Class C mishap summary.

From Sept. 20, 2008, to Dec. 9, 2008, the Navy and Marine Corps had 20 Class-C mishaps involving aircraft.

After reviewing several Class C mishaps and initial investigations, one common, major theme stood out in all these incidents. That theme is "situational awareness," commonly referred to by most aircrew and pilots as SA. Maintainers and ground-crew coordinators not using good SA with respect to their location usually miss key factors in the chain of events leading up to a mishap. Here are some recent mishaps that could have been avoided if good SA had been used:

* Two maintainers had to repair an aircraft's onboard oxygen generating system (OBOGS). The experienced maintainer briefly left the other maintainer unattended during removal of the oxygen monitor. After removing the OBOGS component, the junior maintainer closed the aircraft canopy. He did not notice the cannon plug and wiring still was under the left side of the canopy sill. The lack of SA and maintainer supervision resulted in damage to the canopy and OBOGS.

* An FA-18A ingested a cranial into the No. 2 engine during a maintenance turn. There were many causal factors associated with this mishap. The first were poor communication and lack of assets. The plane captain did not effectively supervise the event and did not relay vital information. Only the No. 1 engine was supposed to be turned at 80 percent to troubleshoot the problematic subsystem. Only one protective-intake screen was available and installed. The No. 2 engine screen was NRFI and not installed. Only four maintainers were present during the maintenance turn, and they lacked supervisors for coordination and proper placement of personnel. The lack of communication, safety barriers, and situational awareness, coupled with the placement and running both engines to 80 percent instead of one, resulted in one maintainer's cranial being pulled off his head and ingested into the No. 2 engine. This situation shows that any step in the chain of events could have been avoided if just one of the maintainers had used SA and followed standardized practices and procedures.

During 2008, there were 41 Class-C maintenance-related mishaps. After detailed investigations and analysis of these events, the primary causal factors were lack of supervision, procedures not followed, poor judgment, and lack of situational awareness. The total monetary cost from these mishaps ranged from $820,000 to $ 4,100,000, based on severity.

The accompanying graph depicts 103 events of submitted Class C mishaps. The areas included are: aircrew error, material events, and maintenance error.

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MSgt. Michael Austin