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|
Attributes | |
ACN | 721653 |
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 | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Experience | maintenance technician : 30 |
ASRS Report | 721653 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical 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 : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
After working yrs and changing brakes on B757; I found an out of limit brake. Being new to this company; I pulled up the aircraft maintenance manual and proceeded to remove it. I received the new brake; and swapped parts to the new brake (brake temperature sensor). I then noticed that the hydraulic fitting wasn't on the new brake. I went to see if other brakes had the same; which they did. To me; this isn't a full brake assembly I have been used to getting. Reading the aircraft maintenance manual; I discovered they don't come with it (or some might) so I proceeded to the ipc and ordered from stores the valve. I wanted to get the brake assembly mounted and tire on and not wait. Some other technicians came to try to remove this valve from the old assembly. I got the brake/wheel on and secured. During this period; the valve arrived and was given to another to install. All this took about 4 hours time. We finished around XA00. I cleaned the area of jacks; tools; and noticed the time. Wow! I ran to get the paperwork. Since I had to sign off the plane for an XB00 departure; I never gave a thought to check the line to the valve; since someone else installed it. Around XA45 I was informed that the #5 brake was leaking and look up parts for the valve. I then broke down the ipc and saw this valve had 2 backup rings and a packing. I asked the persons who installed it later; were there seals with the valve -- no was their answer. They told me they looked up; and the ipc wasn't too clear to them; showing seals. Then we found another section dealing with the removal of this valve; and it was a special tool you need to get it out. As I said earlier; the technicians were trying to remove this to save time. Waiting from stores of a new unit; my mind was so in getting the wheel and brake mounted I lost track of surroundings and took the word of 3 others that saw the valve that it was complete and my rush to get the paperwork done that I should have at least asked did anyone run the hydraulics to check for leaks.
Original NASA ASRS Text
Title: A B757 HAD A #5 BRAKE CHANGE DUE TO WEAR. RPTR STARTED JOB; INSTALLED BRAKE AND WHEEL ASSEMBLY TURNED OVER DISCONNECT FITTING INSTALLATION TO OTHER TECHNICIANS. BRAKE LEAKED DUE TO SEALS AND PACKINGS NOT INSTALLED.
Narrative: AFTER WORKING YRS AND CHANGING BRAKES ON B757; I FOUND AN OUT OF LIMIT BRAKE. BEING NEW TO THIS COMPANY; I PULLED UP THE ACFT MAINT MANUAL AND PROCEEDED TO REMOVE IT. I RECEIVED THE NEW BRAKE; AND SWAPPED PARTS TO THE NEW BRAKE (BRAKE TEMP SENSOR). I THEN NOTICED THAT THE HYD FITTING WASN'T ON THE NEW BRAKE. I WENT TO SEE IF OTHER BRAKES HAD THE SAME; WHICH THEY DID. TO ME; THIS ISN'T A FULL BRAKE ASSEMBLY I HAVE BEEN USED TO GETTING. READING THE ACFT MAINT MANUAL; I DISCOVERED THEY DON'T COME WITH IT (OR SOME MIGHT) SO I PROCEEDED TO THE IPC AND ORDERED FROM STORES THE VALVE. I WANTED TO GET THE BRAKE ASSEMBLY MOUNTED AND TIRE ON AND NOT WAIT. SOME OTHER TECHNICIANS CAME TO TRY TO REMOVE THIS VALVE FROM THE OLD ASSEMBLY. I GOT THE BRAKE/WHEEL ON AND SECURED. DURING THIS PERIOD; THE VALVE ARRIVED AND WAS GIVEN TO ANOTHER TO INSTALL. ALL THIS TOOK ABOUT 4 HRS TIME. WE FINISHED AROUND XA00. I CLEANED THE AREA OF JACKS; TOOLS; AND NOTICED THE TIME. WOW! I RAN TO GET THE PAPERWORK. SINCE I HAD TO SIGN OFF THE PLANE FOR AN XB00 DEP; I NEVER GAVE A THOUGHT TO CHK THE LINE TO THE VALVE; SINCE SOMEONE ELSE INSTALLED IT. AROUND XA45 I WAS INFORMED THAT THE #5 BRAKE WAS LEAKING AND LOOK UP PARTS FOR THE VALVE. I THEN BROKE DOWN THE IPC AND SAW THIS VALVE HAD 2 BACKUP RINGS AND A PACKING. I ASKED THE PERSONS WHO INSTALLED IT LATER; WERE THERE SEALS WITH THE VALVE -- NO WAS THEIR ANSWER. THEY TOLD ME THEY LOOKED UP; AND THE IPC WASN'T TOO CLR TO THEM; SHOWING SEALS. THEN WE FOUND ANOTHER SECTION DEALING WITH THE REMOVAL OF THIS VALVE; AND IT WAS A SPECIAL TOOL YOU NEED TO GET IT OUT. AS I SAID EARLIER; THE TECHNICIANS WERE TRYING TO REMOVE THIS TO SAVE TIME. WAITING FROM STORES OF A NEW UNIT; MY MIND WAS SO IN GETTING THE WHEEL AND BRAKE MOUNTED I LOST TRACK OF SURROUNDINGS AND TOOK THE WORD OF 3 OTHERS THAT SAW THE VALVE THAT IT WAS COMPLETE AND MY RUSH TO GET THE PAPERWORK DONE THAT I SHOULD HAVE AT LEAST ASKED DID ANYONE RUN THE HYDS TO CHK FOR LEAKS.
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.