U.S. Navy photo by Mass Communication Specialist 3rd Class Zach Dalton
RUDIMENTARY ROUTINE By Lt.j.g. Kevin Gable Quite often, the word “routine” is used to describe activities done on a normal basis or in an everyday manner. These actions might be as simple as driving to work or answering the phone. In many occupations, the routine can seem mundane, completed at a subconscious level without the need for prior planning. In aviation, however, there is never an instance in which “routine” describes any evolution. From the beginning of flight training, aviators are taught about the Swiss cheese model. This metaphor is used to describe a sequence of seemingly unrelated events, which if left uninterrupted, create an opportunity for a catastrophic occurrence. The following story, from a few days into a P-8A squadron deployment, highlights a series of events culminating in an incident that could have resulted in fatalities. At numerous points in this story, missteps could have been corrected if those involved had not treated this scenario as routine. In December 2020, after a brief holiday reprieve, a maintenance team was busy wrapping up a scheduled inspection and implementation of a technical directive (TD) on a P-8A Poseidon, which required power to be applied on the aircraft. This maintenance action was a fairly simple task for a highly trained maintenance team with countless hours of experience removing and replacing parts. However, when an aviation electronics technician (AT) collateral duty inspector (CDI) became startled by the sparking of an intentionally loose wire on a 28 Vdc/100 amp circuit grounding on a nearby metal interior component, this scene strayed far from a simple maintenance action.
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The quality assurance investigation later revealed the aircraft maintainers who removed the equipment failed to secure power via the appropriate circuit breaker.
