<< >> NASA ASRS Report 612029, March 2004

During an MD80 right nose tire change, 3 technicians were cited by the quality control audit team for not following published procedures.

Attributes
ACN	612029
Time
Date	200403
Day	Tue
Local Time Of Day	0601 To 1200
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	MD-80 Series (DC-9-80) Undifferentiated or Other Model
Operating Under FAR Part	Part 121
Flight Phase	ground : maintenance ground : parked ground : maintenance
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	612029
Person 2
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	612030
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure non adherence : company policies
Independent Detector	other other : 4
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : schedule pressure contributing factor : manuals performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : installation
Supplementary
Problem Areas	Maintenance Human Performance Environmental Factor Company Aircraft Chart Or Publication
Primary Problem	Maintenance Human Performance

Narrative:

On mar/tue/04, I was involved in changing the right nose tire on aircraft X. Step A1 of the maintenance manual procedure is to install the landing gear ground lock pins. I failed to install the pins as per maintenance manual procedure. I mistakenly referred to the mcm card. This card makes no mention of installing gear pins. I also did not use a thread protector to remove the tire assembly. This was pointed out to me by quality assurance. I stopped the procedure and rectified the problem by getting a thread protector and installing it before proceeding on. Result: gear pins not used. Thread protector installed late. Cold and noisy outside as aircraft around were running engines and taxiing. We were pressed for time to move aircraft. Distraction by quality assurance taking pictures and interfering with installation procedures.

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Original NASA ASRS Text

Title: DURING AN MD80 R NOSE TIRE CHANGE, 3 TECHNICIANS WERE CITED BY THE QUALITY CTL AUDIT TEAM FOR NOT FOLLOWING PUBLISHED PROCS.

Narrative: ON MAR/TUE/04, I WAS INVOLVED IN CHANGING THE R NOSE TIRE ON ACFT X. STEP A1 OF THE MAINT MANUAL PROC IS TO INSTALL THE LNDG GEAR GND LOCK PINS. I FAILED TO INSTALL THE PINS AS PER MAINT MANUAL PROC. I MISTAKENLY REFERRED TO THE MCM CARD. THIS CARD MAKES NO MENTION OF INSTALLING GEAR PINS. I ALSO DID NOT USE A THREAD PROTECTOR TO REMOVE THE TIRE ASSEMBLY. THIS WAS POINTED OUT TO ME BY QUALITY ASSURANCE. I STOPPED THE PROC AND RECTIFIED THE PROB BY GETTING A THREAD PROTECTOR AND INSTALLING IT BEFORE PROCEEDING ON. RESULT: GEAR PINS NOT USED. THREAD PROTECTOR INSTALLED LATE. COLD AND NOISY OUTSIDE AS ACFT AROUND WERE RUNNING ENGS AND TAXIING. WE WERE PRESSED FOR TIME TO MOVE ACFT. DISTR BY QUALITY ASSURANCE TAKING PICTURES AND INTERFERING WITH INSTALLATION PROCS.

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.