Approach - VOL 63, NO.3 by NavalSafetyCommand

Approach THE NAVY AND MARINE CORPS AVIATION SAFETY MAGAZINE

2020, Vol. 63, No. 3 - www.navalsafetycenter.navy.mil

32 PAGES

PILOTS IN ACTION

THEIR BEST STORIES What is Different Today?

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AVIATION SAFETY

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MISSION

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U.S. Navy photo by Petty Officer 3rd Class Indra Bosko - Illustration by Catalina Magee

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2020, VOL63., NO.3 APPROACH

COMMANDER`S NOTE REAR ADMIRAL “LUCKY” LUCHTMANFarewell Letter

Naval Aviation professionals, It has been quite a year! If operating during a pandemic has taught us anything, it is that teamwork and active communication through all available means is critical to our success. While much has changed in our current operating environment, much remains the same. There are commonalities among those units and organizations that pride themselves in having a steadfast commitment to a culture of safety, including: • • •

Active Communication – up, down and across the command. When it comes to safety, everyone has a voice Procedural Compliance – following the rules, conducting maintenance by the books and completing every item on every checklist is critical to safe and effective operations Deckplate Leader Presence – Good leaders are present, engaged and involved in all operations within the command – on day check and during night check.

While this list is not all-inclusive, it provides a snapshot of some of the traits we see in a unit that is committed to preserving readiness and saving lives. There are no secrets in safety, and information is most useful when shared, not only across aviation but also throughout the Naval Enterprise. In order to support your efforts, we recently launched the Risk Management Information Streamlined Incident Reporting (RMI SIR) System, and retired the Web-Enabled Safety System (WESS). SIR is a single point of data entry for safety professionals that is easier and quicker than its WESS predecessor. Most importantly, it allows more time to focus on mishap prevention, improving our ability to deliver safety lessons learned to the Naval Enterprise to support fleet readiness. I am proud of your level of commitment to preserving readiness. We can never stress enough that safety IS readiness. No matter the challenge, our Navy, Marine Corps and civilian personnel continue to meet our mission as warfighters. In closing, I’d like to introduce the Naval Safety Center’s new Command Master Chief, CMDCM(SW/AW/IW) Jimmy Hailey, who joins us from the Naval Service Training Command in Great Lakes. CMC Hailey brings 26 years of experience to the fight, and he and I, along with the entire Naval Safety Center team, remain your safety advocates. We look forward to continuing the conversation!

FEATURES APPROACH STAFF

Dr. Kirk Horton, KMSP Director Jeffrey Jones, Deputy Director, Safety Promotions David Mundy, Deputy Director, Knowledge Management Priscilla Kirsh, Supervisory Editor Catalina Magee, Editor and Layout Designer Lisa Bonner, Webmaster Safety Promotions Staff: Leslie Tomaino Becky Coleman Stephanie Slater Ken Goss Amy Robinson Sarah Langdon MC2 Weston Mohr

WHAT IS DIFFERENT TODAY

U.S. Navy photo by Mass Communication Specialist 3rd Class J. Alexander Delgado

Lessons Learned Staff: Chris Rew, Supervisor Dave Deuel Mike Del Favero

MAKING BIO RELIEF A “NUMBER ONE” PRIORITY U.S. Navy photo by Mass Communication Specialist 2nd Class Anthony Flynn

The Navy & Marine Corps Aviation Safety Magazine 2020 Volume 63, No. 3 RDML “Lucky” Luchtman, Commander, NAVSAFECEN Col David Bussel, Deputy Commander CMDCM Jimmy Hailey, Command Master Chief Naval Safety Center, (757) 444-3520 (DSN 564) Publications, Fax (757) 444-6791 Report a Mishap, (757) 444-2929 (DSN 564)

Aviation Safety Programs Editorial Board Adam Hyams, Deputy Director, Aviation Safety adam.e.hyams@navy.mil Ext. 7226 CDR Roger Leech, Aircraft Operations roger.a.leech@navy.mill Ext. 7117 All Analysts safe-code11@navy.mil Ext. 7811

Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces and put them in hospitals, wheelchairs and coffins. Mishaps ruin equipment and weapons. They diminish our readiness. This magazine’s goal is to help make sure that personnel can devote their time and energy to the mission. We believe there is only one way to do any task: the way that follows the rules and takes precautions against hazards. Approach (ISSN 1094-0405) and (ISSN 1094-0405X online) is published quarterly by Commander, Naval Safety Center, 375 A Street Norfolk, VA 23511-4399 and is an authorized publication for members of the Department of Defense. Contents are not necessarily the official views of, or endorsed by, the U.S. Government, the Department of Defense, or the U.S. Navy. Photos and artwork are representative and do not necessarily show the people or equipment discussed. We reserve the right to edit all manuscripts. Reference to commercial products does not imply Navy endorsement. Unless otherwise stated, material in this magazine may be reprinted without permission; please credit the magazine and author. Approach is available for sale by the Superintendent of Documents, P.O. Box 979050, St Louis, MO 63197-9000, or online at: bookstore.gpo.gov. Telephone credit card orders can be made 8 a.m. to 4 p.m. Eastern time at (866) 512-1800.Periodicals postage paid at Norfolk, Va. and additional mailing offices. Postmaster: Send address changes to Approach, Code 52, Naval Safety Center, 375 A Street, Norfolk, VA 23511-4399. Send article submissions, distribution requests, comments or questions to the address above or email to: SAFE-Approach@navy.mil.

THE VOICE OUT OF NOWHERE HSC-4 BLACK KNIGHTS U.S. Air National Guard photo by Master Sgt. Matt Hecht

2020, VOL63., NO.3 NO.2 APPROACH

Front Cover: Rear Adm. Joey Tynch, commander Logistics Group Western Pacific. U.S. Navy photo by Mass Communication Specialist 2nd Class Christopher A. Veloicaza

SAFETY HABIT PATTERNS: SAVING LIVES WITH MUSCLE MEMORY Photo by Petty Officer 3rd Class Liam Kennedy

Courtesy of U.S. Navy

Photo by Petty Officer 3rd Class Anderson W Branch

STUDY Naval Safety Center Completes Study on Mitigating Shipboard Forklift Risks

UNDER PRESSURE

FUMES IN THE STACK

BRILLIANCE IN THE BASICS

I`LL TAKE A RAIN CHECK

MERGING WITH DEPLOYMENT FROM BELOW THE “TACTICAL HARD DECK”

THE HOSE MUST GO

BRAVO ZULU

HAZARDOUS ADMIN

What is Different

Vision Devices (NVDs), but dark enough to begin to degrade vision. After takeoff, we flew most of the flight unaided, waiting for it to get dark enough for our NVDs to be useful. We donned our NVDs on the way back, trying to give ourselves enough time to get acclimated to them before we arrived back at the carrier.

Today? U.S. Navy photo by Mass Communication Specialist 3rd Class Brianna T. Thompson

By LT Lauren “Bender” Chavis HSM-74 Swamp Foxes

January 21, 2020, was the day before my 28th birthday. I was a last-minute addition to a flight assigned Surface Search Coordination (SSC) in support of the USS DWIGHT D. EISENHOWER Carrier Strike Group as we transited east across the Atlantic Ocean. The crew was fairly senior. The Helicopter Aircraft Commander (HAC) had over 1,000 hours of flight time and was on his second deployment. The co-pilot (H2P), had nearly 650 hours and was deep into the aircraft commander syllabus. The aircrewman, on loan from a sister HSM squadron, was chosen to join our squadron for our deployment preparations specifically because of his muchneeded experience. The HAC and I were also quite comfortable flying together, with over 100 hours of flight and simulator time as a crew. However, I was very new to the carrier environment, having landed on the carrier only once, never at night and never to the spot which would become fateful that night. The original co-pilot scheduled for that night got sick, so I was added to the flight schedule. The flight was planned for what we would call a “gentlemanly” 1.8 hours. At this point in our work-ups, the whole crew was accustomed to flights in excess of three hours, flying day and night in complex missions in preparation for the deployment. By comparison, this flight was benign—short in duration and simple in scope. We took off in “pinky time,” the time just after sunset when the sun’s glow still illuminates the sky—too bright to wear Night

A pilot’s “scan” and how they reference their instruments, changes in different flight regimes. For helicopter pilots, an outside scan is critical. We are trained to determining our altitude, airspeed, angle of bank, and rates of climb and descent by outside references, occasionally scanning inside to our flight instruments. At nighttime and when weather conditions degrade our visual acuity, our scan moves completely inside, trusting our instruments to tell us what the aircraft is doing. An NVD scan is a mix of both and must be practiced to maintain proficiency. We are often warned that NVDs do not “turn night into day,” reminding us that they are, in fact, just another instrument and we must continue to scan the rest of our tools to get a good sense of what the aircraft is doing.

With training and experience, these scans become subconscious, so much so that many pilots become complacent to their complexity. As a practiced crew, on what was a relatively benign flight, we were resting on the laurels of experience. We returned to the carrier as she was conducting fixed-wing carrier qualifications. As such, our aircraft was cleared to land on Spot 7, a helicopter landing spot just aft of the tower, which allows rotary-wing and fixed-wing aircraft to operate simultaneously. The HAC, who was sitting in the left seat, took controls for the landing. We positioned ourselves next to the spot, and the HAC tasked the aircrewman to “call the tail clear” of two jets that were positioned behind the location. As the aircrewman looked backward to ensure there was enough clearance between the tail rotor and the parked jets, the HAC slid the aircraft over the spot.

U.S. Navy photo by Mass Communication Specialist 3rd Class Alan L. Robertson

Visual references to land on Spot 7 are particularly troublesome at night. The rightseat pilot has few ground references until the aircraft is entirely over the deck, and outside references consist mostly of the superstructure of the ship until the line-up line painted on the tower comes into view. Therefore, much of the task of landing on Spot 7, especially at night when peripheral references are scarce, falls on the left-seat pilot and the aircrewman. Additionally, as I was entirely inexperienced landing on Spot 7, the sensory overload of new experience made me even less of a help. While the tower was lighted, the spot was in a shadow, requiring the HAC to scan through the NVDs to the butt-line on the deck to determine fore and aft drift, then under his NVDs to his instruments to determine our altitude, then forward through his NVDs to the Landing Signalman Enlisted (LSE) and the line-up line to determine lateral drift, then repeat. He did this expertly, as we steadied over the spot.

Meanwhile, as we were cleared to land, so too was an E-2C on short final. The E-2 trapped just as the HAC reduced power, committing to a landing on the spot. Just before our wheels touched the deck, the E-2’s wing-tip vortices, circular patterns of rotating air left behind a wing as it generates lift, produced turbulence in its wake. The helicopter, struck by the wake turbulence, began to slide right. The HAC, scanning left to determine his fore and aft drift; the aircrewman, scanning backward to clear the tail rotor; and I, the H2P, with an inexperienced scan in this new environment, did not notice the slide. As we lowered onto the deck with right drift, the tailwheel caught the lip of the deck and we began to roll right. I looked out my window and saw the nets that surround the flight deck and the water beneath them. We were banked dangerously. Noticing the potential for rollover, I came on the controls and froze them in place, counteracted the roll, and then relinquished the controls back to the HAC,

who brought the aircraft back up to a perch and landed again without incident. A post-flight inspection revealed a cracked rim on the tail wheel, as a small reminder of what could have happened. The lesson is one that is often repeated in flight school and safety briefs: complacency kills. It is especially prevalent in experienced crews who are comfortable with the aircraft, the mission and each other. Developing instinctual reactions is the goal of most aviation training. To utilize those reactions, we must be constantly vigilant to changing situations. I was relying too much on previous experience, thinking it would carry me through this new one. Instead, I should have had a healthy respect for the differences between what I knew and what I did not. Before, during and after the flight, we must always ask ourselves, “What is different today?”

Making Bio Relief a “Number One” Priority By LCDR Jess Cameron, VAW-120 Let’s talk about the “elephant”—nay—the “Piddle Pak in the room.” That’s right: get all the giggles out. I’m talking about pee, people— the urge to purge. We need to dust off and reexamine the unnecessarily taboo subject of in-flight biological relief, or “bio relief” because it is unacceptable that we have not yet fully solved the problem. The more we openly discuss bio relief, the better we signal demand 641 with Omega throughout Naval Aviation for Right page: U.S. Navy photo by Mass Communication Specialist 3rd Class Alan L. Robertson safe and effective options for men and women across multiple Type/Model/Series (T/M/S) and at all stages in their flying career. I’ve been on numerous critical Bio relief isn’t a singular event, it doesn’t involve missions with a high degree of sea stories regarding weapons systems or task saturation and involved catastrophic equipment failure, yet everyone mission requirements. I was encounters it. Winged aviators at every level unable to step back from my seat shouldn’t feel like they don’t have a voice on the for what would realistically be at issue, or that they have to remain anonymous least 10 minutes for me to set because of perception or cultural stigma. up to “go” and return to my seat Bio relief can be embarrassing by nature and to resume the mission. Many humiliating in practice when we lack sufficient aviators sacrifice their normal functionality, funding, and supply to successfully bodily function by either holding and safely complete the mission. Let’s not sugar it in or “tactically dehydrating” coat it. It is a readiness issue, and being human is (deliberate dehydration to minimize the need to urinate) for integral to being a warfighter! the flight. The only thing more frustrating than not being Approach featured the relation able to pee safely or effectively in the plane is between dehydration and fatigue not being heard. I’m not the first aviator to openly in the article, “Hydration and confront this problem throughout the decades Fatigue: What’s the Connection?” and across multiple aviation communities. Why (Jul-Aug 2014) which highlights do we seemingly reach dead ends on this critical the negative effects of dehydration problem that affects the health of our aviators, on mental and physical safety of flight, and mission success? I’ll highlight performance. Simply put, aircrew some of these concerns with anecdotes through often resort to “not going” by the lens of my Hawkeye-Greyhound (HEGH) either means rather than dealing community, which remains underrepresented with subpar bio relief options, with on the issue of bio relief, yet strives to make both measures causing negative significant progress matter for all aviation impacts to the health and safety communities. While doing this, I’ll share voices of aircrew. from years past and recommendations for our collective future.

Relief is not a small aside to the mission; in fact, lack of suitable bio relief options affect Naval Aviation readiness at its core. Underneath the surface, the problem is more than just about our bladders; it’s about inclusivity, equity, dignity, and above all—safety. The Navy spends exorbitant time and money to produce highly trained safe and lethal aviators but hasn’t sufficiently applied similar time, funding, and energy toward fully solving the bio relief dilemma. We haven’t fully realized progress despite repeated efforts by aviators, whose stories mirror my own, to make progress over the decades through published community articles, squadron-level, and community HAZREPS across T/M/S, or via Naval Aviation symposia. Today, over 17 years after a VAQ aviator wrote the March 2003 Approach article entitled, “Female Aviators Face a Dilemma: To Pee or Not To Pee,” the dilemma persists for men and women. And although bio relief tends to affect women disproportionately, it is a gender-neutral problem that depends on the type of survival equipment, aircraft, mission, weather, and even crewmember role. For instance, Aircraft Commanders flying with a less experienced pilot may never have the opportunity to relieve themselves. In addition, even if it were easy and convenient to go, many aircrews must still forego safety to unstrap from their seats to use Urinary Collection Devices (UCDs) or relief tubes. Moreover, the struggle is

real for both men and women if dry suits are mandatory, as cold weather survival gear demands improved bio relief options regardless of gender. Therefore, including everyone in the conversation may lead to more creative solutions with perspectives from all angles. So why bring this up now—or should I say—why now, again? Well, imagine not being able to urinate at work. There’s been a resurgence on the bio relief topic with the advent of Aerial Refueling (AR) in the E-2D Hawkeye with extended sortie durations making urination in flight an inevitability. With E-2D AR Fleet transitions underway, our community struggles to solve the “#1” dilemma. So, why can’t every aviator safely and effectively relieve themselves in flight? By “safely,” I’m referring to having access to bio relief devices that comply with the OPNAV N98 requirement not to remove aircraft restraint systems in flight. But UCDs that are cheaper and more widely available such as the Lady J Adapter, Freshette, Piddle Pak, and GoGirl (no, I am not making these brand names up) are not within regulations for every aviator because they generally require removal of flight gear for use. Yet they are the products most commonly purchased by squadron 7F funds, thereby forcing aviators into an unsafe position in flight when they need to urinate. By “effectively,” I’m referring to easy-to-use devices that are both hygienic and costeffective. This could include the aforementioned UCDs in conjunction with E-2/C-2 relief tubes, depending on how comfortable each aviator feels going, as well as when they can be bothered to go depending on the mission. And again, they can be time-consuming depending on one’s anatomy, aircrew role, and mission that day. Fumbling around and detracting from the mission is neither safe nor effective. Some may say that the Advanced Mission Extender Device Max (AMXDmax) is a clear solution to the bio relief dilemma, as it complies with the N98 requirement to allow everyone (jet, rotary, and prop aviators) to urinate while seated, and it has male and female variants. The device is partially funded, with the Navy having already invested $1 million in UCDs and uniforms (like two-piece flight suits) more conducive to bio relief efforts and planning to spend an additional $2 million to complete those endeavors. Military.com featured these goals in its 19 December 2019 article, “The Navy is Buying Equipment that Makes it Easier for Female Pilots to Pee.” The same article noted that the AMXDmax funding initiative began when the issue was raised at the 2018 Female Aviator Career Training Symposium (FACTS).

While the AMXDmax funding and supply initiatives are steps in the right direction, the device itself is no panacea for the bio relief dilemma. First, although the AMXDmax offered improvements from its legacy pump and battery life, it came with a $3K price tag per starter kit in 2017. Many squadrons informed their aircrew that they could perhaps purchase the device, but couldn’t afford to fund the system’s use and maintenance. The cost remains excessive today and often does not include the cost of upkeep and consumables. The acquisition process for the AMXDmax and similar devices remains a significant hurdle, with only slight improvements made along the way. VAW-120 (the only E-2/C-2 FRS) has yet to receive such devices, and they are not projected to become available to staff and student aviators until 2022.

Additionally, the AMXDmax is bulky and poses numerous health risks to its users. A 2017 combined all T/M/S HAZREP entitled, “Current In-Flight Bladder Relief Options are Inadequate and Potentially Unsafe,” outlines not only bio relief procurement concerns, but also disadvantages to the AMXDmax specifically. The HAZREP argues that the AMXDmax has taken a step backward from its legacy system in hygiene and usability, causing health

problems and infections in users and requires an unsustainable process for upkeep. User feedback in the HAZREP included disturbing personal stories, detailing persistent UTIs with usage, aviators forced to use the same pad for multiple urinations in a single sortie, and skin irritation or sores on the body from sitting where the wires go through the pad. With that, the marketing and contract must also be addressed properly, as “multiple urinations on the same flight is very different from using the same pad for multiple flights and the word ‘disposable’ indicates that they are not to be reused” (p 3). Every reader should cringe to think our final solution might be a clumsy, cost-prohibitive product with deceptive advertising that causes unsanitary conditions and discomfort while being awkward to use. To make matters worse, funding and supply still plague the Naval Aviation community with already-approved and tested systems. The 2017 all T/M/S HAZREP cautions against ambiguous timelines on when devices of any kind should be procured, issued, and trained in an aviator’s pipeline. And as if procurement hurdles were not enough, many squadrons do not recognize the extent of the problem because their aviators remain uncomfortable about voicing bio relief concerns or discussing their options (or are simply unaware of their options). Likewise, there is an inconsistent funding policy regarding UCD options between squadrons and Type Wings. We are still uncertain as to whether or not our community was provided a CNAP-approved CVWP 7F fund augment of $167,400 in June 2017 to procure AMXDmax devices for male and female aircrew, and a one-time plus-up of TYCOM 7F funds to assist the procurement of approved bladder relief systems. Note: Across the Naval Enterprise, all requirements must compete for funding in the OPNAV N98 portfolio. When portfolio managers don`t prioritize the requirements enough, those requirements go unfunded.

Photo by Petty Officer 3rd Class Joshua Leonard

And if we were, what exactly were those funds used to purchase? Our questions have gone unanswered. So, where do we go from here? First, we must collectively rethink our solutions when a device is difficult to procure due to cost and when health, safety, and mission success is on the line. Progress is underway through multiple channels and increasingly coordinated efforts such as the System Safety Working Groups (SSWGs), the Aircrew Systems Enabler Naval Aviation Requirements Group (ACS ENARG), FACTS, PMA-202 Aircrew System InService Support Center (ISSC) engagement and advocacy, as well as Small Business Innovation Research, or SBIRs. These working groups offer venues to voice top safety concerns for our communities, while the SBIR initiatives (in conjunction with NAVAIR) are working toward decreasing the price of the AMXDmax while simultaneously developing new and improved systems that address the litany of operational issues. Meanwhile, VAW-120 strives to continue the dialogue and leverage the aforementioned outlets to advocate for better solutions for all aircrew across its platforms. Last year, HEGH FACTS (inspired by the overarching symposium and with the help of our allies at PMA-202, ACCLOGWING, Aviation Survival Training Center (ASTC), Airborne Command & Control Logistics Weapons School (ACCLWS), and VAW/VRC Flight Surgeons and Fleet leadership) was able to bring to light our E-2/C-2 bio relief issues. We then began shaping a plan to signal demand for better bio relief and flight suit options. Through those discussions, ACCLOGWING was able to procure hundreds of Lady Js, GoGirl, and Piddle Paks for VAW-120 staff and students in 2020. Unlike in previous years, new check-ins are now

issued these devices from the beginning of their time in the squadron. Although not the final answer, this small step in UCD procurement for our FRS also supports the 2017 All T/M/S HAZREP’s recommendation that the issuing and training of bladder relief systems begins in the training pipeline. Aviators shouldn’t arrive in the Fleet untrained and illequipped for bio relief. The 2017 HAZREP and our E-2/C-2 symposium also addressed the cultural aspects and shared burden that FRSs and operational squadrons share with regard to tactical dehydration and UCD use. It addresses how device supply, availability, and training should be reinforced in every aviation command. The 2017 HAZREP also goes a step further in recommending that bio relief devices are issued as required ALSS at CNATRA prior to carrier qualification for aviators (pp. 9-10). One small recommendation VAW-120 made was to establish revised Aviation Safety Awareness Program (ASAP) questions to be completed post-flight addressing bio relief issues. We included questions about tactical dehydration, whether crewmembers had to vacate their seats in flight for bio relief, or if aircrew had to remove any survival gear/equipment in-flight for bio relief purposes. Although ASAP is not truly anonymous, the questions can cover both men and women and are a step toward data collection to signal demand and properly document unsafe conditions that help justify future funding for improved products. Additionally, VAW-120 sent aircrew to a Langley Air Force Base female fitment workshop in June 2019 that addressed flight suit fitment and bio relief devices. At the time, the companies Triton and Matech were awaiting the option to be awarded to work on new systems separate from the AMXDmax. Triton submitted a proposal

to an Air Force initiative established in 2017 designed to circumvent bureaucracy and engage new entrepreneurs in Air Force programs, and ISSC believed they could produce a functional product in six months if Triton was awarded the contract. Squadrons eagerly await follow-up information on the matter. Regardless, increased competition has been working to drive down the cost of existing and potential future devices—a win for aviators of all services that should be supported. Let’s go back to the topic of being heard. Related to our “#1” issue, and toilet humor notwithstanding, 2018 should not have been reported as the beginning of Naval Aviation’s bio relief initiative. There is a history of detailed evidence clearly demonstrating the demand for bio relief support and solidarity amongst aviators. Between the 2003 Approach article on the subject; the 2006 AMXD performance specification drafting; the 2008 PMA-202 AMXD starter kit purchase; a 2010 Deputy Director for Air Warfare release of “Requirements for Aircrew Endurance” outlining that bio relief systems will not require the removal of aircraft restraint systems; a 2015 SECNAV inquiry into bio relief; the 2017 All T/M/S HAZREP; 2018 and 2019 FACTS; and all the tales of pump and battery failures by aviators in theater…why must we bring this up again and why can’t we solve it now? This affects the aircrew of both genders across multiple platforms and we’ve been talking about it for years; therefore, we must call on the entire aviation community to get actively engaged in effecting real change and demand that our voice is heard. This change should include safe and effective bio relief options for everyone so that a normal human process is neither embarrassing nor humiliating and isn’t a barrier to the safe and successful execution of our missions.

Holy cow, that is one Peeee-lemma and I agree it must be fixed! The key is not to suffer in silence. Although the author mentioned HAZREPs, only two have been submitted in the last two decades, compared to the 25 submitted for flashlights in the last five years! NAVAIR uses HAZREPs to prioritize funding, so let’s get them workin!

THE

Voice out of By LT Abigail Khushf and LT Maurice Harris

NOWHERE I Today, we’re landing well before sunset and do not plan to fly into the clouds. If we experience Inadvertent Instrument Meteorological Conditions (IMC), we’ll hop onto our instruments, stabilize the aircraft and then try to get out of it the way we got in. If we can’t get out of it, we’ll squawk emergency, climb up, contact air traffic control (ATC) and pick up an approach into the home field. In the very unlikely event that both pilots get vertigo or disorientation, the crew chief will come up through the tunnel, turn on the magic and talk the pilot at controls back onto the gauges one axis at a time. As aviators, we brief this emergency every time we go flying. Pilots learn to recognize their symptoms and transition from a visual to an instrument scan. Throughout their utility syllabus, future utility aircrewmen learn to identify and assist pilots with vertigo. On a low visibility, hazy day in southern California, I launched out of NAS North Island as the co-pilot of a four-person crew on a search and rescue (SAR) training flight. We crossed the Coronado Bridge and turned

eastbound to begin our visual flight rules (VFR) navigation of local hospitals in the San Diego area. I coordinated with Lindbergh International Airport’s tower to enter their airspace for the start of our flight. The Helicopter Aircraft Commander (HAC) voiced up on inter-flight communication (ICS), “North Island is calling VFR, but the visibility looks pretty low right now. If we feel uncomfortable, we’ll just turn around back to the bay and conduct training in the dips.” Having recently flown in a similar haze, I replied, “It’s probably just the haze where you still have three miles of visibility.” We proceeded on our northbound hospital route through the city without issue and turned west at La Jolla. We crossed over the coastal ridges and immediately noticed that the visibility was much less over the water than it was over land. We felt comfortable flying north with the coast in sight, knowing from our weather briefing earlier that the haze was forecasted to burn off during our flight time. As we progressed northbound, visibility improved, but the ceilings steadily reduced. As we

U.S. Navy photo by Mass Communication Specialist 1st Class Christopher B. Janik

approached Dana Point, our crew discussed how the low cloud layer would impede our progress overland. We discussed 1,000-foot ceilings and three miles of visibility as the minimum weather that we would accept for our planned flight route to execute course rules. I brought up the Helicopter Emergency Medical Services tool (internet-based weather and radar tool) and looked at the nearby ceilings and visibility. I conveyed to the crew what I saw. It appeared that the low layer and reduced visibility were almost exclusively along the coast. If we proceeded three miles east of the shoreline, we would have what we needed to climb. We took a look at the fog surrounding Dana Point and discussed lower altitude alternatives to push east to clear the low layers and have the altitude required for the remainder of our route. We pulled out a VFR sectional as we turned south and looked at the coast for a good spot to push east. Referencing the chart, we found a valley that went east for several miles. When we approached, the visibility looked clear enough to see to the other side despite the ceiling.

“Level the nose.” I brought my nose to the horizon on the attitude indicator. I leveled the aircraft at 600 feet and 80 knots (KIAS). I was almost caged onto my instruments. The HAC told me to climb to 1,000 feet and steer a 240 heading. I didn’t ask why I just listened. I entered into a deliberate ascent and steered toward the assigned heading. The HAC flipped through navigation pages on the Mission Display and tuned up SoCal Approach and Long Rifle, the two nearby controlling agencies. She pulled up the table to type in “7700” and declared an emergency when she suddenly paused. She took a deep breath.

U.S. Navy photo by Mass Communication Specialist 3rd Class Nathan Burke

As we turned east, the HAC briefed the crew on the nearby mountain altitudes, why we chose this spot and the altitude and route that we would use to pick our way east. She concluded with, “if anyone feels uncomfortable, we will turn around and head back to conduct overwater training.” It seemed as though we were hitting each wicket. We made it over the beach line, and from there, we picked up the interstate that was to lead us through the valley. It looked like we had about three miles of visibility. At each point, it looked like we were going to make it past the fog bank. Over the interstate, she dropped a mark on top into our navigation system and said, “this will help us get back if we press into the valley and need to find our way back to the ocean.” About two miles into the valley, the visibility reduced, and we were forced to climb higher to remain at an appropriate altitude for populated areas. We started to see traces of clouds around us. We quickly determined that we could not proceed further and initiated a turn to the west. The HAC entered into a left-hand turn and, sitting left seat; I looked to clear the area. I noticed some rising terrain. “You’re clear left,” one of the crewmembers announced. Unsure if the crewmembers had seen the rising terrain and if we had clearance from it in the turn, I announced, “rising terrain on the left.”

The HAC called, “roger coming right.” She turned right, initiating an unintentional slight cyclic climb.One second later, we were in the clouds. The HAC immediately announced, “I have vertigo.” She passed me the controls, and the utility aircrew member positioned himself with a hand on each seat, hovering over the center console. During the control change, we inadvertently turned back to the left and came to a nose-high, left-wing down attitude. Through the chin bubble, I had a visual of some buildings on the ground. I knew that’s where I wanted to be: out of the clouds and at a lower altitude. Blind to the mountains around us and fighting my vertigo from the series of turns, I became fixated on those buildings.

“Watch your descent rate.” It was like the voice out of nowhere. I snapped out of my fixation and finally looked at my instruments. I was at approximately 900 feet per minute descent, coming through 500 feet above ground level (AGL). I brought in power and flipped the contingency power switch when I saw us approaching a torque limit. The HAC, still fighting her vertigo, turned on altitude hold -- something at least to maintain our altitude above the terrain.

“Level the wings.” I listened. I looked at my attitude indicator and leveled the wings.

“We just passed our mark on top. We are back over the water,” HAC said. With water beneath us, we discussed our options as a crew. We chose to begin a controlled descent to try and regain visual meteorological conditions (VMC) and set a hard deck of 500 feet. Still, at the controls, I initiated a stable 500 feet per minute rate of descent. We momentarily leveled off at 800 feet to reset our altitude warning systems for the new altitude. The crew members opened up the cabin door to look straight down and announced that we had blue water beneath us. I never looked up. “I am remaining on instruments,” I said as I initiated our descent down to 500 feet. At 600 feet, the HAC announced that she had visual reference and the coast in sight. We stabilized at 500 feet, and she took the controls. I remained fixated on my instruments for a moment more as we turned south toward the home field. Then I heard the voice of my crew chief. It was the same voice that had talked me onto my instrument scan and out of danger: “That was the most scared I’ve ever been in a helicopter. We’re headed home, right?” His voice was as steady as it had been for the entire three-minute emergency. “Yes, I’m declaring a safety of flight. We are returning to base (RTB),” responded the HAC. We train to understand the symptoms and necessary response for inadvertent IMC and vertigo. We brief procedures before every flight. Despite that, it is so easy to feel that it will never happen to us. On a flight full of haze and fog, we should have been on our guard instead of lulled into a false sense of security. No one in the aircraft expected to go inadvertent IMC, and I never believed that I would be caught in any flight where both pilots simultaneously experienced vertigo. Due to the training my crew chief received and his ability to talk me back onto the controls, we were able to survive this situation and come back home safely.

Safety Habit Patterns: Saving Lives with Muscle Memory By MAJ Matthew Stolzenberg

Photo by Sgt. Randall Clinton

Safety must be a value, mindset, and underlying principle for how the Navy and Marine Corps operate and accomplish the mission. Solid foundations in basic safety practices are the best way to instill safety as the undercurrent in a Sailor’s or Marine’s daily life. The establishment of safety habit patterns in every task will prevent aircraft damage, prevent injuries to personnel and save lives. Safety habit patterns are created through formal and informal processes. Throughout the training pipeline, students are fed procedures and practices that are codified in manuals, required reading pages and standard operating procedures (SOPs). These practices are inherently designed with safety in mind both for the individual and for the task itself, to ensure aircraft and equipment are safe to operate. By following the procedure, the individuals ensure they are safely executing duties. When they deviate from the manual or job guide, safety hazards are encountered, often with undesirable results. In Marine Aerial Refueler Transport Squadron (VMGR) 152, “follow the procedure” is the leadership mantra. Consistently, junior personnel are reminded to look up the process, follow the job guide and not skip steps. Reinforcement of formal safety habit patterns facilitates the adoption of a safety mindset among junior maintenance people, junior enlisted aircrews and new KC-130J copilots. These habit patterns are demonstrated through the everyday actions of individuals when they prevent bad situations from worsening. Two specific incidents come to mind: a tow bar failure during a towing evolution and an engine wash cart fire. In each case, the personnel involved acted swiftly with emergency action items, preventing injury and damage to aircraft. These examples stand out as positive proof that safety habit patterns avert catastrophic consequences. Informally, habit patterns become much more critical since they are habits that are not written and possibly not even passed down as techniques. Most informal habit patterns are simple,

everyday muscle memory actions that apply to how an individual accomplishes a routine task. An example of a good habit pattern is achieving all tools accounted for (ATAF) before each shift. One Sailor or Marine might go through their section’s tools in a certain way to ensure they have accounted for every tool, while another has a separate pattern for reaching ATAF. As long as they complete their process every time with the intended result, they have developed a safety habit pattern that will prevent mishaps due to a missing tool. It is a simple habit to develop, yet there is nothing written down about how to accomplish the task. Recently in VMGR-152, a bad habit pattern was identified, and subsequent guidance passed to ensure it was addressed. Informally, aircrew and maintainers alike would pass through the propeller arc on the KC-130J, and it became routine when an aircraft was in a no-power state. The issue with this habit is in the muscle memory it develops, resulting in someone inadvertently moving through the propeller arc while it is spinning. The consequence would be devastating and is detailed in mishap reports from different types, models and series (TMS) aircraft, most of which end with a fatality. The solution to this informal habit pattern was the establishment of a formal habit pattern. Per the commanding officer’s guidance, a read-and-initial page was created and distributed to all squadron shops requiring all personnel to walk around the propeller arc at all times, regardless of power state. Thus, when the propellers are spinning, muscle memory exists to circumvent disaster.

Safety habits do not all need to be formalized, but the importance of proper safety patterns must be taught from the beginning, reiterated, expanded upon and reconsidered throughout a Sailor or Marine’s career. Navy and Marine Corps flight and aviation maintenance students receive training and education through the “firehose” method with safety messages included at critical junctures. Instead, the development of safety habit patterns should be at the beginning of each training to instill safety as a core value and principle. Establishing a foundational safety mindset will enable sound future safety habit patterns that develop and promulgate through the fleet. Educating the Navy in the safety mindset does not stop with training commands. As individuals progress in their career safety habits, patterns need to be spotchecked as service members move from student to worker and from worker to leader. Safety habits need to be retaught to leaders as they become instructors. The instructors need to be evaluated and debriefed on how they are teaching safety habit patterns to improve and standardize instruction. Finally, best practices need to be gathered and injected back at the bottom of the cycle to complete a safety feedback loop. It is incumbent upon all individuals to develop safety habit patterns, with a specific onus on leaders identifying and correcting poor or dangerous habit patterns. Creating a positive, safe muscle memory habit pattern will prevent injuries and save lives.

Photo by Sgt. Randall Clinton2

r e d n U ure s s e r P By LT Jon Malycke (VX-23) and LT Maggie Johnson (NTWL) Photo by Cpl. Darien Bjorndal

We often hear about Physiological Events (PE) in Naval Aviation but think it will never happen to us. It will be someone else down the flight line. That was the mindset I had when flying back from a benign instrument round-robin when the environmental control system (ECS) in my F/A-18 malfunctioned. With five minutes to land, and descending through 5,000 feet, the cockpit defog lever suddenly went full blast by itself and filled the cockpit with the loud blast of engine bleed air. The defog lever had to be physically wrestled back to the neutral position, and once things quieted down, my Weapons System Officer (WSO) and I saw the cabin pressure gauge was at 2,000 feet below sea level, obviously well outside normal pressure. We confirmed the cockpit had over-pressurized by comparing the pressure sensor on our watches and realized we needed to get on deck. We continued the approach, trapped and fully stopped. On deck, the cockpit was still overpressurized, so we equalized it to ambient and shut down the aircraft. Almost immediately, both of us started to feel light-headed. Didn’t we always feel off after

a flight, or did I not get enough sleep the last few nights? I tried to reason it out for a while before concluding there was an issue. We both went to medical to see the flight surgeon and started to receive treatment.

cockpit over-pressure, my symptoms started to go away, and after ten days, the symptoms were completely gone. My WSO had the same result. By the 14th day, we were both medically cleared and on the flight schedule again.

Over the next few days, the light-headedness didn’t go away and turned into a constant mental fog. I would describe it as if I were buzzed with a couple of beers for the entire day. This was not my usual post-flight fatigue, and it did not go away. We were both taken off the flight schedule and discussed with the Dive Medical Officer (DMO) the pros and cons of going to the hyperbaric chamber. Five days after the incident, after multiple sessions breathing high concentrations of oxygen, with little symptom resolution, I decided to receive pressure treatment. My WSO did not receive hyperbaric treatment. Seven days after the

What struck me the most during the entire event was how little I was prepared to identify the pressure-related symptoms. We all trained on the reduced oxygen breathing device (ROBD) and are very familiar with the standard hypoxia symptoms: flush face, tingly fingers and such. But I was not aware there was an entirely different set of symptoms for pressure-related incidents. They are written clearly into our pocket checklists (PCL) on page E67: vertigo, ear pain and feelings of being squeezed. It is far from a complete list, but the point is, we are way too quick to call a PE hypoxia or decompression sickness (DCS).

While these do occur, they represent only a small number of PEs that aviators are facing. There is a new line of thinking. The Root Cause Corrective Action (RCCA) team and the Aeromedical Action Team (AMAT) at the Bureau of Medicine and Surgery (BUMED) are connecting pressure-related events to possible brain inflammation, similar to a concussion or traumatic brain injury (TBI). The injury’s exact cause is unknown, but the resulting symptoms of this newly-termed acquired brain injury are similar to concussion or TBI: headache, dizziness, excessive fatigue and memory loss. These have been observed and documented in pressure-related incidents in Naval Aviation over the last few years.

various injuries. Do not use the DCS catch-all to capture pressure events when conditions do not meet DCS possibility. Call it what you know. Do not report what it is “like,” because wrong diagnoses can lead to delays in treatment and prolonged injuries. If you know there were both an aircraft malfunction and associated symptoms, then it is a PE. If the aircraft functioned correctly, but an aviator reports symptoms, it is a physiological episode (PHYSEP). The similarity of these terms has confused the aviation community, and it is important to understand that each is a distinct term with different implications. Most of the physiological occurrences are not black and white when it comes to symptoms or aircraft integrity, and the terms are frustratingly similar. When in doubt, instead of wrestling with deciding whether something is a PE or a PHYSEP, ask an expert or use plain language.

primarily used to reduce the size and amount of air bubbles to treat AGE or DCS. While hyperbaric therapy can reduce symptoms due to inflammation, experts believe the best medicine is to let the brain rest when dealing with acquired brain conditions. The aeromedical community is leaning away from hyperbaric therapy, focusing on interdisciplinary care and enhanced case management for brain injuries through the regional care centers. Inpatient evaluation and care are also available through the VA Polytrauma Centers (BUMED Physiological Event Clinical Practice Guideline, 2020).

Despite the confusion of the PE versus PHYSEP, squadrons need to be more specific in initial notification emails and safety reports. Using a carrier landing analogy, here are examples of good and poor event descriptions:

The good news is that overall PE rates have declined by 74%, and pressure-related PE rates have declined by 84% since the peak in November 2017 due to numerous corrective actions (NAE PE Weekly Brief, PE Rates: Peak vs. Today, 2020). The Hornet Health Assessment and Readiness Tool (HLART) flags ECS concerns for maintenance action before failure or a PE. We should expect changes in our procedures and training as findings from the RCCA Team are further implemented.

Furthermore, the Navy Experimental Dive Unit (NEDU) technical report showed the probability of low flight level DCS (below 18,000 feet) as unlikely (around .00001% chance) using pressure swings up to 0.8 psi per second, and no bubble formation in the lungs to account for arterial gas embolisms (AGE) (Doggett, Hickey, & Jewell, 2019). Ongoing research continues in this field to better understand the acute and cumulative pressure injuries to the brain and how to treat them best.

• OK: F/A-18E PE: Pilot experienced lightheadedness following an over-pressurization event. • Fair: E/A-18G: EWO experienced physiological symptoms before landing. • No Grade: F/A-18F: WSO experienced hypoxia-like symptoms. • Bottom line: We need to stop using the terms “hypoxia-like” and “DCS-like.” The RCCA team and years of research have shown, most of the time, we do not see true hypoxia or DCS. Continuing to use these terms when they don’t apply can be detrimental.

The F/A-18 is a great platform, one of the best in the world, but it is not perfect. Valves get stuck and parts get worn. You’re going to have an issue one day in the aircraft that you don’t plan for and maybe unexpectedly find yourself “under pressure.” The best way to be ready for it is to know your procedures and stay educated on how various pressure-related and physiological symptoms can manifest. Once you know the symptoms, you and your flight surgeon can more accurately diagnose any condition and treat it effectively to get you back in the aircraft.

The key for aviators to remember is that in case of pressure-related incidents, don’t jump to conclusions. There are multiple possible diagnoses, and maybe even combinations of

As I look back and have talked to the experts, the chamber treatment was likely not necessary for me. Hyperbaric therapy is

NSC Editorial Note: Findings released earlier this year by the F/A-18 Root Cause and Corrective Action (RCCA) team did not identify a single causal factor for PEs, but rather noted that PEs are frequently multifactorial and involve the complex relationship between aircrew, their flight gear and the aircraft that they are flying. Substantial research into the PE phenomena has allowed us to separate PEs into two distinct categories (pressure and non-pressure) based on the various symptoms that manifest following the event. As of September 2020, F/A-18 PE rates are down 86% and 74% for pressure and non-pressurerelated PEs, respectively, since their peak in Fall 2017. Predictive maintenance provided by the Hornet Health Assessment and Readiness Tool (HhART), in addition to aircraft ECS software upgrades and improvements to aircraft parts, have helped with the reduction in pressurerelated PEs. With respect to non-pressure PEs, it was determined that the On-Board Oxygen Generating System is an extremely robust system that provides contaminantfree concentrated oxygen. Additionally, it was discovered that there are other breathing anomalies that can lead to hypocapnia, which present similar symptoms as what we have commonly referred to as hypoxia in the past.

The Navy-Marine Corps Public Health Center analyzed 266 PEs from June 2016 through May 2019. Of these, 54% were pressurerelated.Symptoms range from headache (most common at 31%) to fatigue, dizziness, pain, and sensory alteration (Health Analysis Department, Navy and Marine Corps Public Health Center, 2020). AMAT noted, of these pressure-related events, few if any fit their specific criteria for DCS.

Photo by Cpl. Darien Bjorndal

Fumes in the Stack

By LT Christopher Robey

IT WAS A DARK NIGHT OVER THE CORAL SEA OFF THE EAST COAST OF AUSTRALIA. COMMAND AND CONTROL SQUADRON (VAW) 125, ATTACHED TO CARRIER AIR WING (CVW) 5 ABOARD USS RONALD REAGAN (CVN 76), LAUNCHED AN E-2D CREW OF FIVE AT 5:50 P.M. FOR AN AIRBORNE EARLY WARNING (AEW) MISSION DUE TO RETURN AT 8:15 P.M.

First, we checked in with the marshal. After receiving our holding instructions, I nosed over, descended to our assigned holding altitude in the marshal stack, and settled in for a standard night carrier (CV) recovery. So we thought. During the descent, I increased the cockpit temperature to avoid humidity fogging from the vents. The air conditioning system was in “auto” mode from the previous flight and performed satisfactorily throughout the mission. Normally, I fly with the system in manual control, and I elected to keep it operating in auto with no issues thus far.

...

Photo by Nathan Burke

Established at 13,000 feet in the marshal stack, the co-pilot suddenly asked the crew a question no one ever wants to hear. “Do you smell that?” The crew paused, then unanimously responded, “Yes.” The smell was unusual and difficult to describe. There was no trace of fuel fumes, but more of an electrical smell. The co-pilot immediately recognized the need to execute the “fire, smoke or fumes” emergency procedure (EP), and directed everyone to don their oxygen masks. We performed an interphone communication system (ICS)

check and began to breathe from the on-board oxygen generation system (OBOGS). The co-pilot directed the crew to turn off the avionics cooling system (Vapor Cycle (VC)) in an attempt to isolate interlocked electrical systems. Shortly after turning the VC off, the co-pilot dropped his mask momentarily to see if the fumes were still present. They were. The radar officer (RO) went forward into the forward equipment compartment (FEC) with the walk-around oxygen bottle to investigate a possible source of the fumes. The RO’s assessment in the FEC, which houses the

bulk of the E-2D electrical components, provided critical information to the crew to isolate the affected equipment better. Upfront, the engines and propellers did not show any signs of malfunction that could potentially introduce fumes into the aircraft. The RO connected to the auxiliary ICS (AUX ICS) system in the FEC and informed us that all systems appeared to be operating normally. The RO returned to his seat as we continued the EP. With the engines and FEC ruled out as a potential source of fire or smoke, the next logical source was the environmental system. Mid-trouble-shooting, marshal assigned new holding instructions and directed us to climb to 15,000 feet. Adding power, we began to climb. The co-pilot removed his mask again to see if the fumes were still present. He immediately donned his mask again and informed the crew that the fumes were getting stronger and coming from the vents. The situation was getting worse, but we now had a better idea of the source. The next step of the “fire, smoke or fumes” EP states: “if the source cannot be immediately isolated, generator switches off.” Before securing generators, however, consideration had to be given to determine the presence of fuel vapors. The generators should not be turned on or off in the presence of fuel fumes or fuel vapors. Not being positive of the fume source and knowing a night-time CV arrestment was our only landing option factored heavily into the decision to leave the generators online. The fourth step of the EP is “Personnel Air Cond switch - As Required.” With everyone breathing safely on OBOGS, we secured the personnel air conditioning switch. Cabin pressurization was quickly lost, so we needed to descend. The co-pilot declared an emergency, squawked 7700, and requested an immediate descent for short vectors to final. For the last time, the co-pilot dropped his mask and noted the fumes were subsiding. Step four seemed to be working. At level 1,200 feet and 20 miles from the deck, the tower contacted us to see if we required a shut down in the wires. We elected to taxi clear of the landing area (LA) after the arrestment but wanted the option to expedite engine shut-downs once clear. Shortly after intercepting final bearing, the landing signals officers (LSO) reached out to confirm no one was experiencing any physiological symptoms, no visual obscurations in the cockpit, and to give us

U.S. Navy photo by Mass Communication Specialist 2nd Class Jesse L. Gonzalez

the “warm and fuzzy” that they would safely get us aboard. We performed one final selfassessment as a crew and informed the LSOs that we were fit to continue the approach. The approach and standard night arrestment were uneventful. We expedited our taxi out of the LA and secured the motors normally. Dropping our masks, we noted the fumes were almost non-existent. We were safe on deck. We learned many lessons from this event worthy of discussion that may be analyzed using the crew resource management (CRM) critical skills: • All individual inputs were heard and valued regardless of rank in the plane that evening. • The communication flowed efficiently during EP execution within the crew as well as externally to the aircraft. In other words, we handled the EP on our own as a crew and only allowed input from outside sources on our terms. • We communicated our intentions directly with what we needed and when. • The decision-making and leadership to declare an emergency to expedite recovery were not only appropriate given the circumstance, but also timely. • The aircraft commander’s situational awareness saved the plane from an undesired state and ultimately resulted in a safe landing. These decisions were made through years of experience within the dynamic aircraft carrier environment. Experience, however, must and should be challenged to provide accurate checks and balances to a crew.

Each crew member was assertive, but especially the mission commander, who helped maintain checklist integrity as the crew was trouble-shooting. No question is insignificant when it relates to the safety of flight. Even one as simple as “do you smell that?”; it can immediately draw attention to a developing situation. The aircraft commander and mission commander conducted quick missionanalysis, adapted and flexed the crew mindset from mission to flight safety. It is paramount to have the crew on the same page, literally and figuratively. A multi-crew platform necessitates reliance on one another and highlights the need for each crewmember to know their roles. In our case, utilizing good CRM allowed us to manage the emergency that evening with each crewmember contributing effectively. It was later determined that the fumes were due to a cooling turbine failure in the air cycle refrigeration unit (the air conditioning). The source of fumes entering the plane was through environmental ducting. Securing power to the air conditioning system, step four of our checklist was vital. The safety of flight is paramount and the priority. Adherence to procedures demands CRM discipline. CRM also provides a framework for aircrew to safely and sequentially step through an EP. If we take the time to analyze case studies, hazard reports, or lessons learned, it becomes apparent how vital CRM is. Keep that in mind should you find fumes in your stack.

It is a cliché that aviators hear and read daily. In some way, shape or form, the cliché is reworked into safety briefs and every squadron commanders’ guidance for flight and maintenance operations. It is a cliché that any aviator can rationalize and defend. We, of course, all want to be brilliant at the basic elements of our job. Whether it is landing in a confined area on schedule or on a ship at sea, serving as a stable platform for aerial refueling or prosecuting a ground target in close proximity to friendly ground forces, each aviator has a basic assigned mission set. Before that individual mission set, we have to be brilliant at the most basic task of safely flying an aircraft from point A to point B. If we cannot perform these basic tasks, be it our assigned mission skills or safely operating an aircraft, there is no reason for the Navy and Marine Corps to maintain a fleet of multimillion dollar aircraft. If we cannot be brilliant at the basics, our planes are nothing more than well-maintained paperweights. Flying them would be a hazard to ourselves as well as the Marines and Sailors whom we support or depend upon us for support. Brilliance in the basics is a matter of professional pride. It also ensures that in a dangerous job, everyone returns home at the end of the day. Brilliance in the basics is a matter of life and death. But, there is danger with such a cliché. Like many clichés, we will eventually tune it out if heard too often. Many of us have played in our minds a kind of cliché bingo during safety briefs, counting how many times we hear a briefer say, “take care of your Sailors and Marines,” “watch out for one another,” “there is no such thing as a stupid question,” “everyone is a safety officer” or “brilliance in the basics.” In the minds of most, the cliché morphs from a trite pearl of truth into a harsh judgment over a well-intentioned individual. If we allow our minds to wander too, we set ourselves up for something worse. Such clichés will become a realized reality following a close call. Just such a close call occurred in January 2020, in the Camp Lejeune Range Complex.

Brilliance in the Basics

By Capt Sean Dzierzanowski, USMC

U.S. Navy Photo by Mass Communication Specialist 2nd Class Jakoeb Vandahlen

A pre-End of Evening Nautical Twilight (EENT) launch into low light The flight schedule had us on for low light level (LLL) division confined area landings (CAL) and low altitude tactics (LAT). Each aircraft commander within the three-ship division was a night systems instructor (NSI). Each copilot and most of the crew chiefs were scheduled to receive initial codes. Like any initial night systems event, the brief focused on various LLL considerations such as the expected illumination, the fidelity of our various sensors in our night vision goggles (NVGs) to our forward-looking infrared (FLIR), and the various expected difficulties that a new student will experience when learning to fly by dash into a confined area in the dark. In an ideal world, we would have taken off in darkness following end of evening EENT. We would have conducted a logical training flow from Marine Corps Air Station New River, N.C., to the briefed LAT route and then to the CAL site where we would fly pattern after pattern until bingo fuel state and every copilot demonstrated proficiency in the required introductory skills. However, we don’t live in a perfect world. Like any busy airspace with a few constricted training areas, range reservations on the LAT route and in the CAL sites drove us to a 5:30 p.m. local time take off, 50 minutes before EENT. In addition, the takeoff times and reservations drove us toward 30 minutes of CALs prior to commencing LAT. With the brief complete and a low show plan discussed with the three crews, in anticipation of the expected poor weather, we walked to the planes. Never mind that I, the division leader, did not address that we would be taking off in a period of relative brightness.

The First Landing Taxiing out, I realized that it was still very bright, as is expected during “pinky time,” that period after sunset and before EENT. Crossing the hold short after receiving takeoff clearance, I announced to the crew over our interphone communications system (ICS) that I would not be goggled for takeoff. Indeed, had I been goggled, I am sure the poor image quality and the sun shining in the goggles would have presented a greater hazard than flying unaided. My copilot and senior crew chief acknowledged the decision to take off de-goggled and said that they would be degoggled as well. The weather on takeoff was, as forecast, poor. A scattered layer at 1,500 feet (above ground level - AGL), while not prohibitive, led us to descend early to avoid the potential for inadvertent instrument meteorological conditions. The winds along course were erratic, fluctuating between eight knots out of the west to five knots out of the south within 10 minutes.

Commanders should have realized that a post-sunset but pre-EENT landing from east to west would have us staring at a setting sun. While a landing into the sun is common in naval aviation, it is a threat that can increase the likelihood of a scan breakdown and must be addressed in planning. A better analysis of this threat could have mitigated our close call.

U.S. Navy photo by Mass Communication Specialist 3rd Class Katie Cox

In addition, an Unmanned Aerial System (UAS) operating out of a landing zone (LZ) approximately three miles west of our intended area activated a restricted operating zone (ROZ) warning there. I figured that an east-to-west ingress was still optimal. Even if a crosswind shifted to a tailwind, we would still be within limits. Besides, the long axis north to south geometry of the zone made a three-ship landing into the zone from the east or west preferable. I was at the controls for the first landing to ensure that the landing points and planned pattern would be safe for a junior copilot. Of course, as we turned to base from our left downwind, we turned directly into a setting sun. I couldn’t see the zone, only a large black shadow where the zone should have been. I flipped my goggles down, thinking, at the moment, that perhaps I could see the area better. As I should have known, all I could still see was a washed-out, blinding image. While flipping them up, I saw the top of a pine tree on my FLIR. At the same time, my crew chief on the ramp directed “no lower” over ICS. At 0.5 nautical miles (nm) from the zone, our radar altimeter read us at 90-100 feet AGL. This is well lower and slower than our normal profile, even given the general advice to new division leads to be a “little lower” to make the profile easier for dash two and three. I jammed my thrust control lever all the way past the soft stop. From our perspective, inside the plane, we missed the tree. Barely. The dash two crew chiefs mentioned in the post-flight debrief that we were very low and that our right main landing gear almost brushed the top of a tree. After coming close to the tree, we regained our profile and landed the aircraft in the zone. A post-landing inspection by the crew chief revealed no apparent damage to the plane. We debriefed the landing and the inadequate approach and continued training as the sun set.

Lessons Learned From a crew resource management (CRM) perspective, the greatest failure in this situation was a basic lack of situational awareness. A flight of three NSI Aircraft

We could have modified the training profile, perhaps doing some practice instrument approaches as singles until after EENT. Waiting until the sun fully set would have provided an optimal training environment for the initial pilot and crew chief students. A discussion with operations and maintenance the day prior could have led to a takeoff time more conducive to our LAT route reservations and our initial students’ training. We could have tried for another zone in the Camp Lejeune range complex. With some coordination from range control, we could have conducted a west to east approach, skirting the eastern edge of the UAS ROZ. At the end of the day, there were options. We were only limited by our own imaginations. But, the root cause was a lack of situational awareness from myself, the designated division lead and a squadron NSI. As I ponder the event and the safety briefs and posters that dot squadron walls, I can think of a few clichés. Paramount, in my mind, is the idea of brilliance in the basics. As fleet aviators, our mission sets drive us to focus upon a variety of complex considerations: ordnance to target matching; assault support landing tables; a myriad of products and planning aids evaluating weather, topographic and illumination levels; various standard operating procedures; and objective area mechanics. All of these factors are layers of complexity we place upon the basic imperative of flight – flying safely from A to B. We should never allow complexity to distract us from flying our aircraft. We must be, first and foremost, aviators brilliant on the basics. We should never forget the most basic rudiments of flight planning, such as knowing where the sun is in relation to your pattern and understanding potential threats to a safe flight. On leadership and individual levels, we should also consider how we convey information. We should ask ourselves, “Did I mindlessly sew together clichés and buzzwords during that safety brief or provide information useful?” “Can I use the experience to be brilliant in the basics?” There are so many things that are deadly in naval aviation. Some are out of your control. However, a sound grounding in the basics of flight planning can mitigate many threats that can kill you. I am offering my story as an elongated defense of a cliché and an appeal for all Naval aviators to be brilliant in the basics.

I’LL TAKE A RAIN CHECK By LT Thomas Sewell On a rainy, overcast morning at Naval Air Station Oceana, it was time to get our jets out to the west coast for deployment. We had a little slop in the timeline, so we weren’t going to make a bad decision with the weather, but we needed to get the jets out of Virginia. What could go wrong?

Photo by Seaman Andrew Schneider

We had ten jets to fly off that morning. The majority of our maintainers, plane captains, and line personnel had already left on earlier Naval Air Logisitcs Office (NALO) flights. It was a tall order to have 10 Naval Aviation Training and Operating Procedures Standardization Manual (NATOPS) ready jets quickly and

properly launched. We conducted a standard NATOPS brief, got ourselves a Dash-1, and made sure we were legal to take off in weather that was down to minimums. It was not a day you would want to shoot a to-minimums approach, but then one never expects to turn around immediately and land back at home field. After we briefed, we decided to wait about a half-hour to see what the weather was going to do and hopefully let some of the lower layers move away from the field. Most of us elected to run our bags out to the jets to avoid carrying them around when we were in our flight gear later. It was still raining when I took my bags out, and the crew of maintainers that was going to launch me was huddled under

I talked to the plane captain (PC) under the LEX and hopped up the ladder for an uneventful startup. The PC who was launching me was supervising a PC under instruction, and there were a few non-standard hand signals that were corrected, but nothing that affected the launch. I got started up, taxied out and watched my flight lead disappear in a cloud of water as he took off in front of me. As I was joining up, I noticed in the corner of my left eye that my gun bay door had come completely open as I took off! I was able to see the lower 1/3 of the door peeking up over the nose just in front of the canopy bough. I immediately knew what had happened: I didn’t go back to all the doors and panels to make sure that they had all been latched down properly before I got into the jet. I had to turn around. The door could potentially come off and go down the left intake. I slowed down as much as I could, communicated with my flight lead that I had to go back to Oceana, and started to adjust gross weight once I had been vectored over the Atlantic. There wasn’t much more I could do except slow down and land, so I called back to base that I was returning with the gun bay door open, but that everything else was normal. I did not declare an emergency, but the decision was in the back of my mind, in case the door came off or I had other indications. The most uncomfortable part of the whole scenario was the PAR to minimums, where I broke out right at 200 feet and then had to stop on a runway where I just saw several spots of standing water minutes before. The approach and landing occurred without incident. I taxied back, got checked out by maintenance and QA, and was cleared to continue the flight to San Diego.

Photo by Seaman Andrew Schneider

the leading edge extension (LEX) to stay dry. All the panels were hanging down instead of being propped open to keep the avionics bays dry. We quickly threw my bags in the jet, and I scurried back to the hangar to stay out of the rain. Up until now, nothing was apparently out of the ordinary, but things were assuredly non-standard. When it was finally time to walk to the jets, it was still raining, and we felt a little rushed to get airborne to start heading to San Diego. We wanted to land before it got dark. I was flying with just one other Junior Officer (JO), and we were excited to be our two-ship of JOs on a cross-country together out to San Diego. There wasn’t anything exotic to preflight on the jet—just a single centerline tank—and it was a quick pre-flight as I conducted the walk-around.

I relied on other people to do their jobs so often that I shed responsibility as the pilot in command in order to save a few extra seconds and stay dry.

So how did this all happen? Ultimately, it was my responsibility to conduct a proper and thorough NATOPS pre-flight, which includes checking the fasteners on the doors before climbing in the jet. I took it for granted that the maintainers always close the doors, and if there had ever been any problems, they would usually be caught on final checks. I should have taken the extra 30 seconds to walk around the jet one last time to make sure it was good to go. It was raining, I had a PC under instruction, the clouds were low, I had made more than one trip to the jet, doors had been closed and reopened, we were thinking about deployment, we had a skeleton crew strung out across ten jets and we had already been delayed. Each one of these factors should have been considered, and the most effective step of mitigation would have been to be thorough in my pre-flight. I relied on other people to do their jobs so often that I shed responsibility as the pilot in command in order to save a few extra seconds and stay dry. That should never be the answer. It is our responsibility to ensure that we are following the proper procedures, most of which are written in blood, to remain safe in an inherently dangerous job. This time it was merely a door coming open, and that was the end of the story. The next time, I might not be so lucky. What if the door had come off and FODed out the left engine? Would I have had to adjust fuel to stop on a soaking wet runway and then I never broke out? What then? I had sacrificed a few seconds in my pre-flight routine but could have sacrificed so much more. I jeopardized an engine, the aircraft, people in their houses below me, and potentially my own life to stay dry. In this case, luck prevailed, but it could have ended in tragedy. Whenever there is a doubt in your mind, there is no doubt—take the extra time to be able to keep doing the best job you’ve ever had.

Merging with Deployment from Below the “Tactical Hard Deck” By LT Charles Kennedy, VFA-115

A word often used in relation to the COVID-19 pandemic is “unprecedented.” We, in the United States Navy, are generally pretty good at meeting unprecedented challenges head-on. However, mitigating the unprecedented safely requires a deliberate approach to risk management. In the lead-up to our 2020 deployment, the “TALONS” of Strike Fighter Squadron (VFA) 115 and the rest of the “BADMAN” team of Carrier Air Wing (CVW) 5, took on the unprecedented challenge of deploying amidst a global pandemic, which required coordinated measures to ensure

Photo by Petty Officer 3rd Class Christopher Gaines

personnel remained healthy without sacrificing our flight proficiency while taking the step to merge with the rest of the strike group. The Navy’s Operational Risk Management (ORM) risk assessment matrix compares the relative probability and relative severity of a risk. Because COVID-19 posed significant known and unknown risk, deploying with insufficient mitigating measures in place would mean a higher risk to mission. A phased Restriction of MovementSequestration (ROM-S) operation

paved the path towards deploying COVID-free. In conjunction with testing, ongoing cleanliness, social distancing, and personal protective equipment such as face masks, these measures help reduce the risk of a shipboard COVID-19 infection. However, restriction of movement posed a challenge to maintaining our flight proficiency leading up to deployment. In 2013, the Navy defined 11 flight hours per month, per pilot as the “tactical hard deck.” Below this required amount of flight hours, historical data revealed that the mishap rate increased significantly.

ROM posed a challenge to meet this benchmark of 11 flight hours. ROM also challenged our aircraft maintainers’ proficiency, who have the highly specialized and technical job of maintaining our advanced aircraft. We, the “TALONS” of VFA-115, routinely operate in support of a free and open IndoPacific, as a part of U.S. Navy’s Forward Deployed Naval Forces (FDNF). Flying the F/A-18E Super Hornet, our squadron comprises about 230 personnel and is forward-deployed to Marine Corps Air Station (MCAS) Iwakuni, Japan and we embark aboard the USS Ronald Reagan (CVN 76). Part of the phased ROM Squadron personnel were divided into “waves” to help build a “bubble of health,” which could be consolidated later on aboard the ship. Each wave comprised key personnel to maintain and support mission goals throughout phased ROM and embarkation. ROM marked the beginning of the deployment, allowing some squadron personnel to continue maintenance and flight operations while others were building the “bubble of health,” helping manage the risk to loss of flight proficiency. From a flying safety perspective, FDNF squadrons maintain a higher operational tempo than non-FDNF squadrons. This contributes to a higher overall level of experience, which helped offset any risk to flight proficiency. Once ROM and testing were complete, our next challenge was to move our force to conduct Field Carrier Landing Practice (FCLP) prior to embarking the ship for underway operations. Getting our pilots and aircraft safely back into the air while continuing to minimize the risk of infection was a different challenge that required a more deliberate approach to risk management. The aircraft were ready for fly-off, and they

were sanitized once their Daily Turn Around (DTA) inspections were complete. This was done both actively, with disinfectant spray, and passively letting any possible contaminant age off. Ensuring the pilots were ready for flyoff posed a more significant challenge. Having been out of the cockpit for more than 14 days, everyone was required to complete Naval Air Training and Operating Procedures Standardization (NATOPS)mandated Immediate Action Exams (IAE). To help overcome this challenge imposed by COVID-19, we incorporated digital copies of the exam to meet the requirement. Briefing posed a challenge as well. While kneeboard cards and digital media were able to be prepared sufficiently long enough ahead of time as to be sanitized prior to walking, weather briefs and Notices-ToAirmen (NOTAMs) needed to be up-to-date and therefore were procured electronically. Because of the early morning departure, a flight brief was conducted via video teleconference the night before. From a maintenance perspective, Aircraft Discrepancy Books (ADB) for each aircraft were prepared and e-mailed to the respective pilots for their review the night prior. Aircraft were signed for on paper, with everyone involved wearing the Personal Protective Equipment (PPE) of gloves and face coverings. Upon walking to the jet, Plane Captains (PCs) wore both flight line and COVID-mitigating PPE. They maintained social distance while conducting their preflight brief and pins check with pilots. Pilots wore masks and gloves until they were situated in the presanitized cockpit. While we were able to take many steps to mitigate the risks of infection, we still had the challenge of pilot proficiency. At the time of the fly-off, on average, our pilots had 4.5 hours of flying time in the last month

and 10.3 hours per month in the last two months. On average, second-wave pilots had 10.9 hours per month over the three months preceding the fly-off. Squadron wide, this corresponded to a 21% and 26% decrease in monthly flight hours in March and April, respectively. With so many essential skills in aviation being perishable, NATOPS is good at specifying currency minimums for aircrew. However, we found that there were not similar currency requirements for our maintenance department. Our maintenance department could essentially do no aircraft maintenance work while in PDS and be fully qualified to do aircraft maintenance and release aircraft safe-for-flight once they arrive in Iwo To, the Japanese Volcano Islands. We also benefited from our Sailors’ depth of qualifications. Rarely did we have only one person qualified to do a specific task. Maintainer proficiency degradation was also mitigated by spreading experienced and qualified maintenance personnel among the various waves, and by being upfront about the risks of executing a full flight schedule after being out of it for nearly a month. FCLPs were only the beginning of increasing our flight proficiency on deployment. We have mitigated risks to avoid major incidents thus far, even as we quickly progress through the crawl-walk-run spectrum of operational tempo as we rebuild proficiency. In June and July, VFA-115 not only met but exceeded its 2019 level of flying, increasing flight hours by 24% and 28%, respectively. Continuing this positive trend will take continued effort and safety awareness from everyone on the team. It took a lot of time, effort, and cost to mitigate these risks and get us underway, but we have already done a lot to further our mission of reassuring our allies and giving our adversaries pause. In early July, the Nimitz and Ronald Reagan strike groups conducted several exercises and operations in the South China Sea to strengthen warfighting readiness and proficiency in an all-domain environment. Later in the month, we executed a trilateral exercise with Japan Maritime Self-Defense Force (JMSDF) and Australian Defense Force (ADF) in the Philippine Sea. While many involved were skeptical about the strike group’s ability to safely execute this aggressive COVID-mitigation plan and transition directly to a high operational-tempo deployment, the success of our collective experience and safety awareness has allowed us to exercise operational concepts and demonstrate to ourselves and others that we, in the U.S. Navy, can be far more capable and flexible than even we realize.

Figure 1: Percent Change Year-Over-Year in VFA-115 Flight Hours from 2019 to 2020

Photo by Joshua P Card

The Hose Must By LCDR Joe Waurio

The Naval Air Training and Operating Procedures Standardization Manual (NATOPS) states that no manual can cover every situation. Strike Fighter Squadron (VFA) 11, the “Red Rippers,” encountered just such a situation, and that led to an F/A-18F being craned off USS Harry S. Truman (CVN 75). Aerial refueling, affectionately known as “tanking,” is a highly visible and necessary mission for any carrier air wing. Tanker pilots are usually senior aircrew that could include cruiseexperienced junior officers, department heads, command leadership, or air wing leadership. F/A-18E/F Super Hornets typically are fitted with an aerial refueling store (ARS) to fuel other Super Hornets, E/A-18G Growlers, and E-2D Advanced Hawkeyes. A tanker-configured Super Hornet has an ARS on its

centerline station, which includes a ram air turbine (RAT) on the front and a basket attached to a hose on the aft section of the pod. The airflow generated by the aircraft turns the RAT, which provides power to extend or retract the hose and basket. A receiving aircraft utilizes a refueling probe to attach their aircraft to the basket and receive fuel. When refueling is complete, the tanker will retract the hose with the basket and subsequently turn off the RAT.

On the day of the mishap, the ship and Carrier Air Wing (CVW) 1 were in the middle of a Composite Training Unit Exercise (COMPTUEX). The weather was beautiful and event three on the day’s air plan had VFA-11 launching a mission tanker to support CVW-1 assets. One of those assets was assigned to our sister squadron, VFA-136, the “Knighthawks.” Before the event brief and flight, the VFA-11 aircrew coordinated with each squadron that was scheduled to receive fuel. All subsequent briefs were executed by NATOPS and CVW-1’s standard operating procedures (SOP). Over the previous year and a half, VFA-11 and the crew of Truman had developed a professional and seamless relationship through two deployments and work-up cycles. Each aircraft in the event taxied to the catapult and launched off Truman without incident. As the mission tanker, Ripper 103 launched and climbed to 10,000 feet overhead. Knighthawk 307 also launched and executed a standard rendezvous with the tanker in accordance with SOP. After powering the RAT and extending the hose, Knighthawk 307 was cleared into the basket by the pilot in Ripper 103. After only receiving 75 pounds of fuel, the ARS basket unexpectedly separated from the hose and remained connected to the refueling probe on Knighthawk 307, which immediately executed emergency breakaway procedures by retarding the throttles to idle, allowing the aircraft to drift aft of the tanker to avoid any further damage.

Aircrew in both aircraft began troubleshooting within their respective cockpits and with the primary flight (Pri Fly) representative. The Pri Fly representative, stationed in the tower of Truman, was an F/A-18E/F NATOPS qualified aircrew. Their prime responsibility is to aide aircrew during an emergency or non-standard procedures, in addition to being a communication relay between aircrew, squadron personnel and aircraft carrier leadership. After troubleshooting, it was determined that Knighthawk 307 was unable to remove the basket from the probe, but the aircraft could return safely and land on the carrier. Knighthawk 307 later landed safely aboard Truman with no issues and with the ARS basket still attached. Ripper 103 had a functioning RAT and an extended hose but no basket. Aircrew in the tanker quickly assessed there were no known issues with the jet. After communicating with Pri Fly, the decision was made by both Pri Fly and Ripper 103 aircrew to retract the hose. The tanker successfully retracted the hose back into the ARS pod and secured the RAT. With the hose retracted, a visual inspection by Knighthawk 307 noted no visual damage. As a result, the tanker returned to Truman with no further incident. Unfortunately, when the aircraft shut down, maintenance personnel inspected the aircraft and determined that the hose had damaged an engine bay door when it was retracted. The basket is designed to keep both the basket and hose stable as the hose is

This was the third such incident of ARS basket separation and F/A-18 Super Hornet damage between August 2018 and July 2019.

extended and retracted from the ARS. Without the basket, the hose became aerodynamically unstable. As the hose was retracted, it began to oscillate and repeatedly whipped the engine bay doors just aft of the ARS, resulting in a Class D mishap. The specific door that was damaged, door 68L, was sent off Truman for evaluation by engineers in Jacksonville, Fla. The engineers returned a “non-repairable” finding. A new door was ordered and fitted. The depot-level repair would take two to three weeks, meaning Ripper 103 was unsuitable for flight and craned off Truman when the ship returned to Norfolk. Thankfully, no one was injured in this mishap, but a jet was removed from the fight for a prolonged period of time. This was the third such incident of ARS basket separation and F/A-18 Super Hornet damage between August 2018 and July 2019. VFA-11 completed a safety investigation report (SIR) for the mishap and produced a NATOPS change recommendation based on the frequency and severity of these mishaps. In the F/A-18E/F pocket checklist (PCL), a full-page is dedicated to ARS malfunctions, but it does not discuss what to do if the basket separates from the hose. Our SIR recommended adding a page to discuss this specific situation in the PCL. In hindsight, the correct decision would have been to sever the hose from the ARS. The ARS hose was unusable after the basket separated from it, and severing would have limited or prevented damage to door 68L. Aviators pride themselves on being able to think critically and make decisions at incredible airspeeds. When things start to go wrong, that’s when aircrew relies heavily on procedures and checklists. However, what happens when a procedure or checklist doesn’t exist? That is when an aviator’s critical thinking and decision-making ability are put to the test. Ask yourself, “What could possibly happen to my aircraft if I do this?” If future aircrews are presented with a situation like Ripper 103, they need to add that into their decisionmaking process.

Photo by Mass Communication Specialist 3rd Class Erica Bechard

BRAVO ZULU AM3 Lindzey Gross

It was the 123`s third fly day of Electronic Attack Squadron two-week detachment to Naval Air Station (NAS) Fallon, in support of its Electronic Warfare Advanced Readiness Program. Aircrew and maintainers were settling into normal detachment operations on the Scorpions’ first time away from NAS Whidbey Island, Wash., since returning from deployment in late 2019. On the day`s first flight, aircrew manned aircraft 543, as dash three of a light division supporting a surface to air counter-tactics mission. Upon completing final checks, the pilot released the parking brake to taxi from the line to arming. As the parking brake was released, the pilot felt the brakes “pop,” and the rudder pedals jolted against his feet. His initial thought was the brakes had stuck from the aircraft sitting overnight. Nose wheel steering and brake checks leaving the line seemed normal for a combat-loaded EA-18G to the relatively inexperienced pilot; however, he felt the jet was slightly more sluggish than usual and attributed it to the location`s higher altitude and hotter weather. The aircraft taxied to the arming area and the pilot set the parking brake. Upon releasing the parking brake post-arming, the pilot noted that the rudder pedals still jolted more than usual but less than the first release.

PR2 Joseph M. Marques

The pilot taxied the aircraft to marshal and again set the parking brake. While in marshal, the pilot discussed the situation with his electronic warfare officer, looking for more experienced input from the senior aircrew member. The pilot felt the jet was taxiing sluggishly but was unsure if it was his inexperience couples with the configuration, altitude and weather.

After pulling back into the line, the aircrew shut down the jet and AM3 Gross assisted in jacking the aircraft. He manually spun the starboard tire and the problem became obvious. There was a clear rattling and shaking coming from the brake assembly. It was later determined the starboard internal brake assembly had fractured into multiple pieces and prevented normal operation of the wheel brake.

Together, the aircrew concluded they should continue to assess the situation as they taxied and use sound judgment to make a final call. Upon releasing the parking brake to taxi to the hold short, the same pedal jolt was noted again. The aircraft pulled onto the taxiway behind the other two flight members, and the pilot set the throttles to 75 percent RPM.

Had 543 been allowed to launch as planned, the broken brake assembly would have likely seized the starboard tire during the takeoff roll, forcing a potential high-speed abort with only one operational brake. AM3’s attention to detail and assertiveness in deciding to down the aircraft prevented a potential mishap, precluding damage to an EA-18G Growler and possible aircrew injury. Bravo Zulu, AM3 Gross!

The aircrew proceeded to begin takeoff checks, but the pilot quickly noticed the jet had a very slight pull to the right and would not accelerate above 10 to 11 knots even at high ground power settings. After factoring these new tendencies, both aircrews agreed they should not take the aircraft flying without addressing the issue. They turned off the taxiway and proceeded back to the line for troubleshooting. Serving as a troubleshooter for the launch, AM3 Lindzey Gross plugged into the jet and the aircrew briefed him on the situation.

- Written by LT Christopher Yueh / VAQ-132

Upon inspecting the starboard main mount, AM3 Gross noticed some minor fraying on the inside of the tire. There was no obvious visible cause of the fraying. After further examination, AM3 Gross discussed the situation with a Quality Assurance Representative (QAR) and recommended the aircraft be “downed” for the starboard brake assembly. The QAR agreed with AM3 Gross and advised the aircrew that he would not be comfortable sending the aircraft flying. The QAR assessed the tire was still safe for taxi and requested the aircraft take a lap around the ramp to confirm the brake anomaly and noted the same tendencies.

On August 4, 2020, while performing a collateral duty inspection of an LPU-32 on aircraft 169002, PR2 Joseph noticed it was not properly equipped with a CO2 bottle. This would have deemed the equipment useless in a survival situation. His steadfast awareness and overall motivation prevented a potential loss of life. PR2 Marques`outstanding performance has justly won his shipmates’ admiration and respect and is in keeping with the highest traditions of the United States Navy. Written by LT Ryan Pajor / Patrol Squadron 16

DC3 Keith Runnells

Walking through a second deck passageway, DC3 Keith Runnells noticed something wasn’t quite right about a tag on a three-way (open, shut, neutral) remote hydraulic valve operator used for a bilge and stripping system valve in one of the shaft alleys. There is a chain connected to the end of the valve’s handwheel to prevent over-rotation. The tag was hanging on this chain. Even though it is a three-way valve, the handwheel can be rotated the full 360 degrees. The chain is not intended to be used as a locking device and has sufficient slack to allow for proper operations. The tag was labeled for the valve to be in the shut position; however, the handwheel was in neutral. The appropriate work center was informed, and work was paused until a replacement tag could be properly hung and verified the rest of the valves on the tagout. The maintenance called for the valve to be shut, so if there was a problem during the maintenance, the fluid would cause the valve to stay shut. Since the valve was placed in neutral, this feature was effectively disabled. DC3 Runnells’ keen eye for safety and superb initiative has proven instrumental in keeping his shipmates` safety a number one priority. - Written by CDR Martin Griggs / CVN 76 USS Ronal Reagan

n i m d A s u o d r a z Ha

-131 Q A V des, r e e tin G s u J d LT n a d e Tod l y K By LT

Sometimes it takes less than a moment for the swiss cheese holes to align. That moment can be especially dangerous when it occurs during the most routine phase of a flight. Several such holes lined up at just that moment for us over the Olympic Peninsula. We were returning from our working airspace as a single ship at 9,000 feet to a standard Naval Air Station Whidbey Island winter weather day. Several overcast layers, constant rain at the field, and icing is the norm for roughly four months of the year at “The Rock,” and this day was proving no different. While transiting the northern coast of the Olympic Peninsula, our radar altimeter (RADALT) alert was intermittently going off as it alternated between 4,000 and 5,200 feet. We acknowledged it over the interphone communication system (ICS) but left the alert altitude set to 5,000 feet when it appeared that we were past the elevated terrain. Seattle’s air traffic center then ordered the expected descent to 8,000 feet and we complied without worrying about the thickening clouds beneath us. Immediately after pushing the stick forward, the front cockpit’s canopy iced over. The pilot vocalized the issue over ICS before looking right to find the windshield anti-ice switch and the electronic warfare officer (EWO) began checking the wings and pulling up the engine status display to check inlet temperatures. What neither of

us was doing at that point was monitoring the descent (aviating). Unbeknownst to the EWO, the pilot was experiencing vertigo from the sudden loss of outside visual reference while looking down to find the windshield anti-ice switch. The RADALT, which we previously elected to sound off at 5,000 feet above the ground, began annunciating and compounding the pilot’s disorientation. The angle of descent quickly exceeded the usual three degrees, reaching 14 degrees nose low. Just eight seconds after we initiated the descent, the EWO noticed the altimeter at 6,000 feet and called for a climb. Seattle Center called our call sign with suitably critical inflection less than a second later. The directive calls from the back cockpit, and Seattle Center reoriented the pilot, who executed a maximum recovery maneuver to 8,000 feet but not before reaching a minimum altitude of 5,600 feet. There are several lessons learned and learned lessons reinforced by this incident. The most obvious is the importance of “Aviate, Navigate, Communicate.” Both crewmembers failed to aviate at the same crucial moment. While the icing was dramatic, it did not immediately threaten the airworthiness of the aircraft. The pilot should have continued to level off the aircraft while using autopilot features to keep it pointed in the right direction. Only after aviating should the pilot have looked down to flip the windshield anti-ice switch. Properly utilizing crew resource management (CRM) would have also prevented the unmonitored descent. We could have verbalized that the EWO would monitor the descent while the pilot

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dealt with the icing. Another lesson learned is RADALT management over mountainous terrain. Choosing to leave the RADALT at 5,000 feet and waiting for the terrain to level out desensitized us to its annunciation. Setting an intermediate altitude, such as 3,800 feet, would have given us better warning of our descent through our assigned altitude. All of these techniques are things we knew how to do but failed to apply at the moment.This breakdown of our scan and CRM could have deteriorated into something much worse. Thankfully, we corrected our mistake in time. From that moment forward, we stayed far ahead of the airplane. That proved beneficial soon when we hydroplaned down the runway after touching down from a precision radar approach (PAR). Having learned the value of CRM and contingency planning, we began talking through our plan in case the same thing occurred on our next attempted landing. Our second approach was waved off on final due to the arresting gear being out of battery. This time, we already had a plan in place to fly a PAR to a short field arrestment on the off-duty runway. With properly applied CRM, we were able to recover our airplane safely. If this same wariness and proactive mindset had been applied earlier in the flight, we would have certainly foreseen the possibility of icing on our descent into the weather. With the proper precautions, we would have already had the engine status page displayed, coordinated roles in monitoring the descent and responded to the icing while utilizing the RADALT more efficiently. What started as a simple training flight rapidly became one we’ll never forget. This flight reinforced the value of CRM while demonstrating how unforgiving aviation can be when we make mistakes. Training hazards can occur during even the most familiar phases of flight, and consistently exercising our most basic aviation skills is what will mitigate them.

By Robert Kneschke via Shutterstock

Naval Safety Center Completes Study on Mitigating Shipboard Forklift Risks By Paul Widish Knowledge Management Afloat Division Head / Naval Safety Center The Naval Safety Center (NAVSAFECEN) is on a path to becoming a center of excellence for modern data analytics to mitigate risk and prevent mishaps. As safety directly impacts both materiel and operational readiness, our ability to provide predictive data is critical to preserving warfighting capability across the Navy and Marine Corps. As the Navy and Marine Corps’ safety advocate, NAVSAFECEN collaborates with stakeholders across all warfare communities to provide relevant information and data to develop leading indicators of risks and hazards. NAVSAFECEN recently responded to a request from Naval Supply Systems Command to conduct an assessment analyzing reported fleet forklift mishap data to identify potentially deficient forklift risk management designs and measure current risk mitigation levels. Forklifts are used daily to perform essential cargo movement onboard ships, from pier side operations to underway replenishments. Forklifts provide efficient cargo movement that would not be safe or possible using only working parties and human lift. Maintaining appropriate human risk controls to operate these machines is essential to prevent injury and avoid damaging critical shipboard systems and supplies. NAVSAFECEN analysts compiled shipboard forklift mishap data from safety reports submitted in the Navy’s current mishap reporting tool, Web-Enabled Safety System (WESS). The available data from 2014 to present revealed 83 percent of the shipboard

forklift mishaps are occurring due to the following factors: 18% Forklift Crew Error 21% Performing Forklift Maintenance (MX) 39% Safety Observer Failure 21% During Forklift Tine Adjustment Knowledge Management (KM) afloat analysts assessed each reported ship class: ADC, CVN, LHA, LHD, LPD and LSD. The data revealed that during the given timeframe, only six total forklift mishaps occurred during all of the operations onboard hospital, LHA, LPD, and LSD ship classes. Given the numbers and frequency of forklift operations necessary to successfully complete amphibious missions, combined with the smaller operational quarters onboard these ship classes over the six-year timeframe, analysts realized safety underreporting must be considered. Looking into the top four mishap categories, the reported mishaps were caused from the following: 1. Forklift Crew Error. Either the crew did not adhere to the safety calls of their safety observer, or the forklift was operated in a manner that resulted in inadequate clearance for operation or caused a nearby pallet strike; 2. Forklift Maintenance. Mishaps occurred during forklift maintenance and resulted in finger cuts, smashed fingers while lifting the battery, electrical shocks tightening battery terminals, and cleaning; 3. Tine Adjustment. A forklift’s tines or forks are normally very heavy and used to counterbalance the

forklift’s center of gravity. As written, tine adjustment mishaps may have all been preventable, citing the tines’ weight as a “common denominator” to each injury, with the injuries occurring due to a person trying to make tine adjustments alone; 4. Safety Observer Failure. These mishaps occurred due to the safety observer’s actions, either being out of position to safely observe the ongoing forklift operations, or losing control of the forklift operations by being unable to “emergency” stop unsafe forklift operations. The current risk controls for shipboard forklifts results in the successful mitigation of 46% of shipboard forklift operational risk and yields a 54% risk design shortfall. This shortfall, coupled with human error factors, increases the vulnerability for incurring mishaps. Individual units must place focused emphasis on identifying and mitigating these risks and practice deliberate procedural compliance. The KM analysts leveraged a developmental Safety Management System (SMS)-based risk assessment model to “zero in” their analysis on the existing procedural guidance and human error management tools – or risk controls – the fleet uses to help mitigate the risks of shipboard forklift operations. By reviewing the primary procedural guidance and human error management tools provided to the fleet to standardize and define general forklift operations, forklift operator training and forklift team training, they were able to determine the larger root causes of reported shipboard forklift mishaps and provide potential solutions for risk design shortfalls.

The KM analysts reviewed the following instructions and management tools: Navy Safety & Occupational Health Program Manual for Forces AFLOAT, OPNAV 5100.19, Section C, Chapter 2, Dry Cargo Operations, Stores Handling, and Rigging, contains solid general forklift safety procedures. Conversely, the Navy Safety & Occupational Health Program Manual (OPNAV 5100.23) states “…the movement of materials in storage facilities using forklift trucks, overhead cranes and powered hand trucks, where materials are stacked above three feet in height…” represent a Job Hazard Category of ‘B,” and a “Moderate” Hazard Level.

existing team forklift operations procedures and HFM standardization present in 5100.19F, P-538 and 43100-6T. Forklift operations were discussed relating to night vision devices and U.S. Army H-47 helicopters. A stand-alone section for general cargo handling and staging, non-ship’s company forklift operator qualification requirements, forklift team operations, general forklift operations, or a minimum safety standards framework for PQS or local JQR design are not contained in this NATOPS. Based on the assessment, the analysts made the following recommendations.

However, no other forklift procedures exist among any other written safety procedures nor is a reference made to use NAVSUP Publication (P)-538 for “all other forklift operation requirements” to help guide forklift users to necessary procedures; therefore, OPNAV 5100.23 was not included in the risk design for the Fleet’s forklift operations.

1. Develop a Forklift Operation Safety Training Video. It may seem too basic, but developing a shipboard forklift operation safety video would help accelerate the understanding of safe forklift (and other) MHE equipment and complement all existing afloat forklift training that is otherwise “hidden” by being embedded in specific rate manuals.

NAVSUP P-538. Management of Materials Handling Equipment (MHE) and Shipboard Mobile Support Equipment provides the primary guidance for “…the management, maintenance, and safe use of industrial MHE and their approved attachments, and Shipboard Mobile Support Equipment (SMSE) at U.S. Navy units ashore and afloat.”

This serves a few purposes:

NAVEDTRA 43100-6T. The analysts looked at the Personnel Qualification Standard (PQS) Catalog to determine if a general forklift operations PQS was available to help “train the trainers” using an organized and standardized methodology that was not developed in the NAVSUP P-538 – and possibly provide a template to help local commands with various forklift devices to develop local job qualification requirements (JQRs) and enable operational and HFM standardizations. However, research revealed there is no stand-alone forklift PQS for the Fleet. There are elements of forklift use standardization embedded in other PQS’, but not contained – and therefore not content managed – solely for managing the diverse skill sets required to safely operate forklifts. LHA/LHD NATOPS Manual (NAVAIR 00-8T106). Analysts looked at the type command’s (TYCOM) procedural guidance for shipboard forklift operations and team cargo procedures based on the lack of

revision was completed. As 83% of reported shipboard forklift mishaps are occurring as a direct result of the current procedural guidance in place to prevent forklift mishaps – making these critical changes will best serve the fleet’s operational readiness. As noted earlier, forklifts are used daily to perform essential cargo movement onboard ships. Updating our procedures and visual aids are but one aspect of the training methodology. Ultimately, forklift operators and safety observers must ensure they comply with instructions, initial and recurrent training and local guidance to avoid that next potential mishap. For access to the full assessment, contact the Naval Safety Center at NAVSAFECEN_CODE521_ MEDIACOMMS@navy.mil

A – Not just one rating operates shipboard forklifts, and training should not require added “extra effort to locate the right training” for Sailors to learn and operate forklifts safely and for leadership to use to develop local procedures; B – Supervised unsafe forklift operations for visual presentation, from pre-op checks and designing a cargo movement plan to actual forklift operator “typical mistakes” could ultimately be a part of the training video content, allowing a real-time and accurate – but safely staged – reenactment of unsafe conditions. This will prove invaluable in “what not to do” as Sailors start training to operate forklifts onboard ships. 2. Develop a General Forklift Operation NAVEDTRA. A general forklift operation NAVEDTRA would provide the Fleet with a tool that provides forklift guidance organized into a more humanly learnable fashion. Integrating a NAVEDTRA with a Forklift Operation Safety Training video would immeasurably strengthen the fleet’s local forklift operation procedures. 3. NAVSUP P-538, Revision 7. During this assessment, the development of NAVSUP P-538 Revision 7 was confirmed through liaison with NAVSUP WSS Mechanicsburg, making the development and deployment of recommended changes in this risk assessment possible before the

Courtesy Photo USS RONALD REAGAN (CVN 76) Photo by: Petty Officer 3rd Class Anthony W. Johnson

2020, VOL63., NO.3 APPROACH

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A DDI TI ONA L PUBL I CATIO N S

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PREVENTING MISHAPS, SAVING LIVES AND PRESERVING READINESS

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