37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 571530 |
Time | |
Date | 200211 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
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 | B757 Undifferentiated or Other Model |
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 : 37 |
ASRS Report | 571530 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 20 maintenance technician : 36 |
ASRS Report | 571867 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : assigned or threatened penalties other other other Other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Manual Chap32 |
Narrative:
During FAA ramp inspection, FAA found cut tire and worn brake on #7 tire and brake on aircraft X. Mechanic's inspection also found #8 tire cut to limits. Changed #8 tire first, with no problems. On removing #7 tire, could not separate tire from brake. Tire and brake removed as 1 unit. Found #7 axle normal. Installed new brake and lubed brake bushing. Installed #7 tire, spin torqued and safetied. 21 days later, according to aircraft records, on a ZZZ1 preflight, #7 tire was found damaged. ZZZ1 mechanics could not remove the tire. Tire and brake was once again removed as a unit. Axle was found to be overheated, blued and damaged. Air carrier informed me of this problem on jan/sun/03. Callback conversation with reporter revealed the following information: the reporter stated the microfiche copy of the maintenance manual was used for the #7 brake and wheel assembly replacement and made no note or mention of the axle spacer. The reporter said a later check of the maintenance copy of the maintenance manual procedure for brake and wheel assembly replacement does note the positioning of the axle spacer. The reporter stated both maintenance manual sources. Microfiche and maintenance computer are being revised.
Original NASA ASRS Text
Title: A B757 WAS DISPATCHED IN NON COMPLIANCE WITH THE AXLE SPACER NOT INSTALLED AFTER REPLACEMENT OF THE R MAIN GEAR #7 BRAKE AND TIRE ASSEMBLY.
Narrative: DURING FAA RAMP INSPECTION, FAA FOUND CUT TIRE AND WORN BRAKE ON #7 TIRE AND BRAKE ON ACFT X. MECH'S INSPECTION ALSO FOUND #8 TIRE CUT TO LIMITS. CHANGED #8 TIRE FIRST, WITH NO PROBS. ON REMOVING #7 TIRE, COULD NOT SEPARATE TIRE FROM BRAKE. TIRE AND BRAKE REMOVED AS 1 UNIT. FOUND #7 AXLE NORMAL. INSTALLED NEW BRAKE AND LUBED BRAKE BUSHING. INSTALLED #7 TIRE, SPIN TORQUED AND SAFETIED. 21 DAYS LATER, ACCORDING TO ACFT RECORDS, ON A ZZZ1 PREFLT, #7 TIRE WAS FOUND DAMAGED. ZZZ1 MECHS COULD NOT REMOVE THE TIRE. TIRE AND BRAKE WAS ONCE AGAIN REMOVED AS A UNIT. AXLE WAS FOUND TO BE OVERHEATED, BLUED AND DAMAGED. ACR INFORMED ME OF THIS PROB ON JAN/SUN/03. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE MICROFICHE COPY OF THE MAINT MANUAL WAS USED FOR THE #7 BRAKE AND WHEEL ASSEMBLY REPLACEMENT AND MADE NO NOTE OR MENTION OF THE AXLE SPACER. THE RPTR SAID A LATER CHK OF THE MAINT COPY OF THE MAINT MANUAL PROCEDURE FOR BRAKE AND WHEEL ASSEMBLY REPLACEMENT DOES NOTE THE POSITIONING OF THE AXLE SPACER. THE RPTR STATED BOTH MAINT MANUAL SOURCES. MICROFICHE AND MAINT COMPUTER ARE BEING REVISED.
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.