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During an MD80 right nose tire change, 3 technicians were cited by the quality control audit team for not following published procedures.
| Attributes | |
| ACN | 612029 |
| Time | |
| Date | 200403 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 612029 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 612030 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure non adherence : company policies |
| Independent Detector | other other : 4 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : installation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Environmental Factor Company Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
On mar/tue/04, I was involved in changing the right nose tire on aircraft X. Step A1 of the maintenance manual procedure is to install the landing gear ground lock pins. I failed to install the pins as per maintenance manual procedure. I mistakenly referred to the mcm card. This card makes no mention of installing gear pins. I also did not use a thread protector to remove the tire assembly. This was pointed out to me by quality assurance. I stopped the procedure and rectified the problem by getting a thread protector and installing it before proceeding on. Result: gear pins not used. Thread protector installed late. Cold and noisy outside as aircraft around were running engines and taxiing. We were pressed for time to move aircraft. Distraction by quality assurance taking pictures and interfering with installation procedures.
Original NASA ASRS Text
Title: DURING AN MD80 R NOSE TIRE CHANGE, 3 TECHNICIANS WERE CITED BY THE QUALITY CTL AUDIT TEAM FOR NOT FOLLOWING PUBLISHED PROCS.
Narrative: ON MAR/TUE/04, I WAS INVOLVED IN CHANGING THE R NOSE TIRE ON ACFT X. STEP A1 OF THE MAINT MANUAL PROC IS TO INSTALL THE LNDG GEAR GND LOCK PINS. I FAILED TO INSTALL THE PINS AS PER MAINT MANUAL PROC. I MISTAKENLY REFERRED TO THE MCM CARD. THIS CARD MAKES NO MENTION OF INSTALLING GEAR PINS. I ALSO DID NOT USE A THREAD PROTECTOR TO REMOVE THE TIRE ASSEMBLY. THIS WAS POINTED OUT TO ME BY QUALITY ASSURANCE. I STOPPED THE PROC AND RECTIFIED THE PROB BY GETTING A THREAD PROTECTOR AND INSTALLING IT BEFORE PROCEEDING ON. RESULT: GEAR PINS NOT USED. THREAD PROTECTOR INSTALLED LATE. COLD AND NOISY OUTSIDE AS ACFT AROUND WERE RUNNING ENGS AND TAXIING. WE WERE PRESSED FOR TIME TO MOVE ACFT. DISTR BY QUALITY ASSURANCE TAKING PICTURES AND INTERFERING WITH INSTALLATION PROCS.
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.