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|
Attributes | |
ACN | 950675 |
Time | |
Date | 201105 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Nose Gear Tire |
Person 1 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Experience | Maintenance Technician 35 |
Person 2 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Experience | Maintenance Technician 31 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
Arrived at work as usual approximately xa:15am. Walked from parking lot to [gate] maintenance area. Checked daily assignment sheet; company e-mail; and routine overnight (ron) aircraft. I was assigned several gates that day. Our normal start time is xc:00am. A B767-300 charter flight from ZZZ-ZZZ1-ZZZ2 arrived approximately xb:40am and was scheduled to depart ZZZ1 at xe:00am. The weather was beautiful; cool; a bright sunny morning. I was a member of a three person team assigned to 'turn' the B767; I am not trained on the B767 but the other members were qualified. We proceeded to the aircraft. I started the visual walk around of the aircraft while the other members did servicing tasks for the [aircraft] turn. Deep cuts; beyond the maintenance manual (M/M) limits; were noted on the number 7 main tire and the left nose tire. The tires were ordered; someone brought the tire change cart; and printed the maintenance manual references. We replaced the number 7 main wheel assembly first; that completed; we moved to the left nose wheel assembly. At this point we noticed the flight information screen at the gate had a revised departure time of xd:00am instead of xe:00am; but no one notified us so we thought we had lost one hour of time and felt the constraint.I remember someone jacking the nose; I removed the locking hardware and axle nut. Coworkers removed the wheel assembly from the axle and installed a serviceable [tire] assembly on the axle. My coworkers visually checked the wheel assembly installation and compared it to the right nose wheel assembly; all appeared normal to them. I did not visually check for the spacer since I was installing the washer and axle nut at the time. We torqued the assembly; torquing up was normal and I installed the safety bolts. Before letting the [aircraft]jack down; I performed a 'wobble' check; all was fine. The gate mounted air conditioning system for the aircraft was running right next to us and it is very loud. For several of us this was the first B767 tire assembly we had ever changed. The logbook was completed and the aircraft departed after its original time of xe:00am; well after our work was completed.the B767-300 flew its flight and a week later a spacer was noted with the tire assembly at the [tire] shop in ZZZ3. They notified maintenance control and the aircraft was tracked [located] at ZZZ4. The mechanics in ZZZ4 inspected the left nose wheel installation and noted the left nose tire spacer was missing so a replacement spacer and wheel assembly were installed. The aircraft flew without incident during the time the spacer was out and no damage was reported.what went wrong/fix: aviation maintenance technician (amt) should have physically touched the [nose wheel axle] spacer to ensure of it's installation. In retrospect; I should have specifically asked if the spacer was installed because the maintenance manual (M/M) notes that the spacer needs to be installed several times. We should have checked each other. We were unfamiliar with the task; although not rushed; we felt the time constraints on this high profile flight. The company should have ensured enough qualified people available. Given our experience level this should not have occurred. I should have not taken the other members word the installation was correct and checked it myself.although I did not sign for the work; I was present and do feel the affects of the incident mentally. Other departments could have done better: ramp control should have verbally kept us informed of any changes to the flight status and departure time changes; this policy was in place several years ago but not now. It should be reinstated. Through other sources; this problem with the spacer has occurred many times prior to this incident. If it's a continual issue; either the manufacturer or the company should address why the spacer comes off the axle so easily and engineer a tighter tolerance or security system that will keep the [wheel/tire] assembly from torquing up properly if the spacer is not installed. Or; [design] the safety bolts [so they] will not install [if spacer is missing]; sort of a fool proof installation process.final thoughts: each member of the team involved in this incident has over 30-years experience with the company; are very good and dedicated mechanics. This oversight has affected each of us deeply and has increased our awareness during team maintenance efforts.
Original NASA ASRS Text
Title: Two line mechanics were informed a contract tire repair shop Mechanic found an axle nut washer stuck to the wheel bearing race of a nose tire they had removed from a B767-300 approximately one week earlier.
Narrative: Arrived at work as usual approximately XA:15am. Walked from parking lot to [gate] Maintenance area. Checked daily assignment sheet; company e-mail; and Routine Overnight (RON) aircraft. I was assigned several gates that day. Our normal start time is XC:00am. A B767-300 charter Flight from ZZZ-ZZZ1-ZZZ2 arrived approximately XB:40am and was scheduled to depart ZZZ1 at XE:00am. The weather was beautiful; cool; a bright sunny morning. I was a member of a three person team assigned to 'turn' the B767; I am not trained on the B767 but the other members were qualified. We proceeded to the aircraft. I started the visual walk around of the aircraft while the other members did servicing tasks for the [aircraft] turn. Deep cuts; beyond the Maintenance Manual (M/M) limits; were noted on the number 7 Main tire and the left nose tire. The tires were ordered; someone brought the tire change cart; and printed the Maintenance Manual references. We replaced the number 7 main wheel assembly first; that completed; we moved to the left nose wheel assembly. At this point we noticed the flight information screen at the gate had a revised departure time of XD:00am instead of XE:00am; but no one notified us so we thought we had lost one hour of time and felt the constraint.I remember someone jacking the nose; I removed the locking hardware and axle nut. Coworkers removed the wheel assembly from the axle and installed a serviceable [tire] assembly on the axle. My coworkers visually checked the wheel assembly installation and compared it to the right nose wheel assembly; all appeared normal to them. I did not visually check for the spacer since I was installing the washer and axle nut at the time. We torqued the assembly; torquing up was normal and I installed the safety bolts. Before letting the [aircraft]jack down; I performed a 'wobble' check; all was fine. The gate mounted air conditioning system for the aircraft was running right next to us and it is very loud. For several of us this was the first B767 tire assembly we had ever changed. The Logbook was completed and the aircraft departed after its original time of XE:00am; well after our work was completed.The B767-300 flew its flight and a week later a spacer was noted with the tire assembly at the [tire] shop in ZZZ3. They notified Maintenance Control and the aircraft was tracked [located] at ZZZ4. The mechanics in ZZZ4 inspected the left nose wheel installation and noted the left nose tire spacer was missing so a replacement spacer and wheel assembly were installed. The aircraft flew without incident during the time the spacer was out and no damage was reported.What went wrong/fix: Aviation Maintenance Technician (AMT) should have physically touched the [nose wheel axle] spacer to ensure of it's installation. In retrospect; I should have specifically asked if the spacer was installed because the Maintenance Manual (M/M) notes that the spacer needs to be installed several times. We should have checked each other. We were unfamiliar with the task; although not rushed; we felt the time constraints on this high profile flight. The company should have ensured enough qualified people available. Given our experience level this should not have occurred. I should have not taken the other members word the installation was correct and checked it myself.Although I did not sign for the work; I was present and do feel the affects of the incident mentally. Other departments could have done better: Ramp Control should have verbally kept us informed of any changes to the flight status and departure time changes; this policy was in place several years ago but not now. It should be reinstated. Through other sources; this problem with the spacer has occurred many times prior to this incident. If it's a continual issue; either the manufacturer or the company should address why the spacer comes off the axle so easily and engineer a tighter tolerance or security system that will keep the [wheel/tire] assembly from torquing up properly if the spacer is not installed. Or; [design] the safety bolts [so they] will not install [if spacer is missing]; sort of a fool proof installation process.Final thoughts: each member of the team involved in this incident has over 30-years experience with the company; are very good and dedicated mechanics. This oversight has affected each of us deeply and has increased our awareness during team Maintenance efforts.
Data retrieved from NASA's ASRS site as of April 2012 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.