2009-08 · NASA ASRS report 846922
Flight crew of a B767-300 flight report that a Maintenance Supervisor is more concerned about dispatching their flight rather than addressing a tire found flat on the right Main Landing Gear. Three Mechanics also report on replacing the two forward tires; but the axle spacer was left off; and the tire overheats and deflates on take-off; causing severe damage to axle on landing.
The Captain; First Officer and myself were getting the B767-300 aircraft ready for departure for flight August 2009. Upon completion of the exterior inspection; the First Officer (FO) informed us that the right inboard; forward tire was flat. I sent a Maintenance report and called ZZZ Maintenance (Mx) to that effect. A few minutes later the Maintenance Supervisor came into the cockpit and was dubious toward our claim that the tire was flat at all. He proclaimed that he saw the tire and that it had adequate PSI and was not flat. At that point the FO escorted him out to the tire in question and together they observed a tire with 120 PSI that was visually smaller than the other tires. Line Maintenance then changed both forward right tires. On taxi; the Captain mentioned that the airplane was pulling slightly to the right. We checked the Status Page and all 8 brake temperature indices were zero. We decided that the airplane was safe for takeoff. Upon rotation at 170 knots the brake temperature light illuminated; so I checked the Status Page again and this time the right inboard forward brake was indicating 9. Following the brake temperature Irregular Procedure; we extended the gear to cool it. We decided it would be a safe course of action to continue to destination (lighter airplane; slower landing speeds) with the concurrence of Maintenance Control and Dispatch. The landing was normal and the brake temperature indices were all zeros or ones. We taxied normally to parking. The post flight Inspection revealed a flat right; inboard forward tire. The deflation was probably caused by the fuse plugs melting due to the excessive heat on the takeoff. The Mechanic in ZZZ3 pointed out that a spacer (which apparently reduces friction) was not installed on that tire.
Subject: Tire Change; Brake Temperature and Maintenance Supervisor's improper Attitude. Pre-flight: 1. Found deflated tire (Right truck inboard forward) on First Officer's (FO) Walk Around; visibly flat with 120 PSI on gauge. 2. Mechanic Supervisor entered cockpit and stated to Crew the tire has pressure and is not flat. 3. Captain asked First Officer (Relief Pilot) to escort Maintenance Supervisor to the tire in question. 4. Upon visually seeing the tire the Supervisor immediately started to call Line Mechanics to service the tire. 5. Supervisor tells First Officer that they will fill the tire and then we can go. 6. First Officer asks Supervisor if he actually looked at the tire before entering the cockpit to tell the Crew that the tire has pressure and is not flat. 7. Supervisor replies; 'no'; that he heard this on the radio. 8. First Officer observes the Supervisor looking over the Line Mechanic as he fills the tire; appearing to rush the Line Mechanic to finish filling the tire.9. At this point a second Supervisor appears (an individual that is normally seen in Operations in the evening to brief the Crews) and First Officer briefs him (on) what has happened and the fact that the other (first) Supervisor had not visibly gone down to check the tire prior to telling the Crew the tire has pressure and is not flat. This second Supervisor was apologetic. 10. The second Supervisor states that since the tire had been checked 45 minutes earlier by Line Mechanics walk around; and since it was 'OK' at that time; they will change the flat tire and its paired outboard tire per MEL. He stated that since the tire went flat in such a quick time that the problem must be greater than a slow leak. 11. Tires are changed 12. Mechanic enters the Flight Deck to release brakes to rotate tire. 13. Mechanic leaves the Flight Deck without any indication that they are done with tire change. 14. Customer Agent then enters the Flight Deck to ask Captain if it's 'OK' to close the door. Captain states that he not aware that the Maintenance work is done and to please ask the Lead Mechanic to come to the Flight Deck. 15. Lead enters Flight Deck and says the work is complete. Captain asks Lead Mechanic; are all the parts put back on correctly and is it all done right. Lead Mechanic reply (is) 'yes'. 16. On taxi out; the Captain notes that the B767-300 is pulling slightly to the right. 17. First Officer checks the break temps and all are on Zero's (0's) prior to entering the active RWY. During Flight: 1. Immediately after takeoff Brake temperature (temp) light is illuminated. 2. Display Status Page shows that the right inboard forward tire is overheated with the indicator exceeding it's maximum value; on 9; so it was blank. 3. Captain directs Relief Pilot to get the brake temperature procedure ready. 4. Captain elects to clean up airplane and climb to a safe altitude to assure obstacle clearance before beginning the Irregular Procedure. 5. Irregular Procedure for brake temp is completed and landing gear is extended to cool the hot brake on the right main gear.6. While gear is extended an additional EICAS message 'Stab Trim is illuminated'. 7. Captain elects to defer that checklist until the Brake Cooling Checklist is completed. 8. Break Temp Checklist is completed 9. Stab Trim Checklist is completed 10. Status Page shows status message 'Landing Gear Monitor'.11. Crew attempts to contact Dispatch via SATCOM but is unsuccessful. There was a brief connection but then the SATCOM disconnected and the SATCOM main menu showed unavailable for the remainder of the flight. 12. Crew contacts Dispatch via VHF. Frequency is garbled and very difficult to understand Dispatch. Dispatch patches Maintenance Control into the call. Maintenance Control was unreadable so Dispatch relays between Crew and Maintenance Control. 13. Captain and Dispatch determine that safety of flight was not in question. 14.Captain elects to continue to destination with Dispatches concurrence. 15. Captain advises that ZZZ1 would be a divert option but returning to ZZZ would not warrant the risks associated with an overweight / heavy weight landing. 16. Flight Attendant sitting over wing states that she heard an abnormal noise upon initial gear retraction; adding that it sounded like a very loud pop. This info was not given to the Flight Deck until the very end of the flight.17. Upon arrival into ZZZ2 approach; an Emergency is Declared as a precautionary measure. Having CFR equipment would be good tool to be our eyes on the ground. 18. Initial weather is below CAT 3 landing minimums and upon Crew discussion the Captain elects not to land with weather below CAT 1. With the possibility of a locked brake and or damaged tires; having adequate directional control with an Auto Landing; as well as runway visual cues; was primary concern. 19. ZZZ3 weather is VFR and determined to be alternate with a 10K RWY for landing.20. No holding necessary; weather comes up to 1500 RVR.21. Cabin crew is advised to perform a Cabin Advisory approximately 1 hour out and that CFR will be available as a precaution. 22. Passengers are advised moments prior to cabin prep for landing that CRF will be on standby as a precaution. 23. Normal landing is achieved. Post Flight: 1. After landing Captain makes the RWY XX turn-off; which is standard operations in ZZZ3 and allows for minimal taxi time. 2. Fire trucks are blocking RWY XX and have to quickly move out of the way while Captain is forced to apply brakes to slow the B767-300. 3. On taxi-in; Crew notes an additional Status Message 'Auto Cabin Controller 2' 4. Post flight Walk Around shows the right main forward inboard tire flat; charring on the tire hub from the excessive heat generated. 5. Metal pieces from the hub were missing and in fact; had fallen off upon landing. A Ground Crew had collected these pieces off the RWY during a RWY sweep that was performed after landing.6. ZZZ3 Mechanic stated that it appears that the bearing spacer was not installed when the tire was replaced causing a bearing failure and subsequent overheat. Questions to consider: 1. When the post Maintenance cleanup occurred; why was the missing bearing not discovered? 2. If the bearing was found on post Maintenance cleanup why was the (Flight) Crew not notified? 3. After landing in ZZZ3; it seemed that the Mechanics on the ground already knew that the bearing was missing; again if they new this why wasn't the Crew notified? Simply stated this event never should have happened. Although the Line Mechanics that actually performed the work on this airplane; did not properly change the tire and missed re-installing the bearing spacer; it is my opinion the problem that perpetuated this event began with the initial Maintenance Supervisor's attitude towards the (Flight) Crew and the Line Mechanics (who were) performing the tire change. This Supervisor came into the Flight Deck with an attitude that put the Crew into a defensive position as he stated that the tire has pressure and is not flat; when in fact; he had never visually checked the tire until at the Captain insistence; that he be escorted by the First Officer down to the actual flat tire. The Supervisor was not only trying to push the Captain to take the plane with an actual flat tire; but he then proceeded to push the Mechanics to hurry the fix. It is blatantly obvious that this Supervisor was only interested in getting the plane off the gate. He never attempted to personally determine if the tire was flat and as to why! It was not until the second Supervisor arrived on scene; that some actual logic was implemented; determining the problem thru good rational decision making; considering that if the tire was ok during the Mechanics Walk Around; that there must be a major problem for it to go completely flat in less than 45 minutes. As previously stated; this never should have happened. If the job of the Maintenance Supervisor is to be the focal point on all last minute mechanical issues and act as a liaison between Maintenance and the (Flight) Crew; then this person has to be held to the highest ethical standards. Pushing to get the aircraft off the gate without properly addressing the problem and then approaching the Captain and Crew with an adversarial attitude is completely unacceptable. This aircraft is now out of revenue service for over 6 days; while the axle is being replaced and for why? Knowing that the Line Mechanics that performed the actual repair were the cause of the improper tire installation; it is just as important to consider that creating an environment to rush; to get the aircraft off the gate; buy this Supervisor; is an attributing factor that led to this event.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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