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|
Attributes | |
ACN | 638596 |
Time | |
Date | 200411 |
Day | Mon |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Controlling Facilities | tower : bos.tower |
Operator | common carrier : air carrier |
Make Model Name | B767-400 and 400 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 17 |
ASRS Report | 638596 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
What typically occurs when an aircraft has arrived at the gate with a worn tire is the technician that discovered it will use the 2-WAY radio to alert the lead (and the rest of the crew) that a tire change is needed. The lead will make sure there are enough people to help remove and replace it and complete the paperwork on time. While one person is getting the required tooling and paperwork, another may be getting the logbook and another may be getting a new tire assembly. Work begins as soon as possible by working together, keeping in mind the short ground time between most flts. To get the job done in the time allotted, without a delay, takes more than 1 person. I don't recall what transpired that day when the washer was inadvertently left off the axle. I do know that I signed the log page believing that that work was performed correctly by me and all those involved in accordance with the aircraft maintenance manual. It was discovered and corrected 4 days later by someone else. (No damage to aircraft -- inspected and installed washer during ground time.)
Original NASA ASRS Text
Title: A B767-400 WAS DISPATCHED AFTER A NOSEWHEEL ASSEMBLY WAS REPLACED. LATER DISCOVERED NOSEWHEEL AXLE WASHER WAS NOT INSTALLED.
Narrative: WHAT TYPICALLY OCCURS WHEN AN ACFT HAS ARRIVED AT THE GATE WITH A WORN TIRE IS THE TECHNICIAN THAT DISCOVERED IT WILL USE THE 2-WAY RADIO TO ALERT THE LEAD (AND THE REST OF THE CREW) THAT A TIRE CHANGE IS NEEDED. THE LEAD WILL MAKE SURE THERE ARE ENOUGH PEOPLE TO HELP REMOVE AND REPLACE IT AND COMPLETE THE PAPERWORK ON TIME. WHILE ONE PERSON IS GETTING THE REQUIRED TOOLING AND PAPERWORK, ANOTHER MAY BE GETTING THE LOGBOOK AND ANOTHER MAY BE GETTING A NEW TIRE ASSEMBLY. WORK BEGINS ASAP BY WORKING TOGETHER, KEEPING IN MIND THE SHORT GND TIME BTWN MOST FLTS. TO GET THE JOB DONE IN THE TIME ALLOTTED, WITHOUT A DELAY, TAKES MORE THAN 1 PERSON. I DON'T RECALL WHAT TRANSPIRED THAT DAY WHEN THE WASHER WAS INADVERTENTLY LEFT OFF THE AXLE. I DO KNOW THAT I SIGNED THE LOG PAGE BELIEVING THAT THAT WORK WAS PERFORMED CORRECTLY BY ME AND ALL THOSE INVOLVED IN ACCORDANCE WITH THE ACFT MAINT MANUAL. IT WAS DISCOVERED AND CORRECTED 4 DAYS LATER BY SOMEONE ELSE. (NO DAMAGE TO ACFT -- INSPECTED AND INSTALLED WASHER DURING GND TIME.)
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.