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Attributes | |
ACN | 731160 |
Time | |
Date | 200703 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 19 |
ASRS Report | 731160 |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During replacement of right nosewheel assembly on a B767-300ER aircraft; the axle nut spacer was accidentally not reinstalled. The aircraft made one revenue flight without incident at which time the missing axle nut spacer was reinstalled. This type of occurrence has happened previously with this type of aircraft. The design of the nosewheel assembly easily makes it possible to install the wheel assembly and torque the axle nut without indication the spacer is missing. Making the spacer a highly visible contrasting color compared with the other pieces of the nosewheel assembly might aid the amt in reducing the possibility of this type of event reoccurring. Also a design change to the axle that would prevent the axle nut safety bolts from being installed without the spacer is another possible solution.
Original NASA ASRS Text
Title: A B767-300 ACFT RIGHT NOSE TIRE WAS REPLACED WITHOUT THE REQUIRED AXLE NUT SPACER BEING RE-INSTALLED.
Narrative: DURING REPLACEMENT OF R NOSEWHEEL ASSEMBLY ON A B767-300ER ACFT; THE AXLE NUT SPACER WAS ACCIDENTALLY NOT REINSTALLED. THE ACFT MADE ONE REVENUE FLT WITHOUT INCIDENT AT WHICH TIME THE MISSING AXLE NUT SPACER WAS REINSTALLED. THIS TYPE OF OCCURRENCE HAS HAPPENED PREVIOUSLY WITH THIS TYPE OF ACFT. THE DESIGN OF THE NOSEWHEEL ASSEMBLY EASILY MAKES IT POSSIBLE TO INSTALL THE WHEEL ASSEMBLY AND TORQUE THE AXLE NUT WITHOUT INDICATION THE SPACER IS MISSING. MAKING THE SPACER A HIGHLY VISIBLE CONTRASTING COLOR COMPARED WITH THE OTHER PIECES OF THE NOSEWHEEL ASSEMBLY MIGHT AID THE AMT IN REDUCING THE POSSIBILITY OF THIS TYPE OF EVENT REOCCURRING. ALSO A DESIGN CHANGE TO THE AXLE THAT WOULD PREVENT THE AXLE NUT SAFETY BOLTS FROM BEING INSTALLED WITHOUT THE SPACER IS ANOTHER POSSIBLE SOLUTION.
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.