You Can’t Dodge a Mainmount

Guesswork On the Flight Deck

Outweighing Mother Nature

You Can’t Dodge a Mainmount

Guesswork On the Flight Deck

Outweighing Mother Nature
2 Mech April-June 1999

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FEATURES

RAdm. Frank M. Dirren, Jr., Commander, Naval Safety Center

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Mech Staff

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Mech (ISSN 1093-8753) is published quarterly by the Commander, Naval Safety Center,

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On the cover:

USS Washington (CVN 73) Persian Gulf – Airwing One aircraft

line up to launch for Operation Southern Watch. Photo by PN3

Sammy Dallal

The Long Flight Home

When you work on airplanes, being in a

hurry often produces even more work.

Anonymous

Wing-Walker Down

Lose a race with a mainmount and win a

trip to medical. AW1 Ian Peterson

Ten Seconds of Guesswork

You gotta know where and when to go on

the flight deck. AO1 Jeffrey Vochatzer

Spotty Passdown Spoils Prop

Inaccurate communications between a day

crew and a night crew cause a mishap.

Lt. Curt Miller

Flight-Control Guillotine

“I could have lost both arms just below the

elbow.” AMS2 Patrick J. VanElzen

Vol. 2, No. 6, Apr – Jun ’99

THE NAVAL SAFETY CENTER’S AVIATION MAINTENANCE MAGAZINE

pg. 4
April-June 1999 Mech 3

Air Wing Toolbox: Centerspread Pullout

Are You Part of the Solution or the Problem?

 Most recent Class A and Class B mishaps

 Tailhook poster John Williams

20

18

16

15

14

12 21 Letters

Got something on your mind? This is the place to

sound off. Keep those letters coming.

22 Bravo Zulu

HMM-268; VF-103; VMAQ-4; VP-8; VP-10; VS-29

24 Crossfeed

Straight talk from maintenance specialists about ALSS,

avionics, the line, maintenance management, and

supervision.

Whom Do You Trust?

No one, when 1,500 psi can get loose.

AMS1William McLeod

Almost Overwhelming Odds

Teamwork wins against Mother Nature.

Capt. Michael Bryan

Why’d It Sink?

Training shapes are supposed to float; this

one didn’t. AD3 Frances A. Nievera

Nightcheck Can Hack It

Binding flight controls are never A799.

ATCS David L. Zagorodney

Attack of the Yellow Gear

The cost of yellow-gear crunches went up

400 percent. Cdr. Kevin Mattonen

DEPARTMENTS

pg. 10 pg. 12

Qualifications Don’t Make You Right

Sometimes you have to follow your gut

instincts. AO2 (AW/NAC) Todd Risner

Joe Casto

www.safetycenter.navy.mil

What’s on Our Web Site?

• Operational Risk Management tools

• Survey schedules

• Staff directory

• Ashore, Approach, Fathom, Ground Warrior,

 Mech magazines, and Aviation Weekly Summary
4 Mech April-June 1999

We were nearing the end of a

UNITAS det in Pisco, Peru, and

the aircraft hadn’t had a major

problem. We’d completed every mission.

With only one recovery left to handle, we

began to think about going home. But

when the aircraft landed around 0800, oil

was streaming from No. 4 engine all the

way aft to the tailpipe.

We isolated the leak to a bad seal,

which meant we had to change a turbine.

We called back to homeplate and learned

that we could expect a new turbine and all

the tools for the job in two days. The

OinC arranged for a few maintenance

people to stay behind to do the work. The

rest of the det’s personnel would leave

the following day on another squadron

aircraft.

Our maintenance crew searched the

base for support equipment. They found an

A-frame engine-stand that looked promising; the Peruvian Air Force used it to

remove and replace their engines. The Aframe required a power cart to

run it. We tried to get one

from the transit line, but they

didn’t have one. They did

provide a huffer and

showed us how to use the

battery pack from it to

power up the A-frame. The next hurdle

was the lack of lighting on the flight line.

The solution to this problem wasn’t the

best: The Peruvian air force’s electricians

made a chain of power cords that reached

all the way across the flight line.

We started working on our turbine at

about 2000. We were tired and frustrated

after repositioning the A-frame what

seemed like 200 times, trying to make the

light-cart work. We should have stopped

for the night, but we pushed on. We finally

managed to remove the engine, change the

turbine, and position the new engine for

installation before we secured for the

night. We intended to come back at 0800

to finish the job.

The next morning, after about four

hours sleep, we hung the engine and did

our maintenance turns; the engine checked

good. We did the daily strictly according

to the MRC deck, and the aircraft was

ready for the flight home. Unfortunately,

our embassy clearance hadn’t been prepared, so we had to wait another day.

After a three-hour preflight early the

next morning, the aircraft lifted off. About

two hours into the flight, No. 4 engine

started leaking oil again. We secured the

engine with the emergency-shutdown

handle, and diverted to Howard Air Force

Base, Panama. Our maintenance crew

concluded that the new engine seal had

PH1 Gerald Lowe
April-June 1999 Mech 5

failed, and that we would have to change

the engine again. We wouldn’t be going

home yet.

The next morning, everything went

almost according to plan. We moved all

our components onto the new engine,

turned in our old engine (non-RFI) to the

host’s hangar crew, and continued working

on the new engine until we needed a

torque wrench. As luck would have it, the

host squadron was using the wrench for a

tire change on a different aircraft. We

waited two hours for the torque wrench

before we could install our new engine.

We re-installed the old propeller onto the

prop shaft, and did the maintenance in

accordance with the MIMs–at least we

thought we did.

With time slipping away

and frustration eating away

at us, we should have

stopped and taken a break,

but our only thought was to

finish the job and go home.

We did a low-power engine

turn and saw no discrepancies, but when we inspected

the engine for leaks, we

found No. 4 engine had a

leak coming from the

engine-driven fuel pump.

We would have to replace it.

Exhausted, we called it a

day and secured to the

barracks.

We hit it again the next

day, confident of going

home. We changed the fuel

pump and launched for a

functional check flight

(FCF), which we completed

with a prop-pump-one light

on the No. 4 engine during landing rollout.

The host’s maintenance crew checked the

aircraft on the deck and found the prop

slightly over-serviced. They deserviced

the prop, and the ground turns

checked good. Our homewardbound trip was scheduled to leave

at 2000 hours. We finally were

going home.

About five minutes after liftoff,

the No. 4 propeller failed and

pitchlocked. We made an emergency landing back at Howard

AFB. During the postflight inspection, we decided we had a bad

prop-control lip-seal because of too

much prop fluid around the

afterbody and the bottom section

forward of the engine’s oil-cooler

intake.

After removing the prop from

the propeller shaft, the host squadron discovered the prop shaft’s rear

brass-cone was missing. That cone

helps support the prop and prop

control and keeps the rear seal seated. We

were embarrassed when we found out

we’d left the cone on the old engine’s prop

shaft, which had been towed away shortly

after we’d removed it. Now for the third

time, we had to replace the prop control and

propeller because of the missing rear cone.

We had spent a lot of time and effort

on the first engine change and still had

made a huge mistake while installing the

prop. Our heads were filled with thoughts

of getting home. If we hadn’t been in such

a hurry, we could have saved all those

man-hours and the assets we used on the

second engine change. We felt relieved

that nothing further happened on the FCF

or the flight home.

When the

aircraft

landed

around 0800,

oil was

streaming

from No. 4

engine all the

way aft to

the tailpipe.

April-June 1999 Mech 3
6 Mech April-June 1999

AA William Stoker

carries a chock for

an SH-3 aboard

USS Saipan (LHA

2). He’s too close

to that wheel, but

the helo is being

towed backward.

by AW1 Ian Peterson

The weight of the aircraft broke both

her lower leg bones and almost every

bone in her foot.

4 Mech April-June 1999

PH2 Benjamin D. Olvey
April-June 1999 Mech 7

and onto her body. The plane captain

manual warns not to get closer than your

own personal height to the mainmount

when moving an aircraft. That policy

ensures that if you trip or fall, you won’t

be in harms way.

The wing-walker was able to return to

work in a few weeks, but only for light

duty. The weight of the aircraft broke both

her lower leg bones and almost every bone

in her foot. She will be permanently

disabled. It’s hard to imagine that an

aircraft moving three miles per hour on a

wide-open flight line can be so dangerous,

but it’s happened before.

Sometimes the most mundane tasks

are the ones that hurt you. There’s nothing

difficult about towing aircraft with trained

personnel. This mishap occurred more

than a decade ago, but I still read and hear

about the same mistake being repeated.

One of those mistakes killed a Sailor in a

similar scenario a short time later. Will

lack of attention bite us again?

AW1 Peterson flies with HSL-47 Det 6 aboard USS

McClusky (FFG 41).

Note: Five people have been killed by

towed aircraft since

1988. Twenty-three

more were hurt

badly enough to

qualify as Class B or

C mishaps. Some

chock-walkers don’t

believe mainmounts

move fast enough to

catch them–they’re

betting their lives on their speed.

The rules are simple: Don’t walk or

stand forward or aft of a tire when the

airplane is moving. If you’re a chockwalker, walk next to the mainmount with

the chocks in your hands, not slung over

your shoulder or hanging from a sponson

or bomb rack. –Ed.

I

t should have been a routine aircraft

move from the line to the wash rack.

No helicopters were turning, most

turnarounds had been done, and qualified

people were available to do the move. The

director barked a few instructions, and

everyone fell into position. Since I was

new to the shop, I didn’t have many planecaptain signatures so I fell in as the starboard wing-walker.

The director handed out whistles,

hooked up the tow bar, called for chocks

and brakes, and we were rolling. Only

seconds elapsed between the director’s last

shouted command and the aircraft moving

before an ear-piercing scream shattered the

silence. By the time the driver reacted to

the whistles and screams, 18,000 pounds

of helicopter had run over the port wingwalker’s foot. The main-mount was resting

about halfway between her knee and ankle.

Though only a few seconds, it seemed an

eternity before the director reversed the

path of the aircraft and backed it down the

victim’s leg and foot.

The port wing-walker had violated

SOP for towing aircraft. She had tried to

place the chocks in the cabin through the

open cabin door while the aircraft was

moving. The mainmount is just forward of

the door, so when the aircraft began to

move, it rolled over the wing-walker’s foot

and up her leg because she got too close to

the wheel. It’s fortunate the aircraft did not

continue rolling up the wing-walker’s leg

April-June 1999 Mech 5
8 Mech April-June 1999

I

t was warm and sunny on the flight

deck of the USS Constellation (CV

64). We had been ready hours before

the first launch of the day. Everything had

been going great until we got the word

about halfway through the first launch:

“Change the second-event birds. The pilots

are due to walk in twenty minutes.” So,

being highly motivated ordies, we got a

quick plan together, readied our load crew

and our AERO-9B Baker box.

With four of us on the roof, and the

rest of our crew doing CAG-ARM duty,

we felt we could handle anything. We

downloaded an enormous load of five

Mk-76s and one Mk-58 MLM. Then we

had to get the multiple ejector rack (MER)

to the replacement aircraft on the other

side of the flight deck and load that aircraft.

That’s when our plan started coming

apart. Mistake number one: Instead of us

placing the 255-pound MER on the

AERO-83/A “MER Tree,” we decided to

carry it from the top of cat 2, over to the

other aircraft on the starboard point,

forward of elevator No.1. We could see an

E-2C taxiing to cat 1, and another aircraft

taxiing off cat 2 and lining up behind the

Hawkeye. As we made our way to the cat

1 JBD, we realized we were caught between taxiing aircraft. The only way out

was back the way we had come. Of course,

we could wait for the JBD to raise and

cross behind the Hawkeye before it went

to full power. You guessed it – we convinced each other to go for it and cross

behind the JBD.

6 Mech April-June 1999
April-June 1999 Mech 9

by AO1 Jeffrey Vochatzer

Mistake number two: As we crossed

behind the JBD and squeezed past the

Hornet, we could hear the Hawkeye going

to takeoff power. The wind generated by

the E-2 tried to blow the MER away; we

wanted to scatter in different directions.

We were well clear of the FA-18, but now

we had an S-3 spotted on elevator 1 where

we were headed. Thanks to the quick

reaction of several people who came to our

aid, we avoided crunching the S-3 with our

battering ram.

It was a quick, eye-opening experience

– a painful 10 seconds of guesswork. We

were all grateful to escape with only minor

scratches and no damaged equipment –

just faces red enough to match our jerseys.

We sat down and discussed what had

happened and just how quickly the flight

deck environment changes. We not only

put ourselves at risk, but also the people

who had come to our aid.

Petty Officer Vochatzer is assigned to VFA-151.

John W. Williams

As we made our way to

cat 1 JBD, we began to

realize we were caught

between taxiing aircraft.

April-June 1999 Mech 7
10 Mech April-June 1999

Spotty Passdown

Spoils Prop

Maintenance control tasked two

AE3s to do a static check on the

No. 4 propeller of a P-3. When

they arrived at the aircraft, the maintenance technicians saw that the prop had

been feathered and the afterbody placed on

top of it. The AEs had trouble unfeathering

the prop during voltage and resistance

checks and called maintenance control for

help. Maintenance control sent two AD3s

to troubleshoot.

Once the mechs unfeathered the prop,

the AEs returned to the aircraft. The mechs

asked them to slide the afterbody back into

position after they’d completed their

maintenance since it looked like it might

rain. The mechs planned to secure it after

the electricians had finished their part of

the check.

When the AEs were finished, they

positioned the afterbody and went looking

for the mechs. They told the mechs’ shift

supervisor that the afterbody was in place

but not secured. The shift supervisor,

distracted by maintenance on several other

aircraft, forgot to write in the mid-check

pass-down log that the No. 4 afterbody had

to be secured before turning up the engine.

Instead, the pass-down read that the

aircraft was ready for engine turn.

Several hours later, maintenance

control directed the duty crew to do engine

turns on No. 1 and No. 4, the final check

for propeller maintenance. Mid-check’s

duty flight engineer (FE) did a preflight

but didn’t adequately check the No. 4

afterbody. The crew started No. 4 in

low rpm, and the FE called

a normal start. As

the FE shifted the

engine to normal

rpm, the lineman

and observer in the

copilot seat saw the No.

4 prop afterbody fly off the

aircraft. They told the FE to

secure the engine.

His hand was still on the paddle

switch so the FE shifted back to low rpm.

The cockpit observer announced that

something had flown off the engine, and

the FE used the E-handle to shut it

down. The crew completed the secure

checklist, then inspected for external damage. The No. 4-prop

afterbody had been ripped away

from the aircraft and had left a

6-inch chunk of blade cuff from

No. 4 prop lying under the

nacelle.

The shift supervisor and the

FE failed to carry out their

responsibilities for a complete pass-down

and preflight. They were the major links in

the chain of events that allowed us to

damage a propeller. Ground-crew coordination training must be more than just

another program, and the skills learned

must be practiced daily.

Lt. Miller flies with VP-30.

 8 Mech April-June 1999

by Lt. Curt Miller

Spotty Passdown

Spoils Prop
April-June 1999 Mech 11

This Sailor is

locking down an

afterbody. If you

forget to do that

before turning up

the corresponding

engine, you can

plan on replacing

the propeller.

...the lineman

and observer

in the copilot

seat saw the

No. 4 prop

afterbody fly

off the aircraft.
12 Mech April-June 1999

Guillotine

Flight-Control

by AMS2 Patrick J. VanElzen

The rudder of a Hornet can

remove your hands as cleanly

as a guillotine when the flight

controls move under hydraulic

pressure.
April-June 1999 Mech 13

Anear miss with an FA-18C

rudder changed my attitude about

taking shortcuts.

Our supervisor ordered another Sailor

and me to change a horizontal-stabilator

actuator – a routine removal and replacement that I’d done many times. After

installing a new hydraulic actuator, we

needed to op-check the system. Bringing

the engines on-line would give us enough

hydraulic pressure to operate the flight

controls.

Before the low-power-turn operator

started the engines, we held a thorough

brief to make sure everyone knew what to

expect. We especially covered safety

procedures before anyone touched the first

switch in the aircraft. After the brief, the

operator brought the engines on-line.

With hydraulic power applied, we

checked the horizontal-stabilator actuator

by starting the built-in tester (BIT) unit.

We looked at the stabilator’s alignment

and tested the Hornet’s back-up flightcontrol mode. That’s when we checked to

see if the leading edge of the stabilator

lined up with a specific rivet on the skin of

the aircraft. This Hornet needed a large

adjustment.

The back-up mode’s mechanical

linkage has a lollipop (bolt and nut assembly) for adjusting alignment. To reach the

lollipop, I climbed on the aircraft and

walked back between the vertical

stabilators. I signaled the plane captain,

who was standing in front and to one side

of the nose, that I wanted to make an

adjustment. He signaled the turn-up

operator to keep his hands out of the

cockpit to make sure none of the flight

control surfaces were moved. After several

adjustments, I finally got the stablilator

aligned.

Next, we checked the switching valves

to ensure hydraulic pressure would be

available in case of an engine failure. Then

we shut down No. 1 engine. In my haste to

finish the job, I reached down past the

offset rudder under the vertical stabilizer

and tried to insert a cotter-key through the

lollipop while hydraulic power was still on

the jet. I didn’t notice my squadronmates

beside the jet trying to warn me of my

mistake; I had placed myself in real peril.

In the FA-18, as hydraulic power

slowly bleeds-off, the flight controls often

cycle without command. Now was no

exception. The rudder suddenly struck my

right arm, and I immediately pulled my

arms out of the actuator-access panel. Had

my reaction been a split-second slower I

could have lost both arms just below the

elbow.

In my haste to finish rigging the

airplane, I hadn’t told the plane captain

what I was doing. That simple mistake

could have ended my naval career and left

me disabled for life.

 Don’t take chances with machinery. If

a hydraulic system and its flight-control

mechanisms have a little life left in them,

keep your hands to yourself.

Petty Officer VanElzen is a metalsmith assigned to

VFA-105.

Had my reaction been a split-second

slower, I would have lost both arms just

below the elbow.

April-June 1999 Mech 11
14 Mech April-June 1999

Working on nightshift, I’d been

assigned to find the source of

an oil leak on our detachment’s

HH-46D’s aft transmission. We’d been

troubleshooting the same gripe for more

than four hours without getting anywhere

when we decided to pull the mix-box

bolts’ access panel. We wanted to see if

there was any fluid leaking from the

transmission’s oil-cooler return-line.

Once we’d removed the access panel,

another technician and I discovered that

the return line had been chafing on a rigid

utility-hydraulic line. Both of us were

merely CDIs; therefore, we asked a

CDQAR to inspect the line. The CDQAR

looked at the lines and said, “The chafing

is bad, but not bad enough to ‘down’ the

aircraft.”

I wasn’t satisfied and asked for a

second QAR’s opinion. He also felt the

chafing wasn’t bad enough to down the

aircraft. He suggested we look it up to be

sure, then measure the chafing to verify

whether or not it was out of limits.

Don’t Make You Right

by A02(AW/NAC) Todd Risner

Petty Officer Risner

found it impossible to

measure the damage

with the oil-cooler

return-line installed on

the aircraft.

12 Mech April-June 1999
April-June 1999 Mech 15

How long would it take for

these lines to wear through

from vibration and cause

the transmission to fail or

the hydraulic pump to

cavitate?

It was impossible to measure the

damage with the line installed on the

aircraft. After several unsuccessful tries,

we removed the line to get an accurate

measurement, which was .032 inches. We

checked our findings against table 9-1 in

the NA Ol-lA-20, which showed the

chafing limit for the line to be .006 inches.

This damage was not just beyond the

designated limit; it was way beyond it.

Once we removed the line from the

aircraft, we could see several damaged

layers of steel laminate that hadn’t been

visible while the line was installed in the

airframe. The transmission-oil line that the

hydraulic line had been chafing against

was also severely worn; we wrote a

discrepancy against both. When we

presented our findings, maintenance

control downed the aircraft.

If you find a problem, stick to your

guns. Use the MIMs to strengthen your

position, and be sure everyone follows

inspection procedures correctly. Material

reliability is an important concern in

maintenance, and even the most qualified

maintenance people can make mistakes.

Petty Officer Risner is a search-and-rescue aircrewman,

and a CDI for power plants and airframes with HC-6 det 2.

This damage was not just beyond the

designated limit, it was way beyond it.

April-June 1999 Mech 13
16 Mech April-June 1999

wire and two packing-nut lock-bolts from

the gland nut. The AMH2, now on the

scene, helped the AMH3 back off the nut.

Both technicians noticed the gland nut was

very hard to back off, but assumed the

problem was caused by sealant on the

threads. When the gland nut reached the

last thread, the nut and steering collar

exploded downward from the force of the

1,500-psi nitrogen charge on the strut. The

steering collar snatched the spanner

wrench and the AMH3’s hand with it.

After breaking his wrist, the wrench

continued downward, hitting his foot and

bruising his ankle. Our AMH3 was lucky

to escape with only minor injuries.

Several elements contributed to the

incident. The squadron didn’t follow the

AYB’s instruction to deflate the strut.

Furthermore, the instructions did not

include an I-level step to ensure the strut

had been deflated. The I-level technician

did not verify this precaution.

Operational risk management (ORM)

was never used in this job; routine tasks

will continue to be dangerous until ORM

becomes second nature. You have to do

your own pre-checks because no one cares

more about your survival than you

do.

Petty Officer McLeod is a QAR and safety petty officer

at AIMD Oceana.

Two metalsmiths from AIMD (an

AMH2 and an AMH3) visited a local

squadron to inspect the steering collar on a

Tomcat’s nose landing gear as directed by

accessories bulletin (AYB)746. Both

technicians had done this job many times;

they were comfortable with it.

The detailed instructions in the AYB

require the squadron to prepare the aircraft

for AIMD’s inspection. They have to jack

the F-14, deflate the strut, remove the

launch bar bungees, remove the launch

bar, and get the strut

ready for the visitors.

Arriving at the

squadron, the two

metalsmiths went to

maintenance control. The maintenance control chief

told them the

aircraft had been

prepared and was

waiting for them.

Without verifying the squadron’s

preparations, the

AMH3 went out to

the aircraft to begin

the job; the AMH2

stayed behind to

look at the records

and get the paperwork for the task.

The AMH3

followed the I-level

part of the step-bystep instructions and

removed the safety

by AMS1 William McLeod

The force of 1,500

psi of nitrogen

releasing from a

strut is explosive.

An aircraft wheel

coming apart can

crush your chest

and tear off your

face at a mere 375-

psi. It’s happened.

The steering

collar exploded

downward and

snatched the

spanner wrench.

14 Mech April-June 1999
April-June 1999 Mech 17

Mother Nature surprises us from time to time when she attacks us with our

own creations. Such was the case for nine Marines who went in harm’s way

against an enemy they could neither see nor hold – a windstorm. – Ed.

by Capt. Michael Bryan

During a deployment to the Marine

Corps Air Combat Center at Twentynine Palms, California, nine Marines were

surprised when high winds lifted a 20-by75-foot piece of fiberglass matting off the

deck and blew it toward their squadron’s

aircraft. Without hesitation, the Marines

ran toward the airborne matting, and

jumped on it to stop the sheet from damaging aircraft. All nine Marines were

dragged several yards, and one was lifted

six feet off the ground. They didn’t give

up, despite what seemed to be a losing

battle.

By the time the wind momentarily

settled down, the huge section of matting

was just inches from parked aircraft. One

Marine was standing on top of a Hornet,

holding the matting off. When other

squadron members saw what was happening, they ran out to help. It took 50 Marines and an aircraft tow-tractor to overcome the force of the wind on such a large

object.

These Marines wrestled a 20-by-75-foot section of fiberglass parking ramp to a standstill in high winds to protect their

squadron’s Hornets.

Working as a team, the original nine

Marines (in photo above, left to right),

LCpl. Jason Contreras, LCpl. Henry

Lopez, LCpl. Trevor Spence, Cpl. Carl

Himes, Jr., Cpl. Juan Buractoan, Sgt.

Jonathan Avendula, Sgt. Brandon Cook,

Sgt. Bradley Flanagan, and SSgt. Derrick

Torrence, prevented damage to several

multi-million-dollar aircraft.

Success would not have been possible

without the help of fellow squadron

members, but the selfless action of the

original nine Marines stopped the matting

long enough for help to arrive. The worst

injury was a minor rope burn.

In recognition of their Herculean

effort, the command awarded these Marines the Navy and Marine Corps Achievement Medal the following day. LtCol.

William Miles, VMFA-232’s CO, felt their

rapid and decisive actions deserved

equally rapid recognition.

Capt. Bryan is a pilot and the power-line division officer

at VMFA-232.

April-June 1999 Mech 15
16 Mech April-June 1999

by AD3 Frances A. Nievera

Lt. Catherine E. Wilson

About noon, I was delivering a

Mk-30/48 training shape by

 forklift to the western helicopter

pad at a NALF. Our aircrews use the shape

to practice recovering targets and torpedoes off the coast of San Clemente Island.

On the way to the pad, I saw one of

our helos on the taxiway, so I turned the

forklift and headed for the shoulder of the

taxiway. I was driving backward like

you’re supposed to. When I crossed onto

the asphalt just off the taxiway, the forklift

rolled over a small taxiway light that stuck

above the ground about an inch or two.

Forklifts don’t have shock absorbers,

so the forklift hit the bump hard. The cage

carrying the practice shape rocked, and its

straps stretched enough to allow the cage

to tilt on its heavy side, even though I had

made sure the straps were wrapped tight

before I started.

Then, everything seemed to switch

into slow motion. First the cage tilted, and

the shape slid. Then the cage tilted again,

and 2,700 pounds of shape slid out and

rolled onto the ground.

The maintenance chief and a QAR

inspected the shape. Nothing appeared
The Mk-2 (helicopter weapon-recovery system) and

training shape are transported by forklift, which will

react violently to even the smallest bump.

...all

2,700

pounds of

the shape

slid out

and rolled

onto the

ground.

damaged, and no one was hurt, so we

loaded it back into the cage, using a

second forklift, and sent it out to the pad

for the aircrew to use on their flight.

The aircrew took the cage and shape,

practiced with it in deep water for about 20

minutes, but then it sank. The shape wasn’t

expensive enough to require a mishap

report, but HC-85 later used the incident to

teach how operational risk management

(ORM) should be used.

Here’s what should have happened if

we had used the five steps of the ORM

process once the shape hit the ground.

Driving the forklift as I did would have

required a more time-critical version.

Identify the hazards: The training

shape could hit other objects during

transport.

Assess the hazards: Dropping a 2,700-

pound shape on the ground may damage it.

Damage could make the shape leak, which

means it might sink.

Make risk decisions: Inspect practice

shape for damage. Test it for leaks, even if

it means canceling training. The training

was not urgent.

Implement controls: Require rigorous

inspection for any equipment damage. Test

the practice shape under controlled shallow-water conditions.

Supervise: Involve contractors who are

familiar with practice shapes. Train

command personnel and develop an

inspection program for shapes. Allow for

special inspections when needed. Have

QA and safety department follow up on

controls.

We relearned some basic lessons in

this incident. First, preflight your equipment before you use it, and inspect it

regularly for wear. Report discrepancies

immediately. Then check the straps and

load before you drive. Make certain the

load won’t shift. Stop and recheck if

conditions change.

Drive support equipment carefully,

and be aware of even small bumps. Stay

alert and drive at the slowest reasonable

speed. Take care to carry the load at the

correct height, and if you should drop it,

get a qualified person to check that the

load is still safe to transport.

Lt. Wilson and Petty Officer Nievera are assigned to

HC-85.
the next night of troubleshooting. That’s

when AMS2 Jeanette Moore and AE3

Scott Mason’s supervisors assigned them

the job.

AMS2 Moore climbed into the cockpit

late that night after all other jets had been

silenced; she systematically began

moving the flight control stick.

AE3 Mason had removed

enough electronics assemblies to allow a better view of

the bell-crank and the flightcontrol cables. He heard a faint sound

coming from the panels aft of where he

was working. He stopped removing parts

and began looking, touching and listening.

Opening the next door aft, he found a

lightly chafed antenna cable. He immediately informed AMS2 Moore.

AMS2 Moore looked at the chafing,

and although she realized how serious this

problem could be, she also recognized that

it alone could not have caused the flight

controls to bind. Using the 18-inch rule,

18 Mech April-June 1999

Every evening, nightcheck crews

everywhere take responsibility for

providing enough “up” aircraft to

fly the following day’s missions. This

night, the squadron’s nightcheck crew

needed to fix a Hornet that had returned

from a flight with a problem. The

pilot’s MAF simply said,

“Binding flight controls.” A

QA rep talked to the pilot,

who said, “I felt a momentary jam in the

controls when I rolled to

starboard in a moderate

climb.”

Aviation maintenance

is demanding, but teamwork

lessens the demands and

creates the synergy that allows

seemingly impossible tasks to be

accomplished. Maintenance control

downed the FA-18, and troubleshooters

removed the cowling. They did an end-toend inspection of the entire flight-control

system. More testing, following the MIMs,

gave negative results. It was well understood in the squadron that MAFs for

binding flight controls never are signed off

“not duplicated on deck” (A799). This

Hornet did not fly the next day. A more

intense investigation would be undertaken

This incident dumbfounded most of

our supervisors: Two people accomplished in only a few minutes what two

shifts couldn’t – a remarkable feat.

There was a single drop

of epoxy directly under

the site of an old repair

(arrow) and close to the

broken clamp.

➚
by ATCS David L. Zagorodney

AE3 Scott Mason and AMS2 Jeanette Moore found the cause of intermittent binding of

flight controls.

she spotted a broken plastic clamp holding

the air lines to the air-data computer

(ADC). Again, very interesting, but alone,

not capable of jamming the flight controls.

Softly touching the backside of the control

cable, she found a drop of epoxy from a

repair above the cable done at some earlier

date. This was the last piece of the puzzle.

The mystery of the hard-to-find jammed

flight control had been solved by teamwork.

 So what had happened? Over time, the

antenna cables migrated into the flightcontrol cables, slowly pushing them

against the clamp. The single drop of

epoxy, not noticed during previous maintenance, was now a burr on the backside of

the flight-control cable. When the epoxy

burr ground against the ADC clamp, the

pilot applied extra force to his control

stick, broke the clamp, and unintentionally

concealed the cause of his plight.

Senior Chief Zagorodney is QAO on a det from Strike

Fighter Wing Pacific.

April-June 1999 Mech 19

The mystery

of the hardto-find

jammed

flight

control was

solved by

teamwork.
20 Mech April-June 1999

The huffer getting fished out of the

water was neither locked nor

chocked after starting an E-2C on

the seawall. The ground crew

disconnected the huffer from

the E-2C; the aircraft went

to high-power and blew

the huffer into the bay.

After finishing another annual

cycle of visits, our survey teams

 identified what is becoming our

biggest enemy and most likely to crunch

airplanes–yellow gear. On a recent visit,

the day after we’d presented our maintenance malpractice brief

with its graphic descriptions of deadly aircraft

moves, my team members had to step in and

stop a move. What was

wrong with it? For

starters, chocks were

draped over a pylon,

whistles were not in mouths, and the taxi

director was riding in the tow tractor with

his back to the move.

That’s not all that bothered me. The

line chief looked out and slunk back into

the hangar without saying a word. Then

the move proceeded through a FOD

walkdown where a number of people in

khaki stopped long enough to get out of

the way but never lifted a finger to stop the

move.

 We’ve racked up $1.3 million in

damages to airplanes by support equipment in the past four years. The cost of

yellow-gear crunches went up nearly 400

percent from 1997 to 1998. At that rate,

we’ll be paying more than a million dollars

a year in just two years, and that’s not

money we’re budgeted to spend.

What baffles me is that the big-wing

communities (P-3, C-9, C-130, E-6) are

committing the most flagrant fouls, which

defies logic. These airplanes aren’t small,

they don’t hide well, and they are not

doing the flight-deck ballet.

 Who’s driving those spiffy little tow

tractors? And who’s watching the drivers?

My people routinely see these guys not

just going too fast, but rolling along at

by Kevin Mattonen, Cdr., USN, Ret.

of the

The cost of yellow-gear

crunches went up nearly

400 percent from 1997

to 1998.
April-June 1999 Mech 21

their tugs’ top end-speed with no regard

for what is being towed. You’d think it a

sufficient wake-up call when a RichardPetty wannabe towed a B-5 stand behind

his NC-2 and did more than $1,700 damage to the wing commander’s car at an

NAS. But no, we still see the same mistakes over and over again.

The best one yet has to be a young

gent dragging homemade support equipment, arcing and sparking across the ramp.

He finally figured out the equipment had

no wheels–after the jury-rigged towing

attachment snapped, and the mystery stand

went screeching across the ramp–that’s

when he realized he had to find a better

way of doing business.

We’re better than this. Let’s step in

now and stop the waste. Officers, put out

the word. Chiefs, get out and lead the way.

These moves have to be by the book. Our

people are ignoring the rules, and somebody is going to get killed.

Mr. Mattonen, Cdr., USN, Ret., was an aviation analyst

at the Naval Safety Center.

Class A Mishaps

Mech January-March 1999

Air Wing Toolbox

By Joe Casto

The mishap aboard USS

Enterprise (CVN 65) on Nov. 8,

1998 claimed the lives of four

Prowler aircrewmen who were

my shipmates and destroyed an

EA-6B and an S-3. Contrary to

Mech’s assertion that “burning

fuel and debris destroyed three

Hornets,” thanks to heroic

firefighting efforts by ship and air

wing personnel, no other aircraft

were destroyed. Two of the

reportedly destroyed FA-18s are

flying daily with CVW-3, and the

third is being repaired. Please try

to stick to the facts. The fleet

depends on you for both information and accuracy. Sensationalism, we can find elsewhere.

LtCol. S. M. Pomeroy

Commanding Officer, VMFA-312

I misread the damage from a

computer readout and printed it

the way I read it; it disturbs me to

realize I was so far off the mark. I

will do my best to win your confidence in Mech—sensationalism is

not our stock in trade.–Ed.

Cover Photo

Mech, July-September 1998

By PH2 Felix Garza

The Sailor on the cover of the

July-September issue is my son,

AO3 Steve R. Glave.

He is assigned to VFA-195

aboard USS Kitty Hawk (CV 63).

My wife, Melody, and I are very

proud of Steve and everyone in

the military for their efforts, day

in and day out, to keep our great

country secure. We fly the American flag in our yard for them and

those before them.

Kenn W. Glave

Executive Travel

Houston, Texas

Thank you for identifying the

Sailor on our cover. We’ve sent

three magazines to you.–Ed.

Mech and Approach

Magazines

We get so busy looking at

what’s wrong that it’s easy to

miss what’s right. What’s right by

me is how you’re doing Approach

and Mech. Both are way improved over what I read up

through the early nineties, both in

packaging and content. I was a

little ashamed when I first found

out in ’85 that the other services

got our magazines–now I’d

proudly compare them to

anyone’s. We can now get Approach and Mech on the web as

well as in print; the people who

put them together deserve a big

thanks from the operators.

Cdr. Steve Lilly

CNAP
BRAVO ZULU

22 Mech April-June1999

Sgt. Anderson (a power plants and line

supervisor) and his crew were removing an

engine from an EA-6B and lowering it with two

HLU-288 bomb hoists. He heard an unusual

noise, stopped work and inspected the forward

bomb hoist cable and attaching points. Two

strands of the cable had severed 4 inches

below the engine mount, and the remaining

cable was about to break.

Sgt. Anderson cleared everyone away and

told a Marine to put a weapons loader under

the engine until they could replace the bomb

hoist.

Had the cable broken, the engine would

have fallen 4 feet, been damaged and might

have injured the maintenance crew.

AD2 Markee, a final checker aboard USS

Dwight D. Eisenhower (CVN 69), noted a small

amount of hydraulic fluid coming from the

port nozzle of Victory 116 as the Tomcat went

into tension for launch. He immediately

suspended the launch and downed the aircraft.

Troubleshooting further, he found a crack in

the port rudder-actuator assembly.

Had AD2 Markee not stopped the launch,

the aircraft would have had an airborne

emergency. Given the location of the crack and

how close it was to the flight-hydraulic system, it could have caused a complete hydraulic

failure.

AME2 Kristoffer C. Drew

VS-29

AD2 Michael P. Markee

VF-103

Sgt. C.L. Anderson

VMAQ-4

During the alert launch of an S-3B Viking aboard

USS Carl Vinson (CVN 70), AME2 Drew pulled an

E-2C mechanic away from the intake of the Viking’s

No. 2 engine. Immediately thereafter, he pulled a

plane captain away from the same engine. An E-2C

turning up close by was compounding the situation,

making it equally dangerous for both ground crews.
April-June 1999 Mech 23

Preflighting an Orion with a student flight

engineer, AMS1 Kalka found a subtle but

dangerous discrepancy. Someone had incorrectly installed the cooling door for an engine

generator. The door, normally open during

engine operation, was closed and rigged

backwards. Undetected, the misrigged door

would have made the generator overheat and

catch on fire, thereby causing an in-flight

emergency.

The command designated Petty Officer

Kalka safety pro of the month for January

1998 for his discovery.

AD3 Ruiz was doing a daily on a P-3C

Orion. While inspecting No. 1 engine, he found

a loose cannon plug on the back of the airturbine starter. Looking closer, he found a

centrifugal switch, that disengages the starter

upon reaching 64-percent RPM, had separated

from the starter casing. Petty Officer Ruiz

promptly told the maintenance-control chief,

who ordered the loose cannon plug and centrifugal switch reattached.

If PO Ruiz had not discovered the problem,

a subsequent engine start could have resulted

in a catastrophic air-turbine starter failure.

Shrapnel from the failed starter could have

severely damaged the engine, aircraft fuselage

and injured nearby personnel.

After the recovery and

shutdown of Dragon 55, an

AV-8B assigned to HMM268(REIN) onboard USS

Tarawa (LHA 1), Sgt. Lyda

noticed smoke coming from

the rear (or “hot nozzles”) of

the Harrier. Looking closer, he

saw a small amount of fluid

had pooled in the hot exhaust

section and was on fire.

Sgt. Lyda ran to the front

of the aircraft, climbed into

the cockpit and dry cycled the

engine to extinguish the fire.

The fluid was from an engineoil leak. Sergeant Lyda’s quick

response stopped a potential

flight-deck fire.

AD3 Thomas Ruiz

VP-10

AMS1 John Kalka

VP-8

Sgt. T. E. Lyda

HMM-268(REIN)
24 Mech April-June 1999

LCdr. Rick Sanders

Head, Aviation Maintenance

and Material Division

AMCS(AW/NAC) Darryl Dunn

Editorial Coordinator

ddunn@safecen.navy.mil

ALSS

The Little Things Will Get You

by PRC(AW) Bill Yeager

Aircrew, before your next preflight, look

through the pockets of your flight suit and

G-suit and see what you find. Next, look in your

helmet bag. Take out the maps, the PCL, the

kneeboard, and other needed items so you can

see way down in the bottom, to the Milky Way

wrappers and the little yellow ear plugs you

wore back in the late eighties. You will find

items that can not only make an aircraft engine

useless but also waste the many man-hours that

QA inspectors spend searching for cockpit FOD.

Sure, you zip up pockets, snap up sides, and

strictly comply with all the directives issued by

your squadron, wing and TYCOM that govern the

FOD program, but are you really covering all the

bases?

Think of all the tool inventories that maintenance technicians go through to do their jobs.

Perhaps you should make the time to check the

contents of your G-suit and helmet bag, as well.

Chief Yeager is a maintenance analyst at the Naval Safety

Center.

by PRC(AW) Bill Yeager

Several conditions can prevent a PR from

handling ordnance, but poor vision is the

most common. Parachute riggers (PRs),with few

exceptions, must be certified to handle explosives. Recent concern about vision standards for

PRs is supported by statistics that show 15

percent of fleet riggers have trouble seeing

some colors or shades.

Color-or shade-blind people cannot be

certified per MANMED (the Manual of the Medical

Department). Failing the military color vision

tests may not be the end of the world or your

career. MANMED also states, that if you can

distinguish colors of traffic signals or other

devices showing red, green and amber, you still

may be qualified.

The NAVSEA OP 05 outlines the requirements, the MANMED outlines the type of physical

required, and OPNAV instruction 8023 requires

qualification. If you handle, inspect, or transport

CADs or flares, you must be certified to the

correct level.

The Bureau of Naval Personnel changed the

requirements for people entering the PR rate

after March 1997. For PRs who joined the Navy

prior to this change, this requirement could

seriously affect your career.

PRs – How’s Your Color Vision?

SEATS and ICAPS Aren’t Just for PRs

by PRC(AW) Bill Yeager

Fleet surveys find very few avionics work

centers document ALSS pool assets with

SEATS (Survival Equipment Asset and Tracking

System) records. However, PR shops at the

organizational level and 800 divisions at the

intermediate level use SEATS-generated forms

for tracking and documentation.

AIMDs are tasked to use the SEATS/ICAPS

(Increased Capability) program to manage ALSS

correctly. However, survival radios, night vision
April-June 1999 Mech 25

devices, and other electronic-ALSS pool items

are leaving AIMD work centers without SEATS

history cards.

You can manage ALSS and track and report

installed explosive devices with the SEATS/ICAPS

program, generating a record of inspection and

configuration for all ALSS components.

Quality assurance reps and avionics supervisors can get SEATS training from their PR shops

or 800 divisions. Consult the SEATS user’s guide

and OPNAVINST 4790.2G for guidance. Chapter

13, authorizes using computer-generated SEATS

history records for aviation life support systems.

Did You Check It? I Didn’t

by Ens. Mike Fleshman

When we hear about a mishap that damages equipment or hurts someone, it’s often

caused by a lack of attention to detail. I came

across a good example while reading the morning messages.

While inspecting an uninstalled MK-GRU7-1

ejection seat before disposal, technicians discovered two live MK 13 MOD 0 signal flares in

the seat pan and both MW19 SEAWARS attached to the parachute harness. The twist on

this event is that the ejection seat had been

stored in a wooden shipping container since

1994. The command with the responsibility for

disposal asked that the seat be inspected for

ordnance before shipping it.

The AESR logbook contained no entry certifying the seat was ordnance-free. Further review of the logbook indicated the only entry

made for this ejection seat was its transfer from

one activity to another.

Obviously, the technicians who did the

shipping and receiving inspections did not

inspect the seat or were not familiar with installed ordnance devices. Any activity that ships

or stores an ejection seat must be sure all ordnance is removed from the seat, parachute, and

seat pan by certified personnel. Also log an

entry in the AESR certifying the seat is ordnance

free.

The people at the command that had to

dispose of the seat were conscientious enough

to request an inspection. Otherwise, technicians

unaware of the ordnance might have been

injured during the disposal of the seat.

Ens. Fleshman is a maintenance analyst at the Naval

Safety Center. He was commissioned 1 March 1999; he is a

former AMEC(AW).

AVIONICS

EMI – An Invisible Enemy

by AEC(AW) Robert Tate

The Gulf War was full of examples of how

precise we can be with our “smart” weapons. Before we gloat, however, let’s not forget

that any system can be defeated by mediocre

maintenance, which is one cause of electromagnetic interference (EMI).

EMI has many other causes, such as electrostatic discharge, high-powered microwaves, and

radio-frequency energy. As a result, naval

aircraft are designed with a certain degree of

“hardness,” a measure of how well the aircraft’s

electronics can withstand electromagnetic

interference. The techniques used to increase

hardness are bonding, grounding, shielding,

and filtering. Over time, corrosion, vibration and

poor maintenance degrade the EMI protection

gained through these techniques.

During safety surveys, our analysts see

corrosion on grounding surfaces and loose

connections. If these conditions are not corrected, EMI can cause strange and dangerous

things. A ship’s radar has made torpedoes fall

from helicopters. Micro-switches have burnt out

on aircraft aboard CVNs. Flight control surfaces

of both rotary- and fixed-wing aircraft have

actuated without command.

The keys to beating this invisible enemy are

vigilance and training. Avionics technicians

must have formal training on EMI and its

causes. The place to start for training is your
26 Mech April-June 1999

type wing, then the TYCOM, and finally NAVAIR.

The CDI, QAR and work-center supervisor

are key players in combating maintenance

malpractice, but the trained technician is our

first line of defense in overcoming the effects of

EMI on our weapons systems.

Chief Tate is a maintenance analyst at the Naval Safety

Center.

LINE

Washing Aircraft on the Fly

by PRC(AW) Bill Yeager

Washing an aircraft reduces corrosion,

improves aerodynamics, and makes the

bird look great. But this job is undeniably dangerous, and, in most cases, done by our least

experienced personnel.

Here are some typical mishaps: A plane

captain straddling the folded tail section of an

H-53 fell and broke his ankle. An airman lost

some fingertips to a P-3 when a second airman

extended a ladder the first airman had been

cleaning. A plane captain severely injured his

legs and feet when he slipped off the wing of a

C-130 and fell 18 feet. An airman fell off the

horizontal stabilizer of a Hawkeye and injured

his face and shoulder. An H-60 pilot burned his

eyes during an all-hands aircraft wash in port.

These mishaps have two common threads:

dangerous cleaning compounds and wet and

slippery surfaces. These hazards, coupled with

the sizes and shapes of the airframes themselves, make washing aircraft a very hazardous

task.

A leading airman generally supervises wash

jobs. In most cases, the only time you see a

“crow” on the wash rack is when the wash is

about to be inspected by a CDI. Some washes

are done without the correct use of PPE and

cleaning compounds.

On your next training day, break out the

MRC deck and review the procedures. This

precaution, along with increased vigilance on

the part of your wash party, will reduce the

chances for a mishap.

MAINTENANCE MANAGEMENT

Here’s Looking at You

by ASCS Edwin Guerra

Our safety surveys give commanding officers

a snap-shot of the “health” of their squadron or AIMD based on how close it conforms to

the Naval Aviation Maintenance Program,

(OPNAVINST 4790.2G), and other instructions.

They should not be compared to Immediate

Superior In Charge (ISIC) inspections, because

the relationship of the Safety Center’s survey

team to the surveyed unit is that of a consultant

to a client.

Safety surveys differ from ISIC inspections in

four major ways. First, the CO must request our

services. Second, we do not give grades during

a survey. Third, the survey process is interactive; we ask questions such as, “Why do you do

it that way?” (There might be a good reason).

When areas of concern are identified, we conduct training and point ways to get back on

track. Finally, as a matter of policy, the results of

the survey are not releasable outside your

command. (Waivers to this policy are only at the

express direction of Commander, Naval Safety

Center.) Therefore, the results of the survey are

briefed only to the surveyed unit’s commanding

officer.

The next time the opportunity for a safety

survey arises, please take advantage of our

services. Copies of the checklists can be downloaded from the Naval Safety Center homepage:

www:norfolk.navy.mil/safecen, or by contacting

any of the personnel listed in the box below at

(757) 444-3520 (DSN 564). You can also e-mail
April-June 1999 Mech 27

us. We are available to help you with any aviation maintenance program.

POC: Branch Ext. e-mail prefix

@safecen.navy.mil

LCdr. R. Sanders Division Head 7265 rsanders

PRC B. Yeager ALSS 7289 byeager

AMEC M. Callahan ALSS 7287 mcallah

ADCS R. Wood Power Plants 7205 rwood

ADCS V. Calderon Power Plants 7218 vcaldero

ADCS G. Jubert Power Plants 7206 gjubert

GySgt. W. Chambers Airframes 7292 wchamber

AMCS J. Huerd Airframes 7217 rhuerd

AMCS R. Stanwood Airframes 7220 rstanwoo

AMCS D. Dunn Airframes 7219 ddunn

AZCS J. Meyers Analytical Data 7269 jmeyers

SSgt. J. Williams Analytical Data 7290 jwilliam

CWO3 R. Kubik Avionics B.O. 7278 rkubik

ATCS T. Smith Avionics 7280 tsmith

AEC R. Tate Avionics 7275 rtate

CWO4 S. Thomas S.E.B.O. 7293 sthomas

ASCS E. Guerra Support Equip. 7291 eguerra

Senior Chief Guerra is a maintenance analyst at the Naval

Safety Center.

How to Manage the Required Reading Board

by AEC(AW) Robert Tate

Active and standing reading boards are great

training tools but only when the supervisors, CPOs and division officers make sure the

boards have pertinent information.

You should update the active board every

day and list new items on the read-and-initial

tracking sheet; the signatures tell you who is

reading the boards. Save the completed forms

and items you remove from the board in a dead

file to document training on a specific item.

Move permanent information to the standing

board.

Once a month, supervisors can use the

bottom row of the read-and-initial form for a

sign-off sheet by writing “Work center supervisor review” in the name block on the left-hand

side of the form. Starting on the row just above

the supervisor’s block, list the months in the

spaces reserved for initials.

In their review, supervisors should remove

items from the active board and place them on

the standing board if they have on-going application. Managed this way, repetitive training

can be cited on the standing board.

Except for cross-locators, nothing should be

on the standing board that has not been on the

active board first.

The standing board reviews important

information, so the read-and-initial sheet is a

monthly tally of who has read its contents.

Put cross-locators only on the standing

board. The cross-locator listing enables supervisors to monitor monthly reviews of important

directives and instructions without having to

hang the entire item on the read board. The best

part is that the individual doing the review must

initial that they have reviewed and understood

these items, too.

 Many read and initial sheets that survey

teams see around the fleet could be trashed if

this part of the standing board was managed

right. Once again, as with the active board, the

completed read-and-initial sheets and all items

removed from the standing board should be

kept in a dead file for the tenure of the supervisor to prove repetitive training.
28 Mech April-June 1999

Do you use a separate safety board? Unless

an instruction or directive mandates one, what’s

on that board that couldn’t be on the active or

standing boards? Safety-meeting minutes can

be placed on the active and standing boards

and partitioned off to make them easy to locate.

If you are directed to have a safety board,

manage it as a standing board. You will still

have monthly reviews, but they may ease the

administrative workload on the supervisor.

Teach new people about the active, standing

(and safety) boards; all personnel who check

into a work center must read and review these

boards. If this practice becomes standard,

everyone in the work center will be on an even

keel and aware of anything that could complicate their job in the squadron. If we correctly

prepare and manage reading boards, we can

turn this sometimes-neglected tool into a valuable training resource.

SUPERVISION

Who Will Need Remedial Training for Lessons Learned?

by AMCS(AW) Rory Stanwood

Reviewing messages, I came across some

disturbing mishaps. They should have been

avoided because they’ve happened before.

Supervisors are supposed to review lessons

learned from reported mishaps and hold training to prevent their troops from making the

same mistakes. The following mishaps are not

originals – I’ve seen them all before.

In one mishap, a nose-landing gear collapsed on a troubleshooter who had ignored a

warning in the MIMs. After a drop check, he

didn’t remove the tape from the MLG weighton-ground (WOG) proximity switch. A QAR also

failed to notice the tape during his inspection.

After the takeoff on the PMCF, the pilot had to

override the downlock to raise the landing gear

which also caused AFCS problems related to a

bypassed WOG switch. The troubleshooting

began as soon as the aircraft returned to the

flight line.

Troubleshooter No. 1 inspected the

wheelwell for damage. Troubleshooter No. 2

entered the cockpit and asked the aircrew to

raise the landing-gear handle. He assured the

pilot the gear would not retract. He dismissed

the pilot’s concern about this action and convinced him to depress the landing-gear-override

button and raise the landing-gear handle. With

the gear handle raised, the engine turning, and

the nose-landing gear unpinned, and the WOG

taped, the gear collapsed and killed troubleshooter No. 1 in the nose wheelwell.

This mishap sequence had numerous warning flags that everyone ignored. If anyone has a

doubt about the correctness or safety of a

procedure, stop.

In a second mishap, a maintenance technician checked the wing-fold handle to ensure it

was in the “fold” position before he started a

hydraulic jenny, but he didn’t have another

technician in the cockpit as required. When the

jenny started, the aircraft’s wings spread into an

adjacent aircraft damaging both birds. The

troubleshooter had been working on an unrelated hydraulic discrepancy.

Investigation revealed the wing-fold handle’s

actuator cable had been adjusted wrong following a slat-gearbox change. This allowed the

wings to spread with the handle in the fold

position. A maintenance technician adjusted

tension on the wing-fold cable and then held

training on emergency procedures for uncommanded wingspread.

Finally, upon application of 75-psi air from a

huffer, the huffer’s airhose violently blew off the

coupling on the pneumatic-duct assembly. A

troubleshooter preparing to bleed the hydraulic

system from the port reservoir just aft of the

huffer-hose’s attachment point bruised his right

cheek when he was struck in the cranial and

face and knocked to the ground. The strapping

seals securing the hose to the coupling had

been installed wrong and allowed the hose to

come off when air pressure was applied.

Use these mishaps as lessons learned in

training your troops. Unfortunately, someone

will probably not get the training. Will it be

someone for whom you are responsible?

Senior Chief Stanwood is a maintenance analyst at the

Naval Safety Center.
I

t had been a long, cold night for the Sailors on

night shift. The wind sliced across the barren

flight line and looked for openings in Sailors‘

foul weather gear. An hour before sunrise, there

was just one more aircraft to move before we

secured. During this move, a young Sailor, the

starboard wing-walker, became disoriented, fell

in front of the moving tire of the towed aircraft,

and was crushed to death. Earlier in the shift,

the Sailor had been counseled for making

mistakes while wing walking. A sad point in this

mishap was that he was found with his safety

whistle inside the pocket of his foul-weather

jacket.

This is just one of the obvious mishaps

discussed during our aviation maintenance

malpractice presentation. After reviewing the

details of the mishap, I could not help but wonder if the situation would have turned out differently if the crew had taken a timeout and applied the five-step ORM process before the

move.

Sports fans are accustomed to seeing

coaches call a timeout at a critical moment in a

game. The coach gathers the players to talk

over their options and plan their strategy. He

makes sure all team members understand their

roles and responsibilities no matter how many

times they have been in similar situations. Your

timeout just needs to last long enough to go

over the plan of attack and discuss potential

hazards (ORM).

Heavy workloads with an undermanned staff

make the stress level skyrocket. The sense of

urgency that maintenance must be done immediately to meet a flight schedule adds to the

problem.

The next time you supervise anything from

an aircraft move to an engine turn, call a time

out. Make sure all your people are qualified,

have the correct equipment, understand their

responsibilities, and are ready – both mentally

and physically – to do the job. This may take a

few extra minutes, but it will be time well spent

if it helps to avoid a mishap.

ADCS(AW) Jubert is a maintenance analyst at the Naval

Safety Center.

Time Out!

by ADCS(AW) George Jubert

Do You Live in the “Fly Zone”?

by ASCS(AW) Edwin Guerra

As a member of the Naval Safety Center’s

survey team, I usually check tool-control

programs. The number of tools I find that are

not in either a work-center’s inventory or a

tool room’s master inventory amazes me.

These findings have convinced me I’m

seeing a dangerous lack of concern.

I keep finding wrenches, sockets, pliers

and other tools in desk drawers, personal

lockers, and in unsecured storage areas.

I have found some supervisors who

don’t want to upset their buddies or create

friction by violating the personal privacy of

desks and lockers. This attitude shows a

disregard for the lives of aircrew and the

families living under the airspace our

aircraft use.

What if an aircraft crashes because

someone didn’t care about the consequences of a missing tool? Look everyPH2 Matthew J. Thomas

where, including lockers and desks. Don’t be

shocked by your accidental findings. Take

control of your extra tools.
by Joe Casto

Are You Part

Solution

Problem?

AN Michael Sadler, VAQ-137

or the

of the

A veteran troubleshooter pitches in to help a

 young plane captain start an aircraft. After

 attaching a huffer hose to a bird, the troubleshooter stands by to disconnect it once the engine is

on line. He doesn’t know the hose isn’t correctly

attached to the huffer. When high-pressure air enters

the hose, the huffer-end comes loose and smacks

the troubleshooter where it really hurts.

You can’t do zip in naval aviation without support equipment (SE). SE allows you to start, move,

and work on aircraft with relative ease. You take it

for granted because you’re so used to SE being there

for you that you don’t pay much attention to it until it

stops working right. Then you blame the ASs (aviation support equipment repair). “They don’t fix our

SE to last” is the usual complaint.

If you ask an AS to define the problem, he’ll tell

you squadron personnel don’t pre-op SE thoroughly

or often enough. They’re too rough on it, and they

use it when they shouldn’t–when the brakes are

weak, for instance. Anyone who has worked in the

hangar or on the flight line for 30 days knows what a

pre-op is. For the underexposed, it’s a preflight for

equipment that doesn’t fly.

Why can’t we get good fixes on yellow gear? Let

me answer this question with a few questions: Do

you pile toolboxes, tie-down chains and chocks on

tractors and huffers or use them as workbenches?

Do you stand on them instead of going after a ladder

or B-4 checkstand? Do you use SE as a taxi on the

line and in the hangar? Do you pre-op or preflight SE

before you use it? Do you report problems (such as

weak brakes) as you find them or wait until the

equipment is a basket case?

The ASs who work on SE see squadron maintenance people abuse SE every day. They take it

personally when 10 different drivers are rough on

that equipment 16 hours a day, running it while it’s

low on fluids, and ignoring minor problems until

they become big ones. Would you take pride in

repairing that SE or just do enough for it pass

minimum standards?
Flight, Flight-Related and Ground Mishaps

Class A Mishaps

Printed as a supplement to Mech by

Commander, Naval Safety Center

Data: Dr. Michael S. Borowsky

For questions or comments, call Joe Casto

(757) 444-3520 Ext. 7247 (DSN 564)

Aircraft Date Command Fatalities

EA-6B 11/08/98 VAQ-130 4

S-3B VS-22 0

FA-18C VMFA-312 0

FA-18C VFA-37 0

FA-18C VFA-37 0

A Prowler’s starboard wing hit the vertical stabilizer of a Viking on the angle

deck during a waveoff. Burning fuel and debris damaged three Hornets. The

Prowler’s crew did not survive; the Viking crew successfully ejected.

CH-46D 11/19/98 HC-8 2

An engine failed during VERTREP and the Sea Knight ditched.

AV-8B 12/03/98 HMM-163 0

A Harrier had an in-flight fire and crashed at sea.

T-2C 01/06/99 VT-9 0

The aircrew ejected after the nosecone departed the aircraft.

AV-8B 01/07/99 VMA-311 0

A Harrier crashed from a 50-foot hover; pilot ejected.

CH-53E (six) 01/18/99 HMH-772 0

AH-1W (three) MAG-49 0

CH-46E HMX-1 0

Ten helos were damaged by severe weather.

FA-18C (two) 01/20/99 VMFA-212 0

A pair of Hornets collided while flying in formation over water.

AW-1H 02/10/99 HMM-365 0

A Super Cobra crashed in the Pamlico Sound during a night ordnance

training flight.

FA-18C 03/10/99 VMFA-212 1

A Hornet disappeared from a radar screen during a night NVG CAS mission.

SH-60B 03/23/99 HSL-43 0

A Sea Hawk crashed into the water during a functional check flight.

Class B Mishaps

SH-60F 01/12/99 HS-7

A sonar dome departed when a Sea Hawk attempted to recover from an

unstable hover.

FA-18C 01/29/99 VMFA-251

Both engines and the belly were damaged when a Hornet flew into a flock of

birds.

FA-18C 02/08/99 VFA-137

A Hornet was struck after it released a missile during an air-to-air missilefire exercise.

SH-60F 02/17/99 HS-15

A sonar transducer departed its cable during a sonar recovery.

EA-6B 02/22/99 VAQ-140

The nose radome departed a Prowler during an approach to the initial for an

overhead break and FODed both engines.

F-14A 02/25/99 VF-41

Both MLG collapsed when a Tomcat trapped during a case 1 recovery.

S-3B 03/10/99 VS-22

A Viking’s port mainmount collapsed on touchdown.

CH-46E 03/12/99 HMM-164

Smoke and flames erupted from the Sea Knight‘s generator and aft transmission area before transition to forward flight.

Remove this insert! Post it until it’s old news,

then display poster on reverse side.

ASs are in short supply, so it isn’t uncommon for

them to initial a couple hundred checks every day.

That estimate includes CDI, tool control and paperwork. You have to wonder how thorough their work

is. At least they don’t have to maintain a squadron’s

IMRL gear. Squadrons are responsible for their own

IMRL gear, but the equipment is usually stored in the

SE compound. That can be confusing when you’re

up to your ears in day-to-day ops. For instance:

Mechs transferring an engine from a stand to an

engine sling were turning a handwheel to raise the

engine. The engine had just lifted off the mounts

when the handwheel stripped from the threaded

shaft of the up-loading adapter. The engine dropped

about 3 inches, and No. 3 prop blade struck the

engine stand’s rails. Investigation revealed severely

corroded and worn threads on the handwheel. There

are no inspection schedules for yokes. So how do we

avoid a repeat by someone else?

The mishap CO says we can’t afford SE failures

with props and engines becoming scarce. He contends that lifting and moving engines is tough

enough without having to worry about the integrity

of support equipment. He has a point, and his

suggestions are easy to follow. Determine which

equipment of your pre-positioned SE and IMRL you’re

responsible for maintaining. Set up inspection schedules and train your people to work on the gear. If you

have equipment that has no inspection schedule, set

up a local requirement for testing and corrosion

control. Be certain your operators pre-op SE every

time they use it. Turn in SE to the pool whenever you

find something wrong; don’t let problem skirmishes

with equipment lead to a war with the SE pool.

Supervisors in the AS rating are not required to

educate operators how to treat SE. ASs are not

supposed to police how the equipment is used;

that’s the responsibility of the operators’ supervisors. So, supervisors, if your operators ignore your

teachings, nail ‘em. You can bet the ASs and COs

want you on their team.