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A B737-300 was dispatched in non compliance with the right main tire hub cap mounting bolts not safetied per the job card.
| Attributes | |
| ACN | 541566 |
| Time | |
| Date | 200203 |
| Day | Wed |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 12 |
| ASRS Report | 541566 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : crew or faa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : lighting contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation |
| Supplementary | |
| Problem Areas | Aircraft Environmental Factor Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
I feel that I safe tied the 3 bolts with a single piece of safety wire. I don't know how and when the safety wire came off. The nuts were found to be not safetied on the following day (03/thu/02). According to aircraft history, there is no history between my tire change and the following day. The nuts were found on a walkaround, by a pilot or FAA, and corrected by maintenance. This was brought to my attention by my 3RD shift manager on mar/tue/02. The only things that could've contributed to me possibly not safetying the 3 bolts are: accomplishing a 'weekly check' by myself and trying to finish in a timely manner, distractions from the fuel control change, and myself trying to make sure I had my work done before the other guys were done and ready to run-up the engine, poor hangar lighting, and 3RD shift work can be very tiring. None of these are good excuses for missing a safety.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE R MAIN TIRE HUB CAP MOUNTING BOLTS NOT SAFETIED PER THE JOB CARD.
Narrative: I FEEL THAT I SAFE TIED THE 3 BOLTS WITH A SINGLE PIECE OF SAFETY WIRE. I DON'T KNOW HOW AND WHEN THE SAFETY WIRE CAME OFF. THE NUTS WERE FOUND TO BE NOT SAFETIED ON THE FOLLOWING DAY (03/THU/02). ACCORDING TO ACFT HISTORY, THERE IS NO HISTORY BTWN MY TIRE CHANGE AND THE FOLLOWING DAY. THE NUTS WERE FOUND ON A WALKAROUND, BY A PLT OR FAA, AND CORRECTED BY MAINT. THIS WAS BROUGHT TO MY ATTN BY MY 3RD SHIFT MGR ON MAR/TUE/02. THE ONLY THINGS THAT COULD'VE CONTRIBUTED TO ME POSSIBLY NOT SAFETYING THE 3 BOLTS ARE: ACCOMPLISHING A 'WEEKLY CHK' BY MYSELF AND TRYING TO FINISH IN A TIMELY MANNER, DISTRACTIONS FROM THE FUEL CTL CHANGE, AND MYSELF TRYING TO MAKE SURE I HAD MY WORK DONE BEFORE THE OTHER GUYS WERE DONE AND READY TO RUN-UP THE ENG, POOR HANGAR LIGHTING, AND 3RD SHIFT WORK CAN BE VERY TIRING. NONE OF THESE ARE GOOD EXCUSES FOR MISSING A SAFETY.
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.