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Mechanic is informed he did not install the nose tires tang type axle spacers during a double tire change on a B767-300 aircraft.
| Attributes | |
| ACN | 790542 |
| Time | |
| Date | 200803 |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B767-300 and 300 ER |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 41 |
| ASRS Report | 790542 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
During a double nose tire change on aircraft X I failed to notice the tang washers were missing when I removed the old tires and installed the new tires without them. There were no tang washers installed on the old tires and the night before they had been retorqued at the hangar. I checked the area after the tire change and there were no parts around so I assumed the tire change was complete. When the washers were missing when I removed the tires I became confused with the thread type between internal and external.
Original NASA ASRS Text
Title: MECHANIC IS INFORMED HE DID NOT INSTALL THE NOSE TIRES TANG TYPE AXLE SPACERS DURING A DOUBLE TIRE CHANGE ON A B767-300 ACFT.
Narrative: DURING A DOUBLE NOSE TIRE CHANGE ON ACFT X I FAILED TO NOTICE THE TANG WASHERS WERE MISSING WHEN I REMOVED THE OLD TIRES AND INSTALLED THE NEW TIRES WITHOUT THEM. THERE WERE NO TANG WASHERS INSTALLED ON THE OLD TIRES AND THE NIGHT BEFORE THEY HAD BEEN RETORQUED AT THE HANGAR. I CHKED THE AREA AFTER THE TIRE CHANGE AND THERE WERE NO PARTS AROUND SO I ASSUMED THE TIRE CHANGE WAS COMPLETE. WHEN THE WASHERS WERE MISSING WHEN I REMOVED THE TIRES I BECAME CONFUSED WITH THE THREAD TYPE BTWN INTERNAL AND EXTERNAL.
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.