Contaminated Oxygen on ‘Air Force One’
In April 2016 Boeing maintenance technicians contaminated the oxygen system of 92-9000, a USAF Boeing VC-25A, one of two converted B747-200Bs flown by the 89th Airlift Wing at Joint Base Andrews, Maryland as Presidential transports (using the call sign Air Force One, only when the President is on board). The damage, done at a Boeing facility at Port San Antonio, Kelly Field, Texas, was spotted before any Presidential flying. It cost $4 million to rectify, making this a Class A mishap in the US DoD classification system.
All oxygen system equipment must be kept absolutely free from traces of oil, grease or flux, as these substances will ignite spontaneously in contact with pressurised oxygen. When a form of lubricant is necessary (e.g. because of a binding thread) the approved or recommended lubricant must be used. Lubricant should be used sparingly to ensure that it does not enter the oxygen system.
Investigators say three Boeing technicians had used a contaminated regulator, tools and other components during leak checks conducted as part of a scheduled inspection 1-10 April 2016.
One technician gave another one items they initially claimed were ‘oxygen-clean’. But the second technician subsequently became aware this was incorrect. When challenged. the first technician allegedly said:
Here [is] some cleaning fluid. Do with it what you want. Use it if you want, but I don’t know anything about it.
The fluid could have been used successfully to decontaminate the items, but investigators found none of the three technicians involved in the leak check were actually trained in the appropriate cleaning technique. The second and third technicians attempted to clean the items but subsequently both the passenger and medical oxygen system became contaminated.
Fatigue and pressure were factors that potentially contributed. Investigators found that maintenance at the Boeing depot had fallen behind schedule and in December 2015 workers had been put on mandatory 12-hour shifts beginning. The three personnel involved has been working six or seven days each week. This strongly suggests they will have been fatigued. We have discussed fatigue previously, looking at a number of case studies: Maintenance Personnel Fatigue and Alertness
The investigators also noted that when Boeing has previously relocated maintenance to Texas from Wichita, Kansas, 172 personnel at the new facility would not meet a USAF 5 years experience requirements. Boeing successfully applied for waivers based on their assessment this was low risk.
The technicians had under gone training in oxygen safety, in one case just 3 weeks earlier. Investigators comment that they “either did not absorb or retain the information”.
The problem on the VC-25A was identified when a non-oxygen clean regulator was found connected and testing confirmed the systems were contaminated.
Boeing paid for the rectification of the damage.
Boeing quality, albeit in production, remains topical: US Air Force forces Boeing to make changes after problems with KC-46 Pegasus production and Boeing Has ‘Severe Situation’ After Parts Left in Tankers, Says Top USAF Buyer
The company has also declared this Friday [15 March 2019] to be “FOD Amnesty Day,” according to an internal company email reviewed by Defense One. The email, which does not mention the KC-46 by name, cites “multiple foreign object debris escapes involving some of our most critical programs.”
“This includes the identification and removal of unnecessary tools, equipment, electronic files, documents and refuse,” said the email from Gena Lovett, vice president for manufacturing, safety and quality, and Ursula English, vice president of total quality. “We all have a responsibility to maintain safe, clean, efficient and FOD-free working areas and it’s so vitally important to who we are we’re making it a [Boeing Defense, Space and Security]-wide priority.”
“FOD is really about every person, everyone in the workforce, following those procedures and bringing a culture of discipline for safety,” he said. “This is an issue of safety and culture.”
And [Will] Roper [US Air Force acquisition chief] does not expect a cultural change immediately, even if Boeing starts delivering plans without debris.
“I’m going to believe it [a culture shift] when I see month after month for a long time, that yes, those practices are now things that aren’t just being done because they have to be done, they’re being done because the workforce says this is a product that we deliver to the Air Force, they’re counting on it being high quality and we own the quality of our product,” he said. “That is how we feel [about] our depots and our production lines and I expect to see that reflected in industry partners that are building critical systems for us.”
We have previously written:
- Professor James Reason’s 12 Principles of Error Management
- Back to the Future: Error Management
- Safety Performance Listening and Learning – AEROSPACE March 2017
- Maintenance Human Factors: The Next Generation
- Airworthiness Matters: Next Generation Maintenance Human Factors
- Flying Control FOD: Screwdriver Found in C208 Controls
- B1900D Emergency Landing: Maintenance Standards & Practices
- United Airways Suffers from ED (Error Dysfunction)
- USAF RC-135V Rivet Joint Oxygen Fire: A military accident investigation has paradoxically determined that a $62.4mn fire was due to a maintenance error but that no human factors were involved.
- Inadequate Maintenance, An Engine Failure and Mishandling: Crash of a USAF WC-130H
- Inadequate Maintenance at a USAF Depot Featured in Fatal USMC KC-130T Accident
- USAF F-16C Crash at Joint Base Andrews: Engine Maintenance Error
- USAF Engine Shop in “Disarray” with a “Method of the Madness”: F-16CM Engine Fire
- What a Difference a Hole Makes: E-8C JSTARS $7.35 million Radar Mishap
- USAF Tool Trouble: “Near Catastrophic” $25mn E-8C FOD Fuel Tank Rupture
- UPDATE 1 April 2019: Tree Top Autorotation for B206L1 After Loose Fuel Line B-Nut Leaks
Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements:
Aerossurance can provide practice guidance and specialist support to successfully implement a MOP.
Aerossurance is pleased to be both sponsoring and presenting at a Royal Aeronautical Society (RAeS) Human Factors Group: Engineering seminar Maintenance Error: Are we learning? to be held on 9 May 2019 at Cranfield University.