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|
Attributes | |
ACN | 813448 |
Time | |
Date | 200811 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | SF 340B |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 813448 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Changed r-hand nose tire assembly. Forgot to install the inboard axle spacer. It occurred at ZZZ1 maintenance facility in the hangar; under normal conditions on third shift. I was the only one involved in the job. ZZZ2 tire shop found missing spacer attached to wheel bearing and notified maintenance control. Road trip to investigate. I cannot explain or give a good reason for forgetting this. Changing a nose tire is a task I have performed in the past without difficulty or problems. I was on my sixth day in a row on overtime; but I did not feel fatigued that I can recall. I can only sum it up as complacency and lack of attentiveness on my part. Pay more attention to the job I'm doing.
Original NASA ASRS Text
Title: MECHANIC IS INFORMED HE DID NOT REINSTALL THE WHEEL SPACER WHEN REPLACING THE RIGHT-HAND NOSE TIRE ON A SAAB-340B AIRCRAFT. TIRE SHOP MECHANIC NOTICED THE SPACER STUCK TO THE REMOVED TIRE BEARING.
Narrative: CHANGED R-HAND NOSE TIRE ASSEMBLY. FORGOT TO INSTALL THE INBOARD AXLE SPACER. IT OCCURRED AT ZZZ1 MAINT FACILITY IN THE HANGAR; UNDER NORMAL CONDITIONS ON THIRD SHIFT. I WAS THE ONLY ONE INVOLVED IN THE JOB. ZZZ2 TIRE SHOP FOUND MISSING SPACER ATTACHED TO WHEEL BEARING AND NOTIFIED MAINT CTL. ROAD TRIP TO INVESTIGATE. I CANNOT EXPLAIN OR GIVE A GOOD REASON FOR FORGETTING THIS. CHANGING A NOSE TIRE IS A TASK I HAVE PERFORMED IN THE PAST WITHOUT DIFFICULTY OR PROBS. I WAS ON MY SIXTH DAY IN A ROW ON OVERTIME; BUT I DID NOT FEEL FATIGUED THAT I CAN RECALL. I CAN ONLY SUM IT UP AS COMPLACENCY AND LACK OF ATTENTIVENESS ON MY PART. PAY MORE ATTN TO THE JOB I'M DOING.
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.