FALL / WINTER 2020
VOL 65. NO.2
AIRCRAFT MAINTENANCE
Ground Handling Complacency
SAFETY FIRST Publication ISSN:
MAINTAINERS IN ACTION
THEIR BEST ADVICE Procedural Noncompliance LEARNING FROM THE PAST
COMMANDER`S LETTER REAR ADMIRAL “LUCKY” LUCHTMAN
As we fly into the latter half of 2020, and the doors begin to shut on this unusual year, I and the MECH magazine want to spotlight the incredible, unwavering efforts of our aircraft maintainers, who continue to keep the U.S. Navy and Marine Corps` aircraft safe and functional, even during this challenging period. When there’s more on our minds, we can inadvertently make mistakes in our work – but when it comes to the vast responsibilities that aviation maintainers shoulder, mishaps can result in millions in damages, injury and – in some cases – even loss of life.
I encourage you to share your stories since the pooling and sharing of knowledge between those in the aviation maintenance field is one of the key ways to prevent aviation catastrophes from happening in the future. Most of all, I want to take this opportunity to thank each individual in the aviation maintenance industry for their hard work, which is essential to the continued success of our country and the lives of our aviators throughout the world.
While Sailors, Marines, and civilians alike have had more responsibility to bear in recent months, aviation safety is still as crucial as ever. This issue highlights the danger of complacency and non-compliance to maintenance regulations, which even the most seasoned aviation maintainers can be vulnerable to.
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Maintenance Safety Team Main Phone Number: 747-444-3520 CDR Rob Beaton Aircraft Maintenance and Material Division Head, robert.e.beaton@navy.mil Ext. 7265 Maj. Andrew Ericson Asst. Division Head, andrew.c.ericson1@navy.mil Ext. 7223 CWO5 Brian Baker Aircraft Maintenance and Material Analytics Branch Head, brian.c.baker5@navy.mil Ext. 7123 CWO3 Lanita Winfrey Aircraft Maintenance Assessments Branch Head, lanita.winfrey@navy.mil Ext. 7278 AFCM (AW) Pedro Gonzalez Maintenance Master Chief, pedro.a.gonzalez@navy.mil Ext. 7290 Master Gunnery Sgt. Joshua Smith Systems Maintenance Branch Head, joshua.m.smith4@navy.mil Ext. 7276 ADCS (AW/SW) Andrew Van Norman Power Plants Analyst, andrew.s.vannorman@navy.mil Ext. 7219 AECS(AW/SW) Michael Perez Electrical Systems Analyst, michael.j.perez1@navy.mil Ext. 7291 AMCS (AW/SW/IW) Anthony Abraham Egress, Environmental Systems Analyst, anthony.abraham1@navy.mil Ext. 7293 AMCS (AW/SW) Thomas Matthew Fain Aviation Structure 0-Level (Fighter), thomas.fain1@navy.mil Ext. 7290 AOCS (AW/SW/IW) Christopher Morris Aviation Weapons Analyst, Christopher.j.morri9@navy.mil Ext. 7143 ASCS (SW/AW) Joseph Hippolyte Support Equipment Analyst, joseph.hippolyte1@navy.mil Ext. 7171 ATCS(AW/SW) William Crawford Avionics Systems Analyst, william.e.crawford@navy.mil Ext. 7221 PRCS(AW) Randi Zetterlund ALSS, Aircrew Equipment Analyst, randi.m.zetterlund1@navy.mil Ext. 7258 ADC (AW) Caitlin Addams Power Plants Analyst, caitlin.addams@navy.mil Ext. 7256 AMC (AW/SW) Mark Pugh Airframes, Hydraulics Analyst (Rotary), mark.pugh1@navy.mil Ext. 7187 Gunnery Sgt. Stanley Berry Airframes, Hydraulics Analyst (Rotary), stanley.j.berry@navy.mil Ext. 7292 Gunnery Sgt. Douglas Green Airframes, Hydraulics Analyst (Fixed Wing), douglas.h.green1@navy.mil Ext. 7244 Gunnery Sgt. Jeff Schmitt Avionics Systems Analyst, Jeffrey.t.schmitt1@navy.mil Ext. 7140 Gunnery Sgt. Crystal Conklin Maintenance Administration Data Analyst, crystal.r.conklin@navy.mil Ext. 7239 Gunnery Sgt. Christopher Watson Weapons Analyst, christopher.a.watso7@navy.mil Ext. 7215
Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces, cause injuries and ruin equipment and weapons. Mishaps diminish our readiness. The goal of this magazine 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. 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.
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MECH Staff Jeffrey Jones Leads the Safety Promotions team (Media and Communication Division and Lessons Learned Division) in developing and executing varied and integrated communication products.
Priscilla Kirsh Manages the multitude of communication products that are produced by a team of outstanding professional communicators, ensuring the Naval Safety Center’s messages are getting out to the Fleet in the most efficient way.
Catalina Magee Editor of Approach and MECH magazines and art director of special products, such as the 2019 Annual Report, 101 Critical Days of Summer, the RMI magazine, posters, presentations, infographics and videos.
Becky Coleman Editor of Ship’s Safety Bulletin (SSB) and Factual Lines About Submarine Hazards (FLASH) newsletters, writer and contributor to special projects. In this issue, Becky worked alongside Catalina as a copy editor.
CONTRIBUTING STAFF LESLIE TOMAINO Communications Strategist STEPHANIE SLATER Communications Strategist LISA BONNER Webmaster KEN GOSS Social Media Manager
JOSEPH HOLBERT MC2 Videographer CHRIS REW Lessons Learned Supervisor DAVE DEUEL Lessons Learned Writer MIKE DEL FAVERO Lessons Learned Writer
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Procedural Noncompliance: The number one Causation of Aviation Mishaps by Maintenance by AMCS (AW/SW) Anthony Abraham
“IF YOU DON’T HAVE TIME TO DO IT RIGHT, WHEN WILL YOU HAVE TIME TO DO IT OVER?”
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QUOTE BY COACH JOHN WOODEN his is a quote of a few words, but it shares a strategy to the achievement of any measurable success. In the world of aviation maintenance, there is only one way of doing things the right way and that is by doing it strictly by the book.
As part of the Naval Safety Center’s assessment team, responsible for comprehensive safety centric looks of all the aviation squadrons across the fleet for both the Navy and Marine Corps alike, I have observed the consequences when maintainers do not adhere to this mandated requirement. It is no coincidence that procedural noncompliance is the number one causation of aviation mishaps by maintenance personnel.
While there are a plethora of noncompliance examples I have observed that give credence to the consequences of not performing maintenance actions strictly by the book, one that immediately comes to mind that best highlights this was in a recent mishap that grabbed my attention. The mishap resulted in an inadvertent and unplanned discharge of an engine fire bottle due to a series of noncompliance lapses by personnel within the maintenance department.
IT IS NO COINCIDENCE THAT PROCEDURAL NONCOMPLIANCE IS THE NUMBER ONE CAUSATION OF AVIATION MISHAPS BY MAINTENANCE PERSONNEL.
THIS MISHAP resulted in an inadvertent and unplanned discharge of an engine fire bottle...
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In this case, it started with identifying a maintenance discrepancy by a squadron pilot who was conducting a pre-flight ground check for a Functional Check Flight (FCF) and noted that the left main landing gear light did not illuminate. The pilot called for a troubleshooter to replace the broken lamp. As soon as the light was replaced, all of the gear lights extinguished while the HOOK light, Spin Recovery light, and the Fire Bottle DISCH light all illuminated. Unable to get the erroneous lights to extinguish and the gear lights to return, the pilot declared the aircraft down for the flight. When the squadron pilot asked Maintenance Control if a Maintenance Action Form (MAF) had been written, he was informed that it was. Later on, you will see where this becomes critical in its contribution to this mishap.
That evening, night check maintainers went out to conduct a seven-day special inspection on that aircraft. While performing the inspection, the first maintainer noted the same light discrepancy as reported by the pilot earlier that day. Furthermore, it was noticed that this discrepancy had not been appropriately documented, contrary to what Maintenance Control had passed. The aircraft maintainer, recognizing that the light configuration was incorrect, called for an additional turn operator to assist with troubleshooting the lights issue. A second maintainer went out to verify the discrepancy but was unable to determine what was causing this issue. Both maintainers agreed to shut down the aircraft, discontinue the inspection, and inform Maintenance Control of what they had found.
THE WORLD OF AVIATION IS HAZARDOUS; THEREFORE, PROCEDURES ARE IN PLACE TO MITIGATE THE POSSIBILITY OF MISHAPS. Next, Quality Assurance (QA) was brought into the loop to get a more experienced maintainer and turn operator involved with the troubleshooting of this discrepancy. QA went to the aircraft to assist in troubleshooting the DISCH light and determined that the best course of action was to execute the appropriate procedure to reset the light. After they performed the steps IAW NFM-500 to reset the DISCH
light, QA directed for the Fire Extinguisher circuit breaker to be reset IAW NFM-500 to attempt to verify that the Fire Extinguish Light would function as designed. Upon selection of the right Engine Fire Light, maintenance personnel noted a loud hiss sound emanating from the right engine and that the READY light did not illuminate. Maintenance personnel immediately secured power to the aircraft and further inspection revealed that the fire-extinguishing bottle was discharged into the right engine. After further investigation, it was found that the aircraft fire bottle functioned as designed and there was no system malfunction. It was determined that while the QA-experienced turn operator followed all steps IAW NFM500 to reset the DISCH light, the procedural steps were not followed within NFM-500 when attempting to verify that the fire extinguish switch was functioning correctly by trying to ascertain the presence of a “ready” light with a fire light depressed. This procedural lapse is what led to the fire extinguisher’s inadvertent and unplanned dispersal into the right engine bay. Maintenance personnel failed to follow the appropriate troubleshooting procedure to verify that the switch was operating as designed and neglected to properly analyze the risks associated with testing the firelight after completing the procedure for resetting the APU Fire Extinguisher. Additionally, as previously noted, the aircraft discrepancy was not adequately documented or updated within the MAF. The MAF was written to state that it was a burned-out
light and did not include the specifics of the unusual light configuration that resulted after replacing the main landing gear light. Had this light configuration been documented appropriately in a MAF, this would have led to the technicians troubleshooting the unusual light configuration and likely to the identification of the grounded wire within the landing gear handle, thereby, preventing the mishap. The world of aviation is very dangerous and procedures are put in place to mitigate the possibility of mishaps. It is not an option of whether you follow those established procedures, but a mandatory requirement. The above accident illustrates the consequences of when you don’t strictly adhere to those procedures in the correct sequence and portrays how easy things can go wrong as a result; it’s why noncompliance of procedures ranks as the very top causal factor in all maintenance-related mishaps. Procedural compliance doesn`t just mean having the publication or PEMA on site; it means following it step by step and noting all cautions, warnings and notes.
REMEMBER Procedural compliance is not an option and is and always has been an All Hands requirement. It is imperative that the procedures are followed.
U.S. Navy photo by Mass Communication Specialist Seaman Olympia O. McCoy
HAD this light configuration been documented appropriately in a MAF...
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Day Check and Stay Check By AFCM (AW) Pedro Gonzalez
This article is dedicated to the night shift supervisors. You are the heart and soul of your maintenance department. I often wonder if that desk Chief ever went home. Early in my career, just like many of you, I worked the night shift – night check or “stay check” as we used to call it back then. It seems no matter what we did, we were always
there so late. We often greeted day check on numerous occasions. We were often tired and could rarely plan our off duty time. I thought when I am in charge, I will put an end to it. I couldn’t understand why we always seemed to get the short end of the stick. Was it because we were on sea duty? It always seemed like our sister squadron was going home before we were. I also felt the desk Chief did not care about us or maybe the Chief did not want to go home. Eventually, I became a shift supervisor. I soon learned the amount of time we stayed at work depended on us. I still thought my desk Chief did not want to go home, but now I was in a position to do something about it. As you advance to positions of greater responsibility and experience, you will encounter roadblocks preventing you from completing your assigned tasks. I frequently asked myself, do we have enough people? Are our technicians trained and qualified? What are the priorities for the night, for the week and long-range? Lastly, how are we going to get there from here?
U.S. Navy photo by Mass Communication Specialist 3rd Class Quinton A. Lee
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As a Petty Officer second class (E-5) and shift supervisor, it was not always easy to understand all the moving pieces that play into the “big picture” of managing aviation maintenance. It often felt like we were working in isolation — airframes against the rest of the squadron.
Photo by Seaman Apprentice Orion Shotton
Fast forward many years later and as we conduct safety assessments around the fleet, I continue to see the same patterns. The same work centers remain in isolation against the rest of the squadron, staying late every night. As in the past, the same questions remain; do you have enough people? How many people do you need? Did the LPO and division Chief include you in their plan to overcome the shortage? Do you perform the bulk of the maintenance on your shift? Are your technicians trained and qualified? You are likely not going to have everyone fully qualified on your shift. If your command has a robust training program, you should have a rotation of qualified apprentices and journeymen on your shift. Your shift likely performs the bulk of the maintenance, so the new Sailors will be exposed to a myriad of discrepancies that is invaluable to their training. The short answer is, you need a
good balance and rotation of apprentices and journeymen. Again, get involved with your LPO and Chief to determine what’s going to work best for your situation. What are the priorities for the night, for the week and long range? The answer to this question has multiple layers; each one of those layers builds upon the previous one. First, what is the priority for the night? Priorities continuously change based on scheduled and unscheduled maintenance and upcoming detachments. The schedule also may be influenced by your work’s backlog. Are you supporting other work centers or waiting for others to complete their tasks? Do you have everything needed to support your workload for today and for future taskings? Are your personnel taking leave, transferring or going to schools? These are some of the issues you need to discuss with your LPO and Chief.
How are we going to get there from here? One of the most common topics cited on command climate surveys is a lack of communication. Did you know you are a critical part of bridging the communication gap? Results from our assessments continually show the breakdown in communication occurs between the E5-O3 levels, which is our middle management. If your shift doesn’t know what is going on, you may be the first point of failure. It is your responsibility as a shift supervisor to know what the future brings. It’s your job to keep them informed. There will be some nights when you will have to make on-the-spot decisions, but that shouldn’t be every night. Remember, the goal is to get in, complete the required tasks safely, effectively, efficiently and go home. You are the first line of defense to make that happen, but it will require a lot of your time, experience and engagement, both up and down the chain of command.
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Complacency By ADCS (AW/SW) Andrew S. Van Norman Ever come home with your arms full of groceries that are falling everywhere only to leave your keys in your front door? How about leaving the oven on after you’ve finished cooking dinner? You could argue that you just forgot to grab those keys or turn that oven off, but both are real, everyday examples of how complacency can sneak up on you. Both instances could have led to accidents that could have been avoided if you had not let your guard down; the oven could have started a fire and the keys could have attracted a burglar.
Photo by Lance Cpl John Hall
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Sometimes when we go on autopilot doing the things we have done repeatedly, day after day, we do not finish the important action steps to ensure bad things do not happen.
But then, some have had to learn the hard way. This can mean damage to equipment, injury, permanent disability, or even worse…death to yourself or a fellow shipmate.
Whether you are the most experienced subject matter expert or the most junior Sailor fresh out of boot camp, we have all experienced some form of complacency. However, there is a big difference between complacency in everyday life actions and working on a multi-million dollar aircraft with the lives of the aircrewmen in your hands. Complacency usually rears its ugly head during actions of repetition. You’ve done this particular job a thousand times, so you can do it in your sleep or blindfolded with two hands behind your back. You let your guard down and that’s when it happens! Complacency sneaks in and the next thing you know, an accident occurs.
It is for these reasons that it is said the procedures and steps in a publication are “written in blood.” Many of these steps, notes, cautions, warnings, are the lessons learned from generations of aviators and maintainers before us who might have learned “the hard way.”
Accidents are precisely that: an accident! You didn’t mean to leave the tie-downs hooked up to the aircraft before the tow evolution or the blade crutches still connected during the spread evolution. You didn’t mean to leave a tool on the aircraft before launch or a switch in the wrong position. You didn’t make sure you followed all the steps you should have before starting the evolution. Now you’re facing a major incident that could have been avoided. All that could have been prevented by simply taking the time to grab that publication, following step by step and not falling into that complacency mode while performing the job at hand.
Not to listen to the audience yelling, “Don`t go in there!” like a horror flick right before they are all wiped out. Do you want to be the cause of someone not going home to their family because you couldn’t follow the steps laid out in front of you? There is a fine line between life and death. Choose wisely.
Maybe it is not the word “complacency” that scares you, but it is the result that should! Many of you have been here in similar scenarios. Some have had close calls, scared enough to learn their lesson after a near mishap, and avoid it, so it never happens again. Some have been lucky enough to get away with it this time, only to repeat it again and again and gamble with a chance at an accident occurring.
They collected and experienced the issues for themselves so we would not have to, so we could safely perform the job. Maintenance by the book! We hear it all the time, but do we listen? Is it worth it to you, your fellow Sailors and Marines working beside you, to their and your families, not to heed the warning from the past?
Only engineers can approve changes to maintenance procedures, but until they do so, it is not a new procedure or a better way of doing it.
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LEARNING FROM THE PAST Thankfully, no damage to the flight deck, personnel or injuries occured. When configured with an AUX tank, the APU pump handle is sandwiched between the bulkhead and the sidewall of the AUX tank reducing environmental influences and accessibility of the pump handle. The handle is held in place by a retaining strap using a wingnut on top and a box bracket at the bottom. This retaining system is located on the bulkhead behind the starboard cabin door. Because this crew’s aircraft did not have an AUX tank installed, it left the pump handle exposed with only the top retaining strap and bottom box bracket holding it in place. The aircraft had daily and turnaround inspections completed the same day as the preflight.
I recently reviewed an MH-60S hazard report (HAZREP) regarding things falling off aircraft (TFOA) involving the auxiliary power unit (APU) pump handle. The handle fell out of the aircraft while the unit was conducting vertical replenishment (VERTREP) operations at sea. This particular flight crew conducted their aircraft’s preflight the day prior to their event during daylight hours. They noted everything was in place and the aircraft was safe and secure for the mission. Sometime after the crew had finished their preflight, the airframers installed troop seats across the aft bulkhead of the cabin. The crew was aware of the maintenance action, but did not complete a follow-up inspection of the area before the flight. This was going to be a somewhat routine VERTREP flight since this detachment was on a deployment and had completed this operation several times. Only two things were out of the ordinary for the crew; they would be flying without an auxiliary (AUX) fuel tank and the aft row of troop seats would be installed. The crew launched at 0630 to commence the day’s operations. At an unknown point during the VERTREP, the pump handle left the cabin and landed on the flight deck of the receiving ship. Flight deck personnel recovered the handle and returned it to the aircraft once the VERTREP ended at 1015.
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However, these inspections do not require maintenance technicians to inspect the security of the pump handle. The crew chief inspected the pump handle on preflight noting the handle was secure in its holder. MH-60S squadrons don’t routinely configure aircraft without AUX tanks or install the aft row of troop seats along the aft cabin bulkhead. This non-routine configuration created a hazard as the maintenance team may have been unaware of the APU pump handle location and could have accidentally loosened the retaining wingnut during the troop seats’ installation. Flight crews do not routinely re-check the security of the APU pump handle when AUX tanks are installed due to its limited accessibility. This likely led to the flight crew’s failure to re-inspect the pump handle after the seats were installed or during the flight. Flight crews also do not routinely conduct VERTREPs with the aft row of troop seats installed. During this VERTREP, the crew was seated in the aft row of troop seats for nearly the entire flight. Due to the proximity of the handle to the starboard aft seat, it is possible the crew member’s flight gear may have snagged the wingnut and loosened the pump handle retaining mechanism during flight. Both of these scenarios could have ultimately caused the handle to leave the aircraft. It is true nowadays we don’t often fly without AUX tanks or with aft row of troop seats installed. However, aircrewmen still have a responsibility to manage the cabin to ensure items don’t fall out of the aircraft. We pre-flight, checking
By AWSCS (AW/SW) Wade Hove for safety and security, but do we check after we lift? For some, the answer may be no. For those, preflight may be the last time they check the aircraft before launch. Our highpaced, ever-changing environment requires time critical operational risk management. This necessitates a periodic reassessment of our surroundings, to include checking the security of our aircraft, inside and out, to ensure our crew remains safe and effective. While most aircrewmen probably look around the cabin for loose gear inflight, they may not do a traditional security check. Once upon a time inflight security checks were a regular occurrence in the H-1, H-3, H-46 and H-53. During a security check personnel would check circuit breakers, switches, hydraulic lines, flight controls, hatches, cargo and anything else that could cause a problem if not working properly or become loose during the flight. With the introduction of the MH-60S, flight crews inherited a very reliable and safe aircraft. Over time, some aircrewmen may have developed a false sense of security that systems and equipment are so reliable and safe they no longer need to check them inflight. Some in our community may now rely more on aircraft warning systems to notify them when something is wrong or a system is degraded. This cultural shift may be the result of complacency that has been bred into some of our aircrewmen. This complacency is perpetuated by some senior crewmembers’ failure to pass on techniques, such as the security check, we have developed from past experiences. Our past experiences shape the techniques we use and the procedures laid out in NATOPS. The saying “NATOPS is written in blood” is constantly repeated. Learning from our past mistakes is vital. As a community it is imperative we continue to pass on best practices to our replacements. I am not saying that all aircrewmen have lost the idea that our job has dangers or feel that we no longer need to check our surroundings. I am merely pointing out one possible causal factor to a common problem, TFOAs. Pay attention to all of your surroundings. Especially when uncommon configurations or changes to normal tasking occurs.
Fit vs Fill
By MGySgt Joshua Smith
As part of the NAVSAFECEN’s assessment team responsible for conducting comprehensive safety centric looks of all the aviation squadrons for the Navy and Marines, I observed it was not abnormal to see Navy squadrons where many of their journeymen-level Sailors were new to their platforms. With an outsider’s understanding of the inner workings of Naval manning, I admit I found this practice was foreign to me and a bit alarming as I observed the challenges work centers and maintenance departments faced when many of their journeymen-level Sailors did not possess prior platform experience in their current aviation platform. I learned the primary causal factor in this originates with the ongoing manning process of “filling” the aviation manning requirements with Sailors of like rate but not necessarily staying within the same platform “fit.” In some cases, this meant not even staying in the same rotary or fixed-wing community. So from the outside observer’s perspective, I must ask the question of what is more critical to a healthy maintenance department, filling the manning within a unit to the maximum extent or having the right “fit” of personnel? As a senior enlisted member on the assessment team, I make it a habit to ask this very question to the senior maintenance leadership on every unit assessment. To date, 100 percent of the maintenance Master Chiefs of those respective units indicated they were more concerned with their Sailors having platform experience and being the right “fit” vice filling every staffing requirement; simply put, quality over quantity.
A senior enlisted perspective from an outsider’s observation
Each military service has its unique practices in meeting its manning requirements. I have always held to the truism that experience counts and pays the most dividends within the aviation world. However, being a Marine and in a different service, it was not until my latest assignment to the Naval Safety Center (NAVSAFECEN) that I became aware of how the Naval Enterprise met these manning requirements for their aviation squadrons.
They made a point of mentioning success usually came down to having the right personnel with the right qualifications and experience and how they are effectively employed within their unit. This inclination was something I give credence to, as I was unable to observe a definitive correlation between a purely maximized staffing level and a successful and effective unit. During our assessments, I observed some maintenance departments with 80 percent manning levels, while possessing the right “fit” were running seamlessly and operating on all cylinders while some other units closer to the 100 percent level were not. Of these struggling maintenance departments, I observed in the more extreme cases some work centers only had about 15-20 percent of their journeymen-level Sailors with previous platform experience and these were struggling with having to carry the load on their shoulders. Additionally, beyond this question regarding “fit/fill” is how those impacted journeymen-level Sailors are affected by this manning strategy where they transfer to a different type of aviation platform based upon their rate rather than their platform experience. To date, less than 10 percent of the journeymenlevel Sailors I encountered and queried favored this practice and garnered any benefits from it. The vast majority felt they had been transferred into a new platform with a disadvantage, as they were no longer working on becoming subject matter experts in their original platform in which training and resources were allocated.
They felt a tremendous amount of stress to get up to speed with peers or meet paygrade expectations, but had to start over again, regain their qualifications and become trusted and skilled assets within their new platform. They believed their journeymen level was not the place to grow more well-rounded with this type of exposure but that these moves should be made at the more senior level as they would reap more benefits with these type transfers as it becomes more about managing people, programs and communication. At the day’s end, there can be no argument that any Service has adequate manning for every facet and it comes down to a careful balancing act of filling staffing requirements but at the same time not sacrificing having the right “fit.” There are unique and undeniable challenges, no matter the direction a Service leans toward accomplishing this feat. However, I must repeat the question I asked previously of what is critical to a healthy maintenance department, filling the manning within a unit to the maximum extent or having the right “fit” of personnel? I think it’s a bit of both, but you must have the right “fit” to achieve any degree of measurable success within your unit. You must have the right “fit” of personnel to have an adequate number of people to properly train, cover all shifts and detachments. Training is the basis of setting up the next generation of journeymen-level maintainers for success.
U.S. Navy photo by Mass Communication Specialist 3rd Class A. A. Cruz
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U.S. Navy photo by Mass Communication Specialist 2nd Class Zhiwei Tan
Support Equipment Planned Maintenance System Noncompliance
By ASCS Joseph Hippolyte The use of unsafe maintenance equipment is an unnecessary risk that should never be viewed as acceptable. Those that maintain and enforce the Support Equipment Planned Maintenance System must understand the significance of abiding by the guidelines of the Naval Aviation Maintenance Program (NAMP) and local policies. Not abiding by set guidelines and procedures could result in injury to personnel, damage to equipment or aircraft. This article will discuss assessment findings, factors contributing to procedural noncompliance and means of mitigating noncompliance. Findings from 20 command assessments have shown a worrying trend of commands sidestepping the directions laid out by the NAMP. In many instances, maintenance history records for equipment used to do work on aircraft had no documentation of the completion of required baseline or subsequent technical directive screenings. Records for lift slings that had recently received nondestructive inspection had no documentation to prove that the slings had passed the inspection and were safe for maintainers. Servicing equipment that was overdue for technical directive compliance had no work order written against them and was still used by maintainers. Maintenance equipment that
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was not in preserved status did not have required preventative maintenance tasks activated. Equipment that was overdue for periodic maintenance was readily available for maintainers to use. Support equipment that is overdue for periodic maintenance is considered down and should never be used. Using down equipment exposes personnel and aircraft to needless hazards. Now that I have discussed some of the assessment findings, I will share some of the contributing factors. After studying all the findings and accounts from numerous assessments, a few of the items were found to be contributing factors to procedural noncompliance. The maintenance department lacked equipment and the ability to see the importance of holding the upkeep of maintenance tools. Also, their records did not keep the same standards as they would for an aircraft. The junior service member that is usually assigned to the program seemed to have a lack of in-depth program knowledge. This happens often due to inadequate training. It was also noted that those who are charged with program oversight are not doing their job. This is a culture problem and must be corrected. Now that I`ve shared some of the contributing factors, I will also name some of the process improvement measures implemented at commands.
Some of the noted practices that seemed to mitigate program noncompliance are as follows: • Having a command culture that stresses and lives by getting the job done and working within the guidelines of the applicable instructions. • Having a process improvement that works and performs weekly hands-on training for the maintenance administration team. This widely increased the administrative team’s knowledge base, which allowed them to pick up where a team member left off. I have also seen commands that have quality assurance implement weekly administrative spot checks, which assist in the identification and correction of discrepancies. This article discussed assessment findings, factors contributing to procedural noncompliance and means of mitigating noncompliance. It is important that those who maintain and enforce the Support Equipment Planned Maintenance System, understand the significance of abiding by program guidelines because not abiding by set guidelines and instructions could result in injury to personnel, damage to equipment or aircraft. In closing, keep in mind that the right decision will often be the hardest one to make.
The leading cause of aviation ground mishaps over the last decade has been the failure to follow procedures. Lives are at risk if procedures are not followed!
QA Primary Function: To ensure quality and safety while preventing defects.
You can’t ensure quality and safety from behind a desk. Though quality assurance is the responsibility of all hands within aviation, the primary responsibility falls on the highly experienced quality assurance representatives and experienced maintenance khaki leadership.
BE ENGAGED AND BE SEEN SETTING THE EXAMPLE AND ENFORCING THE STANDARDS.
FOLLOW PROCEDURES!
AIRCRAFT
U.S. Marine Corps photo by Lance Cpl John Hall
MOVES
BY ATCS (AW/SW/IW) CRISTIE LINK
Many of us have been standing in the hangar bay, waiting on the move crew to situate the E-2 in the forward starboard corner of hangar bay one and wonder how that spotting dolly can get that giant aircraft in such a tight spot without taking out all the support equipment in the process. At least I wonder because I often have issues backing my Ford Explorer into the driveway, and it has 360 view cameras and sensors all over the outside. Unfortunately, even the most in sync move crew will have what is commonly called a “crunch” and often due to variables such as complacency, fatigue, lack of attention to detail, lack of communication, and nonprocedural compliance. In a recent incident on a deployed amphibious assault ship (LHD), trying to manipulate the MV-22 Osprey through an excessive amount of gear in the hangar bay and not ensuring the correct number of personnel were present resulted in damaging the Forward-Looking Infrared (FLIR). The damage`s cost was $68,975.
Had the correct number of personnel been present, the extra eyes would have noticed the issues with the tow bar and stopped the evolution, saving man-hours, time and money.
Not paying attention to the area around the aircraft while directing the aircraft to simultaneously move and fold wings was the main contributor to this specific incident.
In another incident on board a recently deployed aircraft carrier’s flight deck, an E-2C Hawkeye, was being directed to proceed to the arm or disarm area to be sidelined at the same time wings were being folded. As the aircraft came to a stop, with the wing fold already in progress, the port wing tip struck a P-25 fire truck parked in the vicinity damaging the port collision light cover. After further inspection, it was discovered that the wing tip assembly rivets were ripped out of the seam and the wing edge was bent. Fortunately, there was no damage to the P-25 fire truck. The total event cost for this incident was $6,458.
Luckily, in both of these incidents, no one was injured, but that is not always the case. Until aircraft and spotting dollies start coming with 360 degree back up cameras or self-parking options, these are cases that will always require a well-trained team with great communication and hours of practice.
The P-25 was not damaged. We know the impact and risk that comes with it being out of commission as it is a vital item on the flight deck and would have added to the incident’s cost.
Many large ships such as aircraft carriers (CVNs) and LHDs require long shipyard maintenance periods, which results in personnel losing proficiency in qualifications. Meticulous documentation of these qualifications and leadership review of training jackets can be a helpful tool for keeping track of personnel. Teamwork is a powerful asset as long as all personnel on the team are all pulling their weight. Training and practice are key to “muscle memory” and are some items that may help reduce future incidents.
MECH 19
IMRL in the Workcenter By AMC Mark Pugh
The Individual Material Readiness List (IMRL) details specific quantities of aviation support equipment a command needs to support its maintenance requirements. Each IMRL contains equipment particular to a type, model and series aircraft, as well as equipment that can be used on multiple aircraft types; e.g., aircraft tow tractors and tow bars.
parts collecting dust under a bench and many times are reported in a ready for issue (RFI) status.
inventory, lighten your workload and turn in excess items so it is available for others to access.
An average-sized squadron’s IMRL contains hundreds of support equipment line items; the aircraft intermediate maintenance department (AIMD), Marine Aviation Logistics Squadron (MALS) or Fleet Readiness Center (FRC) contains over 1,000 items.
Each command has an IMRL manager responsible for maintaining and updating the list. Workcenter IMRL Petty Officers or NCOs assist in this effort and tell the manager what the workcenters need to perform a job. It is their responsibility to inform the manager of any deletions, additions or corrections to the IMRL to ensure adequate equipment is available to support the mission. Properly managing the IMRL and expediting repair or replacement helps alleviate the risk of unsafe processes and potential workarounds.
Frequently, items may have been issued to a command operating under a detachment concept. If this is no longer the case, work with your command IMRL manager to have your excess assets tailored to fit your current command’s operations. This will release critical IMRL items for other commands that may be waiting for them. Preservation is an option, but keep in mind the work that goes into maintaining records and performing preservation checks must be complied with.
In past assessments, the Naval Safety Center has found multiple issues with workcenter IMRL programs, ranging from workcenters retaining or not turning in broken or NRFI (not ready for issue) equipment – to maintaining many times the number of IMRL items actually needed.
Workcenter supervisors should keep these responsibilities in mind when assigning the workcenter IMRL program collateral duty to junior personnel. Often, these personnel are tasked to visit other commands to borrow specific IMRL items that may not be available or are nonoperational.
Additionally, we often find broken or unused
If your workcenter is maintaining excess
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Good IMRL managers should consistently ask themselves these questions: Do we have enough people to maintain the IMRL assigned? Is there time available to properly perform preoperational checks when required? Do we need additional items to perform maintenance per the publications? If I am going to be away from my duties, who will manage my IMRL?
In summary, managing the IMRL is the workcenter IMRL manager’s responsibility. The command’s mission readiness and preventing unauthorized workarounds absolutely rely on a well-run program. Conducting these actions will ensure its success: • Commands must take a closer look at their protocols and determine if there are breakdowns or workarounds in the system that are contributing to waste and unsafe procedures. • Keeping qualified Sailors who have the experience and knowledge base to maintain the IMRL is important. • Accountability is the name of the game. Excessive gear and a lack of appropriate personnel to maintain and manage the gear is not a best practice. • You will rarely be issued additional IMRL items above your allotted amount. • It takes your individual vigilance to ensure safety and there is no better time to start than now. U.S. Navy photo by Mass Communication Specialist Seaman Alexander Williams Bottom Image: U.S. Navy photo by Mass Communication Specialist 3rd Class Alan L. Robertson
MECH 21
Ground Handling Complacency By GySgt Stanley Berry
We have all heard the saying that “complacency kills.� That statement cannot be argued; therefore, it must be reinforced. Everyone is guilty of it. Complacency is human nature anytime repetition or high tempo are factors. It is no different when it comes to aircraft maintenance and ground handling. From April 2019 to April 2020, there were over 100 groundhandling mishaps throughout the fleet and nearly all of them had complacency as a contributing factor. These mishaps include towing evolutions, wing fold or spread impacts, driving support equipment into aircraft and manual blade rotation impacts. During this timeframe, groundhandling mishaps accounted for nearly eight million dollars in aircraft damage and 20 injuries. Complacency also creates an increased maintenance tempo from the loss of aircraft available for the flight schedule due to increased turnarounds, scheduled inspections, configuration, and movement of available aircraft. In February 2020, I completed a study on the impacts of crunch mishaps in the F/A18E/F Super Hornet and EA-18G Growler
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communities from FY-15. While applicable to all Type/Model/Series (T/M/S), this study displayed a significant impact in monetary repair costs, replacement parts, reduced aircraft availability for training, unscheduled maintenance man-hours, and a drain on an already exhausted parts supply system. Figure 1 displays the rate of ground handling mishaps in the past year by T/M/S. Figure 2 displays the casual factors of all the mishaps reviewed in the study. Nearly 80 percent of all aviation mishaps and hazards are due to human causal factors or errors, and almost all of them are avoidable. To achieve our goal of zero preventable mishaps, we must seek innovative ways to mitigate the human dimension’s risks in the man-machine-environment interface that leads to error-based mishaps. While aircraft across the Naval Aviation Enterprise (NAE) are increasingly technologically advanced, the training for aviation maintainers in terms of quality, sophistication, and training media is not keeping pace. The result is a default in reliance on on-the job training (OJT). The study sought out emerging technologies such as augmented
Figure 1
reality, holograms and virtual reality, which are within our grasp to build tools to influence the cognitive domain and make our aircraft maintainers better. These technologies would be similar to simulation training for pilots, allowing maintainers to get repetitions on specific tasks anytime without the burden of time and opportunity constraints. In the meantime, unit leadership must stay vigilant and ensure tow tractor licensing and training, tow crew supervisor training, briefs, maintenance publications, and collateral duty inspector (CDI) training are utilized effectively and efficiently to overcome the trending ground handling mishaps. As with most issues, continuous leadership and supervision are among the best course of action to mitigate complacency and reduce accidents from ground handling and most other incidents. The best performing commands the Naval Safety Center assesses have CDIs, quality assurance representatives, Chiefs and staff non-commissioned officers that are continuously on the flight line and inside the hangar, monitoring daily activities.
Figure 2
Drawing by Catalina Magee
Ground Loops Follow proper safety practices to reduce the risk of accidents. Electrical cables, tow bars, hoses, chocks, improperly stowed tools, test sets and general clutter can trip you up. Proper lighting, awareness of your surroundings and attention to detail can keep hangar and flight line or deck accidents at bay.
MECH 23
WHAT`S IT WORTH? Is your paycheck worth following the book? By AECS (AW/SW) MICHAEL PEREZ During our safety assessments, one theme we typically witness is Technicians not having the publications on the job. Though it may seem like a pain for someone to have to verify procedures are being followed, there is a steep cost in choosing the former and it is paid for time and time again. This goes along with time wasted by having to complete the job correctly the second time around. This practice of not following the written procedure plagues every platform flown by the Navy and Marine Corps. Below are some mishaps avionic shops have caused by not following written procedures.
SECURED DOG HOUSE
In an F/A-18F squadron, technicians routed a wire bundle incorrectly, causing an arc to gouge a RADAR waveguide switch filter. Cost? $32,554.
Photo by AECS Michael Perez
In an E-6B Mercury squadron, a contractor upgrading the IFF Mode 5 burns out multiple components. Procedures require the installation of a jumper wire across the AC/DC circuit busses. The procedure also requires that this jumper be removed after the installation of Mode 5. The contractor failed to follow this portion of the process, causing a self-induced short in multiple electrical and avionics systems. Cost? $226,131.
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In an MH-60R squadron, a technician (not wearing eye protection) cutting some safety wire on an (Electronic Support Measures) ESM antenna had a piece of safety-wire hit his eye. Cost? Near loss of an eye. In an MH-60S squadron: Maintainers did not follow procedures when folding a tail rotor pylon. Battery power was not applied when the tail rotor pylon was folded and no tail rotor boot was installed. After folding the pylon,
gusting winds caused the tail rotor to freely windmill at dangerous speeds. More procedures were not followed and maintenance personnel applied power to the aircraft with the tail rotor already windmilling, extending the indexer and resulting in it shearing off. Cost? $45,923. These costs don`t account for all of the unplanned maintenance manhours when squadrons are already short on manpower and experience. This also does not account for the added strain placed on a stretched supply system, the number of days the aircraft was unavailable for missions and the list goes on. The good news is that not all squadrons operate this way. On our last assessment in Guam and Okinawa, most technicians had their procedures with them during their assigned tasks. Taking it a step further, some of the best squadrons assessed have the leadership in place that get out from behind their desk and to the flight line, in the hangar bays or on the aircraft. With technicians taking pride in their work and supervisors instilling a culture of excellence, will a squadron’s maintenance department ensure our aircrafts fly and return safely, while growing inexperienced Sailors and Marines into our future fighting force? The photo featured demonstrates how this squadron is doing procedures correctly. An unsecured hydraulics bay cover, aka “Dog house,” can do some intense damage if caught by gusting wind, rotor wash from an adjacent turning helicopter or the immense blast of jet exhaust from a Super Hornet as it turns on the flight deck. The damage done can range from smashing its windscreens, impacting rotor blades, or impacting the leading-edge flap of a nearby jet. So, kudos to the squadron for doing it right, following procedures, having the right people on the job, supervisors and Quality Assurance getting out from behind their desks.
AVOID MISHAPS Before I even attempted my pre-op, he said, “Don’t use this tractor.” I quickly glanced around the front of the hangar to see another tractor that belongs to our squadron. Instead of taking the time to walk back in and check out this tractor, I performed the pre-op on it, hooked up the power cart and proceeded to aircraft 305 to perform the RADALT maintenance.
Scene Camera Operator: PH1 Brien Aho, USN
DO WHAT`S RIGHT By AT2 EDWARD HOLM
It was a typical day. Our squadron had just finished a 10-month deployment and half the squadron was still on leave. After we did a FOD Walkdown, my LPO came back from the maintenance meeting and said we had a Radar Altitude (RADALT) issue on Aircraft 305 that required maintenance. Being a CDI for the last six, almost seven years, I knew what needed to be done. I was the only qualified tractor driver in the shop, so I went through the right steps necessary to check one out. I grabbed a tool tag, checked it out in the tool log and headed over to airframes to check out their tractor. An AM3 in airframes signed out the tractor to me and gave me the 52 cards. I headed out to the front of the hangar where it was parked. As I walked up, one of our QARs was doing a pre-op on the tractor I just checked out.
As we were wrapping up the RADALT on 305, the Line Division supervisor drove up in the tractor I had been told not to use. He parked the tractor in front of the nose of aircraft 305. He wanted to swap tractors to complete aircraft moves and mentioned the gas pedal might be sticking. Now at this point, I should have said, “No, I don’t want to use this tractor.” I should have informed him that QA just said the tractor should not be used. If I had said one thing, I could have prevented the mishap that was about to ensue. As a leader and a seasoned second class, I should have spoken up. The swap occurred and I hopped into this tractor that I knew had issues. The pedal stuck before I even switched it into drive. Once in drive, I could feel the tractor inching forward even with my foot on the brake. In my head, I figured this was going to be an easy job and drove the tractor between two of our aircraft so I could hook up to the power cart. I rolled in front of the power cart as I’ve done so often and tried to put the tractor in reverse. I kept hearing the engine rev and rev, but the tractor would not go into reverse. At this point, I figured why not just go forward, between the two aircraft and take the tractor back to the hangar. I can’t get it to reverse, so why not just take it back to the hangar and get the power cart at a later time? I attempted to do this. As soon as I let off the brake, I felt the tractor lunge forward, impacting the starboard wing of one of our aircraft.
This is one of the reasons we don’t drive in between aircraft. These are the precautions we get trained on. The impact stopped the tractor. I immediately shut it off and ran to Maintenance Control and told them what had just happened. In the coming weeks, what ensued was a series of investigations resulting in a Class B mishap with 1.4 million dollars in damages. Could this have been prevented? Of course, I should have said, “No, I’m not taking this tractor.” I should have informed the Line supervisor when he initially drove over to me that he shouldn’t be driving that tractor, to begin with. I knew that tractor had issues and I shouldn’t have tried to drive it between aircraft. I could have told the Line supervisor, “No, it is not OK to take the good tractor I have.” I should have walked back into the hangar and checked out the good tractor as soon as QA told me the tractor from airframes was bad. Not following the correct procedures and even taking shortcuts can have disastrous consequences. The impact caused damage to the aircraft launcher, outer wing and aileron. Weeks later, the Line supervisor and I had gone to DRB and we both lost our tractor qualification. We had to make multiple statements to QA, the command and safety. I had to go to medical to make sure I wasn’t under the influence. The number of hours wasted, which could have been utilized elsewhere, was damaging to the entire squadron. Additionally, I damaged my reputation as a leader, undermining my leadership. How could I expect to be a leader if I don’t even follow the correct procedures myself? As leaders, we need to do the right thing and say “no” when you see something being done improperly. The proper procedures are there because these types of mishaps have happened before.
One missed step ends in disasters like this. Simple and easy actions such as tagging out broken GSE could prevent huge mishaps. The biggest thing I have learned from all of this is always to follow procedures, small or big, it doesn’t matter. Be a leader and do what’s right, never take anything for granted and do everything correctly by the book.
MECH 25
Tractors Don’t Hurt Airplanes; People Do! “Same day, same two tractors”
By AT2 Adam White
Photo by Senior Airman River Bruce
How do you prevent a tractor from driving into the wing of an airplane and causing $1.5 million worth of damage?
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The obvious answer is, don’t drive a The assistant tractor towards crew chief helps an airplane. Now align the tractor I didn’t directly drive this tractor on the flightline. into an aircraft, but my actions, or lack thereof, directly contributed to this event happening in my command. So let’s dive into this event and see where everything went wrong. It was our first day back at work after having three weeks of post-deployment leave from what many of you have heard was a “not so fun” ten months onboard USS Abraham Lincoln (CVN-72). After our morning maintenance meeting, we (the line shack) had many airplanes to shuffle around between the line, the hangar and the wash rack. I knew that my work center did not have custody of a tractor, so I went to the shop that always does, airframes. I went to airframes and asked the supervisor if they had a tractor that I could borrow for the plane moves that I needed to complete. I was told that they did, but also that the QA from the squadron next to us had found a spring during their FOD walk down, and once that squadron realized it didn’t belong to them, they came over and brought it to our QA. Now, this wasn’t just any normal spring. This spring was larger than most and resembled one that would be attached to a throttle assembly. Our QA conducted their search of the tractors in our command’s custody and found that it came off of the tractor that belonged to airframes. During this
conversation, I was informed that the throttle did not completely return to its idle position. Now, let’s pause right there. When someone tells you that the throttle, an essential part of a tow tractor does not come back to its idle position, I believe that nowadays, the majority of the people would say, “OK, your tractor is broken. Got it.” But this did not cross into my mind. My immediate thought was, “OK, so I’m going to have to use the side of my boot to return the throttle to idle.” And I also believe that many people have been there. I did not slow down and take the time to think about the what if’s in this scenario. I was still in the mindset of ‘go, go, go’! Had I stopped and taken the time to ask the next question that most people would now ask, “Does your tractor pass preop?” the story would stop here, but it doesn’t. So let’s continue. So since I never asked the question, I was never told that the tractor could not be operated. So I proceeded out to the flight line, where I was told the tractor would be since the ATs checked it out from them earlier. Why was the tractor checked out to the AT’s, you ask? I can’t answer that at this juncture of the story. Upon walking outside of the hangar, I found myself standing next to the tractor that was “checked out” by the ATs. There were no ATs present because they had a different tractor hooked up to the power cart on the line working on one of our jets. I conducted my walk around the tractor that I was now standing next to. When I got to the point where I was verifying the throttle, which is at the end of the pre-op, I noticed that it did not fully return to its idle position.
So, here is the second step where I failed that day. I’m willing to bet that many people in the military have driven or operated GSE that did not FULLY pass a pre-operational inspection. This is not the right way to do business. So why didn’t I stop when the throttle didn’t fully retract? Because my first thought was, “I need to get the job done.” I was not rushed; I repeat, no one, not even Maintenance Control rushed me. Surprising, isn’t it?
Looking back on this, I could’ve easily parked this “down” tractor outside the hangar, walked out to the flight line, borrowed the tractor, and picked up the power cart later when I was done moving jets. But I didn’t, so the story must go on. I parked on the flight line in front of the jet that the ATs were working on. I spoke with their supervisor, who is also a friend of mine, and told him what was wrong with the tractor.
At this point in the story, most people are like, “No way maintenance wasn’t rushing them!” But I can assure you; they were not. I simply just wanted to get the job done so that no one was waiting on us (the line shack) to be able to do their job. This was my second opportunity to stop what I was doing and find a tractor that passed its pre-op. From here, I hopped in the tractor and went to the first aircraft that I needed to move. But wait! I didn’t sign a pre-op card! Well, this is because it was signed out to the ATs that were using a different tractor. And since I was never told that the tractor was in a “down” status, I put trust in the others in front of me that performed the pre-op before my using it. Let’s think about that.
After our conversation, he let me take his tractor to make the plane moves and leave the “down” tractor with him. I disconnected his tractor, which was parked in between two of our jets, hopped in and took off. Remember, I told you at the beginning that I did not personally drive into the jet. I moved my jet out of the hangar, took it to wash rack, grabbed another jet off of the line and backed it safely/masterfully into our hangar. This is when the ATs, my friend, came walking through the hangar “with a purpose.” You could see it in his face that something was wrong.
Think about how many times we had put our trust, or faith, in that someone before us and did what they were supposed to do. Why do you think we do that? Is it because we are friends with that person, and we don’t want to question them, or do we just get so used to the same routine that we think “they” must’ve done it? Why don’t we question this when it comes up? I mean, it’s our job right, to question the things that sound a little off?! So, I got in the tractor and slowly made my way into the hangar to conduct our first move. I had to park it and get out to move some SE out of the way when I realized I’m not comfortable driving this tractor close to everything that was in our hangar. I told our hangar bay Chief what was going on and that I would swap it out with the tractor on the line. Hold on! I’m going to drive this tractor to the line now? It never crossed my mind. I took it out to the line, so I wasn’t leaving my fellow teammates without the SE they were using to put the power cart back when they were finished with their work.
As he was walking towards the door to Maintenance Control, he looked at me and said, “I just crashed into a jet.” I could’ve heard a pin drop after he told me that. It wasn’t just a “hit the wing” kind of crash. He hit the launcher on station 11, driving under the outer wing and into the trailing edge flap. In short, a Class B mishap totaling around $1.5 million worth of damage on our first day back at work. Welcome home, right?! As I mentioned throughout this story, I failed on multiple levels during this evolution. I could have spoken up and asked the simple question at the beginning, “does this pass preop?” I could have parked the tractor after conducting my personal inspection when I noticed that the throttle didn’t fully retract. After all that transpired, here is what I knew: The ATs checked out the tractor from airframes and were given the pre-op card first thing. While this was happening, QA had been given the spring from our neighboring squadron and told the ATs not to use it. QA then went to airframes and told “someone” that their tractor was down and not to operate it. The ATs got another tractor and went to do their job but did not check that one out.
I was never told not to use the tractor from airframes because the individual that QA had told prior to that was not in there and the information was not passed on. When I swapped out the tractor on the line, it was with the AT that QA told not to use the tractor that I had driven out there. All in all, it was a complete mess and a reason why everyone in the Navy says “communicate.” It was not his fault that day. We all failed him, as we all failed ourselves. Had any of us stopped and took the time to do the right thing (put a sign on it, complete a proper pre-op, etc.), all of this would’ve been prevented. I failed as a leader and a friend. It’s easy to overlook this with everything that transpired that day, but in the end, I simply failed. I have been in the Navy long enough and sat through more than plenty of ORM and safety briefs to know that I should’ve slowed down and been methodical in my processes. As leaders, we need to remember that our junior Sailors are looking to us to set the example. Even when we don’t think that they are watching, they are. They want to see what we do, how we do it and emulate that to be successful. I sat down and spoke with one of our pilots after this event. I’ve always been able to talk to him, and even vent to him. Regardless of rank, he has always been one to ask, “How are you doing?” And not just because that’s what everyone says in passing, but because he would genuinely want to know how you were doing. He’s always listened and gave feedback, which to me felt more like guidance (even if he didn’t realize it). At the end of our conversation that day, he left me with this: “I think we often get too ahead of ourselves in life. We often forget to take the time to sit back and think about what we’re doing.” Hit the head on the nail! Many of us have done these tasks so many times that it now feels like second nature. So this is not a HE story; this is a “we” story. We caused a Class B mishap, the first day back from leave, after what ended up being a successful ten-month deployment simply because we failed as leaders. Mistakes are going to happen. “To err is to be human.” All I ask is this: please take the time to learn from our mistakes this day; please take the time to “do it right.” Don’t just do it for yourself, but also for the others that may be looking to you for guidance, even when you don’t realize it. They will be the ones that replace us in the future, so let’s make sure we leave this place better than we found it.
MECH 27
BRAVO ZULU
AWO2 Margaret T. Bowden YOUR PHOTO Petty Officer Bowden observed a major safety concern HERE during the pre-flight of an aircraft. During the external preflight, Petty Officer Bowden noticed a loose screw hanging from the P-8A’s EO/IR turret. After a closer inspection of the turret assembly, Petty Officer Bowden found multiple screws not completely fastened and several loose screws laying on top of the turret assembly. Petty Officer Bowden notified the plane captain and Patrol Plane Commander of her findings, the crew then swapped aircraft and avoided a possible mishap. For her actions AWO2 Bowden was awarded the Squadron Safety Professional Award.
Bravo Zulu is a naval signal originally sent by semaphore flags that means “Well done.” The origins of “Bravo Zulu” are in the Allied Naval Signal Book, which for decades has been used by members of the North Atlantic Treaty Organization (NATO), established in 1949. You too can be featured here!
AE2 Wayne Ragas During a ready preflight, aircrew conducted high frequency radio ground checks with a Sailor inside the Electronics and Equipment Bay. AE2 Ragas recognized one of his fellow Sailors was unaccounted inside the Electronics and Equipment bay so he approached his supervisor and immediately halted the unsafe evolution. AE2 Ragas’ decisive and assertive action prevented severe injury to his shipmate. His actions are to be commended as he maintained the high safety standards required for safe operations. A big heartfelt Bravo Zulu to AE2 Wayne Ragas!
AWO2 Rylan Prado AWO2 Prado was acting as the safety observer for a P-8A flight. Preflight was completed without incident but AWO2 Prado didn’t let his guard down. He was in the starboard observer seat for engine starts when he noticed a pen underneath the engine nacelle. He immediately notified the Patrol Plane Captain (PPC) to abort the start and ensured the FOD was removed. His attention to detail and quick, efficient communication prevented a hazardous situation from developing any further. AWO2 Prado was awarded the Commander, Patrol and Reconnaissance Group (CPRG) Safety Pro Award for his actions.
AM3 Dominic Sizemore Congratulations on his selection as a Patrol Squadron SIXTEEN (VP-16) ‘Safety Pro’ for JUNE 2020 for exceptional professionalism while attached to VP-10. On 31 May 2020, while replacing a red engine cover that fell off a VP-16 aircraft, he identified a significant hydraulic leak coming from the aircraft’s main gear wheel well. AM3 Sizemore promptly notified Maintenance Control and had the leak repaired, returning the aircraft to service with no impact to Commander Task Group (CTG) 57.2 operations. His steadfast awareness and overall motivation prevented a potential mishap.
SUBMISSION BZ SUBMISSION GUIDELINES GUIDELINES
Please use the following guidelines when submitting BZ Nominations. Send us a written article (as the above featured BZ stories) at: SAFE-MECH@navy.mil
PHOTOS All photos must be good, clear quality, and in high resolution (300 DPI) or larger than 1MB (per image).
ARTICLE BZ Nomination article length: 90-150 words
When you e-mail your BZ Nomination, include the file and photo. Also, use the author’s name as the filename. Example: CatalinaMagee.doc.
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AN Dimayuga and AN Sanchez Ortiz On 21 November 2019, while Airman Dimayuga and Airman Sanchez Ortiz conducted a preflight walk around Aircraft 169011, they noticed a loose screw on two separate starboard elevator cable access panels. They immediately notified the PPC and radioed Maintenance Control for airframes assistance. After further evaluation by the 120 Collateral Duty Inspector (CDI), it was determined that incorrect screws had been installed on the panels, which caused the screws to back out and protrude. The screws were immediately removed and replaced with the correct ones. Had the Airmen not noticed this discrepancy during their detailed walk around, those screws could have backed out all the way, posing a major FOD concern for all aircraft on the taxiway and runway. For their situational awareness and attention to detail, AN Dimayuga and AN Sanchez Ortiz were awarded Squadron Safety Professional Awards.
SAILORS AND MARINES PREVENTING MISHAPS
Sgt John Ward III and Sgt Kyle Putnam
LS2 Christion Rawls A Bravo Zulu to LS2 Rawls of Strike Fighter Squadron TWO SEVEN (VFA27), attached to Carrier Air Wing FIVE (CVW-5) embarked onboard USS Ronald Reagan (CVN-76), for discovering the carbon dioxide cylinders supplied for all Air Wing float coats onboard were too large. He quickly realized the supplied canisters, if activated, would rapidly over pressurize the float coat bladder, causing them to rupture. He immediately notified the command material control officer and USS Ronald Reagan S-6 Division Officer. His action led to the expeditious addition of the correct cylinders to the Fleet issue load list, ensuring onboard stock availability to all air wing squadrons. Petty Officer Rawls’ attention to detail and sound judgment reduced potential injury and ensured eight squadrons were outfitted with proper flight deck safety equipment. Bravo Zulu, LS2 RAWLS!
ARTICLE SUBMISSION GUIDELINES
E-mail all the stories to: SAFE-MECH@navy.mil Short story: 450- 500 words Long story: 1200-1600 words News briefs: 500 words Photos are encouraged, but optional.
While conducting a functional check flight, the test pilot experienced binding flight controls when applying pressure to the right pedal. The pilot debriefed Quality Assurance that the binding felt like 10-15 pounds of extra pressure to operate the right rudder pedal. During troubleshooting, dayshift airframes mechanics moved the rudder by hand and manually felt the friction point. NATEC Fleet Support Representatives aided in the correct diagnosis of a faulty spring cartridge in the aircraft’s nose. Once the installation of the new spring cartridge was completed by nightshift airframes Collateral Duty Quality Assurance Representatives, Sergeants’ Putnam and Ward III, the binding in the rudder was still present. With the faulty spring cartridge replaced but the binding still present, both sergeants continued to troubleshoot to find additional discrepancies. After several hours of troubleshooting, they discovered that the rudder flight control cable was frayed at a pulley aft of frame 38, near the tail of the aircraft. Locating the frayed portion of the cable was difficult because it was concealed behind the On-Board Oxygen Generation System (OBOGS) concentrator inside panel 61. Upon a closer examination of the immediate area, a rivet buck tail that had been drilled out in a previous repair was found entrapped in the grease lubricating the channel of the aft pulley that the cable ran through. The rudder flight control cable had been chaffing against the rivet whenever the rudder pedals were actuated. This discrepancy already caused significant damage to the cable, and over time would have caused the rudder flight control cable to break, resulting in a catastrophic event leading to potential loss of aircraft and possible physical injury to the pilot. Due to sound maintenance practices, extensive troubleshooting, and attention to detail, Sergeants’ Putnam and Ward III identified and corrected a complex, nonstandard malfunction within a flight control system and prevented the potential loss of an aircraft and injury to aircrew.
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Hole in the hand By AMCS Thomas Matthew Fain Each member of a move crew is armed with a weapon to prevent accidents, a whistle. Just blow the whistle and the move will stop. Well, that’s the way it’s supposed to work. Recently, a squadron’s night shift Maintenance Control told a move crew, which consists of a move director, brake rider, two wing walkers and a tail walker, to come to maintenance and conduct a move brief to tow an aircraft to the paint hangar. After going over the move brief sheet with everyone, the line checked out their cranials and whistles and headed out to hook up the aircraft and tow it down to the hangar.
It is squadron policy to have an E-7 or above to move aircraft in and out of hangar bays. Well, this squadron only had one E-7 or above on this particular night. The maintenance Chief told QA to sit at the maintenance desk so he could watch the move. The hangar already had one aircraft in it, so it would be a tight fit to squeeze two inside. The maintenance Chief was on the right side of the aircraft to ensure the aircraft already inside wasn’t going to be hit. The move crew had whistles in their mouths ready to blow them if something wasn’t going right, or if the aircraft got too close to anything else. The tow tractor driver slowly started to back the aircraft into the hangar bay. The aircraft had to come in at an angle and then be swung around to the left to straighten it out once it was inside the hangar. A faint sound of a whistle was heard and the tow tractor driver hit the brakes as soon as he heard it. Then the whistle became loud and frequent after the aircraft had come to a stop. The Chief ran over to the sound and saw what had happened. The wing walker on the aircraft’s left side had his hand pinned between the horizontal stab and the wall brace of the hangar. The Chief immediately told the driver to pull forward to free the injured Sailor’s hand. The two then ran into the maintenance hangar and called an ambulance because the hand was bleeding profusely and
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was mangled pretty bad. Another wing walker took action and wrapped the Sailor’s hand in a rag and put a belt around his upper arm to slow the bleeding. The wing walker’s hand was able to be saved because of this quick action. It is a standing policy for this squadron to blow the whistle if within three feet of another object. If the personnel had followed this policy, a Sailor wouldn’t have nearly lost his hand.
TAKEAWAYS FROM THIS ACCIDENT: •
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The squadron should have more than one E-7 or above on every shift. The Chief needed to return to the maintenance desk, so he was in a hurry to get the aircraft into place. People should blow their whistles as loud as they can so everyone can hear them. If the Sailor had blown the whistle loudly, the tow tractor driver might have stomped on the brakes and stopped short of crushing his hand. If you are moving an aircraft into a space that is out of the normal, have another meeting at the space in question to go over the plan and to ensure everyone is on the same page. Do not put any body part between the aircraft and another object!
N R U T E H T E R O EF
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VE. THE MO H IT W LVED E. EL INVO N N O HE MOV S T R R E O P F L L L ONNE F TO A ED PERS RM BRIE IR O OLS U N Q A E R M R HE S OR TO T E L L T L IS A . PERFO H E AV VE W E YOU H NNEL HA O S R . ENSUR E P IALL. E ALL T, CRAN H IG . ENSUR L H S NT. FLA QUIPME E T R O P T. THE SUP PRESEN P R O E E D R A P E . AKI L E IS A KH R E H T E . ENSUR
FLIGHT CONTROLS HITTING OPENED PANELS DUE TO SWITCHES OR COCKPIT CONTROLS NOT IN CORRECT POSITION, PANELS THAT WEREN’T PROPERLY INSTALLED, FASTENERS THAT WERE NOT PROPERLY INSTALLED, AS WELL AS ENGINES INGESTING FOD HAVE BEEN A LEADING CAUSE OF HORNET AND GROWLER CLASS B AND C MISHAPS.
Photo illustration by Catalina Magee
