37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 778391 |
Time | |
Date | 200803 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 244 flight time type : 10980 |
ASRS Report | 778391 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 238 flight time type : 238 |
ASRS Report | 778393 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
On arrival in ZZZ we were met by maintenance crew who informed me during maintenance debrief that our aircraft had -700 nose tires installed on it. In checking the logbook; I remembered seeing a write-up on a nose tire change in the days preceding our flight; but didn't think anything about it. A personal inspection of the nose tires confirmed that they had '-700' stenciled on them in yellow ink. The first officer had already left the aircraft for his commute home; so I haven't had the opportunity to question him as to possible reasons he didn't notice the markings on his preflight. Obviously; a large number of people missed the '-700' stencil on the tires; starting with the maintenance team that replaced the tires to all the flight crew doing preflts since the change. My observation of the stenciling is that the letter ring is clear but the letters themselves are fairly thin and really don't stand out. Thicker lettering would make them more visible and more likely to draw attention. Preflts are one of the routine things we do every day -- very easy to see what 'we expect to see' and miss a detail like this. A commitment to a thorough preflight examination every day; every time is vital. Supplemental information from acn 778393: normal preflight; followed by normal flying day. Upon terminating aircraft in ZZZ; I went to my commuter flight. My flying partner utilized the interphone on my commute aircraft (I was already seated in the back) and informed me we had been flying a -500 with -700 nose tires. Ensure nose tires are correct for type of aircraft.
Original NASA ASRS Text
Title: INBOUND FLIGHT CREW IS INFORMED BY MAINT AT THEIR ARRIVING STATION OF HAVING -700 NOSE TIRES INSTALLED ON THEIR B737-500 NOSE GEAR. ACFT HAD BEEN FLYING SEVERAL DAYS WITH INCORRECT NOSE TIRES.
Narrative: ON ARR IN ZZZ WE WERE MET BY MAINT CREW WHO INFORMED ME DURING MAINT DEBRIEF THAT OUR ACFT HAD -700 NOSE TIRES INSTALLED ON IT. IN CHKING THE LOGBOOK; I REMEMBERED SEEING A WRITE-UP ON A NOSE TIRE CHANGE IN THE DAYS PRECEDING OUR FLT; BUT DIDN'T THINK ANYTHING ABOUT IT. A PERSONAL INSPECTION OF THE NOSE TIRES CONFIRMED THAT THEY HAD '-700' STENCILED ON THEM IN YELLOW INK. THE FO HAD ALREADY LEFT THE ACFT FOR HIS COMMUTE HOME; SO I HAVEN'T HAD THE OPPORTUNITY TO QUESTION HIM AS TO POSSIBLE REASONS HE DIDN'T NOTICE THE MARKINGS ON HIS PREFLT. OBVIOUSLY; A LARGE NUMBER OF PEOPLE MISSED THE '-700' STENCIL ON THE TIRES; STARTING WITH THE MAINT TEAM THAT REPLACED THE TIRES TO ALL THE FLT CREW DOING PREFLTS SINCE THE CHANGE. MY OBSERVATION OF THE STENCILING IS THAT THE LETTER RING IS CLR BUT THE LETTERS THEMSELVES ARE FAIRLY THIN AND REALLY DON'T STAND OUT. THICKER LETTERING WOULD MAKE THEM MORE VISIBLE AND MORE LIKELY TO DRAW ATTN. PREFLTS ARE ONE OF THE ROUTINE THINGS WE DO EVERY DAY -- VERY EASY TO SEE WHAT 'WE EXPECT TO SEE' AND MISS A DETAIL LIKE THIS. A COMMITMENT TO A THOROUGH PREFLT EXAMINATION EVERY DAY; EVERY TIME IS VITAL. SUPPLEMENTAL INFO FROM ACN 778393: NORMAL PREFLT; FOLLOWED BY NORMAL FLYING DAY. UPON TERMINATING ACFT IN ZZZ; I WENT TO MY COMMUTER FLT. MY FLYING PARTNER UTILIZED THE INTERPHONE ON MY COMMUTE ACFT (I WAS ALREADY SEATED IN THE BACK) AND INFORMED ME WE HAD BEEN FLYING A -500 WITH -700 NOSE TIRES. ENSURE NOSE TIRES ARE CORRECT FOR TYPE OF ACFT.
Data retrieved from NASA's ASRS site as of May 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.