MECH Magazine - VOL.66 NO.1

VOL. 66, NO. 1 SPRING/SUMMER 2021

Publication ISSN:

TOP 10 MAINTAINER SAFETY LESSONS

U.S. Navy photo by Mass Communication Specialist 3rd Class Rebekah M. Rinckey

We

are

your

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advocate

NavalSafetyCenter.Navy.mil

safety

COMMANDER`S LETTER REAR ADMIRAL F.R. “LUCKY” LUCHTMAN

As we enter a new year, I want to thank you for everything you do to support our mission, our staff and our customers across the Naval Enterprise. As always, saving lives and preserving our resources and combat assets remains our primary objective.

We must continue to lead by example and maintain the day-to-day risk management mindset - keeping in mind the maintenance safety lessons from 2020`s mishaps and setting safer operating conditions. While the current environment may be challenging, we must strive to keep our focus on the missions and tasks in front of us.

Never forget who you are and how important your day-to-day mission is to the Department of the Navy.

number of successful evolutions you accomplished last year, which was no small feat during a very challenging period.

I am ready to see what this year brings. As we head into 2021, I encourage all of you to maintain your commitment to excellence.

Whether you are a newly-assigned Airman or a seasoned Chief, the safe movement of aircraft begins with you!

I’m confident you will continue to hold safety paramount in all maintenance evolutions and during all operations both at sea and ashore.

Continue to send us your articles, ideas and feedback. MECH is your magazine! We love hearing from you!

The pandemic has impacted our daily lives, causing hardships we did not previously imagine, but your resilience and dedication are evident in the

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Maintenance Safety Team Main Phone Number: 747-444-3520 CDR Gary Shelley Aircraft Maintenance and Material Division Head, gary.m.shelley@navy.mil Ext. 7265 Maj. Andrew Ericson Asst. Division Head, andrew.c.ericson1@navy.mil Ext. 7223 CWO5 Brian Baker Aircraft Maintenance and Material Analytics Branch Head, brian.c.baker5@navy.mil Ext. 7123 CWO3 Lanita Winfrey Aircraft Maintenance Assessments Branch Head, lanita.winfrey@navy.mil Ext. 7278 AFCM (AW) Pedro Gonzalez Maintenance Master Chief, pedro.a.gonzalez@navy.mil Ext. 7290 Master Gunnery Sgt. Joshua Smith Systems Maintenance Branch Head, joshua.m.smith4@navy.mil Ext. 7276 AZCM (AW/SW) Courtney Barber Aviation Maintenance Administration, courtney.kittrell2@navy.mil Ext. 7285 ADCS (AW/SW) Andrew Van Norman Power Plants Analyst, andrew.s.vannorman@navy.mil Ext. 7219 AECS (AW/SW) Russel Gross Electrical Systems Analyst, russel.gross@navy.mil Ext. 7291 AMCS (AW/SW/IW) Anthony Abraham Egress, Environmental Systems Analyst, anthony.abraham1@navy.mil Ext. 7293 AMCS (AW/SW) Thomas Matthew Fain Aviation Structure 0-Level (Fighter), thomas.fain1@navy.mil Ext. 7290 AOCS (AW/SW/IW) Christopher Morris Aviation Weapons Analyst, Christopher.j.morri9@navy.mil Ext. 7143 ASCS (SW/AW) Joseph Hippolyte Support Equipment Analyst, joseph.hippolyte1@navy.mil Ext. 7171 ATCS (AW/SW) Cristie Link Avionics Systems Analyst, cristie.o.link@navy.mil Ext. 7221 PRCS (AW) Randi Zetterlund ALSS, Aircrew Equipment Analyst, randi.m.zetterlund1@navy.mil Ext. 7258 AECS (NAC/AW/SW) Wade Hove Aircrew Safety Analyst, wade.l.hove1@navy.mil Ext. 7280 Master Sgt. Stanley Berry Airframes, Hydraulics Analyst (Rotary), stanley.j.berry@navy.mil Ext. 7292 ADC (AW) Caitlin Addams Power Plants Analyst, caitlin.addams@navy.mil Ext. 7256 AMC (AW/SW) Mark Pugh Airframes, Hydraulics Analyst (Rotary), mark.pugh1@navy.mil Ext. 7187 Gunnery Sgt. Krystal Conklin Maintenance Administration Data Analyst, krystal.r.conklin@navy.mil Ext. 7239 Gunnery Sgt. Douglas Green Airframes, Hydraulics Analyst (Fixed Wing), douglas.h.green1@navy.mil Ext. 7244 Gunnery Sgt. Jeff Schmitt Avionics Systems Analyst, Jeffrey.t.schmitt1@navy.mil Ext. 7140 Gunnery Sgt. Christopher Watson Weapons Analyst, christopher.a.watso7@navy.mil Ext. 7215 Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces, cause injuries and damage equipment and weapons. Mishaps diminish our readiness.

The goal of this magazine is to help make sure that personnel can devote their time and energy to the mission. We believe there is only one way to conduct any task: the way that follows the rules and takes precautions against hazards.

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.

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MECH Staff JEFF JONES Leads the Safety Promotions team (Media and Communication Division and Lessons Learned Division) in developing and executing varied and integrated communication products.

PRISCILLA KIRSH Manages the multitude of communication products that are produced by a team of outstanding professional communicators, ensuring the Naval Safety Center’s messages are getting out to the fleet in the most efficient way.

CATALINA MAGEE Editor of Approach and MECH magazines and art director of special products, such as the 2019 Annual Report, 101 Critical Days of Summer, the RMI magazine, posters, presentations, infographics and videos.

CONTRIBUTING STAFF LESLIE TOMAINO Communications Strategist AMY ROBINSON Writer/Editor SARAH LANGDON Writer/Editor BECKY COLEMAN Writer/Editor STEPHANIE SLATER Communications Strategist LISA BONNER Webmaster

KEN GOSS Social Media Manager MC2 (SW/AW) WESTON MOHR Videographer MC2 (SW) DAN WILLOUGHBY Videographer CHRIS REW Lessons Learned Supervisor DAVE DEUEL Lessons Learned Writer MIKE DEL FAVERO Lessons Learned Writer

Let’s get

Social

@NavalSafetyCtr Twitter “Taking the kids trick or treating? Halloween safety tips from the Naval Safety Center.”

@Fleet_Family

“Check out the Naval Safety Center which offers a variety of seasonal safety tips.“

“An F-35C Lightning received at least $2 million in damage from a mishap during an aerial refueling exercise last month, according to Naval Safety Center data.”

@StarsandStripes “Naval Safety Center Prepares Fleet for New Mishap Reporting System.”

@NavyMedicine @AmerHeroesRadio

@NavalSafetyCenter Facebook “Hands down, one of the best managed pages I have encountered on Facebook.

The information is timely, on point and to the point. The graphics and content are inviting to all who encounter it. The response time to inquiries is short and very accurate in response. Add the fact that the Naval Safety Center is on the cutting edge of maritime, aviation, ordnance, occupational, recreational and material safety globally, this page is an indispensable interface in the social media environment.”

Pete Corp “I love what the Naval Safety Center does to keep our service members safe! Thank you!”

Vernell Edwards

“They run an excellent yearly Professional Development Seminar!“

Jonathan Bach “Great information for all to have. You can never be too careful.“

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We thank you for your support.

MECH 5

VOL. 66 NO. 1

contents 03. COMMANDER`S LETTER 08-09. Be the Best

BY AD3 (AW) THOMAS R. SCOTT

10-11. Simple Task, Little Damage, Big Cost

BY AT3 BRYAN MINNEMAN AND AT3 ANTHONY KLEIN

12-13. The Royal Maces

BY AD1 (AW) LUCKYRALP P. BAUN AND AD1 (AW) EVELYN KAMIRI

14. Aircrewmen’s Quest to Eliminate TFOAs

BY AWSCS (NAC/AW/SW) WADE HOVE

15-18. Posters 19. Importance of Adhering to Standards

BY AME2 (AW) TILLMAN U.S. Navy photo by Mass Communication Specialist 2nd Class Ruben Reed

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20-21. Be Ready for the Maintenance Meeting

BY GYSGT DOUGLAS H. GREEN

22-23. A Better Idea

BY ADC (AW) CAITLIN J. ADDAMS

24-25. We Don’t Have Enough Quals!

BY AFCM (AW) PEDRO GONZALEZ

26-27. By the BookAt All Times

BY AM2 CONNOR FICE AND AM2 DAMIAN SHANDS

28-29. Not Your Kid’s Lego U.S. Navy photo by Mass Communication Specialist 3rd Class Rebekah M. Rinckey

BY LT SALMINI SCHUYLER

30-31. BRAVO ZULU

AE2 KEVIN J. HALL PETTY OFFICER JAMIE MARIE LYNCH AM3 JOSHUAEMMANUEL G. ABELLO AWO3 DAVID ROJO

FRONT COVER U.S. NAVY ENSIGN TONY SQUIRES PHOTOGRAPHED BY MC2 GRANT G. GRADY

BACK COVER U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 3RD CLASS ELLIOT SCHAUDT ILLUSTRATION BY CATALINA MAGEE

U.S. Navy photo by Mass Communication Specialist 3rd Class Kaysee Lohmann

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BE THE BEST WHEN AN UNSTOPPABLE FORCE MEETS AN IMMOVABLE OBJECT

By AD3 (AW) Thomas R. Scott

“LIKE MANY OF THE THINGS WE DO IN NAVAL AVIATION, SUCCESSFULLY EXECUTING AN F/A-18E LOW-POWER APU/ENGINE TURN REQUIRES A TEAM EFFORT. IF YOU CHOOSE TO GO IN ALONE, YOU’RE SIGNIFICANTLY LESS LIKELY TO BE SUCCESSFUL.”

Photos courtesy of AD1 (AW) Jonathan J Hunt, ENS Brandon Shackelford and CDR Christopher M Amis

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It was an unusually cold late February night on the flight line at Marine Corps Air Station Iwakuni, home of America’s forward-deployed Carrier Air Wing, CVW-5. Usually, shore-based operations have a little more relaxed pace than underway operations, but this was a hectic shift on top of an unusually busy workweek.

Maintenance control warned everyone that at least two of the currently “down” jets would need to be “up” to successfully execute the flight schedule in the morning. Like many squadrons, ours leaned heavily on night check to get things done. My shop was also spread a little thin as a result of Sailors attending mandatory training in the morning. To pick up a bit of the slack, Maintenance Control tasked our “Mech”-qualified Quality Assurance Representative (QAR) with conducting maintenance instead of conducting their regular duties acting as safety observers.

As a qualified turn operator and Collateral Duty Inspector (CDI), I was well-positioned to make a significant contribution in taking a dent out of the workload. After speaking with the other CDI and qualified “turn body” in the shop, we agreed to split the workload to get as many of the

tasks done as possible. With a plan to work from easiest to hardest, we could complete our own tasks and come together to conquer more challenging tasks at the end of the night. I volunteered to take on two downed generators and an engine wash. All of these tasks required low power turns. I’ve been through the routine of conducting these kinds of turns plenty of times before. When preparing for a turn, a series of steps need to be completed before approaching the jet.

First, the turn operator is supposed to read the Aircraft Discrepancy Book (ADB). Then there is the gathering of all the required personnel. Specifically, you need the turn operator, a plane captain, a CDI, two safety observers and a flight deck Chief.

Once you’ve completed all the prerequisites and gathered the required personnel, a brief is held in maintenance control to ensure everyone is on the same page.

Finally, the turn operator is given a turn card to head out to the jet for final inspections and, eventually, the turn itself. I repeatedly completed this routine and would be lying if I said I wasn’t feeling a little complacent and overconfident with my abilities.

NG I C A EPL I GOT R AND ATOR, WASH G IN ENER INE V O EM ND G E ENG .”

R N ER O TH AFT HE SEC Y FOR ER TUR T EAD POW R OW L

t ou ith of w ne pe ake e fi is ty o m b ld th t t k y. ou d to he je wal us b w e t e t s d i o us t on er th wa e r e t up s u f u n fig was lor o re. A art ht . t ryo I s i e v lig ine nd e I Sa cu to ee e a sinc her d se ed reen eng the d im d i . t t n l t t o t e g i o a ts e s ce the por run t shu e ou onn d an afe ockp thi o r I e d y e p n h y y, ht s rs ha s s c B ol nd Whe tor t afet atel t to aug ff s c ra pe all, I wa the a i i a s ). mo e ed g n p tc go t on It we ex fter thin ed i ry (APU to w th mm cock r go akin and e p y A t h n r o i a t p . t t rn ve o ba ni ega l I s n; the do bre AR tu re e d, I h he er U , I b unti dow t of 64L g in he Q t u n s ou ed Pow on ne me ou the ltin d t nt. n ft ar urn iary ame ed fi ged bed hat resu tifie cide t d o s le n xil c m ag lim t t p, no in e e s U c e u u wa I th e Au AP see te fl nd s o e fla ap. I t th oc oor sk! I of f a n a g g u e th r th hin pm ine tur ed e fl bo so d ta ne as 64L next ng o ight and fo eryt shi eng d. It iling g th Is a w e e i I fl n Ev . My the ene tra rcin e CD d? at th r th rank the itio t e p g e i h e n s p n t c o j w h n p d i f t o a e v n s d pp one ady PU i in a ull p do at h mo and titie a f wh the ges no e h h d re A ck e nd av was to be n an s ki in th on e hin shop h na n p e s o s i e i n th her th gin itio t wh pum flap . at tio , nic xecu ncy ly ot uld e en pos tha ulic the ition u o e s c th ht ze ra th e w mmafe plac e on as po i d li g o c s i Ho tting upri t rea e hy en w full y m l n ve e , us r the g co ight ser anc y. Pa ge the idn’ s, th ev the c o l n d s f fo ttin e fl ul te ht r nd in o d otor ove h in nd dure rmi n th sho ain y lig neve rs a r a als e m es m witc m c e u e m Pe o ry th rfac ps s de proc ce. tion sto tion acen and roth m o n l e a a b u n s o c i e p r s e fl a a r io vi iat th en str . Th , a om r tim ou fit f th Av ce to aint r di ster y we ke c you ope ene l b h m e o sa h ta e va n Na here tion enc pt di of w not ; tak ” We can t! ad avia nfid tem ple uld -ops me! line bes of erco to xam , sho pre to ight the ov rves ct e als our pen he fl be se erfe sion do y t hap n t ve to a p ofes ion, on’ dow stri pr tent “It w and e all at ink, up s w th ters e, a sis istak m

#1

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Simple Task, Little Damage, Big Cost

ON JUNE 30, 2020, TWO VFA-32 AVIONICS TECHNICIANS WERE WORKING ON AN F/A-18F IN ONE OF THE HANGAR BAYS ON THE USS DWIGHT D. EISENHOWER (CVN 69).

U.S. Navy photo by Mass Communication Specialist 3rd Class Peter Burghart

THEIR TASK THAT EVENING INVOLVED REASSEMBLING THE JOINT HELMET-MOUNTED CUEING SYSTEM (JHMCS) IN AN AIRCRAFT’S AFT COCKPIT. THERE ARE SEVERAL PARTS, LOTS OF FASTENERS AND CABLE CONNECTIONS IN PUTTING A SYSTEM BACK TOGETHER.

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By AT3 Bryan Minneman and AT3 Anthony Klein

Amongst the work involved in the process, there is little space for parts. The parts were moved at several different points in time to create space to work in the cockpit. During the installation of the JHMCS equipment, the aircraft was moved between the hangar bays.

Due to the aircraft moving, neither of the Sailors involved recalled when the parts were moved; however, at some point, one of the last pieces that required installation made its way to the very aft section of the canopy sill. This area houses many essential parts, such as canopy seals, actuators, actuator arms, thin-layer explosives and one of the most vital sections of the canopy frame. In the aft section of the canopy sill, the area the part made its way to is very dark, painted black and the part that shifted was black as well.

As work continued past shift turnover, the two Sailors decided they had gotten to the point they needed to turn the job over to the next shift.

As an all tools accounted for (ATAF) evolution was being completed on the toolbox, the other Sailor was closing up the jet. The first function is shutting the canopy. There are multiple steps in closing and verifying the canopy sill is clear of all foreign objects and debris (FOD) is one of them. This step was not performed thoroughly that night. While shutting the canopy, just before it met the canopy sill, both Sailors heard a relatively loud “pop.”

They stopped the evolution immediately and proceeded to reopen the canopy and check the source of the noise. While one Sailor checked the noise source, the other went to inform the Aviation Structural Mechanic (AME) shop of the situation.

At this point, the canopy had already

Right: Photo by Petty Officer 3rd Class Chris Bartlett Left: Photo by Petty Officer 3rd Class Lauren Booher

shut on top of the JHMCS cable plate, damaging both the plate and the aft section of the canopy frame. At first, it looked like a potentially repairable warp in the structure, but it was enough for a mandatory canopy removal and replacement. An F/A-18F has two seats.

This makes the canopy relatively larger and heavier than that of its single-seat counterparts. If you look in the integrated electronic technical manual, you will find that the canopy weighs quite a lot, regardless of the version. The sheer size and weight alone can give you a good indication that it is costly.

When damaged beyond repair, it is expensive enough to be considered a Class C mishap.

Class C mishap classification is any mishap costing more than $60,000 but less than $600,000. Many things could have been done to avoid a mishap, such as thoroughly checking the canopy sill before closure, having a collateral duty inspector or supervisor on the job to double-check the sill, following the steps in the operating publication and avoiding rushing back to the shop.

Had these two Sailors taken the time to slow down and go through all the steps, the mishap could have been avoided.

It is crucial to slow down and take your time on the job. There is no reason to rush to finish a job and cause either a mishap or rework for your shop. It is always good practice to have someone else check your work. Over the last several years, “crunching” canopy sills has been one of the top five Super Hornet maintenance-related mishaps degrading the aircraft’s readiness.

VE TO I T A PER ND M I A S TI `S N ATIO C I AND L B D U E AT P E US H R T A E R ES ENSU ESOURC RR E H T O ED. W O FOLL

MECH 11

The

Royal Maces By AD1 (AW) Luckyralp P. Baun and AD1 (AW) Evelyn Kamiri

“

IT WAS A BEAUTIFUL SUMMER EVENING ONBOARD THE USS RONALD REAGAN (CVN-76).

NOTHING WOULD MAKE ANYONE BELIEVE THAT THIS NIGHT WOULD END UP RESULTING IN AN OVERSIGHT THAT CAUSED CONSIDERABLE DAMAGE TO AN AIRCRAFT. ”

#3 On the flight deck, Sailors attached to Strike Fighter Squadron 27, the “Royal Maces,” were executing a high-power turn-up evolution on one of their F/A-18E Super Hornet aircraft. Side number 205 just received a new set of afterburner spray bars and made a pleasant growl while the maintenance crew swarmed its sides in anticipation of afterburner flames.

Ten minutes into the job and just before the great afterburner flames could come to life, fasteners started flying, leaving one composite door crunched, a trailing edge flap mangled and maintainers wholly demoralized.

Power plants had been one of the backbone workcenters throughout the deployment. Due to high operational tempo, mechs had endured an onslaught of unscheduled maintenance, tackling a significant amount of aircraft discrepancies brought back from routine flight operations.

Due to the COVID-19 environment, the Royal Maces were stuck between low morale and repetitive maintenance, resulting in a level of complacency that proved to be dangerous when not combatted by thorough adherence to procedures and attentiveness to their surroundings.

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Shift change occurred on the flight deck at 1700. It was well into the middle of a hectic flight schedule when the night shift came up to the weather decks to relieve the day shift.

Aircraft 205 was prepared for a highpower turn, which is done to check engine specifics related to maximum thrust, or afterburner, following Technical Troubleshooting Manual A1-F414ATTM-000. Night shift performed an operational check on the long afterburner spray bars and primary bleed air pressure regulating shutoff valve. A newly-created turn crew consisted of a turn operator, plane captain, two safety observers, flight deck Chief, technician and a collateral duty inspector. The team was composed of seasoned technicians and everyone knew their roles in the event.

Everybody manned their positions and was ready to roll. The team had been waiting a significant amount of time and the sun was starting to set over the horizon, blanketing the deck and everyone in darkness, leading to a feeling of complacency and eagerness to start the evolution. After waiting for what felt like an eternity, the flight deck Chief finally signaled them to start the auxiliary power unit.

Photo courtesy to the writers

Both engines came online. Flaps were open. After receiving permission from the plane captain, the collateral duty inspector and his technician approached the starboard engine bay doors to open door 64. As soon as the door came open, the inspector got the plane captain’s attention and handsignaled for an engine cross-bleed to leak-check the shutoff valve. The hand signal, in reference to NAVAIR 00-80T-113 for plane captains, for cross-bleed is an “x” created by either both hands in the daytime or both light wands during a night evolution.

The plane captain saw the signal, but unfortunately, he misinterpreted it for a “close flaps” signal due to the poor visibility. Closing the flaps is relayed by creating a horizontal “v” with both hands closing together. If given at certain angles, this signal can be misconstrued for the cross-bleed signal, especially during low visibility conditions. Without hesitation, the plane captain relayed the turn operator’s misinterpreted signal, resulting in the operator moving the flap switch from full to auto. Almost immediately, the flight surfaces moved. The technician had positive control of the door and was the first

to react by closing the door, but it was too late. Within seconds, fasteners started flying on the flight deck as the trailing edge flap crunched the engine bay door. The flap incurred a jagged 3-inch gash and the door 64 hinge was bent and cracked in several places. Flight surface repair was beyond O-level capability, meaning it could not be done at the squadron level and had to be replaced. The most significant result was that a reputable maintenance crew had lost momentum; their confidence had taken a significant hit. Upon reviewing procedures, conditions and other contributing factors, it became clear that the “swiss cheese concept” is not an empty theory.

Environmental conditions, visibility, poor hand signals, the maintainers’ mental state,communication before the turn and even crew confidence – all, just like cheese holes, lined up to contribute to the accident.

What could have been done to prevent this mishap?

The answer is not simple; it is easy to say, “Don’t mess up,” but it does not accomplish anything.

As Naval Aviation Enterprise maintainers, we must learn from each other’s mistakes; adapt to adverse conditions; stay flexible during trying conditions of a demanding deployment, but not bend beyond a breaking point and learn to slow down and remember risk management.

Understanding personal capabilities and stress levels is a huge factor that should be considered when preparing and briefing a high-risk event like a high-power turn.

Additionally, the team suggested that aircraft turn briefs be conducted at the maintenance desk. The desk provides a quieter place to think clearly, have a safe for flight certifier weigh-in and it is an environment where questions are easier to both ask and answer.

Specifically, the sequence and hand signals expected in the evolution should be briefed, so everyone is on the same page if there is confusion on the flight deck.

The Royal Maces recovered, learned from the mistakes, shared their experience with the team and continued the deployment with a new goal in mind and a familiar mission to fulfill.

U.S. Marine Corps photo by Cpl. Darien J. Bjorndal, 3rd Marine Aircraft Wing/ Illustration by Catalina Magee

MECH 13

AIRCREWMEN’S QUEST TO ELIMINATE TFOAS

Photo by Petty Officer 2nd Class Austin Ingram / Illustration by Catalina Magee

#4

By AWSCS (NAC/AW/SW) Wade Hove

Cabin management is key to eliminating Things Falling Off of Aircraft (TFOA).

TFOAs involving the cabin can be avoided if flight crews follow the instructions governing the storage of equipment and wear of flight gear.

For the most part, looking at the data from past TFOA hazards reports (HAZREPs), we have successfully secured things like go bags, 10/10 kits, Search and Rescue (SAR) bags and most other mission gear.

However, when it comes to small items like lazer eye protection (LEP), flashlights, ammo cans, Helicopter Aircrew Breathing Device (HABD) bottle, we continue to fall short of expectations, due to a lack of attention to detail and failure to follow prescribed procedures.

From day one at boot camp, attention to detail was drummed into us; whether it’s making your rack, aligning the clothes in your locker or any number of lessons. All those seemingly insignificant details were impressed upon us for one reason. To teach us to worry about the small details. One such detail we come across as aircrewmen is checking for and securing loose items in the aircraft or on our flight equipment. We must do this before, during and after each flight.

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In an attempt to do this, most of us use personally purchased karabiners, etched with our bureau numbers (BuNos), of course, to secure our gear in the cabin.

The standard is to hook them forward of the gunner’s seat or attach them to the cargo strap that secures the raft and litter against the aux tank. Each location has its ups and downs. We are expected to use risk management (RM) to decide which location is best for each mission.

Our goal in doing this is to prevent TFOAs, the loss of equipment while operating.

I recently reviewed several HAZREPs related to flights that incurred TFOA incidents or risks. In part, these were due to crewmen disregarding (in one case never taught) the proper use of retaining systems or simply ignoring community best practices. One preventable TFOA involved the loss of LEP during a night Gunnery Exercise (GUNEX). While manipulating the weapon, the crewmen knocked his Night Vision Devices (NVDs) from his helmet. They did not fall from the aircraft; he followed the pubs and wore the safety lanyard. By doing so, he prevented this incident from being a much costlier one. The inadvertent detachment of the NVDs

allowed the LEP to be blown from his face. You would think the LEP retaining strap should have prevented this. It probably would have if he had worn it.

Why wasn’t the strap worn?

The majority of aircrewmen will respond with: “it’s too uncomfortable to wear the retaining strap under a helmet. “ Understandable. However, there are many other “uncomfortable” things we muscle through while in the aircraft. If it is so uncomfortable that you can’t continue the mission or it degrades your effectiveness, an Aviation Safety Awareness Program (ASAP) needs to be written and maybe even a HAZREP. Tell your leadership the issues you’re having with your current equipment.

These are the avenues we have to effect gear improvements. Use them!

Regardless of the why, we have set guidelines that our leadership expects us to follow. We gain a great deal of inherent trust from our leaders just by earning our Wings of Gold.

We must hold ourselves and each other to the standards 24/7. Our actions represent ALL AIRCREWMEN! Do the right thing, ALWAYS!

Did you inspect canopy sills and dorsal deck for foreign object debris (FOD) before closing the canopy?

Over the last seven years, canopy and canopy sill plate damage have ranked in the top five F/A-18 and E/A-18 Class C mishaps due to damage from shutting them on tools, hoses, couplings, helmets and hardware.

STOP!

NavalSafetyCenter.Navy.Mil

Importance of Adhering to Standards

By AME2 (AW) Tillman

Day check was present at the time, but when maintenance control called the shop for a particular discrepancy, there was only one other AME2 and the AME collateral duty quality assurance representative (CDQAR).

Maintenance control informed the CDQAR a pilot during his pre-flight noticed that the emergency oxygen bottle in the seat pan was empty during the pilot’s preflight of the ejection seat. With the launch of aircraft approaching rapidly, there was a sense of urgency in the shop not to be the reason for a missed event.

The CDQAR asked the other AME technician to exchange the depleted emergency oxygen bottle in the seat pan on aircraft 214, an F/A-18E Super Hornet. Exchanging a seat pan is a relatively quick and uncomplicated task, but when done incorrectly, it can be life-threatening to the pilot and hinder his or her ability to eject.

#5 U.S. Navy photo by Mass Communication Specialist Seaman Matt Hall /Illustration by Catalina Magee

As Aviation Structural Mechanic Safety Equipment (AME) technicians, we have a strong sense of pride in our work and feel a sense of accomplishment for being detailoriented. On this particular day, however, a mistake was made. After waking up at 1600 and showing up to work at 1630 – it felt like any other day on the aircraft carrier.

The CDQAR inspected a spare seat pan in the shop and determined it was an entirely sufficient replacement for aircraft 214. While the CDQAR put on his float coat and cranial, he requested the other AME technician’s assistance. As they were getting ready, another AME technician arrived at work and the CDQAR requested he sign out tools and the maintenance publication (A1-F18EA-120-700).

Once at the aircraft, in the aircrew presence, the CDQAR started the evolution by inspecting the installed seat pan and confirmed it was empty.

The CDQAR and first technician disconnected the seat pan, pulled it out of its normal position and handed it down to the other AME technician, who handed up the other seat pan.

As they installed the seat pan, one of the lap belt harness lugs was not placed in its seat bucket lock, so they corrected it immediately. After setting up the seat pan, they took a moment to make sure everything

was in place. The lugs were in the locks and everything seemed fine and connected. They did a double-take to confirm when they realized the yellow shirt was hooked up to move the jet. They rushed off of the aircraft and went to the shop to sign off all required maintenance documents.

After about 30 minutes, they received another phone call explaining that the seat pan was loose.

At that moment, they knew what had been missed. The proper procedures are to align the front fitting of the survival kit with the survival kit support on the seat bucket and install the lap belt harness lugs firmly in seat bucket locks, then pull firmly on lap belts to make sure seat bucket locking plungers have correctly locked the lugs to the seat bucket.

They had forgotten to push the lugs down to lock them and pull on the lap belts to check. Embarrassed as they were, they immediately went to the pilot to apologize for the mistake.

The pilot told them he noticed the seat pan was loose upon utilizing the brake system on the catapult. Shaken, the CDQAR realized that his moment of rushing resulted in a missed sortie, as well as the potential injury the pilot could have suffered. Improper ejection seat maintenance can lead to severe injury, or even worse - death.

That’s why we should never take maintenance lightly and should always follow the proper publications during routine maintenance actions.

In this case, the publication listed the procedure step-by-step, but the technicians - both highly qualified and respected - allowed the pressure of making the launch break their standard habit patterns of by-thebook maintenance.

Adhering to by-the-book maintenance minimizes errors, reduces rework and saves lives.

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“WHEN A WORK CENTER SUPERVISOR ARRIVES AT THE MAINTENANCE MEETING, THEY SHOULD BE PREPARED TO ANSWER ALL QUESTIONS THAT MAY ARISE FROM THE WORK CENTER’S WORKLOAD REPORT. “

By GySgt Douglas H. Green

Y D A E R BE THE FOR

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NTS, E M S SES S A R IFT OU H G S N I D THE “.DUR WITNESSE O T E UP I HAV RS SHOW TING E E M O ANCE EN THE RVIS E N E P T U S MAIN SWER EV OF G N I N OME MORN RED TO A S O T IES EPA THAT R R I R P U O L F Q IL EAD ST IN H E A T H Y SLIG AT LA H T S IFT. ASK H T S E ON.” H T M M NCO U T O IS N THIS

U.S. Navy photo by Mass Communication Specialist 3rd Class Olivia Banmally Nichols / Illustration by Catalina Magee

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Photos from left to right Left: Photo by Seaman Apprentice Isaac Esposito Center: Photo by Petty Officer 3rd Class Joshua Leonard Right: Photo by MCSN Orion K. Shotton

The fact that it is a trend across the fleet is a significant problem with maintenance department efficiency.

This problem can be due to several factors, each slightly different than the next.

However, the result is the same, wasted time and resources, as well as frustration at each level of leadership.

Each work center operates to its requirements. However, there should be some commonality across the board regarding maintenance meetings and pass-downs.

From my experience, we can all do a few things to ease frustrations and help keep tasks and management more efficient.

A few suggestions I would give are: • Arrive early enough to read through the prior shift’s pass-down and familiarize yourself with all completed tasks and those still “in work.” *If possible, get a verbal passdown as well.

• Ensure that all work orders are in the proper status, i.e., M3, M6, or AWP. If they should be AWP but have no parts on order against them, find

out why before the meeting.

• Communicate with other work centers to assist with coordination of task requirements, i.e., de-arming before an electrical systems check.

By doing these tasks before the maintenance meeting, you set your shop up to be fully prepared for the work. You will also be able to communicate any gaps to higher leadership effectively.

This leads to better task efficiency so that everyone is aware of maintenance requirements and maintenance control can then prioritize maintenance tasks appropriately.

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#7

“.AS STAFF AT THE NAVAL SAFETY CENTER, WE OFTEN SPEND A GOOD PORTION OF OUR DAY READING THROUGH MISHAPS AND SAFETY REPORTS THAT COME TO US FROM FAR AND WIDE, WHEREVER THE NAVY OPERATES.”

“WE USUALLY SEE SIMILARITIES IN MISHAPS AND HAZARDS ACROSS DIFFERENT GEOGRAPHICAL REGIONS AND OTHER AIRCRAFT TYPE MODEL SERIES. THE PROBLEMS WE OFTEN SEE ARE NOT UNIQUE TO ANY SINGLE SQUADRON OR COMMAND. ONE OF THE COMMON ISSUES WE SEE IN THE SAFETY REPORTS AND THE FLEET DURING SAFETY ASSESSMENTS IS THE NORMALIZATION OF DEVIATIONS. WE ENCOUNTER THE SAME SITUATIONS OF AN UNAUTHORIZED TOOL OR PROCESS BEING USED AT COMMAND FOR AS LONG AS ANYONE CAN REMEMBER. THERE IS OFTEN NO CLEAR PICTURE OF WHEN THE DEVIATION STARTED, WHOSE IDEA IT WAS OR WHO ALLOWED IT TO BECOME STANDARD PRACTICE.” 22

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U.S. Navy Photo by MCSN Mohamed Labanieh

A Better Idea “REGARDLESS OF THE START, WE SEE THAT THE PROVERBIAL “SWISS CHEESE” FINALLY LINES UP, A MISHAP OR HAZARD HAPPENS AND SUDDENLY, EYES ARE OPEN TO REALIZING THAT ALL ALONG SOMETHING HAS BEEN WRONG RIGHT IN FRONT OF EVERYONE’S EYES. THE AVIATION SAFETY ASSESSMENT TEAM HAS WITNESSED FIRSTHAND MAINTAINERS PERFORMING MAINTENANCE WITH INCORRECT OR UNAUTHORIZED TOOLS, SUPPORT PERFORMED WITH NO PUBLICATIONS, IN A SEQUENCE THAT GOES AGAINST PROCEDURES OR BLATANT SAFETY VIOLATIONS. WHEN ATTENTION IS CALLED TO ANY OF THESE ACTS, WE HEAR, “THIS IS HOW WE’VE ALWAYS DONE IT,” OR, “THIS WAY WORKS BETTER.”

By ADC (AW) Caitlin J. Addams Mishaps resulting from the normalization of a deviation range from the minor lessons-learned-type incidents to severe injury to personnel and costly damage to Department of Defense (DoD) property. It’s safe to say aviation maintainers would agree that there is already enough work to do and inducing unnecessary damage and adding to an already overflowing workload doesn’t help anyone. It is easy to think that deviations can’t be that dangerous, that nothing bad has happened YET. The problem with normalizing deviations is that an experienced maintainer may know a “better way” to do something; they teach that to the next maintainer, who teaches it to the next.

Each time, another corner is being cut. It can quickly go from a molehill to a mountain. Once the culture of a shift, work center, detachment or command goes to the mindset of “it`s okay to deviate from maintenance instruction manuals, program instructions or any written policy,” the door for mishaps swings open a bit wider. All that said, there are times when anyone, from your most seasoned maintainer to the newest airman that just checked in after breakfast, may have a legitimate idea for a better or different tool to complete a job. You may have a better way to complete maintenance or know a step in your maintenance instruction manual that is wrong.

single events when a piece of equipment is not available.

There is potentially a discrepancy with an aircraft that needs deviation authorization to get it to an area with the proper repair capabilities. The critical thing about deviating from the established procedures is to do it the right way and at the right level. Ensuring the paperwork is done means that all the appropriate parties have discussed and weighed in on the risk and benefits. Someone with the proper responsibility level will sign off and approve the action.

Many personnel are not aware of BUPERSINST 1650.13, Beneficial Suggestion Program For The Bureau Of Naval Personnel. This instruction outlines the Navy’s program that is open to both military and civilians, which rewards those with beneficial suggestions or “benny-sugs” with both awards and potentially even cash for those great ideas. Those with ideas that save the Navy time, money, improve operations, enhance productivity and output, improve workplaces, save material, introduce a new tool or piece of equipment and increase safety can submit through the program.

There may be an instance when a tool or piece of equipment is not available to you and a workaround must be found. The point is that there are established procedures to make changes the right way and at the right level. If there is a different tool that would make the job easier, there are processes in place in the Naval Aviation Maintenance Program (NAMP) and through all of the wing commands, to add tools. Changes to publications can be made through Technical Publication Deficiency Reports, which can also be found in the NAMP.

Just like anything else, there is a right way to deviate from current processes and procedures. If done the right way, those deviations can pay off, not only for those who make the suggestions by making their lives easier and safer, but it can also benefit those who follow. Stop and think, reflect on yourself, the shop and command and watch for normalized deviations. Stop them early before someone gets hurt. If there is a better way to do something or different equipment that is faster or easier, do your research, talk to your supervisor, your quality assurance shop and your chain of command to ensure decisions and deviations are made at the appropriate level. Do the paperwork to back yourself up!

There are procedures to request deviations for everything from pay grade requirements to school requirements to paint schemes. There is a process to request a deviation for

For more information about the Beneficial Suggestion Program, visit www.public.navy.mil to find the latest instructions and program guidance.

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#8

We Don’t Have Enough Quals!

By AFCM (AW) Pedro Gonzalez As part of the Safety Assessments, our maintenance team discusses with the workcenter personnel the challenges they are experiencing every day. We do this to identify areas where the workforce feels pressured to produce. Pressure by itself is not a bad thing. Haven’t you heard someone say, “I work better under pressure?” The reality is that if pressure is left unchecked, it can lead to someone making the wrong decision at the wrong time.

One topic that is frequently discussed is the lack of qualifications within the maintenance workcenters.

Manpower and training continue to be hot topics in the agendas of Naval leadership. The fact is that we are constantly asked to do more with less. What can you do at the work center level? Chiefs and supervisors don’t have control over who is coming to your units. Simply put, you get what you get and you have to make it work. This is why it’s so important to know how to manage your resources. Do you have a well-established and effective training program? Are you using it as it was intended?

Top: U.S. Navy photo by Mass Communication Specialist 2nd Class Ruben Reed Middle and Bottom: U.S. Navy photo by Mass Communication Specialist 2nd Class Jan David De Luna Mercado

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Let me share with you what some squadrons are doing to manage maintenance training. There are a few things to consider when it comes to managing personnel within the workcenter.

Where is your replacement

coming from? The squadrons that are doing well have a strong working relationship between the Assistant Maintenance Officer (AMO) and the division leadership.

The AMO is the liaison with the administration department. He or she will notify the division of the prospective gains. Together, the AMO and DIVOs should coordinate any training requirements for the prospective gains. For example, if the person comes from a different platform, are they going to need any platform-specific training (A or C schools) before arrival? Does the billet advertise and reflect the requirements needed? Can the placement office or detailers add the training requirements en route to your unit?

From the workcenter perspective, the bulk of your workforce is from E-1 through E-5. Suppose the maintainers are on their first sea tour. They will likely be in your unit from 36-58 months, depending on their rate. With that said, it is common to see an E-5 being replaced by E-1 – E3. In reality, the replacement for that person leaving today (E-5) is not the person that just checked in (E-1). Instead, it should be someone already in your unit that has completed all the required qualifications. Think about it like a factory assembly line. The next item ready to go is never the one that just started building. It is the item that you have been building for a while and is about to be ready.

U.S. Navy photo by Mass Communication Specialist 2nd Class Jan David De Luna Mercado Illustration by Catalina Magee

WHAT WOULD BE YOUR ANSWER? This is why it’s so crucial that you have a solid training plan. If you were to ask yourself: • What are my expectations for each person to complete the required training?

• What is the timeline to get them qualified?

• What will I do if maintainers fall short in their training and they are not making progress, as they should?

What would be your answer?

The same type of questions apply to those who are not on their first tour and are coming from a different platform. Do you have visual aids in your spaces that show everyone what their status is within the training pipeline? We all know the Advance Skills Management systems (ASM) tracks training qualifications.

However, unless you are logged into the computer, no one is going to see that information.

Maybe, you can track qualifications on the Monthly Maintenance Plan (MMP), but we should not underestimate the value of having some visual aid right there in your space that everyone can see and know how they are doing and where they are in their training.

In the end, you have to find ways to control what you own. Working together at all levels of your squadron will ensure your workcenters have an adequate number of people with the proper qualifications.

Remember, what you are doing today will pay dividends in the future. Look at your programs, make the necessary changes and don’t suffer in silence.

U.S. Navy photo by Mass Communication Specialist Seaman Jackson Adkins Illustration by Catalina Magee

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“M TAS ARCH KED 11, WI 202 TH 0 LOW - AN ERI AVI NG ATI AN ON AIR STR CR UC AFT TUR OFF AL JA MEC CK H S. ANI CC “ OLL TY

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Photo by Naval Safety Center

By the Book-At All Times AIRCRAFT 514 STOOD HIGH IN THE AIR, SUPPORTED BY THREE AIRCRAFT JACKS. EVERYTHING BEGAN NORMALLY. TOOLS WERE CHECKED OUT. THE MAINTAINERS WERE OPERATING THE JACKS. QUALITY ASSURANCE WAS NOTIFIED AND PRESENT. THE TEAM HUDDLED OUTSIDE THE SAFETY AREA TO BRIEF ON LOWERING THE AIRCRAFT. “

By AM2 Connor Fice and AM2 Damian Shands

“Attention to the brief,” the collateral duty inspector (CDI) instructed. “We are lowering aircraft 514 off jacks and we will have two operators per jack. We will begin by jacking the aircraft slightly to break the jack lock collars free.

When all lock collars are loose, we will begin to slowly lower the aircraft to the ground at a slow and steady pace.

If you notice anything unsafe at any point, yell ‘stop,’ and we will assess the issue, correct it and continue. Wear your cranial at all times under the aircraft and listen to all directions.”

The brief had been conducted and now it was time to bring the aircraft down. Everyone began to assume their designated positions. The jacking supervisor was a newly-qualified CDI and his last duty station was a different platform. He remembered back to a situation where they had to lower an aircraft off jacks at Andersen Air Force Base, Guam. The flight line was uneven and when the jet lowered, the jacks became unseated, causing the aircraft to roll backward.

Thankfully, the quick-reacting airframers placed chocks behind the tire and safely entered the cockpit to apply brakes.

The junior CDI began to second-guess whether he should have brakes applied to prevent the aircraft from rolling backward. The jet was jacked up inside a hangar and the CDI wanted to avoid the damage to the aircraft.

Now, second-guessing, he asked another CDI for an opinion and was informed that applying brakes could be done. Feeling a little more confident after asking a fellow inspector, he told them to climb into the cockpit and apply brakes.

Everyone was in place. The jacking supervisor stood in front of the jet and instructed the jack operators to raise the aircraft slightly and release lock collars. Lock collars now free, the CDI then told everyone to open the relief valves slowly. The aircraft began to lower. The jack supervisor began to check both sides of the aircraft to make sure it was lowering evenly.

As the jet got lower, the aircraft suddenly lunged. The jack supervisor immediately yelled for relief valves to be closed and lock collars locked.

He began to walk around the jet and inspect the jacks. Nothing was irregular, and he decided to continue lowering but more slowly and cautiously. The main landing gear tires were now on the deck. Unbeknownst to the supervisor, the jacks were slowly becoming unseated and pitching at a forward angle.

“STOP!” yelled the nose jack operator.

Everyone locked their collars as the CDI approached the nose jack and immediately noticed the danger. He then inspected the wing jacks and those too were pitched forward.

The aircraft was now teetering on unseated jacks and at risk of falling.

As the risk began to get more significant, the junior supervisor utilized risk management. The jet could collapse at any moment and it was too risky to jack it back up. He wanted to quickly determine what had gone wrong and how to fix it without injuring anyone or damaging a jet.

More senior enlisted personnel noticed what was going wrong and stepped in. The conclusion was that the brakes should have been released while lowering the aircraft. The CDI now had to send someone into the cockpit to release brakes slowly so that the pressure stored on the main landing gear wheels could be released and the gear could properly move as the jet is lowered. A Sailor released the parking brake while holding the foot pedals and safely relieved the pressure on the landing gear. The aircraft rolled back and the jacks planted safely on the ground. The team seated the jacks and, with brakes released, continued to bring the aircraft down.

Being a CDI can be very stressful and intimidating. Second-guessing yourself will happen, but it’s imperative to have your safety publications with you at all times and to refer to those first and foremost.

Secondly, a good source of expert advice would be airframe Quality Assurance Representative (QARS).

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Above:Photo by MC2 Christopher Janik Below: Photo by MCSA Oswald Felix Jr.

“TRIDENT 615 WAS ONE OF THE MAIN FLYERS AND HAD SUCCESSFULLY COMPLETED NUMEROUS TRAINING AND OPERATIONAL MISSIONS. HOWEVER, WITH EACH FLIGHT AND EVERY ADDITIONAL HOUR FLOWN, A POTENTIALLY DEVASTATING MISHAP LOOMED ON THE HORIZON.”

Above: Photo by MCSN Caitlin Flynn Below:Photo by Seaman Juel Foster

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Not Your Kid’s Lego “TRIDENT 11, SIDE NUMBER 615 OUTBOUND,” HAD BEEN A TYPICAL RADIO CALL FOR THE HELICOPTER SEA SQUADRON (HSC) 9 AIRCREW OVER THE PRECEDING FIVE MONTHS.”

By LT Salmini Schuyler Trident 615 was transferred to HSC-9 from another squadron. The aircraft had come out of preservation and required an extensive rebuild that took over a year. To get the aircraft up required that all special inspections (7-546 days), a Phase “D” inspection, an acceptance inspection, a post-planned maintenance interval inspection, post-preservation inspection and unscheduled major maintenances be complete. One requirement of the 546-day Special inspection is to remove, inspect and reinstall the flight controls. Along the way, Trident 615 encountered a few unexpected hiccups, but otherwise, the aircraft was ultimately rebuilt and ready for a functional check flight (FCF). The whole process, including FCF, lasted 12 months.

Trident 615 went begrudgingly into flight and did not want to stay there.

Multiple maintenance issues arose over three months. One problem was a leaking primary servo. Replacing the servo requires detachment of flight controls. The work was assigned to the airframe shop and a seasoned aviation structural mechanic second class (AM2) was sent to the aircraft. He did what he had done many times before - pull out the inspection card and conduct the appropriate maintenance publication.

While working, he noticed the lateral pushrod was installed upside down.

He immediately notified maintenance control and the aircraft was grounded for further investigation.

The AM2 was well aware of the effects downing Trident 615 would have. The upside-down pushrod would diminish any chance of Trident 615 making an upcoming critical detachment. He knew that such an error would put the entire airframe shop in the spotlight and that someone could potentially lose his or her qualifications. Nevertheless, he was mature enough to make the tough call, without hesitation, preventing what could have been a fatal outcome. The discrepancy the AM2 discovered was potentially life-threatening due to a lack of redundancy in the control linkages.

These linkages happen to be tough cylindrical rods connected by bolts, directing the 3,000 pounds per square inch servo pressure to change the pitch of rodor blades. Due to complex control mixing and helicopter aerodynamics, a missing input to the swashplate would render the entire rotor head uncontrollable.

Therefore, material or mechanical failure in the linkages would likely result in the total loss of the aircraft and crew.

The pushrod that was found upside down is nearly symmetrical. There is, however, an almost undetectable difference on the forward portion of the pushrod, which is engineered for two reasons. First, it helps drive some of the rotor head load into the airframe. Second, it aligns the pushrod against the bolt. When the pushrod was installed upside down, it caused the bolt to be loaded in an upward motion, taking the entire force of the rotor head.

Additionally, the pushrod was now able to rotate a few degrees due to a lack of alignment. There was no need to look at the engineering force diagrams to realize the potential for a mishap. Once the bolt was removed, it showed significant wear.

Trident 615 had only been flying for three months. The regularly scheduled inspection of this bolt would not have taken place for another 16 months.

The question remaining is, how did the incorrect installation occur? To answer this requires a closer look at the maintenance process. Flight controls must be installed in a systematic order -- in the correct orientation and position.

However, this must be done while in an awkward position. Imagine yourself lying down on top of the helicopter with your head rotated and your arms stretching to reach the controls below the swashplate. To double-check your work, you have to turn your head again to look at the computer’s image behind you, rotated 90 degrees from your orientation. Then, you are passed a control rod that is nearly symmetrical and has to match correctly with the image. The process is like putting a Lego set together with the instructions upside down and with identical pieces!

The AM2 said, “It is very easy to install a pushrod the incorrect way. Sailors installing the pushrods for the first time have significant trouble with the correct placement of the parts. It takes a trained eye to see the minute differences that ensure the proper orientation.”

There are, however, several safety measures in place to prevent incorrect installation. Maintenance manuals have multiple cautions and notes that stress the importance of orientation. Additionally, each rod is labeled with stickers indicating “FWD”, “AFT” and “bolt” positions.

However, the safety labels on the control rods were illegible due to the significant amount of wear.

Worn labels have, unfortunately, become accepted in the MH-60S community.

They can be found throughout the fleet and seldom have replacements been written. Experienced airframers stress the importance of tagging and ensuring correct labeling on all parts as you remove them. One of our squadron’s most experienced airframers regularly uses a permanent marker to indicate proper orientation if a label is too worn to read.

The AM1 admitted that this is a good practice but not directed explicitly in any publication or instruction.

There are multiple sets of eyes on an aircraft between preflight, turnover, daily, periodic and special inspections before it flies a mission.

Above: Photo by MCSN Jacob Hilgendorf Below: Photo by Petty Officer 3rd Class Terence Frank Deleon Guerrero

However, most of those eyes are not those of experienced airframers skilled at detecting discrepancies with flight control orientation. To help prevent future mistakes, a technical publication deficiency report (TPDR) is being written to ensure correct labeling or, better yet, add a prominent, color-coded mark.

Accepting something as seemingly mundane as worn labels almost led to a significant mishap. Blame does not rest on the shoulders of any one individual.

Maintainers and pilots alike should be encouraged to question and correct ambiguous situations, like worn labels that fall below basic safety standards.

Thankfully, our squadron has encouraged individuals to speak up if they see the conditions for potential mishaps and in this case, it likely prevented the loss of an aircraft and lives. Routine acceptance of what may seem to be insignificant discrepancies can aggregate into much more significant and more serious casualties.

Luckily, the solution is simple: If you see something unsafe, say something. Do not accept anything less than the optimum.

From the cleanliness of the quarterdeck to the quality of the tools in the maintenance shops, the little things done right keep our squadrons in the fight.

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BRAVO Z ULU

SAILORS AND MARINES PREVENTING MISHAPS

BRAVO ZULU Bravo Zulu is a naval signal originally sent by semaphore flags and in English, simply means “Well done.” You too can be featured here!

Petty Officer Jamie Marie Lynch

AE2 Kevin J. Hall On 28 August 2020, while executing morning foreign objects and debris (FOD) walk down, AE2 Hall noticed an object protruding from the auxiliary power unit inlet on Aircraft 168436. He immediately notified quality assurance and maintenance control. Upon further inspection, a bird was found inside of the plenum duct. His steadfast awareness and overall motivation prevented a potential mishap. His outstanding performance has justly won his shipmates’ admiration and respect and is in keeping with the highest traditions of the United States Naval Service.

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On 17 Jul 2020, Petty Officer Lynch ensured flight deck personnel’s safety on board the USS NIMITZ by stopping a miscommunication from putting Sailors in danger. While recovering aircraft 615, the Landing Signalman Enlisted(LSE) directed trainees into the rotor arc, unaware the AN/ALE39/47 Counter Measure Dispenser (chaff) needed to be de-armed. Petty Officer Lynch immediately directed the trainees to hold and indicated to the LSE that the chaff was armed. The countermeasures were de-armed and the trainees then moved in to complete the chock and chain evolution.

Petty Officer Lynch’s situational awareness, initiative, and dedication to safety enabled her to identify a significant safety hazard and prevented serious injury.

DID YOU KNOW? The origins of “Bravo Zulu” are in the Allied Naval Signal Book, which for decades has been used by members of NATO, established in 1949.

SUBMISSION GUIDELINES Please use the following guidelines when submitting BZ nominations.

Send us a written article (as the above featured BZ stories) at: SAFE-MECH@navy.mil BRAVO ZULU NOMINATION BZ nomination article length: 90-150 words PHOTOS All photos must be good, clear quality and in high resolution (300 DPI) or larger than 1MB per photo.

AM3 Joshuaemmanuel G. Abello On 24 August 2020, while performing a daily turnaround inspection, AM3 Abello noticed an abnormal bulge on the port side turnbuckle support arm of Aircraft 169000.

He immediately notified maintenance control of the discrepancy. Further, inspection revealed a crack in the arm that required maintenance action. The part was changed and the aircraft returned to service with no operational impact.

His steadfast awareness and overall motivation prevented a potential mishap. AM3 Abello`s outstanding performance has justly won the admiration and respect of his shipmates and is in keeping with the highest traditions of the United States Naval Service.

When you email your BZ nomination, include the file and photo. Also, use the author’s name as the file name.

Example: JohnDoe.doc.

ALL OTHER ARTICLES

AWO3 David Rojo During a normal P-8A interior preflight, observer AWO3 Rojo noticed a broken shear wire on one of the six oxygen bottles on board. He immediately notified the mission commander and plane captain to remedy the situation. This led to a discussion among the squadron that resulted in the identification of three other oxygen bottles incorrectly shear wired on another aircraft.

His attention to detail during a usually benign procedure resulted in increased safety awareness for the entire squadron. AWO3 Rojo was awarded the “Commander, Patrol and Reconnaissance Group” Safety Pro Award for these actions.

Short story: 450- 500 words Long story: 1,200-1,600 words News briefs: 500 words Photos are encouraged, but optional. If you included an image, please add the photo credits as well.

Example: Photo by Jane Doe. E-mail all the stories to: SAFE-MECH@navy.mil We look forward to receiving your great articles!

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