Procedural Noncompliance: The number one Causation of Aviation Mishaps by Maintenance

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?” QUOTE BY COACH JOHN WOODEN

This 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. 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.

IT IS NO COINCIDENCE THAT PROCEDURAL NONCOMPLIANCE IS THE NUMBER ONE CAUSATION OF AVIATION MISHAPS BY MAINTENANCE PERSONNEL.

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.

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

THE WORLD OF AVIATION IS HAZARDOUS; THEREFORE, PROCEDURES ARE IN PLACE TO MITIGATE THE POSSIBILITY OF MISHAPS.

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