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|
Attributes | |
ACN | 675142 |
Time | |
Date | 200510 |
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 | |
Controlling Facilities | tracon : fll.tracon |
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 : powerplant |
Experience | maintenance technician : 30 |
ASRS Report | 675142 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : lighting contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On oct/sun/05; I was assigned to a B767-400; aircraft #abcd. The aircraft was position on pad X approximately 100 ft away from the lights that are positioned along the aircraft parking area. The l-hand nose tire was worn to an unsafe condition. I proceeded to change the l-hand nose gear tire. Under adverse conditions of darkness and time constraints of aircraft movement; I neglected to place the washer on the axle after installation of the wheel assembly. The aircraft that was positioned on pad Y needed to be moved for an early flight that morning. I was also concerned about completing the assigned task of doing the service check on the #2 engine in the allotted time. Callback conversation with reporter revealed the following information: the reporter stated this was the first night assigned to the hangar line crew and felt it was necessary to complete all jobs assigned and not be a burden on the crew. The failure to install the axle washer was an unexplainable action and fortunately was discovered before the airplane was dispatched. The reporter stated the crew supervisor interviewed him after this incident and advised him to slow down.
Original NASA ASRS Text
Title: A B767-400 HAD THE L NOSE TIRE AND WHEEL ASSEMBLY REPLACED. ACFT WAS DELIVERED TO THE GATE WHERE THE AXLE WASHER WAS DISCOVERED MISSING.
Narrative: ON OCT/SUN/05; I WAS ASSIGNED TO A B767-400; ACFT #ABCD. THE ACFT WAS POS ON PAD X APPROX 100 FT AWAY FROM THE LIGHTS THAT ARE POSITIONED ALONG THE ACFT PARKING AREA. THE L-HAND NOSE TIRE WAS WORN TO AN UNSAFE CONDITION. I PROCEEDED TO CHANGE THE L-HAND NOSE GEAR TIRE. UNDER ADVERSE CONDITIONS OF DARKNESS AND TIME CONSTRAINTS OF ACFT MOVEMENT; I NEGLECTED TO PLACE THE WASHER ON THE AXLE AFTER INSTALLATION OF THE WHEEL ASSEMBLY. THE ACFT THAT WAS POSITIONED ON PAD Y NEEDED TO BE MOVED FOR AN EARLY FLT THAT MORNING. I WAS ALSO CONCERNED ABOUT COMPLETING THE ASSIGNED TASK OF DOING THE SVC CHK ON THE #2 ENG IN THE ALLOTTED TIME. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THIS WAS THE FIRST NIGHT ASSIGNED TO THE HANGAR LINE CREW AND FELT IT WAS NECESSARY TO COMPLETE ALL JOBS ASSIGNED AND NOT BE A BURDEN ON THE CREW. THE FAILURE TO INSTALL THE AXLE WASHER WAS AN UNEXPLAINABLE ACTION AND FORTUNATELY WAS DISCOVERED BEFORE THE AIRPLANE WAS DISPATCHED. THE RPTR STATED THE CREW SUPVR INTERVIEWED HIM AFTER THIS INCIDENT AND ADVISED HIM TO SLOW DOWN.
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.