Learning from the Past

By AWSCS (AW/SW) Wade Hove

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.

12 MECH

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. 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 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.