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The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
September 2006 Report Intake
Air Carrier/Air Taxi Pilots 1863
General Aviation Pilots 865
Controllers 298
Cabin/Mechanics/Military/Other 136
TOTAL 3162
ASRS Alerts Issued in September 2006
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 7
Airport facility or procedure 11
ATC procedure or equipment 6
Maintenance procedure 2
Company policy 2
TOTAL 28
“Classic Traps”
The Nose Tire Assembly Trap
In a maintenance scenario reported many times to
ASRS, a technician is asked to change a B767-300 nose
tire assembly. The work is performed and the aircraft is
returned to service. All seems to be well – until a later
inspection finds that the wheel washers or wheel spacers
are missing. Here’s how that can happen:
■ Technician Y and [I] were assigned to the ETOPS
[Extended Range Operations] and overnight check on
Aircraft X. I don’t recall who found the left nose tire
worn, but I proceeded to get the equipment to change the
assembly. Technician Z...rolled out a new tire assembly.
I jacked up the nose tire and loosened the lock bolts and
the axle nut. Usually, once the axle nut is broken loose, the
tang washer will slide right off the axle. Unfortunately, in
this case, the tang washer stuck to the tire assembly, and
neither Technician Y...nor I noticed this...At the conclusion
of the routine check, I signed off the tire on the logbook...
The aircraft departed without incident and a few days
later during a preflight inspection, maintenance noticed the
improperly installed nose tire assembly. The fact is the tang
washer on the removed tire stuck to the bearing with grease
and it did not occur to me that one belonged there with the
new assembly.
Affected airlines have now started adding special
instructions about the B767-300 washers/spacers to their
job cards. In the meantime, maintenance technicians
should be aware that both washers and spacers can stick
to greasy wheel assembly parts, and be easy to miss.
323
Submit Your ASRS Report
ELECTRONICALLY!
Electronic Report Submission (ERS) – the ability to fill
out an ASRS report on a computer and send it to ASRS
via a secure Internet connection – is now operational.
All ASRS Reporting Forms (General Pilot, Air Traffic
Control, Maintenance, and Cabin Crew) can now be sent
electronically via the ASRS website at:
http://asrs.arc.nasa.gov
ASRS has fully explored privacy protection and
confidentiality concerns for secure Electronic Report
Submission. ASRS has worked with NASA’s Jet Propulsion
Laboratories (JPL) – home to the Mars Rovers – to apply
sophisticated new technology to ERS that will ensure
confidentiality.
The next time you experience a safety incident or have a
safety concern, take ERS for a test flight and try out this
new technology!
The Fixation Trap
Fixation (cognitive tunneling) is focusing on some flying
tasks to the exclusion of others that may be just as
important to the safe outcome of flight. A GA pilot flying
single-pilot IFR reported a loss of situational awareness
while preoccupied with icing, an electrical problem, and
programming chores for the GPS.
■ ...I had been cleared by Approach to descend from 9,000
feet and intercept the Runway 15 Localizer. I flew through
the Localizer and missed two calls from Approach. This
resulted in Approach having to reroute two other aircraft.
The weather was deteriorating, with ceilings lowering
rapidly, visibility dropping below 2 miles, and snow. I had
picked up light/moderate ice during the initial descent
from 13,000 feet and observed that the left alternator was
not indicating that it picked up any load. The “alternator
out” warning light was not flashing. In the process of
analyzing the electrical issue and picking up the ATIS, I
lost track of how far past the fix I was. As a result, when
Approach cleared me to 3,500 feet, and to intercept the
Runway 15 Localizer...I did not establish a rate of descent
necessary to comply. Further, in listening to the new ATIS,
loading the approach for Runway 15 in the GPS, and
continuing to monitor parts of the electrical system,
I missed 2 calls from Approach...I also realized that I had
flown through the Localizer...
I fell into the trap of becoming overly focused on parts
of the task, and lost situational awareness...What was
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