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Attributes | |
ACN | 751659 |
Time | |
Date | 200708 |
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 | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 19 |
ASRS Report | 751659 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft came in with a pilot write-up; which was also a repeat of nose shimmy on takeoff and wheel retraction. Before the previous flight leg the right nose tire was changed. In keeping with the applicable fim and amm it came down to replacing the left nose tire in order to more evenly match-up tire wear and tread. The tire was changed in accordance with the amm. The flight was nearing departure time and obviously rushed; I inadvertently forgot to reinstall the nose tire assembly washer. In 19 yrs as a certified a&P mechanic I've never made such a serious mistake and in the future will slow down so as not to repeat this mistake again. I was made aware of this incident by maintenance control this morning and am not aware of any damage being inflicted upon the aircraft or tire assembly at this time. This statement has been recalled to the best of my recollection and knowledge. Callback conversation with reporter revealed the following information: this aircraft had an externally threaded nose wheel axle. The maintenance manual does have an illustration showing the spacer in the tire/wheel replacement; he just did not remember to re-install the axle spacer (washer).
Original NASA ASRS Text
Title: A B767-300ER REPEAT LOG WRITE-UP FOR A NOSE WHEEL SHIMMY ON TAKEOFF AND WHEEL RETRACTION. LEFT NOSE WHEEL SPACER (WASHER) NOT INSTALLED.
Narrative: ACFT CAME IN WITH A PLT WRITE-UP; WHICH WAS ALSO A REPEAT OF NOSE SHIMMY ON TKOF AND WHEEL RETRACTION. BEFORE THE PREVIOUS FLT LEG THE R NOSE TIRE WAS CHANGED. IN KEEPING WITH THE APPLICABLE FIM AND AMM IT CAME DOWN TO REPLACING THE L NOSE TIRE IN ORDER TO MORE EVENLY MATCH-UP TIRE WEAR AND TREAD. THE TIRE WAS CHANGED IN ACCORDANCE WITH THE AMM. THE FLT WAS NEARING DEP TIME AND OBVIOUSLY RUSHED; I INADVERTENTLY FORGOT TO REINSTALL THE NOSE TIRE ASSEMBLY WASHER. IN 19 YRS AS A CERTIFIED A&P MECH I'VE NEVER MADE SUCH A SERIOUS MISTAKE AND IN THE FUTURE WILL SLOW DOWN SO AS NOT TO REPEAT THIS MISTAKE AGAIN. I WAS MADE AWARE OF THIS INCIDENT BY MAINT CTL THIS MORNING AND AM NOT AWARE OF ANY DAMAGE BEING INFLICTED UPON THE ACFT OR TIRE ASSEMBLY AT THIS TIME. THIS STATEMENT HAS BEEN RECALLED TO THE BEST OF MY RECOLLECTION AND KNOWLEDGE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS ACFT HAD AN EXTERNALLY THREADED NOSE WHEEL AXLE. THE MAINT MANUAL DOES HAVE AN ILLUSTRATION SHOWING THE SPACER IN THE TIRE/WHEEL REPLACEMENT; HE JUST DID NOT REMEMBER TO RE-INSTALL THE AXLE SPACER (WASHER).
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.