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A B767-400 was dispatched with the left nose gear axle spacer missing. Job was inspected during reinstallation; but neither person referenced manual or ipc.
| Attributes | |
| ACN | 654676 |
| Time | |
| Date | 200504 |
| 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 | B767-400 and 400 ER |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : fcc technician : powerplant |
| Experience | maintenance technician : 16 |
| ASRS Report | 654676 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure non adherence : far |
| Independent Detector | other other : 4 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : manuals contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : logbook entry performance deficiency : fault isolation |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | B767 M/M Chapter 32 |
Narrative:
I was assigned an inspection on aircraft X left nosewheel assembly for an axle spacer. The other technicians were busy at this time. During the inspection; I was not sure of exactly what I was supposed to be looking for. I summoned my lead technician and together we inspected the wheel and axle assembly; and then reinstalled the wheel. We both agreed that there was nothing missing and even made a visual comparison to the right wheel. I then telephoned the B767-400 coordinator to discuss my findings. 2 days later; other technicians discovered and corrected the discrepancy. In the future; regardless of ground time or departure time; I shall consult the amm or ipc and not depend solely on the visual interpretation or other people's opinion.
Original NASA ASRS Text
Title: A B767-400 WAS DISPATCHED WITH THE L NOSE GEAR AXLE SPACER MISSING. JOB WAS INSPECTED DURING REINSTALLATION; BUT NEITHER PERSON REFED MANUAL OR IPC.
Narrative: I WAS ASSIGNED AN INSPECTION ON ACFT X L NOSEWHEEL ASSEMBLY FOR AN AXLE SPACER. THE OTHER TECHNICIANS WERE BUSY AT THIS TIME. DURING THE INSPECTION; I WAS NOT SURE OF EXACTLY WHAT I WAS SUPPOSED TO BE LOOKING FOR. I SUMMONED MY LEAD TECHNICIAN AND TOGETHER WE INSPECTED THE WHEEL AND AXLE ASSEMBLY; AND THEN REINSTALLED THE WHEEL. WE BOTH AGREED THAT THERE WAS NOTHING MISSING AND EVEN MADE A VISUAL COMPARISON TO THE R WHEEL. I THEN TELEPHONED THE B767-400 COORDINATOR TO DISCUSS MY FINDINGS. 2 DAYS LATER; OTHER TECHNICIANS DISCOVERED AND CORRECTED THE DISCREPANCY. IN THE FUTURE; REGARDLESS OF GND TIME OR DEP TIME; I SHALL CONSULT THE AMM OR IPC AND NOT DEPEND SOLELY ON THE VISUAL INTERP OR OTHER PEOPLE'S OPINION.
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.