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2005: Crossfeed, the year in review.

During CY05, maintenance analysts assigned to the Naval Safety Center traveled to all corners of the globe, doing surveys and giving maintenance malpractice and khaki risk management presentations (MMPs and KRMs) to Sailors and Marines in the fleet. I asked my survey-team shipmates to send me things that "hurt their heads" during surveys in the past year.

We did a total of 85 surveys and 167 MMPs, reaching 19,379 Sailors and Marines; 63 KRMs, giving vital statistics to our senior leadership; and publishing 20 Crossfeed articles in Mech, which distributed 69,485 copies to the fleet. On average, we spent 137 days on the road. Where is this information leading? Well, to the "top 10" discrepancies that we helped supervisors identify during the course of the year!

No. 1: Errors in logbooks, including aircraft, engine and AESRs. The discrepancies ranged from incorporation of technical directives to something as simple as accuracy of dates within each logbook. It is imperative that the logbook tells an accurate story of our aircraft and components. To do this, "attention to detail" is the key to success. Our analysts know the logbooks inside and out and carry with them over 30 years of experience. They are meticulous when it comes to reviewing them.

No. 2: Dirty and FOD-filled toolboxes. Let's face it; they get used extensively in the repair of aircraft. So put a person in charge of their cleanliness on a weekly basis and get our junior people into the habit of taking care of them. That approach will pay dividends in the long run.

No. 3: Improper storage of lithium batteries. It already has been proven that these batteries will explode. By simply storing these batteries by themselves in an approved storage locker away from other hazardous and combustible materials will alleviate the need to rush one of our shipmates to the emergency room.

No. 4: Our next discrepancy is near and dear to my heart. I wrote my first Crossfeed article on this very subject. It is conducting drills and quarterly training on emergency reclamation. Conducting ERT drills are as important as conducting flight-deck drills. If one of your airplanes gets soaked with AFFF, you quickly learn how important your ERT team is. Not holding drills only increases the reaction time it takes to get your aircraft back up.

No. 5: Failure to follow standard operating procedures (SOPs) governing the selection, care, issue and use of respirators. SOPs set the ground-work for a command to both monitor and manage respirator use. SOPs are required and should be posted in the immediate area where maintainers work. More times than not, they are found in the program manager's binder. This is OK if you don't mind folks rummaging through your binder on a day-to-day basis. It is much easier to post them near the location where paints are mixed (for example, a bulkhead or bench). Outside the paint booth is another good place. People need to see the SOP continually so that respirator use, cleanliness, and storage become second nature.

No. 6: Respirator cartridges aren't changed regularly. Some instructions state to change the cartridge if a person senses "break through" of a component, meaning when a chemical is smelled or tasted through a respirator. We recommend cartridges be changed every eight hours. Some commands will change them out at the end of the shift. That is fine, too. The key is to change them and to have the manager or coordinator spot-check to ensure compliance.

No. 7: Improper inspection, cleanliness and storage of respirators. This problem area is related to No. 5 and No. 6. A command can have a good SOP and cartridge swap-out schedule, but improperly stored, inspected, or cleaned respirators defeat the benefits of the other items.

No. 8: Improper identification of multi-piece tools. Without getting into great detail, we see improper identification on combination squares and rivet cutters. Countless times we have looked at the combination square and asked an airframer where the scribe is that goes with the set? Typically, the answer is, "I didn't know that a scribe was supposed to be there." Read the Mech article, "I Didn't Know That," which identifies the problem with multi-piece tools in the fleet. The bottom line is that six pieces exist, vice the two that normally are accounted for on inventory sheets. With a rivet cutter, squadrons often will identify it as a one-piece tool, when, in fact, it has eight leaves, a bolt, a nut, and the piece itself--nine pieces to account for.

No. 9: Lack of neutralizing agents for an electrolyte spill. Commands are required to have six ounces of sodium bicarbonate dissolved in one gallon of water for lead-acid spills, or one quart of distilled white vinegar distilled in one gallon of water for nickel-cadmium spills. These neutralizing agents are priceless should electrolyte spill on someone.

No 10: Work centers do not have industrial hygiene (IH) surveys available. Organizational squadrons are required to have IH surveys completed every two years. AIMDS/MALS are required to have IH surveys done annually. These surveys are useless unless the folks actually doing the work know about the contents of the survey. Unfortunately, this information usually is kept in the safety petty officer's filing cabinet, rather than handed out to work centers. This survey is an important document, and everyone in the work center should read and understand its contents. It gives the shop and its workers a written record of hearing and respirator requirements in the work area, to name a few. Work centers don't need the entire survey, only the portions that relate to their shop and the parts their personnel should review.

That's the top-10 list of discrepancies, but I have an honorable mention that comes from Senior Chief Phil LeCroy. It's an old favorite and continues to be a nagging problem: the improper storage and recordkeeping for tie-down chains. They are required to be stored in homogenous lots, as per CNAFINST 4790.2 series. That statement means TD-1A and TD-1B chains cannot be stored together. They also must be stored in lots of 10, and the records (/51 cards) should reflect preservation and de-preservation, 30-day inspections, and must give accurate information about what chains actually are stored.

We had 154 Class C mishaps during CY2005 that cost the Navy and Marine Corps $9.5 million. The common theme in these mishaps was lack of attention to detail. We certainly can do better and need to use operational risk management (ORM) in every task, even the most trivial ones. Overconfidence in doing a mundane, repetitive job often leads to mishaps. Pay attention to the surroundings and understand that maintainers work in an environment full of risks ... no matter how small. How we identify and manage those risks is the key to completing our mission and doing it safely.

Chief Hofstad is a maintenance analyst at the Naval Safety Center and the coordinator of the Crossfeed section of Mech.

By AMC(AW) Paul Hofstad
COPYRIGHT 2006 U.S. Naval Safety Center
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Title Annotation:Maintenance Management
Author:Hofstad, Paul
Publication:Mech
Geographic Code:1USA
Date:Mar 22, 2006
Words:1166
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