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MECH 360° 2017, Vol. 1 No. 1 The Navy and Marine Corps Aviation Maintenance Safety Magazine 17 Vol. 1, No. 1
MECH360° 2017, Vol. 1 No. 1
The Navy and Marine Corps Aviation Maintenance Safety Magazine
17Vol. 1, No. 1
MECH360°
CONTENTS
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The Navy & Marine Corps Aviation Safety Magazine2017 Volume 1, No. 1
RDML Christopher J. Murray, Commander, Naval Safety CenterCol Matthew Mowery, USMC, Deputy CommanderCMDCM(SW/AW/IW) James Stuart, Command Master ChiefMaggie Menzies, Department Head, Media and Public AffairsNaval Safety Center (757) 444-3520 (DSN 564) Publications Fax (757) 444-6791Report a Mishap (757) 444-2929 (DSN 564)
Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces and put them in hospitals, wheelchairs and coffins. Mishaps ruin equipment and weapons. They diminish our readiness. This magazine’s goal is to help make sure that personnel can devote their time and energy to the mission. We believe there is only one way to do any task: the way that follows the rules and takes precautions against hazards. Combat is hazardous; the time to learn to do a job right is before combat starts.Approach (ISSN 1094-0405) is published bimonthly by Commander, Naval Safety Center, 375 A Street Norfolk, VA 23511-4399, 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. Send article submissions, distribution requests, comments or questions via email to: [email protected] and [email protected]
On the cover:For this first online edition of Approach the front cover features the new 360°SAFE logo that will appear on all of the Naval Safety Center’s publications. 360°SAFE represents the Naval Safety Center’s centralized focus on safety.
Pages20. Overconfidence, Complacency and Checklist, by AD2(AW) Alvin Prakash
22. Crunch Time, by LCDR Todd Petrie
24. You Can’t Do it Alone, by AE2 Jesse Morgan
26. MECH Bravo Zulu
CDR Robert, Beaton, Division Head CWO3 Charles Clay, Branch Head
GySgt Ernesto DelGadillo
[email protected] Ext. [email protected] Ext. [email protected] Ext. 7239
All [email protected] Ext. 7811
Nika Glover, Editor [email protected] Ext. 7257
MECH Staff
Aviation Safety Programs Editorial Board
CONNECT WITH US
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MECH360°
Overconfidence, Complacency andChecklistAs an aviation machinist’s mate and
collateral duty inspector (CDI) for work center 110 (power plants), I
had performed enough engine removals on the F/A-18 Super Hornet to feel very comfortable briefing and leading my team on what seemed to be a routine engine removal evolution to facilitate other maintenance on the aircraft. Before starting the evolution, we briefed the engine drop at the night check mainte-nance meeting and ensured that my team members knew their responsibilities. Both team members had prior engine removal experience and I had removed a F414-GE-400 engine from a Super Hornet within the past month.
Having completed the brief, my two team members checked out all tools required for the job and I placed all three of us in work on the maintenance action form (MAF). Next, we positioned the engine removal cart under the aircraft, ensuring the guide rails were lined up properly to transfer the engine during removal. Once the cart was in place, we ensured that the proper procedure for the job was open in the interactive elec-tronic technical manual (IETM) com-puter we had on hand at the work site. I instructed my team members to remove all the necessary engine accessories for the evolution. Once they were complete, I inspected the engine to make sure all steps had been completed prior to lower-ing it from the aircraft engine bay.
After completing the pre-removal inspection, we raised the cart and locked it to the engine. With the engine mounts disconnected from the aircraft, I instructed the team members to begin lowering the engine and cart. As they did this, I heard an abnormal sound and
told them to stop. I began to inspect the engine cavity and then looked under the engine fan. It was then that I saw the engine anti-ice clamp was still attached to the line coming from the aircraft at the forward fire wall of the engine bay. The anti-ice ducting line was bent, cracked, and broken. We had failed to remove the clamp as we disconnected the engine from the aircraft.
As the team lead for the evolution, it was my responsibility to make sure my team members were following the checklist and to verify all steps had been completed. Instead, I let them complete the engine removal steps from memory without using the personal electronic maintenance aid (PEMA) to verify they had done each item on the checklist. For an engine removal, the IETMs procedure states: “Loosen nut, open duct cou-pling clamp halves, and separate forward anti-icing duct and inlet device aft anti-icing duct flanges.” Once this step is performed, a noticeable gap will develop between the two sections of ducting. When I conducted the visual inspection of the engine to make sure all steps were complete, I failed to notice that the gap did not exist.
After further investigation, we deter-mined that the damage to the engine and aircraft would cost more than $30,000, making it a Class D mishap. Because of my complacency and the overconfidence of my team, we thought we could do a routine engine drop without following the checklist. I definitely learned that no matter how many times I have done a specific job, I need to follow the proce-dure. Failure to do so puts our people and equipment at risk and leads to prevent-able mishaps.
BY AD2 (AW) ALVIN PRAKASH, VFA-195
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Aviation Machinist’s Mate 3rd Class Neiven Torres, assigned to Strike Fighter Squadron One Nine Five (VFA-195), cleans grease out of an F/A-18C Hornet engine cover. (U.S. Navy photo by Mass Communication Specialist Jimmy C. Pan)
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A s many readers of Mech already know, some of the most common ground mishaps plaguing the FA-18 commu-nity are crunches involving doors 64L and 64R. For
non-Hornet maintainers, those are the two engine bay doors that clamshell open on the keel of the aircraft. The reason they keep getting crunched is because when they are open they are directly in the path of the trailing edge flaps (TEF). The vast majority of these crunches occur during non-pilot maintenance turns.
As with most mishaps, there is no one specific reason that these doors get crunched. Two previous editions of Mech featured articles about these specific crunches, each of which had different causes. The article “Best Practice: The Turn,” featured in the Winter 2013-14 Mech was caused by inten-tionally moving the flaps with door 64L open, while the article “How Did We Get Here,” published in Summer 2013 had a crunch involving an unintentional flap movement with the door open. A web enabled safety system (WESS) review of SIRs and
HAZREPs involving these doors show a mixture of crunches caused by intentionally moving the flaps with the doors open and instances where the flaps moved unintentionally with the doors open. Our most recent crunch was one of the latter.
While the author was not personally involved in this turn, he was one of the investigators tasked with figuring out what happened after the fact. In many of these situations, the cause is relatively cut-and-dry. This case was certainly not going to any quick answer.
The mishap started out as an out-of-phase low power turn along with engine installation leak checks. The turn operator was a previously qualified turn operator working on his recerti-fication under the instruction of a department head squadron pilot. The event was properly briefed and the pre-turn walk around was standard with all the aircraft doors closed during the first engine start.
There were a couple of issues with the right engine start and once the engine finally did start the right generator failed to come online. The turn operator and turn instructor then decided to start the left engine, knowing that the left gen-
TimeCrunchBY LCDR TODD PETRIE, VFA-213
Aviation Machinist Mate 3rd Class Brent Laube conducts a low power turn of an F/A-18F Super Hornet under the supervision of plane captain Aircraft Structural Mechanic 3rd Class Dale Little. (Photo by Aviation Electronics Technician 1st Class James Carter)
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erator could power the entire electri-cal system of the aircraft. Once the electrical system came online, the turn operator and turn instructor noted that the aircraft had both R GEN and R DC FAIL cautions, indi-cating that both the AC and DC systems were inoperative on the right engine. Approximately 45 minutes into the turn, the left engine was secured to conduct leak checks. The intent was to execute a crossbleed start of the left engine once leak checks were com-pleted. At this point the TEFs were full down and doors 64L and 64R were both being held opened by maintainers. Approx-imately two minutes later, the flaps began to close with the flap switch still in full. While one maintainer was quick to close his door before the flaps closed, the other was not as quick and door 64R was impacted by
the right TEF, bending the door and causing damage. Figuring out why the flaps moved unintentionally was a
thorough lesson in FA-18F electrical and hydraulic system redundancy. When the turn operator secured the left engine, with the only operable generator, he induced a dual generator failure. Normally, the flight control computers (FCC) and the essential bus would be powered indefinitely by the permanent magnet generators (PMG) on the operating engine. In this case, the right generator and PMG were both failed (R GEN and R DC FAIL cautions), which left the battery as the only electrical source powering the essential bus.
In order to save battery power, the battery switch is mech-anized to shut off two minutes after AC power is secured on deck. Once the battery was secured, the FCCs were no longer powered, which left the aircraft with hydraulic power to the flight control surfaces but no inputs from the FCCs. In this configuration, the TEFs will drive up from 30 degrees down to five degrees down. In this case, they did so with doors 64L and 64R in the way.
This is a rather complicated scenario. Based on the turn
Crunch
operator PQS, it is impractical to expect a turn operator to have this extensive depth of system knowledge. It is also imprac-tical to expect the turn instructor to have that level of sys-tems knowledge, despite being a senior squadron pilot, since aircrew in the Super Hornet don’t spend much time studying scenarios involving unpowered FCCs, a situation that would lead to a loss of control and ultimately to an ejection airborne. Now, even though this is a complicated scenario which is not likely to be repeated often, there are good lessons that can be learned.
In our squadron, as in most other squadrons, we preach “by the book” maintenance. In this case “the book” refers to the interactive electronic technical manual (IETMS), which lists several cautions related to opening doors 64L and 64R while the engines are turning. If the flaps are up, then IETMS directs securing hydraulic power with the hydraulic system 1A and 2B manual shutoff valves in door 51L and 51R and install-ing TEF support brackets to keep the TEFs from sagging once hydraulic power is removed. If the TEFs are down, like in this example, then IETMS cautions “To prevent damage to trailing edge flap or door 64L/R if door is open, hydraulic system 1A and 2B manual shutoff valve in door 51L and 51R must be posi-tioned to OFF to prevent actuation of trailing edge flaps.” This seems rather straightforward; however, closer investigation revealed that these shutoff valves are almost never used. Part of the reason is because these types of “all shops” turns usually involve FCS IBITs, which can’t be conducted with the flaps disconnected. Additionally there seems to be a general distrust of these valves by maintenance personnel. My squadron was only able to gather anecdotal evidence, but most maintenance personnel interviewed stated that these valves are never used because they don’t work.
This author was unable to find any SIRs or HAZREPs where the shutoff valves were used and failed, but the sheer number of crunches would support that these valves are not used as often as they are called for in IETMS. If the shutoff valves had been used in this scenario, they would have isolated the TEFs from the hydraulic system and prevented their retrac-tion into door 64R. Had the valves been used and failed then NAVAIR could conduct an engineering investigation (EI) into why the valves failed and develop a fix. Many squadrons have also developed other techniques to prevent crunches, such as having maintainers hold the doors instead of propping them open, but our mishap proved that technique doesn’t always prevent a mishap.
In the big picture, there are many situations both known and unknown that cause the flaps to move in the FA-18. Every time door 64L or 64R are open with the hydraulic system pow-ered there is a risk of the flaps moving and causing a mishap. If safety measures are being ignored fleetwide then that is a sys-temic problem that needs to be fixed. If the hydraulic isolation valves work, then a “by-the-book” maintenance department should be using them whenever IETMS calls for them.
If they don’t work, then the community needs to document cases of failure so a proper solution can be developed. VFA-213 has reviewed our maintenance procedures and implemented controls to ensure that the hydraulic shut-off valves and TEF locks are used whenever called for by IETMS. Since safety measures are already in place to prevent this problem, the best thing to do is double check our steps to eliminate damage to our assets.
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It was a routine night at the MH-60S Fleet Replacement Squadron (FRS) located on Naval Air Station North Island, Calif. The FRS is generally considered a high-tempo train-
ing command that routinely executes a daily flight schedule requiring five MH-60S aircraft, which sometimes begins shortly after daybreak and goes well into the night. At the time, I was assigned to work center 220, the aviation electrician (AE) shop, and working as the night shift supervisor. I worked alongside an AE collateral duty inspector (CDI) and two other AE maintain-ers, all of which were tasked with routine aircraft troubleshoot-ing and maintenance.
I typically assigned the CDI and one maintainer to tend to flight line troubleshooting and, workload permitting, other main-tenance tasks that was considered small in nature. This gave me the opportunity to focus on the discrepancies that required more in-depth troubleshooting that were often on down aircraft. As the only 220 collateral duty quality assurance representative (CDQAR) on the night shift, I occasionally peeled myself away from projects to ensure the 220 shop was doing its part to keep the flight schedule running and assist the AE CDI with tough matters that arouse throughout the shift. It was not uncommon for me to work on four to nine different aircraft throughout the night. The FRS most certainly lived up to its reputation and provided a very dynamic environment that required constant attention and flexibility at any given time. Those who have ever worked at an FRS would most certainly agree.
Now, my hot ticket discrepancy for the night was aircraft 14. It was scheduled to fill one of the five aircraft requirements for the flight schedule the next day. It had downing discrepancies that caused the embedded global positioning/inertial navigation system (EGI) and automatic flight control system (AFCS) cir-cuit breaker to pop whenever external power was applied to the aircraft. In addition, the backup hydraulic pump would not turn on. The gripes were discovered the night before and this was my first time looking at them.
As I was reviewing the troubleshooting steps that had already been completed and wrote down the in-process (IP) inspection block of the maintenance action form (MAF), I formulated a plan of attack for the gripes associated with aircraft 14. My shift just started and the flight schedule was well under way. Soon after the night shift had relieved the day shift is when multiple AE troubleshooters were called to the flight line for multiple incoming aircraft. The flight schedule has number one priority, so my project for the night was put on hold.
After a few hours, the work tempo slowed down enough for me to start tending to the three downing gripes on aircraft 14. I informed the Chiefs in maintenance control that I may need to swap the No.1 and No.2 direct current (DC) converters because the previous IPs stated that the aircraft had a No.1 DC converter caution light. This was after the wiring continuity/power checks for the DC converters had been completed and were found to be working as advertised. I wanted to start troubleshooting the backup pump because there was a high probability that the No.1 DC converter caution light was originating from a malfunction-ing backup pump.
Another AE and I began the troubleshooting process by removing the No.1 DC converter. We made note of the external wires that were connected to the electrical terminals on the outside of the box. There was a positive wire running from the forward part of the cabin that was connected to the forward positive terminal. The negative wire ran up to the box from
You Can’t Do It Alone
BY AE2 JESSE MORGAN, HSC-3
Aviation Structural Mechanic 3rd Class Tyler Clausen signals an MH-60S Sea Hawk helicopter as it pre-pares to land. (U.S. Navy photo by Mass Communica-tion Specialist 3rd Class Josue L. Escobosa)
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the aft side of the cabin and led to the aft negative terminal. I concluded that since there were only two wires, during removal process, I would just move the positive wiring forward and the negative aft in order to differentiate the two prior to reinstalling. Altering the maintenance procedure was just the first in a series of errors that occurred this very evening. The maintenance publication also called for the terminal cover to be removed prior to the removal of the terminal leads.
The terminal cover had two flathead screws located in a con-fined area and was difficult to reach, which made removing the screws an extremely slow and a painstaking task. In an attempt to be more efficient, I devised a plan that took down the No.1 DC converter first, so that it could be repositioned and allowed for more access to the cover. That gave us more room to fit the regular flat head screwdriver inside the tight space and sped up the process of removing the cover. It worked like a charm however this new and “improvised” method of removal required two people. This was not very convenient because I didn’t have another AE to assist with the job.
Soon, another error was about to occur. I was now going to inspect my own work. We had the No. 1 DC converter down in no time and were ready to remove the No. 2 DC converter. Having figured out the No. 1 side, we used the same methods and applied to the No. 2 side. Once the No. 2 DC converter was removed, we installed it on the No. 1 side for troubleshooting.
“ “I am writing this to those hard chargers out there who
think they can get everything accomplished by themselves. It’s important to remember to be mindful of your limits.
I knew that most of dDC electrical power could be supplied by only using one converter and that most of aircraft lighting was powered by the DC converters. The troubleshooting logic was if everything powered up as normal with only one DC converter installed, I then knew that the removed DC converter was bad. However, if none of the lighting came on then both the convert-ers were most likely good.
After I applied external power to the aircraft, the latter hap-pened. None of the lighting came on. I had a few other trou-bleshooting ideas but wanted to recheck some of the previous items inspected by other maintainers. I then found the problem as to why there was a No. 1 DC converter caution light and a problem with the backup hydraulic pump malfunctioning. Three current limiters located in the No. 2 junction box were blown. We quickly replaced the three current limiters and applied power. Everything came on as advertised without the No. 1 DC converter caution light. I applied backup hydraulic power and that worked as well. This was a great sign. We were closer to getting this aircraft on tomorrow’s schedule! I informed mainte-nance control and started to put the DC converters back in their original spots. Once all that was completed, we headed back to the shop for shift turnover and updated the IPs. As I was writing my IPs, I briefly stated that current limiters needed to be put on order to fix the gripe. However, I never stated that we swapped the converters.
The next day, I found out that aircraft 14 had four or five new downing discrepancies that were found during a turn-around
inspection. These gripes were discovered while doing aircraft lighting checks. One of the multifunctional flight displays had smoke coming from it and multiple circuit breakers had popped when external power was applied. At this point, quality assur-ance launched an investigation to determine the cause of these electrical gripes.
The investigation concluded that the No. 2 DC converter terminal leads were swapped. I was in disbelief and wondered how those wires could have been swapped when I had taken the precautions that I did. As it turns out, during the removal of the No. 2 DC converter, I failed to notice that, unlike the No.1 side, the positive wire ran to the aft terminal and the negative to the forward terminal. When we removed the converter to get to the cover screws we positioned it to look like the No. 1 DC converter side. We placed the forward lead to the forward terminal, the aft lead to the aft terminal. When we placed every-thing back in its original place, we hooked up both converters to mirror one another. The investigation found that all of the nine damaged electrical components caused by the series of errors totaled $121,499, which the Navy classifies as an aviation Class C mishap.
I didn’t know what to think because I had never done any-thing like this before. I was always so careful during my trouble-shooting to follow the publications and place everything back correctly when I was finished. I could go into a variety of causal
factors, but it really only comes down to one thing. Compla-cency! Yes, several errors were made that night to include lack of procedure compliance, inspecting my own work and proper documentation, all of which were done out of complacency. I thought that I could make it work as a “one-man-show,” but in reality, I was working a bit outside my means. I had multiple requirements throughout the night such as helping out the CDI troubleshooter when he needed it and working on the downing discrepancies, all while running the rest of the work center. It was hard to slow down and give the maintenance task at hand the proper amount troubleshooting time that was required. I want to be the best AE in the command. I want to be the “go-to” expert, and I want to take care of anything thrown my way. Because of that, I felt the need to rush and get everything done during my shift. By cutting corners, I ended up causing a Class C mishap.
Since then, I have slowed down a considerable amount. Amazingly, we still fly aircraft every day and we get the job done together, as a team. I am writing this to those hard chargers out there who think they can get everything accomplished by themselves. It’s not wrong whatsoever to have that kind of moti-vation. In fact, we always need more of that in this high-tempo aviation community. But in the end, it’s important to remem-ber to be mindful of your limits, don’t be afraid to pump the brakes from time-to-time, think about the consequences of your actions, and remember the importance of fighting complacency because it affects the team as a whole.
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Bravo Zulu Sailors and Marines Preventing Mishaps
SN REGINALD DIAZSN Reginald Diaz demonstrated impressive concern for aviation
safety while directing a hot refueling evolution for Big Chief 712 at NAS Jacksonville. Airman Diaz observed a rupture in the fuel line at the refueling station pivot arm shortly after the hose was attached to the aircraft. Upon noticing the fuel leak, he immediately secured refueling operations and directed line personnel to disconnect the hose from the aircraft. Once all hoses and personnel were clear of the area Airman Diaz notified the pilots that pressure refueling system was inoperative and confidently taxied the aircraft out of the hot refueling pits. Airman Diaz’s keen attention to detail in identifying the leak and assertive decision to terminate the evolution ensured the safety of flight and line maintenance personnel.
PO3 Le’DARIUS NIXONPetty Officer Third Class Le’Darius Nixon was performing
maintenance on the flight line when he heard a fuel spill called away on the radio. He quickly responded to Vulcan 544 and saw the fuel pouring uncontrollably out from under the spon-son. Immediately he ran inside the aircraft and retrieved the windshield washer reservoir cap to insert into the fuel low point drain poppet valve, which enabled him to stop the fuel spill and avoid any further contamination. His direct efforts led to zero medical casualties and minimized environmental impacts
Bravo Zulu Submission GuidelinesInclude a smooth narrative of the event, names
and ranks of the nominees, and endorsements from the command safety officer and CO.
Approach and Mech BZs must include endorse-ments from squadron CO and appropriate wing or MAG CO.
Send an action photo of the candidate(s) on
the job or crew with the nominee(s) identified in the photo. Photos must be high-res (300 dpi), saved as a JPG. A phone number should also be included.
We cannot work the BZ until we have all these “pieces.” Forgetting the chops delays processing the nomination and its publication.
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