37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 623080 |
Time | |
Date | 200406 |
Day | Wed |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 623080 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : 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 : manuals contributing factor : work cards contributing factor : engineering procedure contributing factor : lighting performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft Chart Or Publication |
Primary Problem | Company |
Situations | |
Publication | Maint Manual Chap 32 |
Narrative:
On june/fri/2004, maintenance in ZZZ1 found that I installed the wrong brake on a B737-700 on june/wed/2004. I installed a B737-800 series brake on a B737-700 aircraft. From what I can recall, I did look at the part number of the new brake assembly and thought I had read the number correctly. The part numbers between the two brake assemblies are 'one' digit different. I did follow the aircraft maintenance manual instructions and was aware of the difference between brake assemblies, but did install the incorrect brake on the aircraft, assuming I had the correct part. Not to deny the blame, but I do remember that the brake container (shipping container), was labeled B737-700. Callback conversation with reporter revealed the following information: the reporter stated the brake change was accomplished in darkness with only a flashlight for light. The reporter said the brake was delivered to the airplane in a large metal can labeled B737-700 brake. The reporter stated the brake was installed using the B737-700 maintenance manual procedures with no note on brake differences between 700, 800 and possibly 900 models. The reporter said the part numbers consisted of 19 numbers and the difference being only two numerals. The reporter stated the brakes were color coded with a DOT, but try finding the DOT with a flashlight in darkness under the wing. The reporter said the difference being the B737-800 has one more brake rotor then the B737-700. The reporter stated if a better brake identification system is not implemented soon, a lot of intermixed brakes are going to be in service.
Original NASA ASRS Text
Title: A B737-700 TECHNICIAN RPTS INSTALLING A B737-800 BRAKE ASSEMBLY ON A B737-700 ACFT. BRAKE DELIVERED IN MARKED CAN LABELED B737-700 BRAKE.
Narrative: ON JUNE/FRI/2004, MAINT IN ZZZ1 FOUND THAT I INSTALLED THE WRONG BRAKE ON A B737-700 ON JUNE/WED/2004. I INSTALLED A B737-800 SERIES BRAKE ON A B737-700 ACFT. FROM WHAT I CAN RECALL, I DID LOOK AT THE PART NUMBER OF THE NEW BRAKE ASSEMBLY AND THOUGHT I HAD READ THE NUMBER CORRECTLY. THE PART NUMBERS BETWEEN THE TWO BRAKE ASSEMBLIES ARE 'ONE' DIGIT DIFFERENT. I DID FOLLOW THE ACFT MAINT MANUAL INSTRUCTIONS AND WAS AWARE OF THE DIFFERENCE BETWEEN BRAKE ASSEMBLIES, BUT DID INSTALL THE INCORRECT BRAKE ON THE ACFT, ASSUMING I HAD THE CORRECT PART. NOT TO DENY THE BLAME, BUT I DO REMEMBER THAT THE BRAKE CONTAINER (SHIPPING CONTAINER), WAS LABELED B737-700. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE BRAKE CHANGE WAS ACCOMPLISHED IN DARKNESS WITH ONLY A FLASHLIGHT FOR LIGHT. THE RPTR SAID THE BRAKE WAS DELIVERED TO THE AIRPLANE IN A LARGE METAL CAN LABELED B737-700 BRAKE. THE RPTR STATED THE BRAKE WAS INSTALLED USING THE B737-700 MAINT MANUAL PROCS WITH NO NOTE ON BRAKE DIFFERENCES BETWEEN 700, 800 AND POSSIBLY 900 MODELS. THE RPTR SAID THE PART NUMBERS CONSISTED OF 19 NUMBERS AND THE DIFFERENCE BEING ONLY TWO NUMERALS. THE RPTR STATED THE BRAKES WERE COLOR CODED WITH A DOT, BUT TRY FINDING THE DOT WITH A FLASHLIGHT IN DARKNESS UNDER THE WING. THE RPTR SAID THE DIFFERENCE BEING THE B737-800 HAS ONE MORE BRAKE ROTOR THEN THE B737-700. THE RPTR STATED IF A BETTER BRAKE IDENTIFICATION SYSTEM IS NOT IMPLEMENTED SOON, A LOT OF INTERMIXED BRAKES ARE GOING TO BE IN SERVICE.
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.