2011-05 · NASA ASRS report 951291
A Line Mechanic reports a B767-300 left nose wheel tire axle spacer was not reinstalled during a tire change. Mechanic notes the Aircraft Maintenance Manual (AMM) does not show how many threads to look for on the nose gear axle after the axle nut is properly torqued.
I was informed we had a Boeing 767-300 aircraft in for an ETOPS Check and Daily Check (DC) going to ZZZZ. Several co-workers did the walk around inspection and called in for one main and one nose tire change. Hearing this I printed up the Aircraft Maintenance Manual (AMM) references for both tire changes. I picked up the tire change cart and headed to the gate to help. After helping with the main tire change; we moved to the nose; jacked and pulled the left-hand nose tire off. After 'F' procedure and Step-4 of AMM 32-45-02; looking at the axle; seeing what we thought was a spacer; we compared both the old and new inner bearing races. They looked the same. So we thought the spacer on the axle was the one in question. After torquing the axle nut on; we checked the amount of threads comparing to the right-hand side [right nose tire axle]. They were the same. So my co-workers felt safe to the sign the job off. Prior to my lowering of aircraft jacks; I watched one of my co-workers do a wiggle check [shake the tire] which passed. I feel the AMM does not identify clearly enough how the spacer interacts with the bearings and axle. Also; it does not show how many threads to look for after the axle nut is properly torqued on. Should threads be visible or not? Maybe a change in the AMM is needed to prevent this ongoing problem.
Reporter stated the axle nut washer; not inner spacer; was the part not reinstalled. He and other mechanics are so focused on making sure the nose gear axle inner spacer is installed; that he forgot to install the left axle/wheel nut washer. Mechanics are still using the term 'spacer' when referencing the axle nut washer. A Mechanic in the Tire Shop found the axle nut washer stuck to the face of the wheel bearing that was removed with the worn tire. The axle nut washer can easily remain stuck to the wheel bearing because of the wheel bearing grease. And because the bearing and the washer are the same color; the washer is easy to miss during the tire removal.Reporter stated many have suggested the axle nut washer be color coded to get the attention of mechanics; but concerns were raised by the Manufacturer about the possibility of chipped paint from the washer flaking off and getting into the bearing race. None of the removal or installation procedures in the Maintenance Manual (M/M) for the B767-300 nose gear tire change have references or illustrations to check the number of axle threads exposed after a tire installation; but the B747-400 tire change procedures do. The right nose tire axle threads had the same amount of axle threads exposed as the left tire he had changed; so they thought everything was alright. His carrier noticed that alert posters showing what to look for during a nose tire change on a B767 had not been posted on their Tire Cart or in the Maintenance room at his Line Station.
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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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