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system of the MA during recently completed Programmed Depot
Maintenance )PDM) performed on the MA.
Additionally, the AIB President found by substantial evidence three
factors which contributed to the mishap. First, the PDM
subcontractor employed ineffective tool control measures. Second,
the PDM subcontractor failed to follow Technical Order (TO) mandated
procedures when employing the fuel vent test plug during PDM.
Third, due to the relatively short period of time between takeoff and
AR, the MC did not have the opportunity to burn a substantial amount
of fuel from the number two fuel tank which could have allowed the
Human Factors Industry News 4
dive “flapper” valve to open. This explains why this mishap did not
occur during AR’s conducted between the time the MA left the PDM
facility and the time of the mishap.
See attachment on email distribution page for PPT.
A Near-Miss - “Red Flags” Not Heeded. (U.S. Navy)
Hearing a piece of metal hit the floor, I
looked down to see wisps of smoke rising
from the rigid gas line of the ejection-seatharness
retract unit. I immediately stopped
work and removed my team from the
Prowler. I secured the aircraft and hurried
into Maintenance Control.
The investigation began. While disarming
the ECMO-1 GRUEA-7 ejection seat in
Ironclaw 501, I accidentally had discharged
a cartridge-actuated device (CAD), nearly
injuring myself and my ordnance team.
I thought I had been following the checklist step by step. I didn’t know
what could have gone wrong. My assistant had felt that something was
wrong as we were going through the checklist—like we perhaps had
missed some steps. We reviewed the checklist and repeated the current
step, but the mechanism still felt jammed. Later, we would learn the step we
were trying was the wrong one.
HOW DID THIS HAPPEN?
One of my co-workers had asked me if I possibly could have missed a
page. He mentioned he’d done the same thing a few days ago but had
caught the mistake early. I went back into the publication and confirmed
that we, indeed, had missed an entire page in the checklist, telling how to
safe the CAD. I should have recognized some red flags leading up to this
error. Because we were doing all of our 364-day inspections in the months
following deployment, we were getting comfortable working on ejection
seats. We had removed and replaced 12 seats in the previous two months,
Human Factors Industry News 5
so we were perhaps getting a little overconfident.
Workload was another red flag. Coupled with the demands of multiple
inspections, the community also was in the midst of an Airframe Bulletin
(AFB), requiring a one-time check of the aircraft’s bleed-air system during
these inspections. Our work center was responsible for the inspection, as
well as replacing any faulty valves. We didn’t use ORM to recognize and
mitigate this workload factor. We should have taken our time and paid
meticulous attention to detail.
Deviating from established procedure was the last red flag. With an
overcommitted work center and numerous tasks at hand, I chose to stray
from the standard procedure by doing the work with fewer than the
required number of personnel. With a dedicated safety observer, perhaps
the missed page would have been caught before the CAD had discharged.
No inspection is so urgent that it requires skimping on safety. You have to
focus, from start to finish. If any thing feels wrong, stop, secure the area,
and ask for fresh eyes to review the process.
Controlling Consequences of Errors Through
Assertiveness
AT ABOUT XA00, ADVISED BY CREW OF ACFT X FOKKER F100 AT ZZZ
CUR/FDR TEST SWITCH INOP. AFTER CALLING MAINT CTL FOREMAN, I
WAS TOLD I WOULD HAVE TO REPLACE SWITCH PANEL BEFORE
DISPATCH. NONE WAS AVAILABLE AT ZZZ. I CONTACTED DUTY MGR FOR
ROB PANEL AUTH. DUTY MGR REQUESTED A ROB FROM ACFT Y AT
HANGAR AND RECEIVED AUTH NUMBER FROM MAINT OPS CTL. I
REMOVED PANEL FROM ACFT Y AND INSTALLED IT ON ACFT Z.
A TEST OF SWITCHES ON PANEL WAS NORMAL AND LOGBOOK SIGNED
AND ACFT DISPATCHED. AFTER RECEIVING REPLACEMENT PANEL AND
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ATTEMPTING TO DO DATA ENTRY IN MAINT COMPUTER, I DISCOVERED
THAT THE WRONG PANEL HAD BEEN ROBBED AND INSTALLED INSTEAD.
ALSO ON LOOKING AT MAINT TEST PROCS IN MAINT MANUAL CHAPTER
34, I DISCOVERED I HAD NOT DONE A FULL TEST OF AVIONICS SWITCH
PANEL. I IMMEDIATELY ADVISED MAINT OPS CTL FOREMAN OF MY
ERRORS AND ASKED HIM TO LOCATE ACFT AND CORRECT MY ERRORS.
I THEN ORDERED PANEL FOR ACFT Y AND SENT SVCABLE PART TO ZZZ
FOR INSTALLATION ON ACFT Z.
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