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|
Attributes | |
ACN | 693147 |
Time | |
Date | 200604 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : iad.airport |
State Reference | DC |
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 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 26 |
ASRS Report | 692478 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain observation : company check pilot oversight : pic |
Experience | flight time last 90 days : 200 flight time total : 9000 flight time type : 3500 |
ASRS Report | 692579 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : brake temp other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
B767-300 maintenance manual 32-45-01 was used and printed for #3 forward tire change. Aircraft X landed at ord after tire change with #3 forward high brake temperature. Amt's found spacer missing on axle between tire and wheel assembly and brake assembly; amt's changed brake and tire and wheel assembly for precaution with original spacer sent. Old spacer was found stuck on; old tire inner bearing of wheel assembly after investigation. I (mr X) inspected the axle prior to wheel installation for damage and spacer installation and misinterpreted the features of the inner brake housing for the presents of the spacer. Nothing else was observed in the completed installation of the tire and wheel assembly change to warn that the spacer was missing; ie; normal torque of axle nut and safety and normal rotation of the wheel. What could be done to prevent recurrence is to paint the spacer yellow or orange to highlight its presence and make it obvious when stuck on the removed wheel bearing or properly installed on the axle.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED AFTER R TRUCK L FRONT WHEEL AND TIRE ASSEMBLY WAS REPLACED. CREW NOTED ON CLBOUT BRAKE TEMP ON REPLACED WHEEL HIGH.
Narrative: B767-300 MAINT MANUAL 32-45-01 WAS USED AND PRINTED FOR #3 FORWARD TIRE CHANGE. ACFT X LANDED AT ORD AFTER TIRE CHANGE WITH #3 FORWARD HIGH BRAKE TEMP. AMT'S FOUND SPACER MISSING ON AXLE BTWN TIRE AND WHEEL ASSEMBLY AND BRAKE ASSEMBLY; AMT'S CHANGED BRAKE AND TIRE AND WHEEL ASSEMBLY FOR PRECAUTION WITH ORIGINAL SPACER SENT. OLD SPACER WAS FOUND STUCK ON; OLD TIRE INNER BEARING OF WHEEL ASSEMBLY AFTER INVESTIGATION. I (MR X) INSPECTED THE AXLE PRIOR TO WHEEL INSTALLATION FOR DAMAGE AND SPACER INSTALLATION AND MISINTERPRETED THE FEATURES OF THE INNER BRAKE HOUSING FOR THE PRESENTS OF THE SPACER. NOTHING ELSE WAS OBSERVED IN THE COMPLETED INSTALLATION OF THE TIRE AND WHEEL ASSEMBLY CHANGE TO WARN THAT THE SPACER WAS MISSING; IE; NORMAL TORQUE OF AXLE NUT AND SAFETY AND NORMAL ROTATION OF THE WHEEL. WHAT COULD BE DONE TO PREVENT RECURRENCE IS TO PAINT THE SPACER YELLOW OR ORANGE TO HIGHLIGHT ITS PRESENCE AND MAKE IT OBVIOUS WHEN STUCK ON THE REMOVED WHEEL BEARING OR PROPERLY INSTALLED ON THE 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.