFF WITH THE BAD TIRE. THE MM MENTIONED THE SPACER BUT WE MISTOOK THE MM THINKING IT WAS THE FRONT SPACER THAT IS BEHIND THE NUT. WE INSTALLED THE NEW TIRE WITHOUT A REAR SPACER. I HAD A FEELING SOMETHING WAS WRONG BUT THE TIRE TORQUED TO PROPER SETTING, AND TURNED NORMAL. THE NEXT DAY IT FLEW TO ZZZ2 AND UPON ARRIVAL ZZZ2 MECH'S FOUND A BLOWN TIRE AND LOCKED UP BRAKE. THE FLT CREW HAD BRAKE TEMP OF 9. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE MAINT MANUAL WAS USED TO REPLACE THE WHEEL AND TIRE ASSEMBLY AND THE PROC DID NOT HAVE ANY PICTORIAL OR ILLUSTRATION OF THE WHEEL SPACER. THE RPTR SAID THE ONLY PICTORIAL SHOWING THE WHEEL SPACER IS IN THE MAINT MANUAL PROC FOR THE BRAKE REPLACEMENT. SUPPLEMENTAL INFO FROM ACN 560272: ON MON, SEPT, I WAS ASSIGNED TO TAKE OVER A BRAKE AND TIRE CHANGE ON ACFT AT GATE. WHEN I ARRIVED THERE, THE DAY SHIFT TECHNICIAN, DAY SHIFT LEAD TECHNICIAN, AND DAY SHIFT TEAM LEADER WERE STANDING BY THE LEFT MAIN LNDG GEAR. THEY TOLD ME THAT THE #1 FORWARD BRAKE ASSEMBLY HAD OVERHEATED AND BLOWN THE FUSE PLUGS ON THE WHEEL ASSEMBLY. HENCE, THEY WERE IN THE PROCESS OF REPLACING BOTH THE BRAKE ASSEMBLY AND WHEEL ASSEMBLY. THE WHEEL ASSEMBLY HAD BEEN REMOVED SO FAR AND I WAS TO CONTINUE FROM THIS POINT. THE DAY SHIFT FOREMAN ASKED ME WHAT A GOOD ESTIMATED TIME TO COMPLETE THE TASK WOULD BE AND I TOLD HIM XB:30 PM. THE AFTERNOON SHIFT LEAD AND GATE TECH ARRIVED TO HELP ME WITH THE REMOVAL OF THE BRAKE ASSEMBLY. WHILE WE WERE STANDING NEXT TO THE LNDG GEAR WAITING FOR THE BRAKE TO COOL DOWN BEFORE WE COULD REMOVE IT SAFELY, THE DAY SHIFT FOREMAN TOLD US THAT A SPACER HE WAS ALLUDING TO. HE SHOWED US THE SPACER THAT IS INSTALLED BTWN THE WHEEL ASSEMBLY AND AXLE NUT AND STATED IT WAS NOT THERE WHEN THE ACFT ARR. THIS MEANT TO ME THAT THE SPACER HAD BEEN LEFT OUT THE PREVIOUS NIGHT IN ZZZ. HE BELIEVED THIS TO BE THE CAUSE OF THE PROB WHEN THE ACFT ARRIVED IN ZZZ2. THE GATE TECHNICIAN AND MYSELF QUESTIONED HIM AS TO WHAT SPACER WE HAD IN OUR POSSESSION WAS THE ONE THAT WAS LEFT OUT IN ZZZ. WE PROCEEDED TO CONTINUE WITH THE JOB, WITH MANY INTERRUPTIONS TO LOOK UP THE PROPER IPC AND MM REFERENCES TO SEE IF EVERYTHING WE NEEDED WAS THERE, KEEPING IN MIND THAT WHEN THE WHEEL AND BRAKE ASSEMBLIES WERE REMOVED THERE WERE PIECES OF BROKEN PARTS ALL OVER THE RAMP. AT ONE POINT WE ALSO ASKED THE DAY SHIFT FOREMAN IF A BEARING-LOOKING PIECE WAS TO BE INSTALLED BTWN THE BRAKE AND WHEEL ASSEMBLIES TO WHICH HE RESPONDED THAT IT WAS THE WHEEL BEARING OFF OF THE OLD WHEEL ASSEMBLY. I WAS ASKED TO GO TO ANOTHER GATE TO SEE IF I COULD BE OF SOME HELP BECAUSE THERE WAS A B777 THAT HAD A MAINT DISCREPANCY AT DEP TIME. WHEN I ARRIVED BACK AT GATE THE WHEEL ASSEMBLY HAD BEEN INSTALLED WHILE I WAS AWAY. FEELING PRESSURED AND RUSHED TO FINISH A JOB I HAD NEVER DONE PREVIOUS BECAUSE THE ACFT HAD BEEN DELAYED AT LEAST THREE HRS, I DID NOT FEEL COMFORTABLE WITH THE WAY THE ENTIRE PROCESS HAD BEEN CARRIED OUT AND HAD NO INTENTIONS OF SIGNING OFF THE DISCREPANCY. THE QUESTION AROSE AS TO IF ADDITIONAL PROCS WERE NECESSARY BECAUSE THE FUSE PLUGS HAD BLOWN AND WE WERE TOLD DON'T WORRY ABOUT IT. I HELPED RETURN ALL OF THE EQUIP THAT WAS USED FOR THE JOB AND THE ACFT DEPARTED. SECOND CALLBACK CONVERSATION FROM ACN # 560272 REVEALED THE FOLLOWING INFO: THE RPTR STATED WHENDISASSEMBLING THE DAMAGED WHEEL AND BRAKE MANY SMALL PIECES FELL OF THE AXLE. THE RPTR SAID THE SUPERVISOR ADVISED THE RPTR AND THE TECHNICIAN ASSISTING IN THE JOB THAT A DOWN LINE STATION RPTS NOT INSTALLING THE WHEEL SPACER ON THE AXLE. THE RPTR STATED THE SUPERVISOR WAS QUESTIONED ON WHAT SPACER WAS NOT INSTALLED AND WAS SHOWN THE AXLE NUT WASHER. THE RPTR SAID PRIOR TO COMPLETING THE JOB HE WAS SENT TO ANOTHER GATE AND ON RETURNING FOUND THE INSTALLATION OF THE BRAKE AND WHEEL ASSEMBLY COMPLETE. THE RPTR STATED BECAUSE OF THE WAY THE WORK WAS RUSHED AND THE INTERRUPTION HE WOULD NOT SIGN OFF THE WORK. THE RPTR SAID THE SUPERVISOR TOOK IT UPON HIMSELF TO SIGN OFF THE WORK IN THE COMPUTER IMPROPERLY.

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.