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A B767-300 was dispatched in non compliance after #1 main tire and wheel were replaced. Later discovered inner wheel spacer not installed.
| Attributes | |
| ACN | 607363 |
| Time | |
| Date | 200311 |
| Day | Sat |
| 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 |
| Navigation In Use | other |
| Flight Phase | ground : parked ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 14.5 |
| ASRS Report | 607363 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 22 |
| ASRS Report | 607467 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
| Independent Detector | other other : 969 |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
On nov/sat/04 I was assigned by my crew chief to see the captain on aircraft X about a tire problem. I was asked by the captain to check the tire pressure on the #1 main tire. Tire pressure was at 150 psi. I informed all parties that this would be a tire change. Myself, crew chief and 2 technicians removed and replaced the #1 main tire on aircraft per the maintenance manual. At no time was there a discussion as to who would do what job. As a group, we did the tire change and I had no reason to doubt the other amt's when I was told the inner spacer was installed.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE AFTER #1 MAIN TIRE AND WHEEL WERE REPLACED. LATER DISCOVERED INNER WHEEL SPACER NOT INSTALLED.
Narrative: ON NOV/SAT/04 I WAS ASSIGNED BY MY CREW CHIEF TO SEE THE CAPT ON ACFT X ABOUT A TIRE PROB. I WAS ASKED BY THE CAPT TO CHK THE TIRE PRESSURE ON THE #1 MAIN TIRE. TIRE PRESSURE WAS AT 150 PSI. I INFORMED ALL PARTIES THAT THIS WOULD BE A TIRE CHANGE. MYSELF, CREW CHIEF AND 2 TECHNICIANS REMOVED AND REPLACED THE #1 MAIN TIRE ON ACFT PER THE MAINT MANUAL. AT NO TIME WAS THERE A DISCUSSION AS TO WHO WOULD DO WHAT JOB. AS A GROUP, WE DID THE TIRE CHANGE AND I HAD NO REASON TO DOUBT THE OTHER AMT'S WHEN I WAS TOLD THE INNER SPACER WAS 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.