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A B767-300ER was dispatched in non compliance with the incorrect #4 brake installed. Misinterp of identify tag caused incident.
| Attributes | |
| ACN | 574320 |
| Time | |
| Date | 200302 |
| 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 |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 22 |
| ASRS Report | 574320 |
| Person 2 | |
| Affiliation | company : air carrier |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 25 |
| ASRS Report | 574321 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : person 4 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other Other |
| Factors | |
| Maintenance | contributing factor : lighting contributing factor : engineering procedure contributing factor : weather performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Working overnight layover check on aircraft on feb/tue/03, #4 brake worn to limits. Proceeded to replace brake. At stores location found brake part number, which was clearly idented for use on aircraft. Proceeded and completed brake replacement per aircraft maintenance manual. Leak check and operations check good. Aircraft dispatched. Upon return to work on feb/wed/03 at XA15, notified brake was to be used on aircraft with modified engineering order only. As we were informed was not engineering order modified. Maintenance replaced brake in question at first flight leg, resulting in delay of aircraft. No report of aircraft damage or other incident.
Original NASA ASRS Text
Title: A B767-300ER WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT #4 BRAKE INSTALLED. MISINTERP OF IDENT TAG CAUSED INCIDENT.
Narrative: WORKING OVERNIGHT LAYOVER CHK ON ACFT ON FEB/TUE/03, #4 BRAKE WORN TO LIMITS. PROCEEDED TO REPLACE BRAKE. AT STORES LOCATION FOUND BRAKE PART NUMBER, WHICH WAS CLRLY IDENTED FOR USE ON ACFT. PROCEEDED AND COMPLETED BRAKE REPLACEMENT PER ACFT MAINT MANUAL. LEAK CHK AND OPS CHK GOOD. ACFT DISPATCHED. UPON RETURN TO WORK ON FEB/WED/03 AT XA15, NOTIFIED BRAKE WAS TO BE USED ON ACFT WITH MODIFIED ENGINEERING ORDER ONLY. AS WE WERE INFORMED WAS NOT ENGINEERING ORDER MODIFIED. MAINT REPLACED BRAKE IN QUESTION AT FIRST FLT LEG, RESULTING IN DELAY OF ACFT. NO RPT OF ACFT DAMAGE OR OTHER INCIDENT.
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.