The Royal Maces

By AD1 (AW) Luckyralp P. Baun and AD1 (AW) Evelyn Kamiri

“IT WAS A BEAUTIFUL SUMMER EVENING ONBOARD THE USS RONALD REAGAN (CVN-76). NOTHING WOULD MAKE ANYONE BELIEVE THAT THIS NIGHT WOULD END UP RESULTING IN AN OVERSIGHT THAT CAUSED CONSIDERABLE DAMAGE TO AN AIRCRAFT. ”

#3

On the flight deck, Sailors attached to Strike Fighter Squadron 27, the “Royal Maces,” were executing a high-power turn-up evolution on one of their F/A-18E Super Hornet aircraft. Side number 205 just received a new set of afterburner spray bars and made a pleasant growl while the maintenance crew swarmed its sides in anticipation of afterburner flames. Ten minutes into the job and just before the great afterburner flames could come to life, fasteners started flying, leaving one composite door crunched, a trailing edge flap mangled and maintainers wholly demoralized.

Power plants had been one of the backbone workcenters throughout the deployment. Due to high operational tempo, mechs had endured an onslaught of unscheduled maintenance, tackling a significant amount of aircraft discrepancies brought back from routine flight operations.

Due to the COVID-19 environment, the Royal Maces were stuck between low morale and repetitive maintenance, resulting in a level of complacency that proved to be dangerous when not combatted by thorough adherence to procedures and attentiveness to their surroundings.

12 MECH

Shift change occurred on the flight deck at 1700. It was well into the middle of a hectic flight schedule when the night shift came up to the weather decks to relieve the day shift.

Aircraft 205 was prepared for a highpower turn, which is done to check engine specifics related to maximum thrust, or afterburner, following Technical Troubleshooting Manual A1-F414ATTM-000. Night shift performed an operational check on the long afterburner spray bars and primary bleed air pressure regulating shutoff valve. A newly-created turn crew consisted of a turn operator, plane captain, two safety observers, flight deck Chief, technician and a collateral duty inspector. The team was composed of seasoned technicians and everyone knew their roles in the event.

Everybody manned their positions and was ready to roll. The team had been waiting a significant amount of time and the sun was starting to set over the horizon, blanketing the deck and everyone in darkness, leading to a feeling of complacency and eagerness to start the evolution. After waiting for what felt like an eternity, the flight deck Chief finally signaled them to start the auxiliary power unit.

Photo courtesy to the writers

Both engines came online. Flaps were open. After receiving permission from the plane captain, the collateral duty inspector and his technician approached the starboard engine bay doors to open door 64. As soon as the door came open, the inspector got the plane captain’s attention and handsignaled for an engine cross-bleed to leak-check the shutoff valve. The hand signal, in reference to NAVAIR 00-80T-113 for plane captains, for cross-bleed is an “x” created by either both hands in the daytime or both light wands during a night evolution.

The plane captain saw the signal, but unfortunately, he misinterpreted it for a “close flaps” signal due to the poor visibility. Closing the flaps is relayed by creating a horizontal “v” with both hands closing together. If given at certain angles, this signal can be misconstrued for the cross-bleed signal, especially during low visibility conditions. Without hesitation, the plane captain relayed the turn operator’s misinterpreted signal, resulting in the operator moving the flap switch from full to auto. Almost immediately, the flight surfaces moved. The technician had positive control of the door and was the first to react by closing the door, but it was too late. Within seconds, fasteners started flying on the flight deck as the trailing edge flap crunched the engine bay door. The flap incurred a jagged 3-inch gash and the door 64 hinge was bent and cracked in several places. Flight surface repair was beyond O-level capability, meaning it could not be done at the squadron level and had to be replaced. The most significant result was that a reputable maintenance crew had lost momentum; their confidence had taken a significant hit. Upon reviewing procedures, conditions and other contributing factors, it became clear that the “swiss cheese concept” is not an empty theory.

Environmental conditions, visibility, poor hand signals, the maintainers’ mental state,communication before the turn and even crew confidence – all, just like cheese holes, lined up to contribute to the accident.

What could have been done to prevent this mishap?

The answer is not simple; it is easy to say, “Don’t mess up,” but it does not accomplish anything. As Naval Aviation Enterprise maintainers, we must learn from each other’s mistakes; adapt to adverse conditions; stay flexible during trying conditions of a demanding deployment, but not bend beyond a breaking point and learn to slow down and remember risk management. Understanding personal capabilities and stress levels is a huge factor that should be considered when preparing and briefing a high-risk event like a high-power turn.

Additionally, the team suggested that aircraft turn briefs be conducted at the maintenance desk. The desk provides a quieter place to think clearly, have a safe for flight certifier weigh-in and it is an environment where questions are easier to both ask and answer. Specifically, the sequence and hand signals expected in the evolution should be briefed, so everyone is on the same page if there is confusion on the flight deck.

The Royal Maces recovered, learned from the mistakes, shared their experience with the team and continued the deployment with a new goal in mind and a familiar mission to fulfill.

U.S. Marine Corps photo by Cpl. Darien J. Bjorndal, 3rd Marine Aircraft Wing/ Illustration by Catalina Magee