37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 645674 |
Time | |
Date | 200501 |
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 | B767-300 and 300 ER |
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 | 645674 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : scheduled maintenance performance deficiency : training performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
I was inside in a hangar doing an overnight 'trans' check. One of the items to be checked on the 'trans' check was to check tires for condition. I found the right nose tire worn to limits. I then made an entry in the logbook stating it was out of limits. I then proceeded to continue with the 'trans' check. Around XA15; I started to change the B767 right nose tire per maintenance manual. I finished with the tire around XB00. I signed the tire off around XB35 stating I replaced the right nose tire and wheel assembly per maintenance manual. Note: when the tire was off of the axle; I did a visual inspection of the old tire; the new tire; and of the axle to make sure if anything was wrong with the tire or axle. I found nothing to be wrong or out of place. I finished out the night and went home around XG30. The next night when I returned to work; I was informed that the right nose tire I changed the night before was not done properly. I was informed that the wheel spacer was missing for the right nose tire and it was found in the morning by the wheel and brake shop when they had received the old tire. When they had received this information; they immediately contacted the day shift foreman. He had the mechanics working the airplane change the right nose tire per maintenance manual and make sure the spacer was installed. Fortunately the aircraft did not fly that day; it was OTS for an engine change. It wasn't returned to service until some time after XN48 on jan/sun/05. No aircraft damage was reported; flight delays or cancellation or turnbacks because of this incident.
Original NASA ASRS Text
Title: A B767-300 R NOSE TIRE AND WHEEL ASSEMBLY WAS REPLACED BUT THE WHEEL SPACER WAS OMITTED. FOUND AND REPLACED PRIOR TO DISPATCH.
Narrative: I WAS INSIDE IN A HANGAR DOING AN OVERNIGHT 'TRANS' CHK. ONE OF THE ITEMS TO BE CHKED ON THE 'TRANS' CHK WAS TO CHK TIRES FOR CONDITION. I FOUND THE R NOSE TIRE WORN TO LIMITS. I THEN MADE AN ENTRY IN THE LOGBOOK STATING IT WAS OUT OF LIMITS. I THEN PROCEEDED TO CONTINUE WITH THE 'TRANS' CHK. AROUND XA15; I STARTED TO CHANGE THE B767 R NOSE TIRE PER MAINT MANUAL. I FINISHED WITH THE TIRE AROUND XB00. I SIGNED THE TIRE OFF AROUND XB35 STATING I REPLACED THE R NOSE TIRE AND WHEEL ASSEMBLY PER MAINT MANUAL. NOTE: WHEN THE TIRE WAS OFF OF THE AXLE; I DID A VISUAL INSPECTION OF THE OLD TIRE; THE NEW TIRE; AND OF THE AXLE TO MAKE SURE IF ANYTHING WAS WRONG WITH THE TIRE OR AXLE. I FOUND NOTHING TO BE WRONG OR OUT OF PLACE. I FINISHED OUT THE NIGHT AND WENT HOME AROUND XG30. THE NEXT NIGHT WHEN I RETURNED TO WORK; I WAS INFORMED THAT THE R NOSE TIRE I CHANGED THE NIGHT BEFORE WAS NOT DONE PROPERLY. I WAS INFORMED THAT THE WHEEL SPACER WAS MISSING FOR THE R NOSE TIRE AND IT WAS FOUND IN THE MORNING BY THE WHEEL AND BRAKE SHOP WHEN THEY HAD RECEIVED THE OLD TIRE. WHEN THEY HAD RECEIVED THIS INFO; THEY IMMEDIATELY CONTACTED THE DAY SHIFT FOREMAN. HE HAD THE MECHS WORKING THE AIRPLANE CHANGE THE R NOSE TIRE PER MAINT MANUAL AND MAKE SURE THE SPACER WAS INSTALLED. FORTUNATELY THE ACFT DID NOT FLY THAT DAY; IT WAS OTS FOR AN ENG CHANGE. IT WASN'T RETURNED TO SVC UNTIL SOME TIME AFTER XN48 ON JAN/SUN/05. NO ACFT DAMAGE WAS RPTED; FLT DELAYS OR CANCELLATION OR TURNBACKS BECAUSE OF THIS INCIDENT.
Data retrieved from NASA's ASRS site as of January 2009 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.