37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 600083 |
Time | |
Date | 200311 |
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 | B737-700 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 600083 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : installation performance deficiency : logbook entry performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On nov/tue/03, I was working on aircraft. I was doing a check and decided that the nose tires needed to be replaced, so I went to retrieve a set of lines so that I could begin to replace the tires per the maintenance manual. I needed to try to finish quickly because somebody else needed the nose jack. When I was down, I began to fill out my tags and my paperwork. I finished my check and proceeded to shut the aircraft down for the night. As far as I knew, I had completed my job correctly. On nov/sat/03, at XA30, I received a copy of aircraft history which showed the tire change made by me on nov/tue/03. I also received a copy of the log page dated nov/sat/03, which stated that on that day on a through flight, the first officer noticed unfamiliar tread on the nose tires. The mechanic proceeded to change the nose tires on the aircraft. As a result, what was found out was that one of the nose tires was a 300/500 tire and the other tire was 700 nose tire. I cannot believe this happened and how I was not able to catch this before the aircraft left my station. I am only grateful that there were no serious consequences and that the problem was corrected. I believe that, in my hurry to help other fellow mechanics that night, I neglected to pay close attention to my parts tags, paperwork and part numbers. The lesson I have learned is that this could have been avoided had I paid more attention and double-checked my paperwork, part numbers and equipment.
Original NASA ASRS Text
Title: A B737-700 WAS DISPATCHED IN NON COMPLIANCE WITH 1 INCORRECT NOSE TIRE INSTALLED.
Narrative: ON NOV/TUE/03, I WAS WORKING ON ACFT. I WAS DOING A CHK AND DECIDED THAT THE NOSE TIRES NEEDED TO BE REPLACED, SO I WENT TO RETRIEVE A SET OF LINES SO THAT I COULD BEGIN TO REPLACE THE TIRES PER THE MAINT MANUAL. I NEEDED TO TRY TO FINISH QUICKLY BECAUSE SOMEBODY ELSE NEEDED THE NOSE JACK. WHEN I WAS DOWN, I BEGAN TO FILL OUT MY TAGS AND MY PAPERWORK. I FINISHED MY CHK AND PROCEEDED TO SHUT THE ACFT DOWN FOR THE NIGHT. AS FAR AS I KNEW, I HAD COMPLETED MY JOB CORRECTLY. ON NOV/SAT/03, AT XA30, I RECEIVED A COPY OF ACFT HISTORY WHICH SHOWED THE TIRE CHANGE MADE BY ME ON NOV/TUE/03. I ALSO RECEIVED A COPY OF THE LOG PAGE DATED NOV/SAT/03, WHICH STATED THAT ON THAT DAY ON A THROUGH FLT, THE FO NOTICED UNFAMILIAR TREAD ON THE NOSE TIRES. THE MECH PROCEEDED TO CHANGE THE NOSE TIRES ON THE ACFT. AS A RESULT, WHAT WAS FOUND OUT WAS THAT ONE OF THE NOSE TIRES WAS A 300/500 TIRE AND THE OTHER TIRE WAS 700 NOSE TIRE. I CANNOT BELIEVE THIS HAPPENED AND HOW I WAS NOT ABLE TO CATCH THIS BEFORE THE ACFT LEFT MY STATION. I AM ONLY GRATEFUL THAT THERE WERE NO SERIOUS CONSEQUENCES AND THAT THE PROB WAS CORRECTED. I BELIEVE THAT, IN MY HURRY TO HELP OTHER FELLOW MECHS THAT NIGHT, I NEGLECTED TO PAY CLOSE ATTN TO MY PARTS TAGS, PAPERWORK AND PART NUMBERS. THE LESSON I HAVE LEARNED IS THAT THIS COULD HAVE BEEN AVOIDED HAD I PAID MORE ATTN AND DOUBLE-CHKED MY PAPERWORK, PART NUMBERS AND EQUIP.
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.