37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 672830 |
Time | |
Date | 200508 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
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 |
Experience | maintenance avionics : 3 maintenance lead technician : 6 maintenance technician : 9 |
ASRS Report | 672830 |
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 |
Independent Detector | other other : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : lighting performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On the night of sep/tue/05; technician Y and myself were assigned to the ETOPS and overnight check on aircraft X. I don't recall who found the left nose tire worn but I proceeded to get the equipment to change the assembly. At this point; technician Z; who was assisting us with the routine check; rolled out a new tire assembly. I jacked up the nose tire and loosened the lock bolts and the axle nut. Usually; once the axle nut is broken loose; the tang washer will slide right off the axle. Unfortunately; in this case; the tang washer stuck to the tire assembly; and neither technician Y; who proceeded to remove the tire from the axle and install the new assembly; nor I noticed this. I don't recall who actually torqued the axle nut to the axle but I remember asking technician Z to make sure there was no spacer stuck to the tire. I ended the procedure by installing the lock bolts. At the conclusion of the routine check; I signed off the tire on the logbook and na'ed the step of the job instruction card where it instructed to confirm that the tang washer or axle washer was installed on externally threaded axles. The aircraft departed without incident and a few days later during a preflight inspection; maintenance noticed the improperly installed nose tire assembly. The fact is the tang washer on the removed tire stuck to the bearing with grease and it did not occur to me that one belonged there with the new assembly. I confused this installation with an internally threaded axle.
Original NASA ASRS Text
Title: A B767-300ER WAS RELEASED FOR SVC WITH THE L NOSE GEAR WHEEL AND TIRE ASSEMBLY INSTALLED WITHOUT THE OTHER AXLE WASHER.
Narrative: ON THE NIGHT OF SEP/TUE/05; TECHNICIAN Y AND MYSELF WERE ASSIGNED TO THE ETOPS AND OVERNIGHT CHK ON ACFT X. I DON'T RECALL WHO FOUND THE L NOSE TIRE WORN BUT I PROCEEDED TO GET THE EQUIP TO CHANGE THE ASSEMBLY. AT THIS POINT; TECHNICIAN Z; WHO WAS ASSISTING US WITH THE ROUTINE CHK; ROLLED OUT A NEW TIRE ASSEMBLY. I JACKED UP THE NOSE TIRE AND LOOSENED THE LOCK BOLTS AND THE AXLE NUT. USUALLY; ONCE THE AXLE NUT IS BROKEN LOOSE; THE TANG WASHER WILL SLIDE RIGHT OFF THE AXLE. UNFORTUNATELY; IN THIS CASE; THE TANG WASHER STUCK TO THE TIRE ASSEMBLY; AND NEITHER TECHNICIAN Y; WHO PROCEEDED TO REMOVE THE TIRE FROM THE AXLE AND INSTALL THE NEW ASSEMBLY; NOR I NOTICED THIS. I DON'T RECALL WHO ACTUALLY TORQUED THE AXLE NUT TO THE AXLE BUT I REMEMBER ASKING TECHNICIAN Z TO MAKE SURE THERE WAS NO SPACER STUCK TO THE TIRE. I ENDED THE PROC BY INSTALLING THE LOCK BOLTS. AT THE CONCLUSION OF THE ROUTINE CHK; I SIGNED OFF THE TIRE ON THE LOGBOOK AND NA'ED THE STEP OF THE JOB INSTRUCTION CARD WHERE IT INSTRUCTED TO CONFIRM THAT THE TANG WASHER OR AXLE WASHER WAS INSTALLED ON EXTERNALLY THREADED AXLES. THE ACFT DEPARTED WITHOUT INCIDENT AND A FEW DAYS LATER DURING A PREFLT INSPECTION; MAINT NOTICED THE IMPROPERLY INSTALLED NOSE TIRE ASSEMBLY. THE FACT IS THE TANG WASHER ON THE REMOVED TIRE STUCK TO THE BEARING WITH GREASE AND IT DID NOT OCCUR TO ME THAT ONE BELONGED THERE WITH THE NEW ASSEMBLY. I CONFUSED THIS INSTALLATION WITH AN INTERNALLY THREADED AXLE.
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.