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A B767-300 was dispatched in non compliance with the wrong type brake assembly installed in #6 main position caused by engineering order aircraft effectivity.
| Attributes | |
| ACN | 512275 |
| Time | |
| Date | 200105 |
| Day | Sat |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : zzzz.artcc |
| Operator | common carrier : air carrier |
| Make Model Name | B767 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance lead technician : 1 maintenance technician : 20 |
| ASRS Report | 512275 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
| Independent Detector | other other : 969 |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : engineering procedure performance deficiency : installation performance deficiency : logbook entry performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
While changing a brake assembly on B767 #6 brake, using referenced engineering order B767 as part number effectivity, wrong brake was installed. Card enclosed comes with brake parts tag, and a sticker on strut of the landing gear instructs to check same engineering order for part numbers effect. Ipc shows 2 each part numbers, 1 pre engineering order, and 1 post engineering order. The engineering order shows in the effective area, all aircraft from 301-328. This is confusing because it leads you to believe the engineering order has been accomplished. The aircraft was grounded in hong kong till they changed the brake. No incident occurred. We have made suggestions to management and quality control to enhance the procedure so it won't happen again.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE WRONG TYPE BRAKE ASSEMBLY INSTALLED IN #6 MAIN POS CAUSED BY ENGINEERING ORDER ACFT EFFECTIVITY.
Narrative: WHILE CHANGING A BRAKE ASSEMBLY ON B767 #6 BRAKE, USING REFED ENGINEERING ORDER B767 AS PART NUMBER EFFECTIVITY, WRONG BRAKE WAS INSTALLED. CARD ENCLOSED COMES WITH BRAKE PARTS TAG, AND A STICKER ON STRUT OF THE LNDG GEAR INSTRUCTS TO CHK SAME ENGINEERING ORDER FOR PART NUMBERS EFFECT. IPC SHOWS 2 EACH PART NUMBERS, 1 PRE ENGINEERING ORDER, AND 1 POST ENGINEERING ORDER. THE ENGINEERING ORDER SHOWS IN THE EFFECTIVE AREA, ALL ACFT FROM 301-328. THIS IS CONFUSING BECAUSE IT LEADS YOU TO BELIEVE THE ENGINEERING ORDER HAS BEEN ACCOMPLISHED. THE ACFT WAS GNDED IN HONG KONG TILL THEY CHANGED THE BRAKE. NO INCIDENT OCCURRED. WE HAVE MADE SUGGESTIONS TO MGMNT AND QUALITY CTL TO ENHANCE THE PROC SO IT WON'T HAPPEN AGAIN.
Data retrieved from NASA's ASRS site as of July 2007 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.