Read Mech_Fall09.pdf text version

The Navy & Marine Corps Aviation Maintenance Safety Magazine

Fall 2009

Liar, Liar

How I Dropped the Bomb

Small Leak,

Big Problem

The Navy & Marine Corps Aviation Maintenance Safety Magazine

FAll 2009, Volume 48 No. 4

RADM Arthur Johnson Col. Mark W. Erb, USMC John Mahoney Naval Safety Center

Commander, Naval Safety Center Deputy Commander Head, Communications and Marketing

(757) 444-3520 (DSN 564) Dial the following extensions any time during the greeting Publications Fax (757) 444-6791 Mech Staff

Lt. David Robb [email protected] Ken Testorff [email protected] Patricia Eaton [email protected]

Editor Ext. 7220 Editor-in-Chief Ext. 7251 Graphic Artist Ext. 7254

Marine Corps photo by LCpl. Victor Cano


Cdr. David Peacott [email protected] Maj. Anthony Frost [email protected] AFCM Kevin Wilhelm [email protected] CWO3 S. T. Cruzpena [email protected] GySgt. Edward Rivera [email protected] AMCS Robert Chenard [email protected] AMCS Jim Litviak [email protected] Vacant ADCS Chris Smith [email protected] GySgt. John Hess [email protected] ASCS Mark Tangney [email protected] CWO5 Ron Stebbins [email protected] GySgt. Robert Linn [email protected] AZC Gainer Clark [email protected] ATCS Thomas Crook [email protected] MSgt. Michael Austin [email protected] GySgt. Todd McCreight [email protected] AMEC Eric Wickham [email protected] PRCS Rich Young [email protected] AEC James Esslinger [email protected] MSgt. John Higgins [email protected] AOCM Craig Trute [email protected] Aircraft Maintenance and Material Division Head Ext. 7265 Asst. Division Head Ext. 7223 Maintenance Master Chief Ext. 7269 Aircraft Maintenance Branch Head Ext. 7258 Airframes/Hydraulic Ext. 7285 Airframes/Hydraulic Ext. 7221 Airframes/Hydraulic Ext. 7276 Power Plants Ext. 7290 Power Plants Ext. 7218 Power Plants Ext. 7190 Support Equipment Ext. 7239 Avionics/ALSS/Analyst Branch Head Ext. 7278 Logs and Records/TD/CTPL Ext. 7074 Logs and Records/TD/CTPL Ext. 7812 Avionics Ext. 7280 Avionics Ext. 7256 Avionics Ext. 7222 Egress/Environmental Ext. 7292 ALSS/Aircrew Equipment Ext. 7219 Electrical Systems Ext. 7291 Ordnance Ext. 7140 Ordnance Ext. 7171

Front cover: A Marine maintainer inspects the tail rotor of an AH-1W Super Cobra. Navy photo by PH2 Kerryl Cacho


2 4 6 8

By AE2(AW) James Couch, VAQ-140 Fibbing about incomplete maintenance will get you more than a buttchewing.

Liar, Liar

By AM1(AW) Sherwin Briones, HSC-3 The pubs work great... when they are referenced.

Port and Starboard

By AOAN Robert Garcia, VFA-115 An ordnance newbie and his supervisor learn a 369-pound lesson about safety, supervision and communication.

How I Dropped the Bomb

By PR3 Ciera Blair, VAW-126 A junior PR calls attention to a community-wide issue.

Kinks in the Hose

Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces and put them in hospitals, wheelchairs and coffins. Mishaps ruin equipment and weapons. They diminish our readiness. This magazine's goal is to help make sure that personnel can devote their time and energy to the mission. We believe there is only one way to do any task: the way that follows the rules and takes precautions against hazards. Combat is hazardous; the time to learn to do a job right is before combat starts. Mech (ISSN 1093-8753) is published quarterly by Commander, Naval Safety Center, and is an authorized publication for members of the Department of Defense. Contents are not necessarily the official views of, or endorsed by, the U.S. Government, the Department of Defense, or the U.S. Navy. Photos and artwork are representative and do not necessarily show the people or equipment discussed. We reserve the right to edit all manuscripts. Reference to commercial products does not imply Navy endorsement. Unless otherwise stated, material in this magazine may be reprinted without permission; please credit the magazine and author. Periodicals postage paid at Norfolk, Va., and additional mailing offices. POSTMASTER: Send address changes to Mech, Naval Safety Center, 375 A Street, Norfolk, VA 23511-4399. Send articles, BZs and letters to the address above, or via e-mail to the Mech staff, [email protected] Visit us on-line at

10 12

By AE1(AW) Cody Schultz, VAQ-139 Multiple flights--one shocking discovery.

How Many Screws? How Many Flights?

By AM1(AW) Jason Hartwick and AM1 (AW) Joshua Holloway, VP-10 Not-so-fair winds and a skipped step create an unnecessary burden for these desert Sailors.

Batten Down the... Rudder?

Navy photo by MC2 Gregory Streit

Navy photo by MC2 Cynthia Griggs

14 Small Leak, Big Problem 18 20


By AMC Frederick Owens, HSL-51 A void in communications causes the avoidable to happen.

By AM2(AW) Tymond Brown, VR-57 Cautions are given for a reason.

By AM2(AW) Guadalupe Gomez, VFA-41 As this airframer learned, bad maintenance will come back to haunt you.

Was That Bushing Installed?


16 22 25 32

A pictorial homage to the people who keep aircraft flying.

Maintainers in the Trenches Bravo Zulu Crossfeed

HMH-465, HSL-49, HMM-364, VAQ-131, VAQ-133, and VR-55

Maintenance experts talk about working at the Naval Safety Center, trend analysis, quality assurance, article submissions, ALSS, logs and records, tools and Class C mishaps.

Navy photo by MC3 Torrey Lee

Mishap Stats Sierra Hotel


STATEMENT OF OWNERSHIP, MANAGEMENT AND CIRCULATION 01 October 2009 The United States Postal Service requires all publications publish a statement of ownership, management and circulation. Date ­ 01 October 2009 Title of Publication ­ Mech ISSN ­ Publication No. ­ 1093-8753 Frequency of Issue ­ Quarterly Location of Office of Publication Commander Naval Safety Center 375 A Street Norfolk, VA 23511-4399 Publisher ­ U.S. Navy Editor ­ Lt. David Robb Owner ­ United States Navy Total no. copies printed ­ 16,907 No. copies distributed ­ 16,641 No. copies not distributed ­ 266 Total copies distributed and not distributed ­ 16,907 Issue date for circulation data above ­ Summer 2009

Commands that have completed surveys, culture workshops and MRM presentations.

Liar, Liar

By AE2(AW) James Couch


am an aviation electrician's mate second class. I used to be an LPO and a CDI, but all of that changed in a matter of minutes. During flight operations aboard USS Dwight D. Eisenhower (CVN-69), my shop was tasked with repairing an aircraft that had landed with a downing discrepancy. That discrepancy involved the flightcontrol-surface trim system, more specifically, the pitch trim. I quickly discovered that the stab-trim actuator was jammed internally. Due to a manpower shortage in my shop at that time, I was picked to start the maintenance on the aircraft, with another CDI to inspect my work. I had the removal-and-installation section of the MIM printed out for the job I was doing. I signed out my tools and headed to the flight deck to begin. During the removal process, I came to a point where I had to dismount the standard centralair-data computer (SCADC) from its rack and

move it so I could continue. The SCADC is a vital component in that it receives inputs from the pitotstatic system, which in turn drives the barometric altimeter and airspeed indicator, both of which are critical instruments for the aircrew. After moving the SCADC, I discovered that I still didn't have enough room to get to a cotter pin and locking nut that I had to remove. At that point, I decided to deviate from the MIM. I disconnected the SCADC and removed it so I could access the cotter pin, locking nut, and electrical connector located behind it. With the SCADC removed, the job flew by. I removed the actuator and turned it in to supply. All I had left to do was to receive the new part and to install it. After I received the new actuator, I notified maintenance control that I had the new part and was going back to work on the discrepancy. The controller told me that I needed to expedite installation because the aircraft had been slated for the evening flight schedule. I went to work. I measured the actuator's nominal length--without a CDI to witness my



measurement--and began to install the actuator back into the aircraft. I ran into a couple of bumps and tangles in my hurry and got frustrated, but I eventually finished the installation. I reconnected the SCADC, secured it, checked my tools, and grabbed a QAR to inspect my work. This is where it all went downhill for me. Following up on his pass down from another QAR from the opposite shift, the QAR inspected my work and asked if I had disconnected the SCADC. At that point, I did the unthinkable: I lied. After talking to the QAR, I went down to maintenance control and told them that installation was complete and that they could opcheck the system. The controller also asked me if I had removed the SCADC. Once again, I lied. I walked maintenance-control personnel through my removal and installation process--quoting from the MIM-- and assured them I hadn't disconnected or removed the SCADC. I was dIsmIssed, only to be called back to maintenance control a short while later. When I arrived, I knew I was in trouble. Again, they asked me if I had removed the SCADC. Once again--

knowing I had been caught--I lied. That's when maintenance control called upon the testimony of the day-check QAR standing in front of me. It was only after he looked at me and said, "Yes, you did," that I finally `fessed up. I don't know why I persisted with a lie that was so dangerous. My reasoning was to dodge a 30-minute opcheck of the pitot-static system. I was sure the SCADC was "good" because I had worked on it. You see, disconnecting the SCADC requires a test to ensure it is working. This test could prevent something catastrophic from occurring if, for some reason, the SCADC isn't working right. But, I was in too much of a hurry to get the aircraft "up" for the flight schedule. After everything was said and done, I was relieved of my position as LPO. My status as a CDI also was terminated--all because I had been willing to sacrifice my integrity. Without integrity, there can be no trust, and how do you work with someone who can't be trusted? Integrity and trust are two things you gain over time through hard work--and that you can lose in an instant.

Petty Officer Couch works in the electrician shop at VAQ-140.

Fall 2009


Port and Starbo

By AM1(AW) Sherwin Briones hey say a picture is worth a thousand words, but it also can be worth several hours of unnecessary maintenance and wasted manhours. Relying on assumptions and perceptions often can get us into trouble. We must have a completely accurate assessment of the work that needs doing and use all the resources at our disposal to make sure that happens. We came in to the squadron, as we do most nights, expecting our nightly routine and whatever hiccups that might occur. We did a turnover for tools, got a pass down of what needed to be done, and awaited our maintenance meeting. During that meeting, we learned the priorities for what needed to be done for the flight schedule the following day. It seemed like a normal night--not too many pressing tasks but enough to keep us busy.


One task was to remove and replace a forward primary servo from the flight controls on one of our MH-60S helicopters. I did my research, checking through the pubs for the procedures. Because I had read the procedures but wasn't sure of the specifics, I asked a fellow CDI if he ever had removed a forward primary servo. I had pulled one a long time ago but wanted to refresh my memory. He had some experience, so I asked him to show me--on an aircraft--exactly what part we needed to pull. I climbed onto the squadron aircraft, while he pointed out (by gesturing from the ground) which servos to pull. It was all starting to come back to me, but I still made sure to ask which one was the forward servo. In all, there are three primary servos: forward, aft and lateral. Easy enough, right? Well, I still had to ask him how they are positioned. "How does it go?" I asked. "From left to right, or right to left?" He replied, "It's the one on the starboard side," which clicked in my head as being on the right side, right? Well, not so much. I didn't remember that the "starboard" side may actually be on your port side, depending on your orientation to the aircraft. Regardless, had I checked the pubs more closely, the illustration would have shown the proper servo positioning. At this point, I gathered up my workers, got my electronic pub, and headed out to the aircraft. Like a good CDI, I did everything I was supposed to: signed out and checked the tools,




a sailor aboard the Usns shasta (t-ae 33) attaches an ammunition crate to a mh-60s seahawk assigned to hsC-3 to be transported to Uss nimitz (CVn-68).

Navy photo by MCSN Matthew Haws

put the MAF in-work, and followed the procedures step-by-step. A couple turns of some wrenches, a few cotter keys, and some safety wire were all that was left to keep us from finishing the job. When the last bolt was pulled out, we removed the forward primary servo... or so we thought. I then began the task of ordering a replacement part. It was a "repairable," so I filled out my "removed" block. However, as I was filling it out, I noticed that the serial numbers didn't match, which seemed odd, but I still was adjusting to the new Optimized Nalcomis system and thought it just might be a misunderstanding. I remembered that the Optimized instructor once had said, "If the serial numbers don't match, don't just change it--verify it with maintenance first." Our AZ3 came in and asked if the serial number matched the one on the SRC Card. I looked and verified that the serial numbers did not match. I then noticed that the card read "Forward Primary Servo." Sensing the probable error, I went to maintenance

and asked to see the card for the lateral primary servo. Sure enough, its serial number matched the number from the part I had removed. I began to feel very foolish. The maintenance chief asked me if I had pulled the right part. I told him I thought I had, but I asked to look at the pubs one more time. Sure enough, when I looked at the illustration in the pub, it proved that I had removed the wrong one. When I let the maintenance chief know what had happened, he just shook his head at me and said, "Put this one back in and start removing the correct part." All in all, I had caused more work for the work center and for maintenance overall. It took an extra hour to reinstall the lateral primary servo and another three hours to remove and install the forward primary servo. I know now that I must look at every step and verify positions as depicted in the pubs. Luckily, the aircraft still made the flight, and nothing (except my pride) was damaged.

Petty Officer Briones worked in the airframes shop at HSC-3.

Fall 2009


How I Dropped the Bomb

By AOAN Robert Garcia


was fresh out of "A" and "C" Schools when I reported to my command. After hearing all the stories and briefs about the fleet, I was glad I finally had made it. When I saw the aircraft-laden flight line, I realized this was the real deal. I wanted to get hands-on training and learn as much as I could about doing my job on the aircraft and become the best ordnanceman possible. I spent the first week checking in and getting familiar with my new environment. I heard many safety lectures. I kept hearing one phrase: "If you're not sure about something, ask." My ordnance-team members were smart, seasoned and eager to teach me the ropes. My next two weeks were spent working 12-hour shifts on the flight deck, loading and downloading various missiles and bombs. The squadron was flying 20 to 30 sorties daily. It seemed every jet had to be loaded or downloaded every cycle. The flight deck still was very new to me. I was learning the basics of my job and the hazards of the flight deck at the same time. Seeing the busy environment and intense job I was doing made me more eager and motivated to involve myself further. Despite the blue "T" (for trainee) on the back of my cranial, I was starting to feel comfortable on the flight deck. One day, I was working on an aircraft when my team leader told me to unlock the BRU-32 on station 10 on another aircraft. I rushed to the other aircraft, knowing what I had to do. When I arrived, station 10 was empty. Station 9, however, had an improved multiple ejector rack (IMER), with a laser-guided training round (LGTR) attached to it. I never had done anything to a station with nothing on it, so my first instinct was to go to station 9, with the attached IMER and LGTR.

IMER with LGTR attached, file photo Mech


I went through the procedures I had been taught to unlock a station, and just as Sir Isaac Newton would have predicted, the 280-pound IMER and 89-pound LGTR fell straight to the deck. I was in shock and immediately ran to notify my team leader. If only I hadn't been in such a hurry and had heeded the guidance I'd heard repeatedly about being unsure, this incident never would have occurred. I since have learned you never assume anything or operate beyond your abilities, no matter how fast something needs doing. Supervisor's Notes: AO2(AW) Frank Alfano

This incident occurred right after the third recovery of a hectic day. Both aircraft came back late and were scheduled to go out on the very next launch, leaving us limited time to reload the aircraft. I had a well-trained team, except for the one new guy who had been onboard less than a month. after reloadIng the first aircraft, I began my turnaround inspection; meanwhile, the rest of the team went to the second aircraft. During my inspection, I discovered that station 10 was locked, with no simulated code. Locked stations on the Hornet are used for simulating smart weapons. Arriving at the second aircraft, I saw that the new team member was the only one not busy. I got his attention and sent him back to the first aircraft to unlock station 10. I asked him if he understood; he nodded and left with no further questions about his task. In retrospect, I should have realized why he was the only one not busy--he still was learning. He probably was not the best person for the job. I'm lucky no one was injured and that only a training asset was damaged. I would like to share some valuable lessons learned and an explanation of what I call "SSC": safety, supervision and communication. Safety: As ordnancemen, anyone can stop an evolution and ask questions at any time, no matter the situation. Supervision: As his supervisor, I should have recognized that he didn't have the requisite skills to work on his own. Communication: A breakdown in communication definitely occurred. I didn't get feedback on what he did and did not understand.

Airman Garcia and Petty Officer Alfano work in the ordnance shop at VFA-115.

Fall 2009


Kinks in the Hose

By PR3 Ciera Blair


lair, we need you on the flight deck to look at another chute!" By this point on tailored ships training assessment (TSTA), I had been hearing this phrase frequently, and I knew what to expect. I inventoried my cranial, float coat, and tool pouch and made my way up to the flight deck to see what the problem was. As I arrived at the aircraft, the plane captain told me that one of the aircrew was having a problem with his seat-parachute rigging. I looked over the seat and saw that the oxygen hose from the emergency oxygensupply system was kinked where the hose exited the seat. We don't normally look for this problem, but this kink looked bad, so before I started working on the seat, I consulted with my division LPO. She told me to pull the parachute and to replace it with another one, which I did. From that point on, we started looking at this hose on all our aircraft. We ended up finding four more hoses with kinks at the same spot--a problem we hadn't seen before this at-sea period. At first, it seemed we were the only E-2C squadron having this problem. The issue was starting to overwhelm our maintainers in I-level maintenance at AIMD because they only had so many backup parachutes. Our maintenance department soon realized we had a serious problem on our hands. Initially, our shop considered that maintainers inadvertently might be damaging the emergency-oxygen system. We held meetings to make everyone more aware of their surroundings when they were inside the aircraft. Various controls were put in place. The first of these was not taking



our tool pouches around the seats, so that the pouches wouldn't get entangled with the hose. Next, we considered that the aircrew could be contributing to the problem when moving seats and adjusting themselves during flight. We speculated that aircrew might be pushing the hose against the seat and inadvertently bending it. While it's hard to point a finger at specific people, we knew we needed to fix this problem immediately. the emergenCy-oxygen hose is a very important part of the A/P22P-20 crewbackpack assembly. If aircrew have to make an emergency escape, they would need oxygen at high altitudes. They also would need oxygen if smoke were to fill the aircraft. The aircrew connect these oxygen hoses to their CRU-103 regulators, which connect to their face masks. They then can breathe, using the emergency oxygensupply system in the seat. It could be fatal to aircrew if their hoses were kinked and oxygen could not flow freely to their masks. Soon after we identified this problem, our squadron initiated a hazrep to inform

other E-2C Hawkeye squadrons. Soon after the hazrep's release, other squadrons began to report they, too, were finding kinked hoses. They reported it was because of our hazrep that they had inspected the hoses. Some of them found as many as five damaged hoses per aircraft. NAVAIR is now looking into this issue, trying to come up with a fix. Changes also are being made to the maintenance procedures, requiring kinked hoses to be pressure checked. These tests--performed by O-level maintainers--will determine whether the kinks are restricting airflow to the masks. As a result, squadron maintenance will have less hassle because, if the hoses check good, taking them to AIMD no longer will be necessary. My big take-away from this event is that maintainers must slow down and be more vigilant when doing daily aircraft maintenance. Be careful when working around parachutes, as well as any equipment that can be damaged easily.

Petty Officer Blair works in the PR shop at VAW-126.

Fall 2009


How Many Flights?

By AE1(AW) Cody Schultz hose were the questions I got from maintenance control when I reported screws missing in the starboard wheelwell of Warcat 502. It had been more than six months since our squadron had been to the ship, and the workup cycle was upon us. The squadron was a week into tailored ships training assessment (TSTA) on board USS Ronald Reagan (CVN-76), preparing for more training flights. Earlier, I had made my way to the flight deck to prepare the aircraft for its first flight of the day. As I had approached the aircraft, the plane captain had said he wanted to show me something strange. He had pointed out a panel in the starboard wheelwell that was missing nearly all of its 48 screws. My first thought was, "How could somebody have missed this discrepancy?" Then I wondered, "Did I miss this myself last night when I recovered the aircraft?" We're all human and prone to make mistakes, but when you take into account all the procedures required prior to flying an aircraft, this discrepancy should have been caught much sooner by aircrew, QA or plane captains. Prior to TSTA, after returning from a detachment to NAS Fallon, the squadron had two jets undergoing periodic maintenance inspections (PMIs). One jet had two outer-wing replacements. Another needed a main-landing-gear change, along with countless other inspections. All of this maintenance had to be done before the Thanksgiving stand-down period. Following the stand-down, our squadron was scheduled to depart for TSTA; there was little time for maintenance work before the fly-off. Due to a lack of space in our own hangar, the work on Warcat 502 had been started in a neighboring squadron's hangar. An AD3 began by removing required panels. Shortly afterward, space in our squadron's hangar opened up. The AD3 was told to stop his work, so that the jet could be moved to our squadron's hangar. He placed the loose screws

How Many Screws?


in a bag and secured it to the panel, leaving only two screws in place. With the aircraft back in our hangar, the AD3 left the panel in place because he (and others) assumed that the panel did not have to be removed as part of the inspections. After some debate--and without checking a reference--maintainers decided to leave the panel alone. Days later, another maintainer started to reinstall the removed screws but was stopped abruptly, so that other maintenance could be done. The maintainer took the remaining 44 screws back to his shop. After all maintenance was completed, the aircraft was ready for its A-Profile FCF. Before the jet was ready for takeoff, an all-shops turn, a daily turnaround, and a fastener inspection were conducted. Warcat 502 flew the FCF and returned in a "down" status for various discrepancies. Mechs fixed the problems; a second crew flew 502 on another FCF. Once again, all before-flight inspections were conducted before the aircraft launched. The jet returned from this FCF in an "up" status, and the maintainers departed on a four-day weekend. The following Monday morning, maintainers flew to San Diego to meet up with the four squadron aircraft flown from NAS Whidbey Island. The aircraft flew twice more from San Diego on training flights before launching to the Reagan on Wednesday morning. A week had passed since the squadron started flight operations on board, and the air wing was getting ready to start another day of flying. I reported to the flight deck that morning to begin my final fastener checks. First, though, the plane captain for Warcat 502 asked me to look at the panel described above. I couldn't believe my eyes: I could see only two screws holding a 10-inch-by-10-inch panel in the starboard wheelwell. I thought, "How in the world could this have happened?"



I went Into maintenance control and told the senior chief of the discovery. The LPO in the mech shop then was notified. No one had any idea how the screws had gone missing or for how long. I checked NALCOMIS--no MAFs were written on the panel. The LPO went to the flight deck and verified that there were two screws attached to the panel, in addition to the two clearly visible from the ground. The jet was placed in a "down" status. A MAF was written quickly to address the missing screws, and new screws were ordered for the panel. With all of the screws installed, the aircraft was placed back in an "up" status for flight. After the discovery, I investigated to find how this discrepancy could have gone undetected for so long. What I found was amazing: The panel was supposed to have been removed for the PMI. The access area never was inspected. No documentation other than the PMI MAF was initiated.

The original screws were thrown away--someone thought they belonged to a port wheelwell panel that had been removed and replaced with new screws. The jet had flown 15 flights before the missing screws were discovered. The most shocking revelation was the number of eyes that had looked over this jet up to the point of the initial discovery: all 15 sets of aircrew, 15 plane captains, 15 QARs, and countless other maintainers who had been working on Warcat 502. After the dust settled, it was clear that training was required. Our QAO held preflight training with aircrew, plane captains, and the line shack. Also, the QA LPO held training with the rest of the maintenance department during the next squadron safety stand-down. The training emphasized using the maintenance requirement card (MRC) and maintenance instruction manuals (MIMs) when doing maintenance. Communication with maintenance control and QA also was stressed.

Petty Officer Schultz works in QA at VAQ-139.

Fall 2009


Batten Down the...

By AM1(AW) Jason Hartwick and AM1(AW) Joshua Holloway


e were only one month into a dynamic P-3C Orion deployment in the 5th Fleet area of responsibility (AOR) when the rudder-boost-package actuator began leaking out of limits on one of our aircraft. Normally, the solution is as simple as replacing the packing in the actuator, but not this time. During the removal inspection, we discovered that the actuator was corroded internally. With the nearest replacement actuator located in the supply chain in Pearl Harbor, Hawaii, (and the aircraft scheduled for an "early go" the following morning), maintenance control decided to cannibalize the actuator off another aircraft. That aircraft had been "downed" for an extended fuel-cell maintenance procedure.

The airframe technician charged with removing the good actuator was a seasoned maintainer but only had been working on P-3Cs for about a year. The maintainer was familiar with the installation procedures but had no experience removing an actuator. The airframe work center had a heavy workload on that particular night, so the technicianin-charge requested the help of the night-shift airframe QAR. The two maintainers checked out the required tools and went to work at approximately 2200, knowing they only would have about five hours to cannibalize the good actuator from one aircraft and install it on the other, perform leak and operational checks, and take a hydraulic contamination sampling. No problem, right?

push rod assembly "dog bone" damage

"skin" damage (internal view)




The rudder-boost actuator is located in a tight space in the empennage of the P-3C, which leaves little room to work and almost no light to review the maintenance checklist. The maintainers staged the appropriate publications outside the empennageaccess panel on the maintenance stand. The on-scene QAR wanted to teach the other technicians how to remove the actuator from the boost assembly, so he agreed to perform the maintenance functions. Meanwhile, one technician CDI'd his work, and several others observed. wIth a deadlIne loomIng, both the QAR and CDI failed to read through each step in the checklist push rod assembly and inadvertently skipped a step in the removal "dog bone" damage procedures. The skipped step required installation of a rudder batten if the aircraft was slated to be outside for an extended period of time with the linkage disconnected. The rudder batten is a tool designed to prevent the rudder from moving. With a sense of accomplishment, the maintainers met the challenge, accounted for all tools, and ensured the work order was signed off before the aircrew showed up the next morning for preflight checks. Every metric indicated a completely successful maintenance evolution. However, when the desert winds increased the following day, the unsecured rudder on the cannibalized aircraft began to blow violently from side-toside, tearing the aircraft "skin" in three places. Both viscous damper arms (and associated brackets) also were bent. The situation could have been more severe had it not been caught so early. Regardless, it took three days, 150 manhours, and $900 in parts to repair the damage--all completely avoidable, if only the maintainers had followed the checklist during the original maintenance evolution. With limited parts, people and financial resources in today's Navy, there is no room for these kinds of mistakes in aviation maintenance. Ensure that the appropriate publications are followed step-by-step every time. Anything less is unacceptable.

Petty Officer Hartwick works in QA and Petty Officer Holloway works in the airframes shop, both at VP-10.

"skin" damage (external view)

Fall 2009


(25-Gallon) Problem

By AMC Frederick Owens verything started on a Thursday evening, shortly after Warlord 704 was moved to the flight line. The aircraft had just had some major maintenance--including some work on its fuel cell--and we had to refuel it before we could start the functional check-flight. As the plane captain supervised the refueling evolution, everything

Small Leak, Big


seemed to be OK until about five minutes into the event--that's when the fireguard noticed fuel streaming from the fuel-dump tube. The fireguard yelled immediately to stop work and secure power to the helicopter. Fuel was flowing rapidly; it took a few minutes for responders to handle the situation. The emergency-spill kit

Navy photo by PH3 Gary Granger



was effective, and the spill was contained after approximately 25 gallons had spilled. Environmental experts were called to the scene. Because no fuel had made it into the flight-line drainage system, no report outside the command was required. More importantly, none of the fuel had ignited, no one had been injured, and no aircraft were damaged. However, numerous man-hours had been wasted, as roughly 20 people had had to stop what they were doing to help contain the spill. The important point is that this event easily could have been prevented with better communication and adherence to procedures right from the start. A small fuel leak and a problem with the fuel-dump system actually had been found in Warlord 704 six nights before this episode. I was in maintenance control when my maintenance team had noticed these problems during an operational check of the fuel-dump system. Maintainers had noticed that fuel kept dumping after the fuel-dump switch was secured. The dumping even continued after the fuel-dump circuit breakers were pulled. The team also had noticed that some fuel was coming out of the drain ports in the transition section of the aircraft. No fuel is supposed to come out from anywhere, other than the fueldump tube when conducting a fuel dump. The team already had planned to catch fuel coming out of the fuel-dump tube with a two-inch drain hose and a defuel cart, so they weren't as concerned with the malfunctioning fuel-dump system as they were about the leak coming from the drain port. The team repositioned a drip pan under the suspiciously leaking drain port and notified me in maintenance control. I made a phone call to get the aircraft fully defueled, so that we could fix any problems with the system. The defuel truck arrived, and the helicopter was defueled.

Here's where communication became critical. The technicians came in after defueling the aircraft and told me that the aircraft no longer was dumping fuel. "The line will need to be repaired, though," they said. I told them to go back out to the aircraft, apply power, and check the system to make sure it no longer was dumping fuel. after some tIme, the system was rechecked, and again the technicians came back and told me the system did not dump fuel. At this point, I misunderstood what they were telling me. Based on what the technicians said, I thought the fueldump system now had been fixed, and there was just a leak somewhere else in the system. The truth, though, is that the technicians were telling me that the dump system still had problems in general. The exact nature of the problem--whether it had been narrowed down to the fuel-dump system or some other leak--was not identified clearly, investigated thoroughly, or discussed. Thinking that the fuel-dump system had been corrected (and that there was just some other leak), I instructed my technicians to sign off the fuel-dumpcheck MAF and to write a separate discrepancy for the leaking fuel line. A weekend passed, and technicians eventually did find another leak in the system: A portion of the fuel-dump tube had cracked. Another MAF was written, and parts were ordered to fix the crack. But the fuel-dump problem never was solved. Communication played a critical role here, as my maintenance team and I forgot about the original fuel-dump problem. We later found out that the fuel-dump check had not been done correctly. The maintenance manual clearly says that personnel shall "make sure that the fuel-dump shutoff valve is closed" during the fueldump operational check. No one had followed this procedure. As a result, no one knew the valve was not receiving power and could not close. The original fuel dump never should have been signed off until after a fuel-dump check had been done. Everyone had assumed another leak existed in the system and that repairing the cracked fuel-dump tube would have taken care of any issues. There is no room for ambiguity when tasking subordinates or reporting the status of task completion to superiors.

AMC Owens works at HSL-51.

Fall 2009


Maintainers in

sgt. shannon flaherty from hmh-466 replaces a Ch-53e Super Stallion's automated flight control computer. marine Corps photo by sgt. Juan alfonso ad1 James gregorio, assigned to the jet-engine shop in the aviation intermediate maintenance department (aImd), installs a wiring harness on an fa-18e super hornet engine aboard Uss george washington (CVn-73).navy photo by mCsn adam thomas

am2 michael smith assists am3 erika mata with her daily inspection on an sh-60f sea hawk helicopter from hs-4 aboard Uss ronald reagan (CVn-76). navy photo by mCsa amanda ray



n the Trenches

sgt. dustin trujillo, assigned to the "Condors" of hmh-464, embarked aboard Uss Kearsarge (lhd-3) takes apart the rotor assembly of a Ch-53e super stallion as part of a scheduled maintenance. navy photo by mCsa Joshua nuzzo

aviation ordnancemen from the "diamondbacks" of Vfa-102, download 20mm cannon rounds from an fa-18f super hornet aboard Uss george washington (CVn-73). navy photo by mC1 John hageman

ad2 Josh lazanis and ad2 anthony ward, both assigned to VaQ-135, perform maintenance on the enginebay door of an ea-6b Prowler aboard Uss nimitz (CVn-68). navy photo by mC2 gregory striet

Fall 2009 17


By AM2(AW) Tymond Brown


aintenance procedures not only show how to maintain and repair equipment, they keep us from making mistakes. "Notes," "warnings" and "cautions" in maintenance manuals capture our attention and remind us of the possible hazards, as well as their consequences. The C-40A Clipper's governing publications are written differently than most Navy maintenance manuals. However, "notes," "warnings" and "cautions" remain just as important. Besides routine maintenance that was scheduled one evening, a significant amount of work for the

night shift also was planned to correct ongoing hydraulic leaks with aircraft RX-835. The 100division night check was tasked with the following: changing a main-mount tire and landing gear brake, removing and replacing two ground-spoiler actuators and a nose landing-gear actuator, and changing a main landing-gear actuator. The normal night-check CDI wasn't available because of two simultaneous overseas detachments and other operational commitments. To address this CDI shortfall, an additional QAR from the day check was scheduled to work that night. The night started on the wrong foot; I noticed technicians changing the main landing-gear (MLG)

tire without using the maintenance manual. I intervened. Shortly afterward, I noticed they were skipping steps in the maintenance manual. I immediately stopped the work and told them how important it is to follow the maintenance manual step-by-step. Things seemed to run more smoothly after that. Around 0400, we began installing the MLG actuator. This part was attached to the walking beam and the hanger beam (per the manual). When the technicians raised the actuator into place, though, they noticed that the piston-end had rotated 90 degrees, which made it impossible to align. Some 100-division personnel disassembled the walking beam, hanger beam, and actuator so they could attach the latter part to the trunion and rotate it to the proper alignment. When we started reassembling the parts, we missed a "caution" that pertains to alignment of the main pin, which connects the components of the landing-gear assembly. As a QAR, I should not have missed this caution, which states: "Make sure the head of the pin is pointed aft. Incorrect orientation of the pin may cause gouging of the main landing-gear support beam." As you already may have guessed, we installed the pin backward. After completing the incorrect installation, night check secured, leaving the MLG drop-check for day check. dUrIng thIs droP-CheCK, day-check personnel heard a loud "bang!" when they retracted the landing gear. They stopped and inspected the area but found no damage. Some suspected the bang was the result of insufficient lubrication, so they applied more grease to the fittings. In subsequent drop-checks, the banging noise lessened and then stopped. Some assumed naively that the grease had worked its way into the fittings, and the MAF was signed off.



Pin installed correctly

Pin installed incorrectly

As a QAR, I should not have missed this caution, which states: "Make sure the head of the pin is pointed aft. Incorrect orientation of the pin may cause gouging of the main landing-gear support beam."

Damaged support beam

The next day, the aircraft flew a scheduled mission. On approach to McChord AFB, the landing gear extended and locked, but it took one minute and six seconds (53 seconds longer than the 13-second limitation). When the aircraft returned home, maintenance issued another MAF. More troubleshooting revealed the actuator was faulty. Maintainers removed and cleaned it, then discovered that the bolt holding the pin in question had gouged the panelsupport beam. That problem had caused the noise during the gear's drop-checks. According to the structural-repair manual, the damage to the support beam was beyond repair limitations. Consequently, the aircraft was down for three days, while we waited for engineer-approval of a temporary fix. The permanent fix would have to wait until the aircraft entered the next depot-level maintenance evolution. This embarrassing event has been a wake-up call for all of us at the squadron. Things could have been much worse. Lives hang in the balance of our actions, or lack of them. As a QAR, it's my responsibility to catch things and to stop them from happening. Everything we had done correctly that night was erased by the one thing we all missed: adherence to our maintenance manuals. Because of this incident, ORM checklists now are incorporated into our maintenance evolutions. We also hold monthly QA/CDI training that focuses on major discrepancies, quality of work, responsibilities, and publication usage. If you don't use the publications properly and follow the instructions step-by-step, you can damage aircraft. As a result, maintenance man-hours are wasted, and lives are put at risk.

Petty Officer Brown works in the airframes shop at VR-57.

Fall 2009


Was That Bushing Installed?

By AM2(AW) Guadalupe Gomez


hile completing an 84-day inspection on Fast Eagle 102, two airframe technicians noticed excessive play in the starboard rudder. They removed access panel 100R and discovered that the upper-forward mount on the rudder-servo cylinder was broken. After removing the cylinder, they found that the lower-mount bushing was missing. As a result, most of the load from the actuator had been on only the upper lug, leading to the failure. An investigation revealed this actuator had been installed almost a year before the incident. One of the in-process inspections on the installation MAF read: "WITNESSED INSTALLATION OF STBD RUDDER ACTUATOR IAW IETMS." I had signed that process inspection ... a year ago. I couldn't remember the installation sequence exactly as it occurred, but one thing was certain: The bushing was missing. My training and experience (and culpability) directed me to seek out the cause. Due to its location and the view afforded postinstallation, it's extremely difficult to determine if the bushing is in place. Errors of this nature and magnitude can occur easily, especially if the associated technical manuals are not followed. I

stress the importance of taking the extra time to thoroughly follow procedures, to double-check the finished product, and to ensure the correct processes in between are executed. In this case, no structural damage was done to the airframe. More importantly, though, the failure and subsequent excessive play did not cause the aircrew to lose control of the aircraft in flight. The maintenance department and QA continually seek to ensure personnel always use the MIMs (step-by-step) every time. Being a CDI is an immense responsibility. I encourage all CDIs to maintain consistent supervision, especially when critical primary flight-control components are installed. A moment of inattention today can have catastrophic implications years from now.

Petty Officer Gomez worked in the airframes shop at VFA-41.




a maintainer. I serve in a maintenance organization to provide operational weapons and operationally-ready weapon systems that are essential to guard and to protect my country, to protect our democratic way of life, and to promote peace throughout the world. I am prepared to give my life in the defense of my country. made on us and to maintain all equipment in the best possible condition of readiness and use. possible level.

I WILL train myself and the men and women under my charge to be ready for all demands

I WILL maintain my maintenance proficiency and technical competence at the highest I WILL follow all orders and adhere to the prescribed technical data. I will know my

directives and will not allow any deviation. I will provide quality maintenance at all times and under all conditions. safety rules and practices. I never will produce nor permit a condition to develop that would cause loss of life, limb or materiel.

I WILL follow and enforce all safe practices. I will be especially mindful of weapon-system I WILL always conserve the resources of personnel, materiel and time. I WILL enforce and carry out all maintenance actions required to satisfy the maintenance

priorities established for mission accomplishment.

I WILL adhere to and enforce high standards of personal appearance--both on and off duty. I WILL take pride in my job, my maintenance unit, and my place of honor in the preservation

of peace and democracy.

Code of Conduct Maintainer

Fall 2009 21

for the

Send BZs to: [email protected]

Cpl. Michael Hatzenbuhler HMH-465

While doing the final walk-around inspection of his aircraft, Cpl. Hatzenbuhler checked the tail rotor and saw that the pitch beam was oscillating back and forth. Knowing this part is supposed to be stationary, he notified the pilots, who radioed QA to do an inspection. They found the pitch-beam shaft was shimmed improperly, making the aircraft unsafe for flight.



AE3 Nicholas Deweese and AM2 Keston Raymond HSL-49 Det.2 While embarked on USS Pinckney (DDG-91), the aircrew of Red Stinger 104 ran systems checks before the first launch of the day. Petty Officer Deweese was checking the status of the pitch-lock pins on the primary servos when he heard an unusual ratcheting sound coming from the main transmission. He immediately alerted the aircrew. The sound only could be heard during control checks. You didn't hear it in the aircraft, and you didn't feel it in the flight controls. Further investigation by Petty Officer Raymond revealed that both the forward and aft scissor-assembly-sleeve bushings were elongated, causing excessive wear and movement of both scissor assemblies.

LCpl. Daniel Zawicki HMM-364 Lance Corporal Zawicki was doing his duties as a CH-46E plane captain when he found six bolts loose and spinning on the aircraft's aft rotor head. These bolts are used to secure the tie bar in place, which, in turn, connects the pitch-varying arm to the rotor head. Further investigation revealed that the nuts securing the bolts merely had been hand-tightened. Lance Corporal Zawicki immediately informed his chain of command, and maintainers fixed the problem.

AM3 Tyler Weigel VAQ-131 Petty Officer Weigel had to fill a mobile air-start unit (A/U47A-5). When he moved the unit to a JP-8 tank for filling, he noticed that the tank wasn't grounded. In fact, it hadn't been grounded since construction on that area of the flight line had been completed two months earlier. If the tank had been affected by static discharge or had been hit by lightning, it could have exploded. Once flightline managers were notified of the problem, they called the contractors responsible for the construction and grounding of the tank. Everything was fixed the next day.

Fall 2009


AEAN Cody Logsdon VAQ-133 Airman Logsdon was returning from the flight line when he saw fuel spilling out the tail section of a VAQ-134 aircraft. He immediately put a bucket under the fuel spill and told another trainee to notify VAQ-134's ready room. His actions helped avoid a much more serious fuel spill.

AWF1(AW) Bryan Seifried VR-55 During a logistics mission, a C-130T had an intermittent, unsafe landing-gear indication upon landing. However, no discrepancy could be found or duplicated after postflight inspection, so Petty Officer Seifried started searching for signs of malfunction outside the suspected trouble area. When he reached into a void where the landing-gear drive shaft extends up into the bulkhead of the aircraft, he found that the landing-gear drive shaft was disconnected from the landing gear at a failed disconnect-coupling.

AO2(AW) Adrel Alcarazmedina HSL-49 Det. 5 While embarked on USS Thach (FFG43), Petty Officer Alcarazmedina noticed that the port extended-pylon on a sister squadron's aircraft was not locked in place. Petty Officer Alcarazmedina notified the aircraft commander and inserted the locking pins while the aircraft spun on deck.




Survey Team

By AMCS(AW) Robert Chenard

Maintenance Officer Cdr. david Peacott [email protected] Editorial Coordinator msgt. michael austin [email protected]

Why Work for the Naval Safety Center? Why Not?

ost Sailors and Marines don't know what we aviation-maintenance analysts do at the Naval Safety Center (NSC). In most cases, maintainers seek orders to something involving the flight line. The general thinking is that if it isn't duty on or near the flight line, it can't be relevant to aviation maintenance. Analyst duty here at NSC is just as important (if not more so) to aviation maintenance, than a shore-duty, O- or I-Level tour. Let's look at some of our duties. Our most important service is as members of the aviation-maintenance safety-survey team. We survey more than 100 Navy and Marine Corps commands every year. We see just about every possible way to manage a NAMP program--good, bad, or "needs improvement." Because we're all senior enlisted leaders and have managed these programs ourselves, this area is where we can make the most difference in aviation maintenance. Combine our experiences with our time-inservice (factoring in the multitude of surveys we've been on), and you can see how helpful we can be to program managers. We are teachers. We show program managers where they are straying away from the intent of the NAMP, the best way to get back on course, and how to stay there. Also, we are trained to identify Navy Occupational Safety and Health (NAVOSH) issues. We ensure each unit is aware of potential hazards within their operating environment. Hand-in-hand with our survey duties, we write articles for Mech, speaking directly to the


fleet about problem trends we find on surveys. We also get to explain how to correct them and how to prevent them. We highlight best practices. We also answer questions from the fleet (by phone, e-mail or web feedback). Whether it be a quick answer to a commonly asked question (check out the maintenance FAQs section on our website at mil/aviation/maintenance/FAQ/default.htm), or something that requires a little research, our maintenance SMEs are here to provide the customer (fleet maintainers) with the most accurate answer possible. Perhaps the most rewarding part our job is the ability to take all the lessons learned back to sea duty. Imagine taking all those best practices--gleaned from across the spectrum of the Navy and Marine Corps aviation community--and seeding your new command. To do this, though, we first need to change the stigma many wrongly attach to taking orders to the Naval Safety Center. This is not a last stop on the road to retirement. Instead, think of it as an advanced management course and a chance to serve as a subject-matter expert, while rubbing elbows with aviation-maintenance specialists around the fleet. If you want to work hard to improve aviation maintenance fleet-wide and to increase your own value to the Navy as an analyst, duty at the Naval Safety Center is the way to go. Senior Chief Chenard is a maintenance analyst at the Naval Safety Center. In November 2009, he is taking his experiences as an analyst back to the fleet.

Fall 2009


Trend Analysis

Self-Assessment Tools Available Online

By AZC Gainer Clark


e analysts here at the Naval Safety Center (NSC) have posted a spreadsheet of real-time trends on the NSC website (http:/ maintenance/index.asp). It tracks maintenance discrepancies by work center and by the percentage of occurrences we uncover during our safety surveys. Use this information when doing self-evaluations of programs. Reviewing the spreadsheet,

as well as COMNAVAIRFORINST 4790.2A CH 1 and the computerized self-evaluation checklist (CSEC), during self-evaluations will help maintenance departments identify hazards that otherwise may be overlooked in day-to-day operations. Our modified CSEC also is available on the NSC website. Chief Clark is a maintenance analyst at the Naval Safety Center.



Quality Assurance

Shock Hazard or Just a Fluke: Recall of Fluke Digital Clamp Meters

By MSgt. Michael Austin

Problem: A recent safety bulletin (DTG 121909Z Aug 09) and a press release from Fluke Corporation describe a potential short on the circuit board of Fluke digital clamp meters, which may lead to inaccurate voltage readings. These readings may result in low or no voltage indications on a live circuit. Solutions and Best Practices: This safety issue directly affects QA representatives, AEs,

ATs, IMRL/tool-room managers, and assigned personnel. I strongly recommend that you check . the serial numbers of your meters ASAP If you have any on your tool/IMRL asset-inventory list, take them out of service. That's the guidance in the safety bulletin and a manufacturer's recall, as well as from the Consumer Product Safety Commission. For more information on the recall, check these resources: · Consumer Product Safety Commission · Fluke Corporation http://us.fluke. com/usen/Home/default.htm Master Sergeant Austin is a maintenance analyst at the Naval Safety Center.

Fall 2009


Crossfeed Coordinator

Calling All Marines

By MSgt. Michael Austin

ome of our Marine readers think the Naval Safety Center represents just the Navy. Not so. Marine SNCOs and officers make up almost half of our maintenance survey team. We provide detailed investigations, analysis, research, surveys, and ORM tools to the Navy and to the Marines Corps. Also, we provide real-time trend analysis and best-practice maintenance information on the command website and in Mech magazine. I encourage more of you to write Mech articles, short stories, lessons learned, and Bravo Zulus. We also need your photos. Everyone has an experience or story that could benefit another. Sharing your experiences in Mech isn't about airing dirty laundry, it's about preventing mishaps. Master Sergeant Austin is a maintenance analyst at the Naval Safety Center.



TFOA: Things Falling Off Aircrewmen


Problem: Recently, faulty flight equipment has created several potential FOD hazards. Examples include Mk-80 pencil flares falling out of a flight vest, on/off switches falling off flashlights, and an NVD battery pack detaching from a helmet. Solution: The most effective ways to prevent FOD from faulty flight equipment are preflight inspections and scheduled inspections. A good habit to practice during inspections is to concentrate on verifying correctness, instead of just looking for defects. Train your eyes and hands to scan and to test the equipment in a systematic manner, while verifying that only the correct configurations and conditions exist. If you do this right, the defects will pop out at you. Remember, a casual inspection (just looking for

defects) can easily result in a missed discrepancy. Besides doing high-quality inspections, ALSS technicians must be proactive in recognizing possible manufacturer's defects or design flaws. These flaws sometimes don't reveal themselves until after months (or even years) of use. If you see a need for improvement, be an agent of positive change and submit an action chit to PMA202. Best Practices: These recently surveyed commands have very proactive flight-gear inspections: VFA-81, VP-1, HSL-43, and HSC-23. Their best practices include designated areas for doing pre-flight inspections, with checklists displayed prominently nearby. Senior Chief Young is a maintenance analyst at the Naval Safety Center.



Logs and Records

Optimized NALCOMIS: Trouble With Low (or No) Bandwidth?

By GySgt. Robert Linn

Problem: Squadrons deployed to areas with low or no bandwidth have problems with Optimized NALCOMIS, which uses the Internet to send, receive and update through replication. When the server is not connected, replication attempts persist. These repeated efforts can cause the server to crash, leading to two major problems: loss of data and wasted man-hours. Solutions: Appendix E of Training Management Information System (TMIS) EE689-LASAG-010 (the system administrator manual) gives pre-detachment recommendations, such as pack-up checklists and suggested timelines to minimize problems associated with deployments or detachments. This appendix is online at the Space and Naval Warfare System (SPAWAR) website: https://webnet.scn.spawar. System%20and%20Database%20Administration%20Guide.pdf. Appendix J contains instructions on what to do when moving squadron servers, how to stop replication, and what to do in case of low or no bandwidth. If squadrons follow the procedures in place, there should be minimal problems. Best Practices: Follow the pre-deployment recommendations before detachment or deployment, and make contingency plans. Also, contact the system administrator for your destination before detachment or deployment. If none is available, contact SPAWAR. It is easier to fix a problem when you have the assets at hand. Gunnery Sergeant Linn is a maintenance analyst at the Naval Safety Center.


Clear Case for Clear Grease Guns: Follow-Up

By ASCS Mark Tangney

ou may recall the grease-gun Crossfeed article from Mech Spring 2007 (http://www. spring07/default.htm). It highlighted the advantages of an innovative new grease gun "droptested" by us here at the Safety Center and by maintainers in the fleet. It is durable, colorcoded and has clear tubing, making it easy to identify the type of grease inside. Clear Grease Guns are now available to the fleet. They can be ordered using PN 12CMBLK, NIIN 01-550-8352 or can be open-purchased. For more information on these grease guns,


check out the manufacturer's website: http:// Senior Chief Tangney is a maintenance analyst at the Naval Safety Center.

Fall 2009


Class C Mishap Summary

By MSgt. Michael Austin

rom June 2, 2009, to Sept. 1, 2009, the Navy and Marine Corps had 31 Class C mishaps involving aircraft. A preliminary review of these 31 mishaps indicates 13 (42 percent) of them were maintenancerelated. Causes included various supervisory, maintenance and material factors, most of which could have been prevented by ORM. Below is a list of recent, avoidable maintenance-related Class C mishaps: 1. FA-18C: Aircraft tow evolution damaged radome and aileron. 2. EP-3E: B-2 stand hit starboard elevator. 3. C-40A: Hangar fall-support bracket fell and damaged starboard fuselage. 4. HH-60: Hydraulics bay panel blew off, hitting another aircraft. 5. FA-18F: Two aircraft crunched during taxi evolution. 6. CH-53E: Nose gear fell off on approach for landing. 7. EA-6B: Arresting hook was released onto a maintainer's leg. 8. MH-60S: Maintainer fell off aircraft while doing maintenance. 9. EA-6B: Fuel spray vented onto the canopy of an aircraft, delaminating it. 10. FA-18C: Outer right-wing-fold-assembly damaged during maintenance. 11. FA-18A: Panel blown off during flight-deck ops. 12. FA-18E: Panel access #18 blown overboard. 13. E-2C: Aircraft taxied into parked aircraft.




outboard wing

angle drive unit

inboard leading-edge flap inboard wing

outboard leading-edge flap transmission

ANy MISHAP that could have been avoided is one too many. The events that occurred "on the fly" stand out, especially the following three. In each, routine events turned ugly when crews didn't use time-critical risk management (TCRM). · Item #1: A tow crew assembled to hangar and secure the squadron's aircraft. "Bam!" A radome and aileron were damaged. The damaged aircraft then were "downed" for conditional inspections and repair. Thousands of dollars were wasted, and mission readiness was hindered. · Items #5 and #13: Both involved taxiing aircraft into other aircraft. Poor S.A. + Lack of TCRM = Crunch. It's easy to see why proactive management and training of plane captains and taxi directors is key. Another area to emphasize is plane captain and director evaluations. They should be spaced out far enough so that the QA-monitored evaluations and qualifications aren't done at the same time. Also, supervisors need to ensure they (and their crews) are trained to recognize when the fatigue of long maintenancehours is setting in.

torque tube

bottom inboard wing frame

Item #10 shows what can happen with improper maintenance, a lack of supervisory guidance, and poor adherence to the pubs. These factors contributed to maintenanceinduced damage of the starboard outer-wingfold-assembly. The maintainer did not install and set up the electronic drive unit (EDU) according to published guidelines. The maintenance instruction manual, A1-F18AC-570-310, (Change 5) Work Package 058 00, page 3 states: "CAUTION: Structural damage to the wing will occur if the EDU is not run to its spread limit before installation." The pictures tell the story. Master Sergeant Austin is a maintenance analyst at the Naval Safety Center and coordinates the Crossfeed section of Mech.

Fall 2009


Flight, Flight-Related, and Ground Class A and B Mishaps 07/09/2009 to 09/07/2009

Class A Mishaps

Date Type Aircraft 07/21/2009 HH-60H Aircraft impacted ground. Command HSC-84 07/20/2009 FA-18A+ VFA-204 Bird strike damaged starboard engine. No injuries. 07/30/2009 AH-1W HMLA-167 Maintainer sustained severe facial injury while conducting static hydraulic servo check. 08/07/2009 FA-18A+ Dual bleed-air warning lights in flight. VFA-204

08/13/2009 FA-18F VFA-122 Starboard engine fire during familiarization flight. No injuries. 08/25/2009 FA-18C VFA-113 Aircraft fire during maintenance turn. No injuries.

Class B Mishaps

Date Type Aircraft 07/17/2009 T-34C Engine fire in flight. No injuries. Command VT-28

08/11/2009 RC-12F VXS-1 Engine-driven generator indicator light came on, followed by engine fire. 08/18/2009 AV-8B VX-31 Starboard wing damaged during proficiency flight. 08/25/2009 FA-18A+ VMFA-314 AIM-120 launched inadvertently from station-6.

07/18/2009 MV-22B VMM-261 Mid-wing fire indication and WFPS activation during postflight inspection.

Printed as a supplement to Mech from Naval Safety Center Data Cdr. Paul Bunnell

For questions or comments, call Lt. David Robb (757) 444-3520 Ext. 7220 (DSN 564)




Helping Sailors and Marines Help Themselves

Safety Surveys

VaQ-131 VP-46 VaQ-133 nas whidbey Island sar Vr-61 VP-1 mals-16 hsl-49 hsC-23 hmm-165 hsm-41 frCsw san diego hsl-43 flight ops det. north Island Vfa-81 Vfa-213 Vaw-121 hmt-302 Vmr-1 Vmm-365 Vmat-203

Commander, Naval Safety Center would like to recognize the following aviation commands for their recent participation in safety surveys, culture workshops, and maintenance-malpractice resource-management (MRM) presentations for the months of July-September.

Vma-542 mals-14 Vmm-266 hsC-22 awsts


Cmo-10 CPrw-10 Vfa-87 amo Course, nas Pensacola hmla-469 Vmfa-115 Vmfa (aw)-224 hm-15 Vfa-213 Vmat-203 Vmfa-115 mals-31 Vmfa-312 Vr-55 hmm-364 VaQ-133 Vt-7

Culture Workshops

Vr-56 tw-2 Vx-1 Vfa-15 hsC-12 Vfa-125 hsl-43 Vmfa(aw)-242 VP-46 dCma sikorsky aircraft h&hs mCas yuma Vaw-77 Vt-10 hsC-23 VQ-2 Vfa-94 hmm-165 Vaw-116 Vfa-31 Vfa-34 Vt-28 VPU-1

For more information or to get on the schedule, please contact: Safety Surveys: Maj. Anthony Frost, USMC at 757-444-3520 Ext. 7223, MRM: AMCS(AW) James Litviak at 757-444-3520 Ext. 7276, Culture Workshop: Cdr. Duke Dietz at 757-444-3520 Ext. 7212.

Insurance that your next road trip will be a round trip.





36 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate