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Let's get it done.

It was another busy Monday morning at VAW120. We had a 13-event flight schedule. We were busily preparing for an upcoming CQ detachment and trying to ensure we would have enough full mission capable (FMC) aircraft.

Airframes was just short of being overwhelmed with maintenance when a plane captain entered the shop and explained that during his walk-around on aircraft 632, a C-2A Greyhound, he discovered an uninstalled panel lying on the cargo ramp. He said that aircraft was to be manned-up for a morning flight, which meant that the panel needed to be installed without delay.

I headed to the flight line with him to identify which panel was missing, and I tried to recall the last maintenance action performed on the aircraft, because it did not make sense that the panel was not installed. A collateral duty inspector (CDI) had signed off on the maintenance action. I remembered that our night shift from Friday had been tasked with performing a pre-carrier inspection and high-time, truss-bolt removal and replacement. The two high-time truss bolts meant that mechs had to remove the ramp panel. The original maintenance action form (MAF) for the bolts had been signed off the previous Friday.

"They forgot to re-install the panel," I thought.

I didn't want to lose the event. I went back to the shop, grabbed an airman, and tasked him to find the screws for the floorboard, while I checked out a speed handle to perform the panel install. I figured the task wouldn't take more than a few minutes.

Because the cargo ramp was in the up-and-closed position, we couldn't install the floorboard panel. The installation required about 1/5 inches of clearance between the ramp and the fuselage. After a short discussion, we decided to manually pump the ramp open. We felt familiar with the procedure, but we did not have our maintenance pubs in front of us. What we didn't know was that pumping the ramp closed was no big deal, but pumping the ramp open had some cautions associated with it. The procedure was in our pubs, but the cautions were not. The cautions, well known amongst the aircrew, were only contained in the NATOPS. To paraphrase, the caution states that the cargo doors and ramp system should only be operated with the hand pump when combined-system-hydraulic power and electrical power are not available.

Well, combined-system-hydraulic power and electrical power could have been available, but we did not take the time to ask. That was strike one. NATOPS continues, "When operating the cargo doors and ramp system with hand pump, it is possible for the ramp to get out of sequence and this may cause structural damage." We were unaware that structural damage could result from manual operation using the hand pump--strike two.

NATOPS continues, "When lowering the ramp by means of the hand pump, ensure that both sides unlock completely and come down evenly. If not, recycle ramp to the closed position before reopening the ramp." Again, we were ill-informed--strike three.

When the center door opens and stabilizes, a mech has to hold the butterfly doors closed until enough pressure has built up to forcibly open both doors at the same time. If both butterfly doors don't open, the ramp is out of sequence and must be recycled to the closed position before continuing. If both butterfly doors open, you can stop pumping.

We pumped the handle three or four times and nothing happened. I told the airman to stop, and I went back to the work center to discuss what was going on with a CDI. I needed to know why the ramp wasn't opening. Imagine my shock when I returned to the aircraft with the CDI in tow to see the skin of the ramp buckled and warped.

I now know that I should have gone to maintenance control once I verified the ramp panel was not installed. I should have told them I wanted to pump the ramp open to install the panel. Had I done that, they would have told me that even though the MIMs say I can do it, it's a procedure that shouldn't be done because of the associated risk.

What my readers may not know is that C-2A ramps are not in abundance these days. In fact, they do not exist in the supply system. The only way to get a new ramp is to take it from another aircraft while the broken one is being repaired by depot-level maintenance. I was not present as the airman pumped the ramp, but I take full responsibility of the incident. I was the senior person, and the airman was looking to me for leadership. I provided that leadership in the form of "let's get it done," and he followed suit.

Take your time and think things through. I do not know the cost of the damage, but I do know that we lost the asset and the event for the day. When a quick solution seems like a viable option, this should give you pause.

I now realize how little I knew about the operation of this system. Our standard operating procedures state that we were supposed to notify maintenance control for approval to use the manual method, and that maintenance control was to ensure adequate supervision was in place prior to the start of the evolution. We now have a control be in place to prevent a recurrence, and the MIMs will be revised by a pending Technical Publications Discrepancy Report.

Aviation Maintenance Risk Management Checklist

MAINTAINER

BEFORE THE TASK

1. Am I qualified, authorized, and confident to undertake the task?

2. Do I have people to assist mentor, and supervise me?

3. Have I been thoroughly briefed on the task by my supervisor?

4. Have I told my supervisor of any physical or mental limitations that may impact my performance?

5. Have hazards been identified, reported, controlled and documented?

6. Do I have a clear understanding of my responsibilities?

7. Has sufficient time been allocated to undertake the task?

8. Do I have the necessary authorized publications, procedures, and instructions?

9. Do I have the serviceable, authorized support equipment, and tools required?

DURING THE TASK

1. Am I working IAW authorized policy, processes, and procedures?

2. Am I ensuring all in-process and mandatory inspections are being conducted?

3. Am I receiving adequate supervision for my level of experience?

4. Am I informing my supervisor of task execution and any concerns?

5. Am I monitoring and reporting hazards as work progresses?

AFTER THE TASK

1. Was the job done IAW authorized policy, processes, and procedures?

2. Were all in-processes and mandatory inspections conducted?

3. Did the work completed satisfy initial task requirements?

4. Have I accounted for/returned all tools and support equipment?

5. Is proper documentation <NALCOMIS/OOMA) complete?

6. Have I certified all work I have completed?

7. Do procedures exist for uncompleted and follow-on maintenance?

8. Have I debriefed the task to my supervisor?

9. Have all supporting maintenance tasks been documented?

10. Did I debrief issues/concerns to improve the task or process to my supervisor?

SUPERVISOR

BEFORE THE TASK

1. Am I qualified, authorized, and confident to undertake maintainer supervision?

2. Do I understand who I am supervising and what is being supervised?

3. Have I briefed those directly responsible for conducting the task?

4. Have I told my supervisor of any physical or mental limitations that may have an impart on myself or the maintainer performance?

5. Have all hazards been identified, reported, controlled, and documented?

6. Do I understand my responsibilities with respect to the task and supervision?

7. Has sufficient time been allocated to undertake the task?

8. Does my team have the authorized publications, procedures, and instructions required?

9. Does my team have the required tools and serviceabe support equipment required?

DURING THE TASK

1. Am I supervising IAW authorized policy, processes, and procedures?

2. Am I ensuring all in-process and mandatory inspections are done?

3. Am I giving/receiving adequate feedback from/to personnel?

4. Am I informing my supervisor of task execution and any concerns?

5. Am I monitoring and reporting hazards as the work progresses?

AFTER THE TASK

1. Was maintenance done IAW authorized policy, processes, and procedures?

2. Did I ensure that all in-process and mandatory inspections were completed?

3. Did the work completed satisfy initial task requirements?

4. Did I provide the appropriate level of supervision throughout the task?

5. Have I debriefed the task with the maintainer?

6. Have (documented all the inspections I was responsible for/or I conducted?

7. Have I confirmed that conditions exist for any follow-on maintenance?

8. Have all supporting maintenance tasks been documented?

9. Have I articulated task turnover info via maintenance docs. logs, and verbal brief?

10. Have I briefed maintenance control on task revision details and the maintenance status of further task requirements?

MAINTENANCE CONTROL

BEFORE THE TASK

1. Am I and my workforce qualified and authorized to do maintenance?

2. Has sufficient personnel/time been allocated to the tasks?

3. Have hazards been identified, discussed, controlled, and documented?

4. Do I understand my responsibilities with respect to maintenance management?

5. Do I have the authorized data, procedures, and instructions required?

6. Have I communicated task requirements clearly and documented?

7. Does the unit have the necessary serviceable support equipment and authorized tools?

8. Have I dearly communicated and documented task requirements?

9. Are there any factors that may have an impact on the physical or mental performance of personnel?

10. Have I been briefed on all maintenance to be conducted?

DURING THE TASK

1. Am I supervising 1AW authorized policy, processes, and procedures?

2. Are all in-process and mandatory inspections being conducted?

3. Am I giving/receiving adequate feedback to/from personnel on task?

4. Am I informing my supervisor of the maintenance status and any concerns?

5. Am I managing risk(s) as the work progresses?

6. Am I monitoring personnel performance and reporting any concerns?

AFTER THE TASK

1. Is maintenance certified I AW authorized policy, processes, and procedures?

2. Are in-process and mandatory inspections completed and documented?

3. Have I documented the inspections I performed and/or was responsible for accomplishing?

4. Have I confirmed corrective actions satisfy Initial task requirements?

5. Have I debriefed the task with the supervisor?

6. Are maintenance actions documented for follow-up actions, if required?

7. Were all supporting tasks documented and certified?

8. Is task info (maintenance docs. logs, briefs) clear and concise?

9. Has the Commanding Officer been briefed on task revision details and the status of further task requirements?

10. Have I conducted my responsibilities with due diligence?

AM1 Riley is with VAW-120

By AM1 Daryl Riley
COPYRIGHT 2014 U.S. Naval Safety Center
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Author:Riley, Daryl
Publication:Mech
Date:Jun 22, 2014
Words:1791
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