Class C mishap summary.
From March 2, 2009, to June 1, 2009, the Navy and Marine Corps had 40 Class C mishaps involving aircraft--a 37 percent increase from the same period in 2008.
A preliminary review of these mishaps indicates that 50 percent were maintenance-related, 12 percent were aircrew-related, and 38 percent were weather- or material-related. Eleven (27 percent) of the 40 mishaps involved TFOA and FOD and stem from various supervisory, maintenance and material causal factors. All could have been prevented had ORM practices been applied. Here are some examples of recent mishaps:
FA-18C port engine was damaged by FOD during flight operations. The X-band antenna fell off and was ingested into the engine, which also caused minor damage to the intake cowling. Investigation revealed that, during maintenance on the X-band antenna, an aircraft maintainer had overtorqued the mounting bolts and retaining fastener hardware. Lack of supervisory and publication guidance also contributed to this mishap.
AH-1W canopy-removal system (CRS) detonated while depot-level maintenance personnel worked on the aircraft. The front, center and rear sections of the canopy were damaged, and two civilian ordnance technicians suffered minor injuries. Although the preliminary investigation is ongoing, this mishap highlights the importance of proper CRS, egress and explosive-safety training within both military and civilian maintenance teams.
AH-1W was damaged by a fire in the vicinity of the starboard engine during hot-fuel operations. The AH-1W was operating with a weapons load and had landed on spot 5. The aircraft was de-armed and chained. The aircrew requested a hot fuel prior to shutdown; the supporting crew complied. Maintenance had been done on the assigned fueling station (station 4); however, the equipment to be used was not marked accordingly, and a defective fuel nozzle was placed back into service.
The AH-1W aircrew had permission for hot fuel, but when the system was activated, fuel sprayed immediately from the sample port of the defective nozzle. It covered an area of the starboard side of the aircraft, from the rear-seat canopy to the exhaust duct. Once the fuel spray reached the hot exhaust duct, personnel nearby heard a "Pop!" Fuel vapors ignited on and around the aircraft. The pilots observed a fire-caution warning light and activated the fire-suppression system. Both aircraft engines were shut down, and the pilots egressed the aircraft. The crash-fire-rescue team extinguished the fire and sprayed the ordnance for a long time.
This mishap could have resulted in much greater damage and loss of life had the ordnance detonated. Fortunately, no Marines or Sailors were injured seriously, but two suffered minor injury from smoke inhalation. The root causal factors of the mishap were failures of ground support to supervise, manage assets, and clearly mark the operational status of support equipment.
The Class-C mishaps this quarter involved a broad range of maintainers, from depot to organizational level, as well as operational support. They show a lack of continued supervision, a lack of attention to detail, and a lack of applied operational risk management. Coupled with safety training for all ranks and phases of aircraft maintenance, these elements are essential to mission success and a safe Navy and Marine Corps team.
By MSgt. Michael Austin
Master Sergeant Austin is a maintenance analyst at the Naval Safety Center and coordinator of the Crossfeed section of Mech.
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|Date:||Jun 22, 2009|
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