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A B737-300 nose gear steering collars and bushings were improperly installed by an unqualified technician.
| Attributes | |
| ACN | 589043 |
| Time | |
| Date | 200307 |
| Day | Sun |
| Local Time Of Day | 0001 To 0600 |
| 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 | B737-500 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 589043 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : unqualified personnel performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : training |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Company Environmental Factor |
| Primary Problem | Maintenance Human Performance |
Narrative:
On jul/fri/03 at XB30, I was informed by my supervisor that there may have been a problem with the installation of the steering collar bushing that was part of my work assignment on jul/sun/03 (3RD life, time life component, on the nose gear) on aircraft X. I was trying to evaluate what may have led up to a possible oversight on the correct positioning of the bearing. There were several events that could have contributed to the oversight. 1) I had just returned to work after attending a funeral. 2) my wife is very distraught over the death of her mother. 3) my wife is ill. 4) I commute to work and my flight was cancelled, which caused me to arrive at work 20 mins late. 5) I have never performed any maintenance on any gear other than changing tires and servicing the struts. 6) lack of supervision (since this was a critical job and as I have been told by several senior mechanics that it is also a 2 man job). 7) distraction -- since it takes 2 people to install the bearing. 8) being rushed for time. 9) I knew that this assignment had to be completed for a flight in the morning.
Original NASA ASRS Text
Title: A B737-300 NOSE GEAR STEERING COLLARS AND BUSHINGS WERE IMPROPERLY INSTALLED BY AN UNQUALIFIED TECHNICIAN.
Narrative: ON JUL/FRI/03 AT XB30, I WAS INFORMED BY MY SUPVR THAT THERE MAY HAVE BEEN A PROB WITH THE INSTALLATION OF THE STEERING COLLAR BUSHING THAT WAS PART OF MY WORK ASSIGNMENT ON JUL/SUN/03 (3RD LIFE, TIME LIFE COMPONENT, ON THE NOSE GEAR) ON ACFT X. I WAS TRYING TO EVALUATE WHAT MAY HAVE LED UP TO A POSSIBLE OVERSIGHT ON THE CORRECT POSITIONING OF THE BEARING. THERE WERE SEVERAL EVENTS THAT COULD HAVE CONTRIBUTED TO THE OVERSIGHT. 1) I HAD JUST RETURNED TO WORK AFTER ATTENDING A FUNERAL. 2) MY WIFE IS VERY DISTRAUGHT OVER THE DEATH OF HER MOTHER. 3) MY WIFE IS ILL. 4) I COMMUTE TO WORK AND MY FLT WAS CANCELLED, WHICH CAUSED ME TO ARRIVE AT WORK 20 MINS LATE. 5) I HAVE NEVER PERFORMED ANY MAINT ON ANY GEAR OTHER THAN CHANGING TIRES AND SVCING THE STRUTS. 6) LACK OF SUPERVISION (SINCE THIS WAS A CRITICAL JOB AND AS I HAVE BEEN TOLD BY SEVERAL SENIOR MECHS THAT IT IS ALSO A 2 MAN JOB). 7) DISTR -- SINCE IT TAKES 2 PEOPLE TO INSTALL THE BEARING. 8) BEING RUSHED FOR TIME. 9) I KNEW THAT THIS ASSIGNMENT HAD TO BE COMPLETED FOR A FLT IN THE MORNING.
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.