Deliberate Process Improvement Promoting a Culture of Aviation Safety

By Lt. j.g. Jihoon Heo, CVN 77

The phrase “written in blood” is commonly used in aviation and aviation maintenance about procedures in publications to underscore the importance of following each step in sequence, and heeding notes, cautions and warnings. Even when maintenance is completed correctly, there may be room for error.

nose gear causing the aircraft to drop. When it dropped, it struck the dolly operator on the head which was protected by a cranial. Although the Sailor walked to medical under their own power, they were flown off the ship later for further evaluation.

An investigation into the incident found the arms of the dolly failed due to a loss of hydraulic pressure. After reviewing the publications, including the pre-operational checklist, there was no step in the procedures to check the emergency spread valves. Had those been checked on the SD-1D dolly that struck the Sailor, it would have prevented the incident.

A few months later, the ship was rocking due to heavy seas and winds. A squadron checked out a utility crane to perform maintenance on a horizontal stabilizer. While performing a preoperational check, the crane tipped over, fell, causing damage to the boom cable. Thankfully, no Sailors or aircraft were injured.

Again, an investigation into the incident found that Sailors performed required pre-operational checks. However, they hand-cranked the crane above the recommended height before the legs of the crane were spread. This caused the crane to tip over. The investigation concluded that the pre-operational checklist did not mention using tie-down chains with the crane when spreading the legs and bringing the crane at full height, despite the maintenance publication outlining the requirement.

Investigators and Sailors alike thought, “If the maintenance publication says that, why didn’t the pre-operational checklist say it as well?”

After discussion with engineers and subject matter experts from Naval Air Warfare Center Aircraft Division (NAWCAD) Lakehurst, they learned that this was not a first-of-its kind incident. The engineers and subject matter experts mentioned that it had occurred on several other afloat commands.

In both cases, George H.W. Bush’s Aircraft Intermediate Maintenance Department (AIMD) submitted Category 1 Technical Publication Deficiency Reports (TPDR) which were immediately approved.

While moving an aircraft in the hangar bay, a SD-1D aircraft spotting dolly failed during the strike group’s final deployment certification exercise. The arms of the dolly separated from the

The moral of the story? Maintainers and leaders across the fleet need to be familiar with and use the Navy’s deficiency reporting programs when issues arise. It is the only way that we become more safe and efficient as an organization. The next time you are performing maintenance or conducting a pre-operational check, remember every step, note, caution or warning was written in blood.