The Navy & Marine Corps Aviation Maintenance Safety Magazine Spring 2008 www.safetycenter.navy.mil One Job at a Time Why I Blew It Fire-Bottle Follies
Vol. 47, No. 2 Spring 2008The Navy & Marine Corps Aviation Maintenance Safety MagazineMaintenance and ORMBy Cdr. Bert Ortiz, Naval Safety Center The MO is searching for an organization to use as the model maintenance program. Chaff, Flares and CADs Can KillBy George Alston, NAVAIR ISSC (AIR 4.5.4. 1), Jacksonville Anyone dealing with chaff, flares or CADs needs to heed the warnings.One Job at a TimeBy AE2 Andrew Peterson, HSL-51 An AE learns a valuable lesson.Fire-Bottle FolliesBy AE2(AW/SW) Stephanie Teixeira, VFA-136 Its important that all maintainers know emer gency procedures.Assuming Is a Bad ThingBy AO2(AW) Jason Binney and AO3(AW) Briggs, VFA-41 Not following proper maintenance procedures results in Captains Mast for two AOs.Why I Blew ItBy Lt. Adrian Dawson, VP-47 A pilot disregards the aircraft cleaning checklist.How To Lose Your QualsBy AME1(AW) John Shorb, VR-48 An AME lost his quals, but not his life.Washing Eyes With SoapBy AN Derick Jaramilo, VAW-116 A maintainer is rushed to medical after a plane wash.Hand Taco TuesdayBy AN Justin Henderson, VFA-27 An airman learns the hard way that thump tests dont work.Features3 4 7 10 20 8 13 14whats19RADM A. J. Johnson, Commander, Naval Safety Center Col. Mark Vanous, Deputy Commander John Mahoney, Head, Communications and Marketing Department Naval Safety Center (757) 444-3520 (DSN 564) Dial the following extensions any time during the greetingYou can e-mail any staff member by using their first name.last email@example.com, except as noted. Mech Staff Dan Steber, Editor 7247 firstname.lastname@example.org Patricia Eaton, Graphic Artist 7254 Publication FAX (757) 444-6791 Aircraft Maintenance & Material Division Cdr. Bert Ortiz, Division Head 7265 Capt. Chris Foley, USMC, Assistant Division Head 7223 AFCM Johnnie Simmons, Maintenance Master Chief 7269 email@example.com Airframe/Powerplant Branch CW03 Lawrence Stewart, Branch Head 7258 ADCS(AW) Mike Tate, Maintenance Analyst 7290 firstname.lastname@example.org ADCS(AW/SW) Chris Smith, Maintenance Analyst 7218 email@example.com AMCS(AW) Robert Chenard, Maintenance Analyst 7221 AMC(AW) James Litviak, Maintenance Analyst 7276 firstname.lastname@example.org Support Equipment ASCS(AW/SW) Reginald Evans, Maintenance Analyst 7293 Avionics/ALSS/Analyst Branch CW04 Ron Stebbins, Branch Head 7278 PRC(AW) Brian Westcott, Maintenance Analyst 7219 AMEC(AW) Eric Wickham, Maintenance Analyst 7292 AEC(AW) James Esslinger, Maintenance Analyst 7291 ATC(AW) Danny Williams, Maintenance Analyst 7280 email@example.com Ordnance GySgt. John Higgins 7140 AOCS(AW/SW) Ronald Carpenter 7171 Analysts SSgt. David Jenkins-Jackson 7074Mishaps waste our 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 commands goal is to help make sure that personnel can devote their time and energy to the mission, and that any losses are due to enemy action, not to our own errors, shortcuts or failure to manage risk. We believe there is only one way to do any task: the way that follows the rules and takes precautions against hazards. Combat is dangerous and demanding enough. 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, SAFE-Mech@navy.mil. Visit us on-line at www.safetycenter.navy.mil.
Front cover: Sailors assigned to the Checkmates of VFA-211 perform scheduled maintenance on the MA161A2 20mm machine gun weapon system on an FA-18F Super Hornet in the hangar bay aboard the nuclearpowered aircraft carrier USS Enterprise (CVN-65). Navy photo by PH2 Milosz Reterski.Just a ScrapeBy AM2(AW) John Franklin, VFA-34 A downed Hornet goes flying and a CDI learns to investigate all problems 100 percent of the time.Rushed Tool CheckBy Lt. Dave Bigay, HSL-46 Rushed maintenance results in a lost flashlight in an SH-60B hydraulics bay.Departments22 IBC 25 2 12Admirals Corner: Sailors Helping Sailors, Marines Helping MarinesBy RADM A. J. Johnson The admiral challenges maintainers to adhere to good maintenance practices and to help each other.A Final GoodbyeBy Dan Steber, Naval Safety Center The Mech man is moving on after eight years of service as the editor of Mech.Good, Bad and UglyPhotos and short summaries of the best and worst found around the fleet.17 2 24 16 18 29insideAir-Wing Toolbox: Joint Discrepancy Reporting System (JDRS) Being DevelopedBy Jeff Hobrath, NAWCAD, NAS Patuxent River, Md. A good overview of JDRS scheduled to launch in Spring 2008.Mishap Stats Maintainers in the TrenchesA pictorial homage to the people who keep planes flying.Bravo ZuluHS-7, HMM-365, CGAS Kodiak, HSL-42, HSL-44, HSL-42 Det. 1, HSL-37 Det. 2, HSL-51, HSL-37, VAW-117, VFA-102, VPU-2, and VR-56CrossfeedMaintenance experts talk about safety survey teams, HAZMAT and Class C Mishaps.Sierra HotelCommands that have completed surveys, culture workshops and MRM presentations.Navy photo by MCSN(AW) Jhi Scott
2 Mech Mech This issue of Mech is a good example of why main tainers need to pay attention and help each other. Dropped drop-tanks, unintentional activation of flares or chaff, and inadvertent firing of CADs, all can spell trouble. You may have heard of our Sailor-to-Sailor Safety program. We taped testimonials about DUIs, off-duty incidents, and on-duty mishaps; and I was horri fied to listen to a maintainer tell the story of a flare mishap aboard a carrier last year. In that incident, a shipmate was burned ter ribly. That mishap still is under investigation, so we cant discuss specifics or even share the video that we taped. However, it fits the theme of this current issue. When maintainers dont pay attention, are tired, or dont use the book, bad things happen. Heed the Sailors Helping Sailors, Marines Helping MarinesAdmirals CornerFrom Commander, Naval Safety Center RADM A. J. Johnson By Dan SteberThis issue is about a problem we face from time to time: inadvertent activation of CADs, flares, and chaff. I threw in a few examples of dropped drop tanks, too, because we also have had a few of them. The CAD numbers are clear, and Ive included some for you to review. You can see that the numbers fluctuate, but they are excessive. The admiral pointed out how bad it can get in his intro. I had the pleasure of filming those Sailor-to-Sailor spots and also suffered the pain of hearing some of those stories. The move to video has come to the Naval Safety Center, and I now will be involved with it on a day to day basis.A Final Goodbyewarnings found in each of these stories. Challenge your fellow maintainers to follow written instructions, adhere to good maintenance practices, and use all safety and protective equipment. It never ceases to amaze me, when we have a preventable mishap, that no one stepped up to the plate to prevent it, despite obvious opportunity to do so. Sailor to Sailor, Marine to Marinelets work together and stop these senseless errors and mishaps. One person can make a difference when you commit yourself to not allowing shoddy maintenance to occur at your command. We hope to do some inter esting things and already are introducing a podcast and vod cast site. We have been shoot ing celebrity public service announcements, victim testimo nials, and informational spots. I hope to do some mainte nance-related videos in the near future and do things of interest that also will be educational. That includes a series of spots on maintenance programs that will show what makes some good and others bad. Its been a joy for the past eight years to have been the editor. Im moving into the video world, but main tainers will still be part of my work.
Mech 3 Mech Spring 2008 Spring 2008By Cdr. Bert OrtizI mentioned in my last story that I have been fortunate to visit and work with many Oand I-level Navy and Marine Corps aviation units around the world. In addition to the safety surveys and culture workshops that give you a unique perspective on both positive and neg ative trends, we also provide a good look at how ORM is being implemented in the fleet. In this and every issue of Mech you will read stories of woe from the maintenance world. I believe most of these incidents could have been miti gated through proactive use of ORM. Whether the long, deliberate five-step process or on the fly, time-critical type, maintainers must identify the hazards being faced, assess the risk, make risk decisions, implement controls, and supervise, supervise, supervise. This issue, in particular, has several stories about a long-time problem that spikes from time to time: inadver tent activation or ejection of CADs, flares and chaff, along with dropped drop tanks. It seems we face this problem every couple of years. We put a lot of attention on the issue. It stays in check for a few years but then comes back to bite us in the butt. I have a few thoughts about ORM, how it applies in maintenance situations and fits this issue, and about recurring maintenance problems. We all are tasked with incorporating ORM into every thing we do, and to be frank, what we have seen is that the only thing that happens in this area is the yearly training check in the block. I dont see ORM added to maintenance-training plans. I dont see tangible ORM practices being identified in the safety-council meetings or actively used in shops. I have yet to find an organi zation with a true, model maintenanceORM program that I can point at and show you a way to incorporate ORM principles practically. Sure, we see the principles generally applied in main tenance meetings, pre-aircraft wash or move briefs, work-center meetings and passdowns, but these things have not changed in the 30 years Ive been in the Navy. So how do we truly incorporate ORM and have it improve our business in a tangible way? I always recommend each unit do a deliberate review on major maintenance evolutions (engine or stab changes) or even a minor one (aircraft move or wash). Do it during your training day or during the safety-council meeting. Look it up on TRACS, which is the online, total risk-assessment-and-control system. It already may have been done, and you can save time and effort! When you do this deliberate review and identify, assess and mitigate all the risks associated with that evolution, youll end up with a pretty decent briefing guide for the task. One additional thing you can do is to ask this ques tion on the bottom of the deliberate review: Whats changed or different today? This one simple step will make the review valid for the time you use it, and do use it each time you brief a task. Post it on TRACS for others to use as well! It truly can be a great tool to get a fresh look at things each time and really apply all that training in ORM. Go aheadstir it up! Next time Im around your unit, show me what youve done to inculcate ORM in maintenance. Give me the location I can point to as the model program! Cdr. Ortiz is the maintenance officer at the Naval Safety Center. Maintenance and ORMI am truly honored to have been the editor of Mech and incredibly proud of the hundreds of maintainers who wrote e-mails and told leaders that the magazine was an integral part of your day-to-day safety efforts. You told us how you used Mech in shop training and safety lectures and the critical role it played in maintenance and safety efforts. Mech is your magazine. I simply was the lucky guy to assemble it each quarter and bring useful stories to light. LCDR John Ruane will take over. John was a plane captain in E-2s and a maintainer in P-3s before becom ing an officer. Im sure hell do a great job. Im not going far and will stay involved at some level. Thanks. Dan.
4 Mech Mech AO3 Cary Buel installs a MJU-49/B Decoy Flare bucket into the ALE-47 Counter Measure Dispensing system on a P-3C Orion assigned to VP-9. The Counter Measure Dispensing system is vital to the survivability of the P-3C by Navy photo by MC1 Eric BensonChaff, Flares and CADs By George AlstonThe ALE-39 and ALE-47 countermeasures dispensers have saved many lives and air craft. This same system can be deadly when maintenance technicians fail to follow safety procedures found in the maintenance manuals. Weve had too many reports of maintenance error and inadvertent ejection of chaff, flares and cartridges. The attached excerpts taken from one of many recent reportsthis one an ALE-47 explosive event report (EER)show the affects in one case. Unfortunately, weve had a rash of cases, and everyone who handles these items needs to be aware of the dangers faced every day with these small but powerful items.Can Kill
Mech 5 Mech Spring 2008 1. CHAIN OF EVENTS: A CH-53E AIRCRAFT CONFIGURED WITH 30 MJU-32 AND 30 MJU-49 RETURNED FROM AN ARMED MISSION WITH AN ALE-47 DISCREPANCY. THE AIRCREW PROPERLY DE-ARMED THE ALEPODS AND CONDUCTED A NORMAL SHUTDOWN. THE ORDNANCE DIVI SION WAS TASKED BY MAINTENANCE CONTROL TO REMOVE THE DISPENSER MAGAZINES AS SOON AS POSSIBLE. THE HELICOPTER AIRCRAFT COMMANDER(HAC) DEBRIEFED THE SENIOR T/M/S AVIONICS TECHNICIAN THAT, ALTHOUGH THE ALE47 CIRCUIT BREAKERS WERE PULLED OUT AND THE CONTROL PANEL WAS ON STANDBY, THE ALE CONDUCTED AN IN-FLIGHT UNCOMMANDED DIS PENSING OF FLARES.THIS AIRCRAFT WAS NEEDED THE NEXT DAY FOR A COMBAT MISSION, SO MAIN TENANCE CONTROL REQUESTED THAT THE ORD NANCE DIVISION ASSIST THE AVIONICS DIVISION WITH THE ALE-47 DISCREPANCY. AVIONICS SENT THREE TECHNICIANS TO THE AIRCRAFT TO INVES TIGATE THE PROBLEM. THE ALM-290 TEST SET WAS NOT READILY AVAILABLE, SO THE ORDNANCE TECHNICIAN ASSIGNED TO ASSIST AVIONICS LEFT THE EXPLOSIVE EVENT AIRCRAFT TO RETRIEVE THE TEST SET FROM A CONCURRENT AH/UH DOWNLOADING EVOLUTION IN ANOTHER LOCA TION ON THE AIRFIELD. TECHNICIAN #1 WRONGLY ASSUMED ALL EXPENDABLES HAD BEEN REMOVED AND PROCEEDED DIRECTLY INTO THE AIRCRAFT WITHOUT INSPECTING THE MATERIAL CONDITION OF THE ALE PODS. HE DISCONNECTED THE APPROPRIATE CIR CUIT BREAKERS AND THEN APPLIED POWER TO THE AIRCRAFT IN ORDER TO METER THE APPRO PRIATE ALE COMPONENTS. TECHNICIAN #1S TROUBLESHOOTING REVEALED THAT THERE WAS NO POWER GETTING TO THE SYSTEM. TECHNI CIAN #1 THEN PUSHED IN THE CIRCUIT BREAKERS, WHICH ENERGIZED THE SYSTEM WITH 28 VOLTS AT THE CIRCUIT BREAKER. TECHNICIAN #1 EXAM INED THE FIRING SWITCHES IN THE CABIN AND REALIZED NONE OF THE COUNTERMEASURE DIS PENSING SWITCHES HAD ILLUMINATED.HE THEN ASKED TECHNICIAN #2 TO ARM BOTH ALE-47 PODS, WHICH STILL HAD NOT BEEN DOWNLOADED BY THE ORDNANCE DIVISION. TECHNICIAN #2 ASSUMED THAT EVERYONE WAS AWARE THAT THE PODS WERE STILL LOADED AND WITHOUT HESITATION ARMED THE PODS. TECHNICIAN #1, WHO WAS SITTING ON THE JUMP SEAT NEAR THE COCKPIT, REQUESTED TECHNI CIAN #3 TO PLACE THE ALE-47 GROUND OVERRIDE SWITCH INTO THE ON POSITION. TECHNICIAN #1 PRESSED THE ALE FIRING SWITCH IN THE CABIN, WHICH RESULTED IN ONE FLARE BEING JET TISONED FROM EACH ALE POD. TECHNICIAN #1 INSTANTLY RECOGNIZED THAT COUNTERMEA SURES ORDNANCE HAD BEEN EXPENDED AND SHUT THE AIRCRAFT AUXILIARY POWER PLANT OFF AND REPORTED THE INCIDENT TO THE CHAIN OF COMMAND. 1. CAUSE OF MISHAP OR DEFICIENCY: HUMAN ERROR, CAUSE DESCRIPTION: MAINTENANCE LEADERSHIP DID NOT COM MUNICATE PRIORITIES TO WORKCENTERS. THERE WAS A LACK OF SITUATIONAL AWARE NESS BY THE AVIONICS TECHNICIANS. JUNIOR AVIONICS TECHNICIANS DISPLAYED A LACK OF ASSERTIVENESS.THERE WAS A FAILURE TO ADHERE TO ESTABLISHED PROCEDURES AND APPLICABLE MIMS BY MAINTENANCE PERSONNEL.THERE WAS A FAILURE OF MAINTE NANCE PROCESS AND CONTROL OF WORK. 2. PERSONNEL FAILED TO FOLLOW PROPER PRO CEDURE, OR FOLLOW APPLICABLE MIMS 3. PERSONNEL WERE ATTEMPTING TO EXPE DITE MAINTENANCE ACTION FOR FOLLOW-ON MIS SIONS. C. THE SUPERVISOR WAS PRESENT, QUALIFICA TIONS OR CERTIFICATIONS: NOT REQUIRED, THE INDIVIDUAL WAS TRAINED IN THE TASK. GOLF: RECOMMEND THAT REFRESHER COURSES BE CONDUCTED FOR ALL PERSONNEL PRIOR TO ANY INITIAL AVIATION ORDNANCE EVO LUTIONS EMPHAZING ORDNANCE SAFETY AND AWARENESS. RECOMMEND THAT THE SENIOR TECHNICIAN INVOLVED IN THE EXPLOSIVE EVENT CONDUCT AFTER-ACTION BRIEFS FOR ALL MAIN TENANCE DEPARTMENT PERSONNEL WITH AN EMPHASIS ON ORDNANCE SAFETY, AWARENESS, AND THE IMPORTANCE OF FOLLOWING PROPER MAINTENANCE PROCEDURES. LESSONS LEARNED ARE AS FOLLOWS: 1) CONDUCT A MAINTENANCE COORDINATION MEETING IMMEDIATELY FOL LOWING ORDNANCE EVOLUTIONS IN ORDER TO ESTABLISH PRIORITIES AND MAINTENANCE GUID ANCE FOR ALL WORKCENTERS. 2) MAINTENANCE TECHNICIANS ASSIGNED TO CONDUCT MAINTE NANCE/TROUBLESHOOTING ON ORDNANCE EVO LUTION AIRCRAFT MUST CONDUCT A THOROUGH LOOK-INSPECTION, PAYING PARTICULAR ATTEN TION TO AIRCRAFT WEAPONS STATIONS. ENSURE THE TECHNICIANS THEN DISCUSS THE UPCOMING MAINTENANCE EVOLUTION. 3) ENSURE DOCUMEN TATION HAS BEEN COMPLETED AND THAT EACH AIRCRAFT IS IDENTIFIED AS HAVING ORDNANCE ABOARD. 4) ALWAYS UTILIZE CHECKLISTS AND APPLICABLE MAINTENANCE MANUALS. IN CON CLUSION, REFRAIN FROM BEING IN SUCH A RUSH THAT YOUR ACTIONS COMPROMISE SAFETY. ASK QUESTIONS IF YOU HAVE DOUBTS. COMPLACENCY KILLS.Chaff, Flares and CADs
6 6 Mech Mech This message pointed out a few things that can and should take place. However, another step that might help prevent problems that maintenance technicians cause would be to have them sign a statement on the MAF before going out to the aircraft. The statement would say: I will check each dispenser on the aircraft for magazines. I will not do maintenance on an aircraft with magazines installed in a dispenser. This one simple statement may make them more aware and less likely to have a problem. Aircraft with PODs (helos) would have an additional sentence: While performing maintenance on the aircraft, I will not place the POD arm/safety handle in the arm position if a magazine is installed in the dispenser. Anyone dealing with chaff, flares or CADs needs to heed the warnings pointed out in this story and in the supplied message. If not, the next story may be about the death or serious injury to a maintainer. Mr. Alston works with the EW Fleet Support Team, NAVAIR ISSC (AIR 188.8.131.52), Jacksonville, Fla. The new Tire and Wheel safety poster is in and can be ordered online at www.safetycenter.navy.mil,under media and safety posters.
Mech Mech 7 Spring 2008By AE2 Andrew PetersonEveryone tried to tell me about the vast differ ences between the small boys and a carrier, in terms of size, speed, and scope of operations. No big deal, I thought. I understood that my role as a maintainer boiled down to two primary functions: to fix and maintain the helos in the hangar bay, and to launch and recover the helos on the flight deck. Well I learned a new lesson one day when I rushed from the hangar bay to the flight deck between jobs. The incident occurred on my first carrier cruise aboard USS Kitty Hawk as an SH-60B maintainer for HSL-51 Det. 3. All my previous deployments with the squadron for nearly four years had been on guided-mis sile cruisers as part of a one-aircraft detachment. I really didnt think this ship would be any different. Boy was I wrong! Warlord 703 was well into scheduled phase main tenance and fully de-paneled in the hangar bay. I was doing a standard fire-bottle op-check and going stepby-step on the IETMS laptop. The fire bottles and the CADS had been removed from the aircraft, and the volt meter verified no stray voltage existed. To test the 10g impact-switch circuit, I disconnected the cannon plug and ran an insulated jumper cable across the leads. This simulates the impact of a 10g crash landing when the fire-extinguisher circuit breaker is closed, which then would discharge both fire bottles simultaneously. The fire bottles were removed at this point. All checks were good! I was in the process of finish ing up the last few steps, when I got called to the flight deck to recover Warlord 710. No sweat, I thought, the phase would be over in record time. As I was climbing the ladder to the flight deck, all I could think about was the rapid progress on 703. The fact that I had left the insulated jumper cable attached to the impact-switch leads must have slipped my mind. We recovered 710 and finished the normal routine of engine wash, fold and stuff in the helo hole. Everyone on night check, including myself, spent the remainder of the evening on inspections and gripes written after 710s flight. The following day, the AOs began hooking up the CADS and fire bottles on 703. As it so happened, another maintainer closed the fire-extinguisher circuit breaker during the course of the phase. The inevitable result was the discharge of the No. 2 fire bottle into the No. 2 engine. Fortunately, the No. 1 fire bottle had not been connected yet, or it would have fired, too. When I got the word, I was in utter disbelief. How could I make such a simple mistake? Needless to say, my senior chief was in utter disbelief as well! I cant repeat some of the words he had for me. These CADS can injure people. I cant imagine how I would have felt had I been responsible for a shipmate losing his finger, hand, sight, or even his life. Thankfully, no one was hurt because of my carelessness. Despite being the lead AE on my detachment, I put another person at risk because I forgot to remove a 4-inch piece of wire. I forever will be reminded of this incident each time I CDI a discrepancy. I have heard the words, In this job, distractions can be deadly, but they mean much more to me now. I learned an important lesson: Maintainers must do every job, no matter how big or small, from start to finish. And do one job at a time. Petty Officer Peterson works in the AE shop at HSL-51. One Job at a Time Knowing the system and how to prevent problems is the key to success.
By AE2(AW/SW) Stephanie TeixeiraOne evening during deployment, pilots were manning up for the first night launch. As a troubleshooter with VFA-136, I was making my way to the back of the jet to check hydraulic gauge No. 1 on the left side of the aircraft, while one of our pilots climbed into the cockpit. The night was ready to heat up. As I was writing down the numbers on the launch card, the pilot started the APU. Normally, when the APU starts at night, you can see some orange flames coming from the exhaust. However, this time, the flames kept growing bigger and wider. They started hit ting the deck and flowing out the sides of the aircraft. I was worried because the flames were larger than I ever had seen before, so I gave the PC the fire signal with my wand. The PC was confused at first but eventually gave the pilot the shutdown signal. The APU spooled down, and the fire went out. I had been watching the PC and knew that he did not pass the correct signal for an APU fire. So, to clarify the situation, I ran up to the starboard side of the jet and yelled to the pilot, You had an APU fire. In the mean time, our flight-deck chief and another troubleshooter already had started to pump up the APU. To make sure we didnt have any mixed signals, I crossed to the port side of the FA-18C, climbed up the ladder, and told the pilot what had happened. I could have just plugged into the aircraft to pass that information; however, that would have taken too long. I told him to wait for us to pump up the APU, so we could try the start again. He acknowl edged what I told him by saying OK, so I climbed down from the LEX to help the other troubleshooter with the APU. Once we were ready to start again, we gave the PC the signal to start the APU, and the pilot started the jet without incident. After final checks, the flight-deck crew broke down the jet and taxied it toward the cata pults. A few minutes later, the pilot called himself down and taxied back for shutdown. What the heck had hap pened now?Navy photo by PH1(AW) Brien Aho 8 Mech
9 Spring 2008 It turned out the jet was down before it was started the second time. The pilot noticed during the first start that his jet was getting a lot of attention on the flight deck. He looked at his PC, who was a new trainee, giving him a signal with the light wands. The pilot became confused because the signal appeared to be a cross between the start and shut-down-engine signals. In the background, the pilot thought he saw the PC instructor standing behind the PC trainee give a fire signal without wands. Based on the conflicting signals and confusion, the pilot decided it was best to shut off the APU. The pilot was anxious because he did not understand what was going on. When he saw me mouth the word fire from the right side of the jet, he decided to execute the first steps of the APU fire-emergency procedure, which was to blow the fire-extinguisher bottle. However, since things seemed to have calmed down around his aircraft, he never completed the pro cedure, which called for him to exit the aircraft. No one on the deck and around the aircraft knew that the pilots emergency procedures were to blow the fire bottle. Had we known, or had the pilot climbed out of the jet, we would have suspected that the jet was down. The pilot assumed we knew that he had fired the extinguisher, but we had no idea. In fact, the trouble shooter in the wheel well pumping up the APU noticed a hissing sound and had mist spray into his face, but he didnt think it was the fire-extinguishing agent from the bottle. Since no one had heard the CADS fire, no one thought of checking the fire bottle or asking the pilot if he had blown the extin guisher. Had the trouble shooters checked the MMP codes before the chocks and chains had been removed for taxi, we would have seen a 988 code, indicating that the fire bottle had been dis charged. We instantly would have known that the jet was down. When I talked to the pilot after I climbed up the ladder, he did not mention the extinguisher because he thought I already knew. Thinking that we needed the jet turning to troubleshoot, he restarted it. Only later, as he taxied toward the catapult, did the CATCC representative confirm he was down. In the end, we learned many lessons from this expe rience. Everyone must play an active role and communi cate clearly and concisely with each other. A PC trainee must have better supervision with a new pilot. PC instructors need to take charge and pass proper signals if their trainee doesnt handle a situation correctly. They also should have their own set of wands. PC trainees must know their emergency signals. Its important that all maintainers know emergency procedures. In our case, only maintainers with a low-power turn qual knew the pilots APU fire procedures. Implementing training like this will keep the ground crew from trying to restart the APU after a fire-bottle discharge. Regardless of what is going on, procedures must be followed. Because of the fire, the ground crew got behind and felt rushed trying to launch the jet before the catapults were secured. As a result, we forgot to check the MMPs. Had we stopped for a second and reviewed our procedures, this situation wouldnt have happened. Even though each of us thought we knew what was going on, none of us knew all that had happened until well after the incident. Fortunately, the extinguishing agent did not harm the troubleshooter, and the jet did not go flying in a down status. We shouldnt depend on luck, but we were lucky that this incident cost us only a sortie. Petty Officer Teixeira is a troubleshooter with VFA-136. Mech
10 Mech Mech for the guillotine check, using the AWM-102 tester to complete this function. Typically it works great; how ever, this time it was acting up. I had to spend some extra time with the tester before using it. Back in the cockpit, AO3 Briggs removed the safety controls on the ARS control panel and was ready to test the system. Normally, the CADs are removed from the aircraft during testing, so they do not actually fire when the system is tested. The test is done to make sure the firing process works from the cockpit, in case aircrew have to sever the refueling hose in flight. Since we trusted that the CADs had been removed, we did not verify whether they actually were installed in the ARS pod. Since the AO3 knew how long the prep work took, she had a built-in timer for this test. After waiting the normal amount of time, she engaged the firing switch in the cockpit. As it turns out, the CADs were installed, so they blew. The hose was cut, and the refueling basket To say things had become routine during the last few weeks of a six-month combat cruise is an understatement. The constant repetition of certain maintenance procedures led team members to make assumptions that ended in a memorable incident. We were on our last hour of night check. We needed to arm the jets for the morning flight schedule and to do an air-refueling store (ARS) guillotine check. We had done these procedures countless times on cruise. As the CDI, I thought that Fast Eagle 106 required these checks, so my team member and I signed out our tools, went to the roof, found the jet, and went to work. We did not put our job into work in NALCOMIS before we left maintenance control. We found 106 and assumed the jet was not armed; we implicitly trusted our ship mates to leave the jet unarmed before the tests. Upon reaching the jet, AO3 Briggs climbed into the cockpit and prepped the necessary switches for the test. I stayed underneath the jet and prepared the ARS pod Is a Bad ThingAssuming By AO2(AW) Jason Binney and AO3(AW) Briggs
Mech 11 Mech Spring 2008 fell to the flight deck. Fortunately, no one was injured when this happened. After realizing what had happened, we notified maintenance control. They asked us why we had tested 106 when we were supposed to check 113. This is where all the pieces of the puzzle came together. We had con fused the side number needing the checks, and we likely would have realized our mistake had we used NAL COMIS. In addition to the side number mix-up, we also chose to do this test with two people, instead of three. A third person is essential to this test because the person in the cockpit cannot communicate directly with the person underneath the jet. Had that middleman been there to relay communications between the two of us, we could have avoided firing the cad, cutting the hose, and dam aging the ARS pod. The biggest mistake we made was assuming the CADS had been removed. Assuming anything as a maintainer, particularly for an ordnanceman, is fraught with danger. The jets we maintain are weapons, and we always should treat them as loaded guns, no matter what the circumstances. Verifying that the jet is dearmed takes about as long as it takes to say it. We had no excuse for not having verified the jet was dearmed or for not using a checklist. While no one was injured by this incident, we did nearly $15,000 worth of damage to the ARS pod and disabled a valuable air-wing asset. Furthermore, we tar nished our squadrons stellar reputation as the air wings Golden Wrench unit. We went to captains mast for this error and subsequently lost our qualifications. We are now team members working to regain them. We would like to be able to go back and change what happened, but we cant. We were a bit fatigued and gethome-itis had set in. But when the routine becomes too routine, its time to be extra careful. Petty Officers Binney and Briggs work in the ordnance shop at VFA-41. Working on a buddy store requires attention from the blades to the basket. Navy photo by PH3 Shannon Renfroe
12 Spray painting requires the right gear, right place, and right amount of cleanliness. The note on the readyservice locker is clear, but the smoking pit clearly is too close for comfort. Mech Mech 12 Well-organized safety boards with information, posters or magazine excerpts improve safety awareness.
Mech Mech Spring 2008 13By Lt. Adrian DawsonI was doing an interior aircraft cleaning of one of our squadron birds along with the rest of my crew. It was only the second time I ever had done it, and the job was simple. You wipe down certain areas, vacuum and mop the floors, and then call it a day. But, like everything else in the Navy, we have a checklist for this menial task. Had I used it, that simple document would have prevented my unfortunate incident. Like any desert, the conditions are notoriously dusty at our forward-deployed location. So as a pilot, I started my portion of the aircraft cleaning in the place I feel most at home: the flight station. I started with the hori zontal surfaces that had collected dust. And there was a lot of it. As my flight engineer was walking out to the aircraft with the checklist in his hand, I began to clean around the emergency-shutdown handles. On P-3 aircraft, protected behind the e-handles, are the fire bottle (HRD: high-rate discharge) buttons, which release an extinguishing agent into the engine nacelles in the event of a fire. You probably can see where this is going. I successfully cleaned around the No.s 4, 3 and 2 e-handles without any problems. However, while clean ing around the No. 1 handle, I heard the distinct click every upgrading pilot can recognize. It happened when my index finger hit something, which turned out to be the HRD button. With a sick feeling in my stomach, I looked to the right, so I could scan the forward load center, which contains various circuit-breaker panels. Confirming what I already suspected, I saw that the circuit breakers for normal fire extinguishing were set. Holding on to a sliver of hope, I put on my hearing pro tection and walked outside to check the HRD pressure gauge for the No. 1 engine. Seeing that the needle was pegged at 0, I knew the final nail was in my coffin. I slowly dragged myself back onto the aircraft and into the flight station, only to see my flight engineer dutifully running the aircraft-clean checklist. By the way, step 1, sub-step h, is Pull primary HRD C/Bs. RTFC! Which in this case stands for Run The Freaking Checklist. In aviation, we use terms like situational awareness, which essentially means how close your perception of whats going on mirrors reality. It is a term that should not be reserved for missions or flights. Where was my SA as I was cleaning around those e-handles? Did I know whether the breakers were in or out? Unfortunately, not until it was too late. The worst part is that Im a former ground-safety officer for our squadron. No one is more aware than I am about mid-deployment complacency, focusing on the task at hand, everyone is a safety officer, and procedures are there for a reason. My job was to orga nize safety stand-downs, make sure people know their safety chain of command, and even write articles for the monthly safety newsletter. I think the takeaway here is to approach every event with the same intensity and attention to detail. Treat a simple aircraft cleaning as if it were an overland combat mission to support ground troops. Treat that ready preflight as if it were a search-and-rescue mission for a downed comrade. Bottom line: No one is immune to complacency or procedures, not even a qualified aircraft commander and former GSO. Lt. Dawson is a pilot at VP-47.Why I Blew ItNavy photo by PH2 Jennifer Bailey
14 Mech Mech 14 By AME1(AW) John ShorbI had 32 days left until I checked out of the com mand and headed from Washington D.C. to Point Mugu, Calif. I was the only qualified QAR working, and all of the shops needed me to CDI their MAFs. But I was seasoned to this work tempo, and being an AME1 and full-systems QAR meant I practically could do it all. I had been working in QA longer than anyone else in the command and had seen it all, or so I thought. Our first priority was to remove and replace three of five, M-193 fire-extinguishing CADs for high time. As the QA/SO for the task, I was ready to go. Our ord nance board just had qualified two third class petty officers as ordnance handlers, and this was to be their first live ordnance evolution. We prepared for our task, placed the MAFs in work, set HERO condition, and roped off the aircraft. We carried our tools and parts out to the aircraft and set up to work. We removed the right engine and APU fire bottles. The right bottle has two CADs, and the APU has only one. The left engine CADs had been replaced three months before, so they were good and didnt need to be removed. Once the bottles were out, we removed the old CADs, installed the new ones, and prepared to do our firing-circuitry test. We decided to take a break. I made a head call and checked with the other shops to check progress on the gripes with our other aircraft. When we came back, we were ready to hook up electrical power to the aircraft and do the test. The first note in the book about the test says, This test will discharge the fire bottles. No kidding, How To Lose Your
Mech 15 Mech Spring 2008 15so we removed them. The second step of the test says to remove the positive leads of all the CADs. Well, if the bottles are out, the leads are off. We then checked the voltage at the leads to make sure there was 28 volts to fire the CADs. I asked one of the workers to go to the cockpit and pull-and-turn the fire handles, while I stayed with the second maintainer in the tail to check the voltage. We hooked up to the right bottle leads and turned the right-hand fire handle to shot No. 1: 28 volts, checks good. We turned the right-hand fire handle to shot No. 2: BOOM!! 28 volts went to the left bottle, the CAD exploded and sent the extinguishing agent into the right engine nacelle. The fireextinguishing system worked as advertised. My first thought was that I had killed the worker in the tail compartment reading the volts. I asked him if he was OK, and he said, Yeah, just a little hard of hearing after that explosion that went off. As we climbed out of the tail compartment and could see the white smoke coming out of the engine nacelle, it hit meI was an idiot. The second maintainer came out of the cockpit and asked if we were all OK? We answered yes, but we were just a little shaken up. The CAD went off less than three feet from us. We gathered all our tools, How To Lose Your locked up everything, and went to maintenance to give them the news. Maintenance controls first reaction was, Yeah right, so youre done? Can we secure from HERO con dition and get some work done? To convince them, it took about 10 minutes of discussion and a visit to the aircraft. Why didnt they believe me? I guess because Im the ordnance program manager, and guys like me dont make mistakesuntil now. In my case, I lost my ordnance certification, which in turn makes me ineligible as a full-system QAR for workcenter 13B. As an ordnance board member and program manager, I also am required to be ordnancecertified, so there went those positions. But none of that matters to me at the moment. I almost had killed a shipmate. That is the part that I cannot fully grasp. He has a wife and baby, and a mother and father could have lost a son. Speaking of family, my wife just had our first child 17 days ago. I could have widowed my wife and could have left a newborn baby without a father. Naval aviation can be dangerous, but its not until something like this happens that you realize just how dangerous. No one was hurt, and no damage was done. This was my freebie, but Ill have to work at my new command to back my quals. Most people will forget this event ever happened, but I will live with the memory for the rest of my life. Petty Officer Shorb worked in the AME shop at VR-48 when he wrote this story. Jeff Hobrath is a retired PR chief who has volunteered to help MECH with this comic series. We take some liberty with the Rats for the price of a message through humor. For more info on Jeff Hobrath, simply do a search for Jeff Hobrath on the internet.
16 Mech Mech By Jeff HobrathIn August 2006, the Joint Aeronautical Logistics Commanders (JALC) sponsored the Navy, Marine Corps, Army, Air Force, Coast Guard, and Defense Contract Management Agency (DCMA) to develop a Joint Deficiency Reporting System (JDRS), based on NAVAIRs NAMDRP program. JDRS provides a common, seamless solution to report, track and resolve technical deficien cies that the fleet identify across the Aeronautical Enterprise. JDRS is a cross-service, webenabled, automated tracking system designed to initiate, process and track deficiency reports from the fleet through the full investigation process.Joint Discrepancy Reporting System (JDRS) Being Developed
Mech 17 Mech Spring 2008 17Printed as a supplement to Mech from Naval Safety Center Data Cdr. Ed HobbsFor questions or comments, call Dan Steber (757) 444-3520 Ext. 7247 (DSN 564)Flight, Flight-Related, and Ground Class A and B Mishaps 12/17/2007 to 02/26/2008Class A MishapsDate Type Aircraft Command 01/07/2008 FA-18E VFA-105 Two Hornets were lost at sea after a mid-air collision. Aircrew survived. 01/16/2008 MH-53E HM-15 01/21/2008 EA-6B VAQ-136 turn. 02/12/2008 EA-6B VAQ-136 Aircraft lost over water during large-force exercise. Aircrew recovered. 02/13/2008 AV-8B HMM-365 Class B MishapsDate Type Aircraft Command 01/17/2008 MH-60S HSC-3 Helicopter experienced hard landing at NOLF. 01/17/2008 SH-60B HSL-40 01/19/2008 AH-1W HMT-303 pitch. 01/30/2008 EA-6B VAQ-129 During night CQ, underside of rudder struck landing area following waveoff. 2/04/2008 FA-18D VFA-125 02/07/2008 FA-18C VFA-83 02/11/2008 FA-18F COMSTRKFIGHTWINGPAC turn. 02/11/2008 KC-130T VMGR-452 02/20/2008 P-3C VP-10 Starboard wingtip area collided with crash rescue vehicle. No NAVAIRs NAMDRP/JDRS development team consists of senior programmers, functional requirement experts, application testers, and various program-sup port personnel at NAS Patuxent River, Md. Working alongside the JDRS development team are support teams from the Navy, Marine Corps, Army, Air Force, Coast Guard and DCMA. Currently, NAMDRP serves more than 9,400 users, averaging 225 transactions per day and 4.5 million hits per year. With the addition of Air Force, Army, Coast Guard, DCMA, and other agencies, JDRS will sup port more than 20,000 users processing 50,000-plus deficiency reports annually, making it one of the most robust joint-service web applications ever developed. The benefits of JDRS are significant, and they include: Improved quality of material and readiness Enhanced visibility of deficiency reports across all services Increased visibility of critical safety items throughout the aeronautical enterprise Reduced total ownership cost and cycle time Partnered efforts between government and industry Improved exhibit inventory management and management metrics Automated routing of deficiency reports and ease of use The various JDRS deficiency reports includes: product quality deficiency reports (PQDRs); engi neering investigations (EIs); material deficiency reports(MDRs); acceptance inspection deficiency reports (AIDRs); and hazardous material reports (HMRs). Technical publication deficiency reports (TPDRs) will be added in the near future. JDRS is scheduled to launch in spring 2008. Mr. Hobrath works for NAWCAD, Code 7.2.2, NAMDRP/JDRS Program Office, NAS Patuxent River, Md.
A maintenance crew works on an FA-18C Hornet assigned to the Stingers of Strike Fighter Squadron (VFA-113), during Ronald ReaganTrenchesin theMaintainers Cpls. William Thornton (left) and Jeffers Page, along with other Marines, roll an engine out from an F/A-18 Hornet at Al Asad, Iraq. The Marines are with the phase maintenance section of Marine All-Weather Fighter Attack Squadron 533, Photo by Cpl. Jonathan Teslevich deck aboard USS George Washington 18 Mech
19 Spring 2008 and they flushed out my eyes several more times before sending me to a hospital off base. When I arrived at the emergency room, I barely could see anything at all. I was admitted and stayed there over night with a saline solu tion hooked up to my eyesa very painful process. In the morning, I went to see a specialist to see if any permanent damage had occurred. Luckily, the diag nosis was favorable, and I wasnt going to have any longterm side effects. I did, however, receive a prescription medicine to help with the healing. On top of having to take medication for two weeks, my vision was affected for the whole period. It took a while to return to normal. The biggest lesson I learned from the entire experience is that we use PPE for a reason, and it should be worn anytime hazmat is handled. Unfortunately, I had to learn the hard way. Airman Jaramillo works in the line division at VAW-116. By AN Derick JaramilloMy story is about another simple job gone wrong. We just were washing an airplane; what could go wrong? Yes, I have heard the stories of turco and other people, but this job is easy. I didnt believe anything could happen to me. Im smarter than that, and I always wear eye protectionwell, almost always. One evening, my shipmates and I were washing one of our E-2Cs. Everything was going smoothly, and the job was getting done rather quickly. When we finished, I removed my PPE and started to clean up the area. I was moving a bucket of wash soap out of the way when some of it splashed into my eyes. I immediately ran to the eyewash station to rinse out the soap I rinsed several times, but the burning did not stop. My vision began to blur badly and my eyes began to swell. I told my supervisor about my problem, and he told the maintenance-control chief. I was rushed to medical, Washing Eyes With Soap Mech
20 Mech Mech By AN Justin HendersonI woke up that Tuesday evening, expecting a normal night at work. A few hours later, I had a safety inci dent that almost crushed my right hand. When I got to the shop, I began my typical airman duties: Pre-op some SE gear, carry some toolboxes, hold the flashlightyou knownothing out of the ordi nary. My PO3 then received a phone call from the AOs. They needed some help dropping a 480-gallon tank for inspection. No big deal, I thought. Ive dropped plenty of tanks. I didnt realize at the time how ter rible those words sound, even though other maintainers have said them in the past with bad results. We arrived at the jet in hangar bay No. 2 and found four ordies already there. We had everything needed for the job: a speed-handle, the proper 7/16-inch socket to unlock the BRU, four peopleincluding meto assist lowering the tank, and an AO1 CDI to drop the tank. We were all set, or so it appeared. An empty external drop-tank dolly sat on the other side of the jet, between a pallet-jack and some other equipment. Two tractors blocked direct access to the dolly, so we couldnt get to it as quickly as we would have liked. And it was required for this job. The tank was dry-hung, meaning it was connected to the wing, but the fuel line was not attached or feed ing fuel into the tank. The inspection was a quick job for the AOs, and we had the resources and time to move the gear to get that dolly. However, everyone wanted to get the job done, so we decided to do a manual drop. That means two people carry the forward end of the tank, and two people carry the aft end. One person then unlocks and drops the tank. Hand TacoNavy photo by PH3 Jonathan ChandlerTuesday
Mech 21 Mech Spring 2008 After dipping the tank to make sure its empty, be sure the people at both ends of the tank are ready before you release it. Thump tests dont work, and you cant always believe gauges. Dip the tank before you try to drop it. If the man releasing the tank from the bomb both ends are going to be holding roughly We took up our positions, and I asked the AD3, Hey, is there any fuel in this tank? He in turn asked the AOs. After a couple of headshakes, we were ready to drop the tank. It was at that point when I seriously should have considered the gravity (pun intended) of the whole situa tion and applied some ORM. AO1 called, Ready in the back, ready in the front, here comes the weight! I next heard the telltale click that Ill never forget. The tank became solid, dead weight. We all lost our grip, and the tank fell to the ground with a wet thud. The tank still had about 200 pounds of fuel inside. We had another problemmy right hand was sand wiched between the non-skid and the bottom of the tank. At that point, everyone in the hangar bay knew it, too, because I let out a long, horrifying howl. Panicked and in pain, I jerked my hand free of the sandwich that just had turned my hand into a taco. My hand already was swelling, and sharp, knife-like pains tore through my arm. I could feel my bones burning white-hot. As the people around me came to help, I literally was seeing stars. We all shook off the mistake, secured the tank, and went back to the shop. My hand still was throbbing, though, and I no longer was able to make a fist. The supervisor sent me to medical for an exam. This simple mistake caused two fractures and a broken piece of bone in my wrist. I now am on light and limitedduty for four to six weeks, with possible surgery in my future. To make matters worse, I increased the workload on my shipmates because our shop now is down a man.Situations like this happen too often, and it almost always is because of perceived pressure that makes us work to get a job done too quickly. In this case, we really had the time but pushed anyway. Maintainers always have two options: the right way and the wrong way. In this case, we should have asked an ABH to move the tractors for five minutes so we could have gotten the dolly and dropped the tank correctly. It was that simple. We had the tools and the resources, but we didnt have the required patience. We also didnt practice good ORM. At times like this, someone needs to step up and say, This situation isnt right or Maybe we should try something else or simply, This isnt safe, Im not doing it. Nobody is going to think any lesser of you for doing a job the right way. Airman Henderson works in the mech shop at VFA-27. A couple other things would have helped: the book, checklist and more importantly, not doing a thump test. Mech has said it 237 times since 1961, the first year Mech came out, a thump test doesnt workperiod. Pop the cap, do a dip check, and stop injuring maintainers.Ed.Although these photos show an EA-6B, the dip test is valid for all drop-tanks.
Mech Mech 22 By AM2(AW) John FranklinI think everyone has heard what happens when you assume anything. As the saying goes, You make an ass out of you and me. Its a clever saying and is easy to remember. Never did I believe it would apply to me, but one day, it did. I had been an airframe CDI for a year and never fully understood the responsibility that comes with that position, until my mistake. When a maintainer becomes Just a Scrape a CDI, their responsibility increases, as does the trust of everyone in the squadronofficer and enlisted. As a CDI, I am responsible for the quality of work done on the jet, making sure it is safe for the pilots who will fly it and capable of achieving its assigned missions. A good general description of a CDIs responsibilities is that we are an extended arm of QA division. My story is simple, and my mistake almost cost me the trust of the pilots and maintenance department when I assumed, rather than inspected. Im a troubleshooter in my squadron and work nights. We were within a week of deploying, and that time can be very hectic at any squadron. Pilots fly a lot of hours and do field carrier-landing practices. Maintainers work hard to give ops enough jets to get all the crews carrier-qualified before we deploy. This week was routine for the troubleshooters, but airframes had an unusually heavy workload. With our flight schedule over and being an airframer, I decided to help them with their workload. They had an air craft on jacks to service the struts and to comply with a recent technical directive (TD). While helping with the struts and the TD, we found more work. All the tires and brakes were worn. They were within limits, but, this close to deployment, we decided to take advantage of the aircraft being on jacks and change them. I began to feel the burden of all the maintenance done that evening, both with airframes and troubleshooters. I dont mean to say I couldnt handle both jobs, but somewhere during the night, I failed to stay aware of all the work. The worn tires and brakes had been pulled off and turned in, and we were waiting for the new ones to arrive. Once they came in, I took them to the aircraft. Navy photo by PHAN Geoffrey Lewis
Mech 23 Mech Spring 2008 23At that same time, one of our PCs came to me and told me of a gripe on the aircraft. He said the aircraft had a scratch on the horizontal stab. Of course, a scratch can mean many things, from chipped paint to a gouge or just a mark on the jet. Hornets often have paint damage on the stabs, and this is what I thought the PC was refer ring to. Using what turned out to be terrible judgment, I told the PC not to worry about the scratch and contin ued to work on the jacked aircraft. The scratch turned out to be a gouge in the alu minum section on the leading edge of the stab. Once the damage was inspected, we found it was not within limits, meaning the stab should have been repaired or replaced. This type of damage has very small limita tions (< .0030-inch on the leading edge). A quick visual inspection wouldnt have told me that the damage wasnt within limits, but it would have forced me to question the damage and look up the limitations in the structuralrepair manual. Damage to the leading edge of the stab, a primary flight-control surface, could lead to abnormal flight conditions, thus compromising the safety of the pilot. I consider myself a hard-working and competent airframer. PCs come to me when they find something wrong with the jets. Almost always99.9 percent of the timeI investigate the problem and determine what to do. This time, I didnt, and the experience taught me that every situation that comes up is unique. Just because a scratch sometimes turns out to be nothing doesnt mean it always will be that way. I should have told the PC to write a MAF, and then I or another quali fied airframer would have looked at it before the next flight. This one step would have prevented us from flying a down aircraft. I also could have asked how the stab was scratched. As it turns out, the stab was damaged when the aft section of the FLIR pod dislodged in flight and hit the leading edge of the stab. Had I investigated the report of a scratch and examined the surrounding area, I would have noticed this section missing and realized where the damage had come from. The Naval Safety Center gives maintainers a good analogy to explain how mishaps occur; they call it the Swiss Cheese model or theory. This approach states that, for a mishap to occur, all the holes in the Swiss cheese have to line up. I had an opportunity to block one of those holes but missed my chance. Luckily, no mishap occurred. The holes lined up this time when I assumed the damage was negligible and when the damage was missed during the FLIR daily walk around of the jets the fol lowing morning, and pre-flight inspection. After the aircraft went flying and returned safely, the squadron was fortunate that the holes finally were blocked after a post-flight inspection. This simple mistake endangered the safety of a jet and life of a pilot, and it nearly caused my co-workers and management to lose faith in my abilities. Had I taken just five minutes to grab a flashlight and examine the stab, I would have noticed the damage and would have realized it wasnt normal. The stab was removed and repaired after only one flight. Its unfortunate that it took an incident like this one to open my eyes, but it shows how one person not taking each situation seriously could lead to an aircraft mishap. I have learned a great deal from this event. I now investigate the problem 100 percent of the time and determine what to do. I also have rebuilt the confidence of leadership in my abilities. Petty Officer Franklin was a troubleshooter with VFA-34 when he wrote this story. the bare metal, length and depth of the gouge. paint damage in the center of the picture.
24 Mech Mech By Lt. Dave Bigay Tool-control procedures have proven effective and are in place for a reason. However, the programs effectiveness is con tingent on whether the procedures are followed to the letter, every time, and without fail. Follow them, and pilots need not worry. Neglect the procedures, even for a moment, and the results have the potential to be disastrous. While performing a daily inspection on the flight line at night, on one of the squadrons SH-60B aircraft, a plane captain found a discrepancy that required repair before an aircraft could launch on its functional check flight (FCF) the next morning. After checking out tools from the tool room, the detachments lead AD and two junior ADs did the required maintenance. When suf ficient flashlights were not available in the on-hand toolboxes, an additional flashlight was brought from a toolbox in the hangar. When the team finished the job, they hastily packed up their tools, did a tool inventory on the toolboxes at the aircraft, and went their separate ways. The following morning, more detachment person nel did a tool inventory before breaking for lunch and discovered that a flashlight was missing from one of the toolboxes. After they unsuccessfully searched for the missing flashlight, QA was notified of the missing tool, and all aircraft were recalled. The flashlight was found in the hydraulics bay of the FCF aircraft that had been repaired the previous night. The hydraulics bay on the H-60 is located directly over the cockpit and cabin of the helicopter and provides the transfer of all of the pilots control inputs to the rotor hub. This compartment contains dozens of servos, rods and linkages, where a tool could jam, render the flight controls useless, and result in an aircraft crash. Although the det thought all the tools had been accounted for, it later was discovered that a flashlight from another toolbox somehow had made its way into the missing flashlights toolbox. A simple error had led to nearly disastrous results. If you ask most maintainers, post-maintenance FCFs are like a trip to the dentist: The sooner its over, the better. While the motivation behind this attitude is purely a desire to get the aircraft back to work support ing the mission as soon as possible, its easy to see where this attitude can be a recipe for disaster. This is a good reminder for supervisors that mainte nance never should be rushed. Whether its in the qual ity of the maintenance being done, tool control, or the paperwork to back it all up, the chance something was missed increases exponentially when we rush a job, or in this case, during post-maintenance cleanup. Lt. Bigay is a pilot with HSL-46.Rushed Tool Check
Mech 25 Mech Spring 2008 Send BZs to: SAFE-Mech@navy. Quarterof theBZAMAA Ryan Marshall HS-7 While doing a turnaround inspec Marshall determined one of the tailrotor blades felt loose, compared to the others. He did a teeter test, which checks for spar integrity and a delami nating tail rotor. He then found a few QA. After removing the outboard reten tion plate, a QAR found the composite to separate from each other, causing the tail rotor spar to crack along the retention plate. Had the delamination and cracks gone unnoticed, the tail-rotor blade likely would have failed during the
26 Mech Mech AT2 Tyler Vidas HSL-42 On a routine FOD inspection on found a disconnected wire for the directional-control valve, which is used aircraft been flown in this condition, engines would have been inoperable in case of an emergency. His quick actions prevented further problems, and the gripe AM2 Mark Thomas HSL-44 During a routine inspection of noticed the sealant deteriorating on the main transmission. A closer look revealed that the input module was corroded severely at critical mounting points. this problem, a catastrophic main-trans mission failure would have been likely. AE2 Daniel Coffey HSL-42 Det. 1 During a routine weekly aircraft wash aboard USS Klakring of the main-rotor blades of his detach and could have resulted in catastrophic failure had it gone undetected. led to a timely repair, returning their sole aircraft to full mission-capable status. Cpl. Sophia Reiser HMM-365 were pushed too far forward. A closer look revealed the inner race for one of was missing. Center said the missing inner race might have caused catastrophic failure of the in the loss of the aircraft and the lives of the crew. AM2 Dustin Maxey HSL-42 USS Vicksburg Maxey found a cracked piston on the YAW boost-servo assembly of Proud Warrior 431. After discovering the problem on an early morning daily-andturnaround inspection, he immediately control. tion to detail, quick action, and thorough knowledge of plane-captain procedures prevented a potentially catastrophic chain of events. AMT2 Michael Gustaveson CGAS Kodiak, Alaska During a recent search-and-rescue (SAR) case to Adak, Alaska, Petty denly noticed the yellow main-rotor-blade damper was installed incorrectly. to detail prevented a premature failure of a dynamic component and prevented a potential aircraft mishap.
Mech 27 Mech Spring 2008 AN Chad Helstrom HSL-51 While doing corrosion work on an stage tail-rotor servos were not seated controls the aircrafts heading through the tail rotor. Further inspection revealed that the jam nuts on the backside of the pylon had backed off. His good troubleshooting effort during a mundane task prevented AO2 Alex Ramosruano HSL-37 During a plane captain preflight inspection of the engine compartment of noticed a missing torque stripe on the B-nut for the load-demand-spindle (LDS) cable. A closer look at the B-nut showed the LDS cable was not secured correctly to the hydro-mechanical control unit (HMU). wrote a downing discrepancy. His ability emergency. AM3 Trevor Shivdayal HSL-37 Det. 2 Chosin located a pinhole leak in a hydraulic-pres hole, the leak would have gone unnoticed Petty Officer Shivdayals keen attention-to-detail and meticulous trou bleshooting technique prevented a partial hydraulic-system failure and in-flight emergency. AM2 Phillip Boykin VAW-117 hummer hole aboard the USS Nimitz engine, he felt the aircraft shift in an unexpected manner. The aircrafts wings had begun to spread unexpectedly. He quickly cycled the wing-spread lever from folded to spread and back to folded while taking the condition lever to ground stop. This action stopped the wings and caused them to refold, preventing aircraft and equipment. AM2(AW) Philip Sadler HSL-37 Det. 2 Reuben James a possible mishap when he noticed seri ous exfoliation corrosion on the hinge bracket of the APU door. Had it gone unnoticed, the hinge likely would have failed, causing the APU door to depart the aircraft. He immediately downed the aircraft and corrected the problem, AD3 Brian Reynolds HSL-51 and immediately reported it to a QA. The crack turned out to be a P&E repair. His keen eye and quick action prevented a
28 Mech Mech AD2 Chris Davis and AD3 Marvin Freshwater VFA-102 had been troubleshooting an over-fueling gripe on replacing the wing highand low-level pilot valves, fuel continued spilling out the vents. Undeterred, they suspected a failure of the high-level pilot valve in the the top of the fuel cell had collapsed. A closer look at the bladder cell showed several rub marks and damage beyond usable limits to the nylon barrier. They ultimately found a problem with the lacing was fuel cell and saving hundreds of man-hours in future troubleshooting. AE2(AW) James Beach VR-56 On a look-phase inspection on the port and starboard wingtip-lighting assemblies looked like they had melted. From experience, he knew this prob lem might be the result of a lightning hit. During the subsequent conditional inspection, he also found a large, burnedout hole on the elevator control tab, allowed both strobe assemblies and the elevator control tab to be replaced, quickly returning the aircraft to service. AM1 Matthew Allen VPU-2 While doing a routine daily inspec noticed what appeared to be a small crack on the forward skin of the starboard ailerons trim tab. After a closer look, he found that the attaching hardware for the connecting road to the inboard trim tab was missing, and the remaining hardware in the outboard connecting rod was worn. The missing hardware had caused the rod to rub through the trim-tab skin. The associated linkages were damaged beyond repair. eye discovered a discrepancy that was not easily seen and could have caused of aircraft and crew. AD1 Joshua Sullivan VPU-2 ing starboard wing observer for a P-3 was started, AD1 Sullivan noticed the situation and using sound principles of ground-resource management, he sig naled the lineman to instruct the aircrew to shut down engines. Upon closer inspection, he discovered the door was beyond repair and worked quickly to replace the top after-body. The aircraft then was able to safely execute a suc cessful combat mission.
Mech 29 Mech Spring 2008crossfeed Editorial Coordinator ADCS(AW) Michael Tate Safety SurveysBy Dan SteberA dedicated team of maintenance and safety professionals gathered several days before a short trip to North Carolina. The maintainers and topside members met to discuss the logistics for the survey trip and commands being looked at. It was the first step in a well-choreographed trip that would affect two squadrons: VMM-162 and VMAQ-2. They would be just two of more than 150 squadrons the safety center team looks at each year.Shortly after arrival in Havelock, NC, the mainte nance team mustered for one final brief before the first survey, which actually took place at MCAS New River in Jacksonvillea 45-minute drive away. The team leader, Capt. Chris Foley and Master Chief Johnnie Simmons briefed the upcoming schedule, the forecasted weather, and team conduct. The next morning, an early team left the hotel before sunrise. They headed out early to look at the maintenance meeting and FOD walkdown. These are two critical events that start the day off at com mands around the fleet. VMM-162 would be no dif ferent. We simply are looking at how they conduct business, said ADCS Mike Tate. A lot happens early in the morning. The rest of the team arrived about 30-minutes later and mustered in the Gold Eagles Ready Room. It was clear, looking around the room, that this squadron takes safety seriously. CNO Safety S plaques ran down one complete wall: 1956, 71, 83, 90, 96, 98, 99, 2000, 01, 02, and 03. LtCol. Karsten Heckl, VMM-162, briefed his people about the visit and introduced the teams senior officer, LtCol. Jon McCartney. He addressed the past successes the command faced during group and ADMAT inspections, saying, Weve been adamant about doing things the right way. The staff NCOs across the command are good, and they are known across the community. LtCol. McCartney introduced the topside folks and told the CO and the command, Well give you a good honest look. And when we walk awaywe leave with nothing, the results stay with you. That point has been a highlight of the Naval Safety Center surveys. Some of the team calls it the white hat approach, meaning no punitive results come from the survey. The team looks for, finds and reports problem areas, but it then is up to the com mand to take action to fix any discrepancies. The problem areas are not reported to the group, wing or type commander. After Capt. Foley and Master Chief Simmons introduced and matched up maintenance counter parts, the team and work center supervisors headed to the shops to begin the survey. In airframes, Cpl. Mike Green of Atlanta, GA., worked with AMC(AW) James Litviak on some cor rosion control items. They looked at respirator fit tests and discussed ways to avoid problems, including a recommendation for 100% fit test. They looked at training records, passdown logs, tool control, and many other maintenance programs. In another maintenance space, ADCS(AW/SW) Chris Smith worked with Sgt. Ed Bukowski of Ripon, WI. They went through the commands tool room with a fine-tooth comb. When asked about any sur prises, the Sgt. said, Hearing stickers on the etch ers. I thought the sound was well under decibels. It showed why we must keep up with programs. We never can take our jobs lightly. The level of detail that the team looks at sur prises people. Sgt. Wesley Sweeny of Atlanta, GA was working with AEC(AW) James Esslinger and Safety Survey Teams Aid Squadrons
30 Mech Mech repeated a often-heard comment during the twoday trip: I thought the team just was going to look at safety items like electrical plugs, extinguishers, hazmat, and similar items. The Sgt. did say that the team, Gave us ideas seen in other squadrons theyve looked at around the world and will make it [programs] easier and better. He went on to describe that the survey definitely was different than inspections hed been through. When asked what was different, he explained the teams process of asking a question, showing what they had, and then moving into the training mode. He added, It was one of the best looks Ive had. The chief never made it feel like a reprimand. We discussed things. He broke out the reference, and we talked about what the book says and how we do things. The chief gave me things to look at and people to call should I get stuck. GySgt. Jason Kanakis, a 20-year Marine, plankowner, QA chief from Detroit, Mi., said, You end up learning something new. Cpl. Carlos Santiago of Wilmington, Del., an admin clerk, said I picked up some info thats in the manual, stuff thats in black and white. We had a nice give and take training session. This survey helped polish my experience, gave me a broader outlook on my role in the squadron. We covered areas so I could learn and make sure safety proce dures are being followed. SSgt. Yancy Genoa, paraloft shop supervisor, said, I enjoyed the visit. It was more calming than other inspections. The way PRC Brian Westcott went through the programs and showed us how to do things more effectively and efficiently was great. The team ended day one with a debrief, and all supervisors were invited back to the ready room. The maintenance team members already had briefed their counterparts in the work centers, but this gathering was a chance for them to hear an overall, generalized ranking and comparison with other squadrons. That session also went over posi tive things found throughout the command. The Golden Eagles were slightly better than average. The next day, the team visited VMAQ-2, and the day went very much the same. The skipper, LtCol. Robert Sherrill, had a prebrief in his office with the Naval Safety Centers topside team and Capt. Foley. We appreciate you
Mech 31 Mech Spring 2008 AirframesBy AMCS(AW) Robert Chenard Hazardous Material CNAF 4790.2A, CH 10, Par. 10.19.3.4(Q) states the HMC&M Supervisor shall maintain a HAZMAT log to identify material issued, used, retained for reuse, and disposed of as HAZWASTE. Finding unaccounted for HAZMAT in shop spaces is a common problem, so dont let co-workers put you in a bind. You also want to show that you track and follow-up on daily use materials. A best practice Ive seen is to require a tool tag for HM, and then carry that material over to the next day if it really is required to be held over night. MSDS and unique identifiers go hand in hand. CNAF 4790.2A, CH 10, Par. 10.19.3.4(C), requires the HMC&M supervisor to maintain an up-to-date library of MSDS, and OPNAVINST 5100.23G, para. 0702g(5) is the requirement for the unique identifier. A Right to Know Station is where MSDS binders should be kept. The best place for this is where it can be reached in an emergency. It should not be locked up, or kept in a work center that is not open when personnel are working. A unique identifier is a numbering system to quickly identify the material in case of an emer gency. The identifier should be kept as simple as possible and be located on the chemical label, MSDS, AUL, and inventory sheets. You can use let ters, numbers, the MSDS number, or any combina tion. The key is quick identification and retrieval. Finally, HAZMAT needs to be in an approved container and have a label. Secondary labeling is required for all containers when HM has been trans ferred from original containers. A best practice Fixing Airframe-Related Problems Part IIcoming down to look at us, Sherrill said. I think youll find a good group of professionals. LtCol. McCartney echoed his earlier statement about leaving with nothing, but he added, but trends and best practices that your command may want to share with us. That one sentence summed up an important value of the survey process. A squadron gets a free look, but the Navy and Marine Corps win because of the sharing of ideas, programs and effective efforts than may work at other commands in the fleet. LtCol. McCartney has a favorite saying, Open the kimonos, show us what youve got, and let us help you with any issues that you might have. No squadron is perfect. Some are a little better than others, but every maintainer and aviator is doing their best to make things safe.AFCM(AW) Johnnie Simmons told the maintainers at VMAQ-2, My guys love going around and finding issues, but they then shift to the training mode to help you out. And once again, the team did just that with their one-day, snapshot look at maintenance.Sgt. Joe Medrano of San Antonio, Texas, said, Chief Westcott was a good inspector and did things differently. He actually sat here and went through the programs. We discussed things and I got a lot of good training from him. Those comments were consistent and similar with everyone. GySgt. Scott King, QA Chief, said the survey was more than he had expected. I like the idea of someone coming in, taking a look, and telling us how were doing. And then we quickly can get back to business. Its not a long, drawn-out process. I also like the fact the team followed a specific check list. The program-tracking database Senior Chief Tate recommended was a great idea. It will help me follow-up on all programs and audit discrepancies. LtCol. Sherrill summed it all up with one simple statement, Your look gives us a good rudder steer on where we have to go. For more information on the survey teams and to get their published schedule, visit the Naval Safety Center website at www.safetycenter.navy.mil/ aviation/checklists/default.htm and www.safetycen ter.navy.mil/aviation/surveys.htm.
32 Mech Mech Class C Mishap SummaryBy ADCS(AW) Michael S. TateFrom December 18, 2007 to March 13, 2008, the Navy and Marine Corps had 12 Class C Mishaps involving 12 aircraft. Once again this quarter, we had a lot more TFOAs. We must get better at this area because it costs us time and money, and it has the potential to injure people on the ground. QA needs to do trend analysis to prevent the recurrence of TFOAs. We had a few other incidents, including a Sailor who suffered a severe thumb injury while work ing on landing gear, and there were more aircraft crunches. These events are very similar to last quarter. One new item was equipment shorting out during maintenance. We need to look a little closer at this problem. The most common cause of shorted equip ment is multiple maintenance actions being done simultaneously on aircraft. No one is saying you cant do multiple actions. In fact, it is necessary to keep our aircraft on the flight schedule. However, we often lack awareness of other maintenance actions being performed on the aircraft. Its very easy to go from one maintenance action to another, but unfortunately, that approach creates tunnel vision. For example, we troubleshoot a maintenance action on one aircraft and order parts, and then troubleshoot another aircraft, while waiting for the parts. The down side occurs when we get the parts a few hours later, run back out to the aircraft, and fail to repeat the set-up checks. We forget to make sure the breakers are set where we left them, verify power isnt applied, or check with maintenance control to see if other maintenance has been or is being done on the aircraft. Our haste to get the job done often can lead to more work, damaged parts, and an injury. Never is maintenance pressure so high that we cant get the job done using the book. That pres sure is real, and we know your supervisor and main tenance want the gripe fixed now, along with the other 10 items you need to complete today. Only you can decide how you react to these pressures. But remember, pressure is not an excuse to take shortcuts. Take the prep time to do the job right. Its time well spent and ultimately will allow us to have more aircraft ready for the flight schedule. Senior Chief Tate is a maintenance analyst at the Naval Safety Center and coordinator of the Cross feed section of Mech. Ive seen is printing and laminating the small label (DD 2521) and then safety wiring it to the secondary container, for example, a grease gun. Best Practice: Our grading scale compares your command against what we are seeing in the rest of the Navy and Marine Corps. Below Average lets you know more effort is necessary with pro grams. Above Average says you abide with the ref erences, and you are doing more than other com mands, but you still have room for improvement. Here is a sampling of recent visits where commands have had good programs: VFA-87: Six above average programs, none below average. FRC NW: Five above average programs, none below average. VMR-1: Two above average programs, none below average. HSC-22, HSC-25, HSL-37, MALS-31, VAQ-133, VMFA-312, and VMM-263: One above average pro gram, none below average. Your command can be on this list with just a few simple steps. Senior Chief Chenard is a maintenance analyst at the Naval Safety Center. Survey ScheduleMay 2008 Cherry Point New River June 2008 PAX River Brunswick Maine August 2008 NAS Whidbey Island September 2008 Camp Pendleton North Island
Mech Mech H otelSierraHelping Sailors and Marines Help ThemselvesSierra H otelCommander, 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 December-March.Safety Surveys Culture Workshops MRMsVT-21 VMFA-242 HT-8 VT-86 VT-22 VRC-30 HT-18 VAW-113 HM-15 HSL-49 HT-28 VAW-116 VT-28 VMM-162 VT-2 VAW-112 VT-27 VMAQ-1 VFA-102 VR-55 VT-31 HSC-84 HS-14 HMMT-164 VT-35 HM-14 VT-3 HMLA/T-303 VMFT-401 VFA-195 VT-6 HMLA-267 VMA-311 VFA-27 VAW-115 VR-56 VMA-211 VFA-102 VT-4 VAW-123 HS-10 VAQ-136 VT-10 VMAQ-3 HSL-48 HSM-71 VFA-14 VMMT-204 VAW-123 VAQ-129 VFA-22 HM-14 VAW-125 VAQ-137 VR-48 HS-11 VP-16 VAQ-138 VR-58 HS-15 VP-5 VAQ-141 VT-6 HSC-22 VQ-3 VAW-112 HSC-28 VQ-4 VFA-115 HSL-42 HSL-47 VFA-122 For more information or to get on the schedule, please contact: Safety Surveys: Capt. Chris Foley, USMC at 757-444-3520 Ext. 7223, MRM: AEC Matthew Cooper at 757-444-3520 Ext. 7275, Culture Workshop: Cdr. John Morrison at 757-444-3520 Ext. 7213.VFA-34 VAW-124 VX-23 AIMD Atsugi AMO School CVW-5 Squadrons HCS-26 RESTACSUPWING FRC MID Atlantic