37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 695594 |
Time | |
Date | 200604 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 695594 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 695595 |
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 : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : manuals performance deficiency : testing performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft below a tire on landing due possibly to maintenance action performed by myself. Crossed hydraulic lines were determined to have caused the aircraft to blow a tire due to locked brakes causing the plane to exit the runway. My part in the maintenance activity prior to the incident included signing for the installation of the wheel speed transducers and the brakes which were never removed for the initial task of gear removal. I verified the proper installation of these components on the l-hand gear and these components were determined to be properly installed. Due to the length of time between the incident and the actual maintenance and the number of legs flown without incident; it is possible that some form of undocumented maintenance could also be suspect. Due to the inconsistent nature of the braking failures it also seems that possibly some other factor including system defects may have also contributed.
Original NASA ASRS Text
Title: AN EMB145 ON LNDG HAD A L MAIN TIRE BLOW CAUSING THE ACFT TO VEER L AND DEPART THE RWY. CAUSED BY INCORRECT HYD BRAKE LINE CONNECTIONS.
Narrative: ACFT BELOW A TIRE ON LNDG DUE POSSIBLY TO MAINT ACTION PERFORMED BY MYSELF. CROSSED HYD LINES WERE DETERMINED TO HAVE CAUSED THE ACFT TO BLOW A TIRE DUE TO LOCKED BRAKES CAUSING THE PLANE TO EXIT THE RWY. MY PART IN THE MAINT ACTIVITY PRIOR TO THE INCIDENT INCLUDED SIGNING FOR THE INSTALLATION OF THE WHEEL SPD TRANSDUCERS AND THE BRAKES WHICH WERE NEVER REMOVED FOR THE INITIAL TASK OF GEAR REMOVAL. I VERIFIED THE PROPER INSTALLATION OF THESE COMPONENTS ON THE L-HAND GEAR AND THESE COMPONENTS WERE DETERMINED TO BE PROPERLY INSTALLED. DUE TO THE LENGTH OF TIME BTWN THE INCIDENT AND THE ACTUAL MAINT AND THE NUMBER OF LEGS FLOWN WITHOUT INCIDENT; IT IS POSSIBLE THAT SOME FORM OF UNDOCUMENTED MAINT COULD ALSO BE SUSPECT. DUE TO THE INCONSISTENT NATURE OF THE BRAKING FAILURES IT ALSO SEEMS THAT POSSIBLY SOME OTHER FACTOR INCLUDING SYS DEFECTS MAY HAVE ALSO CONTRIBUTED.
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.