37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 578094 |
Time | |
Date | 200303 |
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 | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 2 |
ASRS Report | 578094 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : manuals contributing factor : schedule pressure performance deficiency : inspection performance deficiency : unqualified personnel performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
I am a line amt with air carrier X, based at ZZZ airport. On mar/wed/03, at approximately XA00, an air carrier X B767 landed and experienced very high number 3 brake temperatures on rollout. I was radio contacted and advised of the problem by the air carrier maintenance tower. Upon arrival at the gate, I applied conditioned air towards the brake assembly. Excessive heat from the brake caused a thermal release of the number 3 wheel assembly. A lead amt arrived to my aid. He then radioed the maintenance office, requesting a brake and wheel assembly for aircraft. Other mechanics arrived and began removing the wheel and brake. The 'new' brake and wheel arrived at the gate, and the brake was installed on the aircraft. Trouble was encountered while trying to install the wheel on the brake. It was then determined that the incorrect wheel had been delivered. While the correct wheel assembly was being located and brought to the aircraft, the lead amt confirmed twice with the maintenance office that the correct brake had been installed. The correct wheel assembly then arrived at the gate and was installed on the aircraft. A leak check was performed on the brake, and I signed off on the work. I then released the aircraft back to service. I was contacted by my duty manager today (apr/thu/03) at XB00 and asked to come to the airport and give a written statement. Once the removed brake had made it to the shop, they determined that a pre-engineering change order brake had been installed on a post engineering change order aircraft. To my understanding, the incorrect brake has been removed from the aircraft, and no significant events occurred while it was being installed.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT BRAKE AND WHEEL ASSEMBLY INSTALLED IN #2 POS.
Narrative: I AM A LINE AMT WITH ACR X, BASED AT ZZZ ARPT. ON MAR/WED/03, AT APPROX XA00, AN ACR X B767 LANDED AND EXPERIENCED VERY HIGH NUMBER 3 BRAKE TEMPS ON ROLLOUT. I WAS RADIO CONTACTED AND ADVISED OF THE PROB BY THE ACR MAINT TWR. UPON ARR AT THE GATE, I APPLIED CONDITIONED AIR TOWARDS THE BRAKE ASSEMBLY. EXCESSIVE HEAT FROM THE BRAKE CAUSED A THERMAL RELEASE OF THE NUMBER 3 WHEEL ASSEMBLY. A LEAD AMT ARRIVED TO MY AID. HE THEN RADIOED THE MAINT OFFICE, REQUESTING A BRAKE AND WHEEL ASSEMBLY FOR ACFT. OTHER MECHS ARRIVED AND BEGAN REMOVING THE WHEEL AND BRAKE. THE 'NEW' BRAKE AND WHEEL ARRIVED AT THE GATE, AND THE BRAKE WAS INSTALLED ON THE ACFT. TROUBLE WAS ENCOUNTERED WHILE TRYING TO INSTALL THE WHEEL ON THE BRAKE. IT WAS THEN DETERMINED THAT THE INCORRECT WHEEL HAD BEEN DELIVERED. WHILE THE CORRECT WHEEL ASSEMBLY WAS BEING LOCATED AND BROUGHT TO THE ACFT, THE LEAD AMT CONFIRMED TWICE WITH THE MAINT OFFICE THAT THE CORRECT BRAKE HAD BEEN INSTALLED. THE CORRECT WHEEL ASSEMBLY THEN ARRIVED AT THE GATE AND WAS INSTALLED ON THE ACFT. A LEAK CHK WAS PERFORMED ON THE BRAKE, AND I SIGNED OFF ON THE WORK. I THEN RELEASED THE ACFT BACK TO SVC. I WAS CONTACTED BY MY DUTY MGR TODAY (APR/THU/03) AT XB00 AND ASKED TO COME TO THE ARPT AND GIVE A WRITTEN STATEMENT. ONCE THE REMOVED BRAKE HAD MADE IT TO THE SHOP, THEY DETERMINED THAT A PRE-ENGINEERING CHANGE ORDER BRAKE HAD BEEN INSTALLED ON A POST ENGINEERING CHANGE ORDER ACFT. TO MY UNDERSTANDING, THE INCORRECT BRAKE HAS BEEN REMOVED FROM THE ACFT, AND NO SIGNIFICANT EVENTS OCCURRED WHILE IT WAS BEING INSTALLED.
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.