37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 571556 |
Time | |
Date | 200301 |
Day | Tue |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
ASRS Report | 571556 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 571555 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Nose Tire Job Card |
Narrative:
I received all parts tags, vendor certificates, and parts tags for all wheels and brakes. I reviewed all the data for correct information and conformity before I filed 'spares,' entered parts tags onto the wheels report, and finally purged the old tags. On this occasion, I noticed that the #1 nosewheel installed was for a -700 series aircraft and the #2 nosewheel installed was for a -300/-500 series aircraft. As a restr under air traffic area 32-20, it is unacceptable to mix these wheel assemblies on the nose position. I discovered this error on jan/sun/03, and after informing the supervisor, who contacted someone in quality, the wheels were changed the next sun, jan/03 in ZZZ. This was the second mismatch I have seen in the past 6-8 weeks. I do not know what causes these errors. To correct this, I would suggest recurrent training. It might have had the wrong stamp on the part, or used wrong rack to store the tire and mixed the -300 to -500 nose tire with -700 nose tires. They could easily be mismatched. In the future, we should have separate racks for -300 to -500 and -700's. That would be very distinguishable between those parts. That won't happen to anybody any more.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT L NOSE TIRE, A B737-700 NOSE TIRE INSTALLED.
Narrative: I RECEIVED ALL PARTS TAGS, VENDOR CERTIFICATES, AND PARTS TAGS FOR ALL WHEELS AND BRAKES. I REVIEWED ALL THE DATA FOR CORRECT INFO AND CONFORMITY BEFORE I FILED 'SPARES,' ENTERED PARTS TAGS ONTO THE WHEELS RPT, AND FINALLY PURGED THE OLD TAGS. ON THIS OCCASION, I NOTICED THAT THE #1 NOSEWHEEL INSTALLED WAS FOR A -700 SERIES ACFT AND THE #2 NOSEWHEEL INSTALLED WAS FOR A -300/-500 SERIES ACFT. AS A RESTR UNDER ATA 32-20, IT IS UNACCEPTABLE TO MIX THESE WHEEL ASSEMBLIES ON THE NOSE POS. I DISCOVERED THIS ERROR ON JAN/SUN/03, AND AFTER INFORMING THE SUPVR, WHO CONTACTED SOMEONE IN QUALITY, THE WHEELS WERE CHANGED THE NEXT SUN, JAN/03 IN ZZZ. THIS WAS THE SECOND MISMATCH I HAVE SEEN IN THE PAST 6-8 WKS. I DO NOT KNOW WHAT CAUSES THESE ERRORS. TO CORRECT THIS, I WOULD SUGGEST RECURRENT TRAINING. IT MIGHT HAVE HAD THE WRONG STAMP ON THE PART, OR USED WRONG RACK TO STORE THE TIRE AND MIXED THE -300 TO -500 NOSE TIRE WITH -700 NOSE TIRES. THEY COULD EASILY BE MISMATCHED. IN THE FUTURE, WE SHOULD HAVE SEPARATE RACKS FOR -300 TO -500 AND -700'S. THAT WOULD BE VERY DISTINGUISHABLE BTWN THOSE PARTS. THAT WON'T HAPPEN TO ANYBODY ANY MORE.
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.