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|
Attributes | |
ACN | 585610 |
Time | |
Date | 200306 |
Day | Wed |
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 | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 17 |
ASRS Report | 585610 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : powerplant technician : inspection authority technician : airframe |
Experience | maintenance technician : 17 |
ASRS Report | 585612 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other other : gnd 1 & 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : repair |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
On jun/wed/03, I helped change and replace #4 rear brake assembly on aircraft X. I helped remove and install brake assembly and also safety hydraulic fitting to brake. Installed anti-rotation pin only. Let another mechanic install bolt, nut and washer for anti-rotation pin. Cleared area while other mechanic was installing anti-rotation pin assembly. Callback conversation with reporter revealed the following information: the reporter stated the brake was replaced by several technicians and the reporter inserted the anti-rotation pin but left bolt, nut and washer to be installed on the pin by another technician. The reporter said no card was written up to cover the remainder of the job. The reporter said the airplane made 2 lndgs and the pin fell out on the second landing damaging the airplane hydraulic lines and wiring. The reporter stated the anti-rotation pin bolt was never torqued and was on only finger tight.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH #4 BRAKE ANTI-ROTATION PIN IMPROPERLY INSTALLED. ACFT INCURRED DAMAGE ON LNDG.
Narrative: ON JUN/WED/03, I HELPED CHANGE AND REPLACE #4 REAR BRAKE ASSEMBLY ON ACFT X. I HELPED REMOVE AND INSTALL BRAKE ASSEMBLY AND ALSO SAFETY HYD FITTING TO BRAKE. INSTALLED ANTI-ROTATION PIN ONLY. LET ANOTHER MECH INSTALL BOLT, NUT AND WASHER FOR ANTI-ROTATION PIN. CLRED AREA WHILE OTHER MECH WAS INSTALLING ANTI-ROTATION PIN ASSEMBLY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE BRAKE WAS REPLACED BY SEVERAL TECHNICIANS AND THE RPTR INSERTED THE ANTI-ROTATION PIN BUT LEFT BOLT, NUT AND WASHER TO BE INSTALLED ON THE PIN BY ANOTHER TECHNICIAN. THE RPTR SAID NO CARD WAS WRITTEN UP TO COVER THE REMAINDER OF THE JOB. THE RPTR SAID THE AIRPLANE MADE 2 LNDGS AND THE PIN FELL OUT ON THE SECOND LNDG DAMAGING THE AIRPLANE HYD LINES AND WIRING. THE RPTR STATED THE ANTI-ROTATION PIN BOLT WAS NEVER TORQUED AND WAS ON ONLY FINGER TIGHT.
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.