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washer. In [my] years as a certifi ed Airframe and Powerplant
mechanic, I’ve never made such as serious mistake and in the
future will slow down so as not to repeat this mistake again.
In the past two years, ASRS has received at least 16 reports
of B767-300 nose gear washers not being installed. These
aircraft have two types of axle washers. One type is internally
threaded and the other is externally threaded. The externally
threaded washers are the ones that are usually forgotten
during nose tire installation.
ASRS Alerts Issued in July 2008
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 5
Airport facility or procedure 4
ATC procedure or equipment 1
Maintenance procedures 1
Total 11
ance-rt e error th t
“Dozen”“Dirty Dozen”The in ASRS Maintenance Reporting
345
Lack of Resources
Maintenance technicians trying to accomplish a strut
replacement on a B737-800 failed to follow standard aircraft
jacking confi guration. The contributing “dirty dozen” factor:
Lack of Resources: Use of improper equipment
􀂄 [We made] a fi eld trip for aircraft strut replacement. We
arrived and started inspecting what we had for equipment,
tools, and parts. When [we] determined that we were missing
a cup for one of the wing jacks, we ordered that and some
miscellaneous parts from [airport] ZZZ1. We installed the
right wing jack and the tail jack in place for stability to
remove the #4 brake and #3 tire and brake. We were unable
to accomplish this without an axle jack. Instead of waiting for
the cup to come from ZZZ1, we jacked the right axle with the
axle jack enough to remove the bad brakes and tire. When the
cup came from ZZZ1, we installed it on the left wing jack and
placed it in position under the wing. Upon setting that jack
in place, we went to check the other jacks to prepare them
for jacking and we found that the tail jack had slipped off of
the jack pad and punched a hole through the fuselage just
forward and outboard of the jack pad.
Complacency
Complacency is a state of self-satisfaction that is often coupled
with unawareness of impending trouble. A maintenance
technician learned that it is risky to assume that someone else
has given you the right part.
Complacency: Failure to verify effectivity
􀂄 Aircraft ‘X’ came in with #2 engine, system #1 ignition on
MEL. After pushback the #2 engine would not start. We called
for the Control Center to order us 2 exciter units, which I
installed. The operational check failed. At this point it was the
end of our shift. In order to avoid paperwork issues with the
next shift, I signed off the log page as replaced units test fails
and opened a new log page. Today I found out in (computer
system) that the next shift had to replace both exciter units
again due to (incorrect) effectivity, which fi xed the problem.
Next shift found the problem and it was corrected before
fl ight. I should have verifi ed the effectivity, not assume the
(controller) ordering the parts would do so.
Stress, Fatigue, and Distraction
A triple whammy of human factors led to failure of a B737-
300’s engine reversers to stow on landing rollout:
Stress: Rushing to fi nish jobs
Fatigue: Not getting enough sleep
Distraction: Interrupted work assignments
􀂄 I was assigned 2 aircraft...Working the B737 window
heat problem #2 right window, I pulled circuit breakers and
2 boxes, window heat controller [WHC] and the engine
accessory unit [EAU] in the electronics bay to gain access
to the back side of the WHC bench plugs to do resistance
checks, reference maintenance manuals and wiring diagrams.
Once I found the problem, I gathered the parts and crimpers
I needed. At this time I was told by my lead to drop what I
was doing and start working write-ups on a B747. I was told
that a widebody had priority over a narrow body. Because I
was in the middle of a job on the B737 I fi nished repairing the
broken feed wire to the #2 window, replaced WHC and EAU,
and pushed in all breakers. Checked and tested window heat
in which the #2 window heat was operating OK. I started
working on the B747 until the end of shift. I received a call
from the shift supervisor telling me that the B737 landing at
another airport had the reversers deployed but would not
stow on rollout. Pilots shut the engines down and were towed
to the gate. Maintenance noticed that the EAU was missing.
A new EAU was installed and the original EAU was found
lying inside [the] E&E compartment on top of the drip curtain
　
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