37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 720987 |
Time | |
Date | 200612 |
Local Time Of Day | 0001 To 0600 |
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 Undifferentiated or Other Model |
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 : 15 |
ASRS Report | 720987 |
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 : published procedure non adherence : far |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated other other |
Factors | |
Maintenance | performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Nose Tire & Wheel Replacement |
Narrative:
On dec/sun/06; at approximately XA00; my partner and I replaced the right nose tire on a B767 aircraft that was worn beyond limits. I signed the logbook entry for the replacement and the aircraft was returned to service. I was notified by my supervisor on dec/sat/06; that an FAA inspector had found the improper installation on a routine ramp check. It was determined that the axle nut washer was not installed during the tire replacement. I was questioned by management about the incident on dec/sat/06; and questioned by the FAA inspector on dec/sun/06. The FAA inspector stated that this was an industry wide problem and they were fact finding to try and solve the problem. I informed the inspector that my partner nor I had neither been formally trained on the B767; but we were aware there had been problems with the tire installations in the past. We were using the maintenance manual reference during the installation; but we still somehow missed the installation of the washer. The washer was not found and we don't know if it was stuck to the old tire and wheel assembly or if it had been omitted on the previous tire change. The FAA asked for recommendations to solve this problem and suggested making the procedure a task card item. I agreed that I think this would help along with being an rii item. The aircraft had not flown at the time of this finding and the outcome of this incident is still pending.
Original NASA ASRS Text
Title: A B767-300 WAS RELEASED FOR SVC AFTER THE R NOSE TIRE AND WHEEL ASSEMBLY WAS REPLACED. FAA SAFETY INSPECTOR FOUND AXLE WASHER NOT INSTALLED.
Narrative: ON DEC/SUN/06; AT APPROX XA00; MY PARTNER AND I REPLACED THE R NOSE TIRE ON A B767 ACFT THAT WAS WORN BEYOND LIMITS. I SIGNED THE LOGBOOK ENTRY FOR THE REPLACEMENT AND THE ACFT WAS RETURNED TO SVC. I WAS NOTIFIED BY MY SUPVR ON DEC/SAT/06; THAT AN FAA INSPECTOR HAD FOUND THE IMPROPER INSTALLATION ON A ROUTINE RAMP CHK. IT WAS DETERMINED THAT THE AXLE NUT WASHER WAS NOT INSTALLED DURING THE TIRE REPLACEMENT. I WAS QUESTIONED BY MGMNT ABOUT THE INCIDENT ON DEC/SAT/06; AND QUESTIONED BY THE FAA INSPECTOR ON DEC/SUN/06. THE FAA INSPECTOR STATED THAT THIS WAS AN INDUSTRY WIDE PROB AND THEY WERE FACT FINDING TO TRY AND SOLVE THE PROB. I INFORMED THE INSPECTOR THAT MY PARTNER NOR I HAD NEITHER BEEN FORMALLY TRAINED ON THE B767; BUT WE WERE AWARE THERE HAD BEEN PROBS WITH THE TIRE INSTALLATIONS IN THE PAST. WE WERE USING THE MAINT MANUAL REF DURING THE INSTALLATION; BUT WE STILL SOMEHOW MISSED THE INSTALLATION OF THE WASHER. THE WASHER WAS NOT FOUND AND WE DON'T KNOW IF IT WAS STUCK TO THE OLD TIRE AND WHEEL ASSEMBLY OR IF IT HAD BEEN OMITTED ON THE PREVIOUS TIRE CHANGE. THE FAA ASKED FOR RECOMMENDATIONS TO SOLVE THIS PROB AND SUGGESTED MAKING THE PROC A TASK CARD ITEM. I AGREED THAT I THINK THIS WOULD HELP ALONG WITH BEING AN RII ITEM. THE ACFT HAD NOT FLOWN AT THE TIME OF THIS FINDING AND THE OUTCOME OF THIS INCIDENT IS STILL PENDING.
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.