A Better Idea

#7

“.AS STAFF AT THE NAVAL SAFETY CENTER, WE OFTEN SPEND A GOOD PORTION OF OUR DAY READING THROUGH MISHAPS AND SAFETY REPORTS THAT COME TO US FROM FAR AND WIDE, WHEREVER THE NAVY OPERATES.”

“WE USUALLY SEE SIMILARITIES IN MISHAPS AND HAZARDS ACROSS DIFFERENT GEOGRAPHICAL REGIONS AND OTHER AIRCRAFT TYPE MODEL SERIES. THE PROBLEMS WE OFTEN SEE ARE NOT UNIQUE TO ANY SINGLE SQUADRON OR COMMAND. ONE OF THE COMMON ISSUES WE SEE IN THE SAFETY REPORTS AND THE FLEET DURING SAFETY ASSESSMENTS IS THE NORMALIZATION OF DEVIATIONS. WE ENCOUNTER THE SAME SITUATIONS OF AN UNAUTHORIZED TOOL OR PROCESS BEING USED AT COMMAND FOR AS LONG AS ANYONE CAN REMEMBER. THERE IS OFTEN NO CLEAR PICTURE OF WHEN THE DEVIATION STARTED, WHOSE IDEA IT WAS OR WHO ALLOWED IT TO BECOME STANDARD PRACTICE.”

A Better Idea

“REGARDLESS OF THE START, WE SEE THAT THE PROVERBIAL “SWISS CHEESE” FINALLY LINES UP, A MISHAP OR HAZARD HAPPENS AND SUDDENLY, EYES ARE OPEN TO REALIZING THAT ALL ALONG SOMETHING HAS BEEN WRONG RIGHT IN FRONT OF EVERYONE’S EYES. THE AVIATION SAFETY ASSESSMENT TEAM HAS WITNESSED FIRSTHAND MAINTAINERS PERFORMING MAINTENANCE WITH INCORRECT OR UNAUTHORIZED TOOLS, SUPPORT PERFORMED WITH NO PUBLICATIONS, IN A SEQUENCE THAT GOES AGAINST PROCEDURES OR BLATANT SAFETY VIOLATIONS. WHEN ATTENTION IS CALLED TO ANY OF THESE ACTS, WE HEAR, “THIS IS HOW WE’VE ALWAYS DONE IT,” OR, “THIS WAY WORKS BETTER.”

By ADC (AW) Caitlin J. Addams

Mishaps resulting from the normalization of a deviation range from the minor lessons-learned-type incidents to severe injury to personnel and costly damage to Department of Defense (DoD) property. It’s safe to say aviation maintainers would agree that there is already enough work to do and inducing unnecessary damage and adding to an already overflowing workload doesn’t help anyone. It is easy to think that deviations can’t be that dangerous, that nothing bad has happened YET.

The problem with normalizing deviations is that an experienced maintainer may know a “better way” to do something; they teach that to the next maintainer, who teaches it to the next. Each time, another corner is being cut. It can quickly go from a molehill to a mountain. Once the culture of a shift, work center, detachment or command goes to the mindset of “it`s okay to deviate from maintenance instruction manuals, program instructions or any written policy,” the door for mishaps swings open a bit wider. All that said, there are times when anyone, from your most seasoned maintainer to the newest airman that just checked in after breakfast, may have a legitimate idea for a better or different tool to complete a job. You may have a better way to complete maintenance or know a step in your maintenance instruction manual that is wrong.

There may be an instance when a tool or piece of equipment is not available to you and a workaround must be found. The point is that there are established procedures to make changes the right way and at the right level. If there is a different tool that would make the job easier, there are processes in place in the Naval Aviation Maintenance Program (NAMP) and through all of the wing commands, to add tools. Changes to publications can be made through Technical Publication Deficiency Reports, which can also be found in the NAMP.

There are procedures to request deviations for everything from pay grade requirements to school requirements to paint schemes. There is a process to request a deviation for single events when a piece of equipment is not available. There is potentially a discrepancy with an aircraft that needs deviation authorization to get it to an area with the proper repair capabilities. The critical thing about deviating from the established procedures is to do it the right way and at the right level. Ensuring the paperwork is done means that all the appropriate parties have discussed and weighed in on the risk and benefits. Someone with the proper responsibility level will sign off and approve the action.

Many personnel are not aware of BUPERSINST 1650.13, Beneficial Suggestion Program For The Bureau Of Naval Personnel. This instruction outlines the Navy’s program that is open to both military and civilians, which rewards those with beneficial suggestions or “benny-sugs” with both awards and potentially even cash for those great ideas. Those with ideas that save the Navy time, money, improve operations, enhance productivity and output, improve workplaces, save material, introduce a new tool or piece of equipment and increase safety can submit through the program.

Just like anything else, there is a right way to deviate from current processes and procedures. If done the right way, those deviations can pay off, not only for those who make the suggestions by making their lives easier and safer, but it can also benefit those who follow. Stop and think, reflect on yourself, the shop and command and watch for normalized deviations. Stop them early before someone gets hurt. If there is a better way to do something or different equipment that is faster or easier, do your research, talk to your supervisor, your quality assurance shop and your chain of command to ensure decisions and deviations are made at the appropriate level. Do the paperwork to back yourself up!

For more information about the Beneficial Suggestion Program, visit www.public.navy.mil to find the latest instructions and program guidance.