 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
A fokker 100 on taxi out from the gate had #4 wheel and tire assembly depart the airplane. Caused by axle nut and lock bolts not aligned and torqued.
| Attributes | |
| ACN | 567563 |
| Time | |
| Date | 200211 |
| Day | Mon |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Fokker 100 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 567563 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 568587 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far |
| Resolutory Action | none taken : detected after the fact |
| Consequence | faa : investigated other other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : training performance deficiency : non compliance with legal requirements performance deficiency : unqualified personnel |
| Supplementary | |
| Problem Areas | Company Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | Maintenance Manual |
Narrative:
On the day of occurrence I volunteered to assist with a brake change on aircraft X. I assumed that until today that it was a normal brake change. Callback conversation with reporter revealed the following information: the reporter stated the two technicians replacing the brake and tire and wheel assembly had never done the job before and were close to finishing up the job. The reporter said I assisted them by installing the axle nut finger tight and advised them the axle nut needed to be torqued and the axle nut lock bolts needed to be aligned with the axle nut slots. The reporter stated the job card does not spell out clearly the axle nut position after torquing to align the axle nut lock blocks with the axle nut slots. The reporter stated he inserted the axle nut lock bolts into the axle nut and left the job. The reporter said the wheel and tire assembly departed the aircraft on taxi out and severely damaged the strut axle requiring a complete strut replacement. The reporter stated this was the third incident of wheel and tire assemblies departing the aircraft primarily due to a deficient job card not clearly describing the axle nut lock bolt alignment with the axle lock slot.
Original NASA ASRS Text
Title: A FOKKER 100 ON TAXI OUT FROM THE GATE HAD #4 WHEEL AND TIRE ASSEMBLY DEPART THE AIRPLANE. CAUSED BY AXLE NUT AND LOCK BOLTS NOT ALIGNED AND TORQUED.
Narrative: ON THE DAY OF OCCURRENCE I VOLUNTEERED TO ASSIST WITH A BRAKE CHANGE ON ACFT X. I ASSUMED THAT UNTIL TODAY THAT IT WAS A NORMAL BRAKE CHANGE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE TWO TECHNICIANS REPLACING THE BRAKE AND TIRE AND WHEEL ASSEMBLY HAD NEVER DONE THE JOB BEFORE AND WERE CLOSE TO FINISHING UP THE JOB. THE RPTR SAID I ASSISTED THEM BY INSTALLING THE AXLE NUT FINGER TIGHT AND ADVISED THEM THE AXLE NUT NEEDED TO BE TORQUED AND THE AXLE NUT LOCK BOLTS NEEDED TO BE ALIGNED WITH THE AXLE NUT SLOTS. THE RPTR STATED THE JOB CARD DOES NOT SPELL OUT CLEARLY THE AXLE NUT POSITION AFTER TORQUING TO ALIGN THE AXLE NUT LOCK BLOCKS WITH THE AXLE NUT SLOTS. THE RPTR STATED HE INSERTED THE AXLE NUT LOCK BOLTS INTO THE AXLE NUT AND LEFT THE JOB. THE RPTR SAID THE WHEEL AND TIRE ASSEMBLY DEPARTED THE ACFT ON TAXI OUT AND SEVERELY DAMAGED THE STRUT AXLE REQUIRING A COMPLETE STRUT REPLACEMENT. THE RPTR STATED THIS WAS THE THIRD INCIDENT OF WHEEL AND TIRE ASSEMBLIES DEPARTING THE ACFT PRIMARILY DUE TO A DEFICIENT JOB CARD NOT CLEARLY DESCRIBING THE AXLE NUT LOCK BOLT ALIGNMENT WITH THE AXLE LOCK SLOT.
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.