USAF T-38C Downed by Bird Strike
USAF T-38C Downed by Bird Strike On 17 August 2018, Northrop Grumman T-38C Talon 68-8206 of the USAF 71st Flying Training Wing, crashed in a field approximately 62 miles west of its base at Vance AFB, Oklahoma. The jet trainer was the lead of a two ship formation performing low-level training. The USAF Accident Investigation Board report, released 20 March 2019, explains that: While flying at approximately 1,000-1,500 feet above the ground and looking over his left wing at his wingman, the [pilot of the T-38C] heard a loud noise on the right side of the aircraft. The pilot, an instructor and the sole occupant, then heard an audible fire warning, saw the right (number 2)engine fire light and detected indications of right-hand flight control hydraulic and right generator failures. While initiating a climb away from the low-level route, the [pilot] experienced a degradation in aircraft controllability and his wingman reported seeing a visible fire…. The [pilot] successfully ejected from the aircraft, sustaining minor injuries. The aircraft was approximately 3,000 feet AGL, 195 knots, 10 degrees nose low, and with a descent rate of 3,500 feet per minute [with] approximately 60 degrees of right bank at the time of ejection. The T-38C, valued at $11mn, was destroyed. The investigation found the aircraft had ingested a Swainson’s Hawk, typically 0.9 kg (32 oz), into the number 2 engine. The bird was identified by experts at the Smithsonian Institute. Investigators say: This bird strike caused the catastrophic loss of the engine and a fire in the forward engine bay. The fire melted through the aircraft skin, exposing the Flight Control and Utility Hydraulic Systems’ flexible hydraulic pressure and return lines to extreme heat, causing the degradation, and ultimate loss, of aircraft controllability. However, the fire and loss of flight control authority necessitated ejection… Safety Resources We have previously written: USAF HH-60G Downed by Geese in Norfolk, 7 January 2014 Swedish Military NOE Helicopter Bird Strike: During a low-level night two-ship training flight a Swedish Armed Forces Agusta 109LUH collided with a large bird. Safety Lessons from a Fatal Helicopter Bird Strike: A fatal accident occurred on 4 Jan 2009 involving Sikorsky S-76C++ N748P of PHI that highlighted a range safety lessons. We also discuss current activity on enhancing bird strike requirements. Power of Prediction: Foresight and Flocking Birds looks at how a double engine loss due to striking Canada Geese had been predicted 8 years before the US Airways Flight 1549 ditching in the Hudson (which was just days after the Louisiana helicopter accident). NTSB Recommendations on JT15D Failure to Meet Certification Bird Strike Requirements Final Report Issued on 2008 Bird Strike Accident in Rome USMC CH-53E Readiness Crisis and Mid Air Collision Catastrophe RCAF Production Pressures Compromised Culture Investigation into F-22A Take Off Accident Highlights a Cultural Issue AC-130J Prototype Written-Off After Flight Test LOC-I Overstress C-130J Control Restriction Accident, Jalalabad Korean T-50 Accident at Singapore Airshow UPDATE 30 March 2019: Contaminated Oxygen on ‘Air Force One’ Poor standards at a Boeing maintenance facility resulted in contamination of two oxygen systems on a USAF Presidential VC-25 (B747). UPDATE 30 October 2019: ‘Crazy’ KC-10 Boom Loss: Informal Maintenance Shift Handovers and Skipped Tasks UPDATE 7 November 2020: Deadly Dusk Air Ambulance Bird Strike UPDATE 30 December 2020: AS350B3/H125 Bird Strike with Red Kite UPDATE 23 March 2022: Big Bustard Busts Blade: Propeller Blade Failure After Bird Strike About 8% US military of all Class A, B and C aviation mishaps from fiscal 2011 through 2017 resulted from wildlife...
read moreMaintenance Misdiagnosis Precursor to EC135T2 Tail Rotor Control Failure
Maintenance Misdiagnosis Precursor to EC135T2 TRCF in Japan On 9 December 2007 Eurocopter EC135T2 JA31NH, operated by All Nippon Helicopter, took off from Tokyo Heliport for a ferry flight to Shizuoka Heliport. The helicopter crashed on approach after a loss of tail rotor (fenestron) control. The pilot died and a mechanic onboard was seriously injured. Investigators from the Japan Transport Safety Board (JTSB) determined that following the propagation of a fatigue crack, the tail rotor (TR) control rod had ruptured at the threaded connection to the yaw actuator during the flight and this made the tail rotor uncontrollable. As the helicopter decelerating, the fuselage started to rotate, possibly after power was increased for a go-around, and the aircraft lost height and impacted the ground. The investigators comment in their safety investigation report that: …it is considered highly probable that the captain did not perform an emergency procedure for the tail rotor failure conditions, as provided in the flight manual. It is considered probable that his failure to perform such an operation reflected the absence of a syllabus for tail rotor failure in the periodic training for the captain. The investigators note that: The maintenance manual provides that the periodical inspection of the TR control, including that of the ball pivot, must be performed every 800 flight hours or every three years, whichever occurs first. A periodical check for the Aircraft was performed by the Maintenance Service Company on March 9, 2006, 368 h 25 min in flight time before the occurrence of the accident. But there was no looseness in the threaded area of the Rod. There was no abnormality with the ball pivot, either. However: After the accident, it was found that the ball pivot had become stiff in the sliding surface due to corrosion. It is considered highly probable that the unusual feeling in the anti-torque pedal movement, which had been reported by several pilots, was caused by the stiffening of the ball pivot… The investigation revealed that troubleshooting was performed on 20 October 2007, 45:35 flying hours before the accident, but this: …was not performed in accordance with the trouble shooting procedure provided in the English written maintenance manual of the aircraft manufacturer. As a result, the inspection of the ball pivot was not performed and its stiffening was not found. In addition, the fact that the joint of the tail rotor control rod and the yaw actuator has a left-handed thread is provided in the English written maintenance manual of the aircraft manufacturer, but it is considered somewhat likely that the mechanic involved in this case, while intending to tighten the joint, actually turned the joint to the opposite direction to loosen it. The investigators concluded that: Therefore, it is considered highly probable that the threaded area of the Rod had become loose and the ball pivot had stiff sometime after the periodical inspection performed by the Maintenance Service Company and as a result, a crack created in the threaded area of the Rod. They went on: …it is considered highly probable that repetitive bending loads in excess of the fatigue strength had been applied on the Rod due to the loosening of the joint of the Rod and the yaw actuator and the stiffening of the ball pivot as well as a resonance phenomenon following the stiffening. As to the stiffening of the...
read moreEasyjet A320 Flap / Landing Gear Mis-selections
Easyjet A320 Flap / Landing Gear Mis-selections The UK Air Accidents Investigation Branch (AAIB) have reported on inadvertent flap retraction on departure from Liverpool John Lennon Airport on 24 June 2018, involving Easyjet Airbus A320 G-EZOZ. Incident Flight The crew were on the third sector of the day, from Liverpool to Paris Charles de Gaulle. The takeoff was planned from Runway 27 with Configuration 1+F (leading edge slats extended to 18° and trailing edge flaps extended to 10°) and an aircraft gross weight of 62.6 t. The co-pilot was the Pilot Flying (PF). The AAIB report that: The takeoff roll was normal. …after lift-off the co-pilot called for “gear up”; the commander replied “gear” but inadvertently placed her hand on the flap lever instead of the landing gear lever and selected Flap 0. She realised the error and moved the flap lever back to the Flap 1 position, whereby the slats remained extended but the flaps continued to retract. The co-pilot recalled hearing the commander call “gear” and looking at the gear lever but not seeing the commander’s hand on the lever. However, by this time the flap lever had already been moved and returned. Data from the Quick Access Reorder (QAR) showed that passing 181 ft radalt height at 162 kt, both the flap and slat angles had started to reduce. The slat angle reduced slightly from 18° to 17.2° but then returned to 18°. The flap angle continued to retract to 0°. No movement of the flap lever was recorded. However, flap lever position is only recorded every two seconds, so it is likely that the lever was moved and returned in less than this time. Passing 330 ft radalt the landing gear was selected UP. Climbing through 600 ft radalt, pitch angle was reduced to 10° and the airspeed started to increase. Passing 800 ft radalt, speed had increased to 185 kt and the pitch angle was increased to 15°. Passing 1,350ft radalt the thrust levers were retarded to climb power and the pitch attitude reduced to 10°. Flap 0 was selected passing 1,650 ft as speed increased through 200 kt. By 2,000 ft radalt the slats had fully retracted. The AAIB note that: Both pilots…focused on flying the aircraft. They reduced the pitch attitude to accelerate and, maintaining a positive rate of climb, retracted the landing gear. They considered using TOGA thrust but decided this was not necessary. Throughout the incident the airspeed remained above Vls [the lowest selectable speed]. Once the aircraft was stabilised, the autopilot was engaged and the slats were retracted. The flight was completed without further incident. Discussion The AAIB note that… …neither pilot could identify any reason why the slip had occurred. They were not aware of any distraction and did not report feeling fatigued. The AAIB explain the flap system logic as being as follows: When the flap lever is moved to Position 0 from CONFIG 1+F after takeoff, the flaps and ]leading edge] slats begin retracting at the same time if the airspeed is above 148 kt. …when the airspeed is above 100 kt, moving the flap lever from Position 0 to 1 commands CONFIG 1 rather than CONFIG 1+F, extending the slats but not the flaps. If, after takeoff (and above 100 kt), the flap lever is moved from Position 1 to 0 and then back to 1, the slats and flaps begin to...
read moreUSAF Tool Trouble: “Near Catastrophic” $25mn E-8C FOD Fuel Tank Rupture
USAF Tool Trouble: “Near Catastrophic” $25mn E-8C FOD Fuel Tank Rupture On 13 March 2009 USAF Northrop Grumman E-8C JSTARS 93-0597 (a heavily modified Boeing 707-300 surveillance aircraft) was in the process of refuelling from a KC-135T tanker according to a USAF Accident Investigation Board. After uplifting around 30,000 lbs of fuel the crew heard a “loud bang throughout the midsection of the aircraft.” Refuelling was paused while the E-8C crew checked for damage. None was identified and fuelling recommenced but “another series of loud noises and vibrations” were “heard and felt throughout the aircraft.” Onboard the KC-135T the boom operator saw fuel streaming from the E-8C. Once alerted the E-8C crew also spotted fuel pouring from “at least two holes in the left wing, just inboard of the number two engine.” The E-8C diverted back to its base at Al Udeid Air Base in Qatar. On inspection, it was found that $25 million worth of damage had occurred when the no 2 main fuel tank had been over pressured and ruptured is a way that was described as “near catastrophic”. Investigators found that a maintenance sub-contractor, FFC, employed by Northrop Grumman, had left a fuel vent test plug in one of the fuel tank’s climb relief vents during Programmed Depot Maintenance (PDM) tank de-seal/re-seal maintenance at the Northrop Grumman Lake Charles Maintenance and Modification Center in Louisiana. The sub-contractor had reportedly failed to follow the USAF Technical Order (TO) procedures when using the plug during base maintenance. “The PDM subcontractor employed ineffective tool control measures,” say investigators. The procedures required tool checks at the start and end of each shift, but there was no evidence the tool was identified as missing. In fact, there were no records of any tools being taken into the fuel tanks, which was not credible considering the work that was completed. The plug was required to be fitted with a red ‘streamer’ but it was found without one too. Due to the relatively short period of time between take-off and aerial refueling, E-8C did not have the opportunity to burn much fuel from the number two fuel tank which would have allowed a secondary dive valve, to open (as occurred during the aerial refuelling when the aircraft deployed to theatre) and provide an alternative means to vent pressure. Other Safety Resources A similar, but unrelated event occurred on USAF Lockheed C-141 Starlifter 61-2778 on 21 September 2001: During preflight inspection a fuel leak was discovered… Maintenance personnel were unable to locate or repair the fuel leak, so they inserted fuel tank vent plugs and pressurized the fuel tank The leak was found and repaired. Once the repair was completed, the fuel systems technician exited the fuel tank but failed to document or request an in-progress inspection, to ensure all tools and materials are removed from the fuel tank; and fuel tank plugs (if used) are extracted from the fuel tank vents. Thus a fuel vent plug was not removed. As the aircraft was being [subsequently] refueled [on the ground], upon reaching approximately 120,000 lbs of jet fuel, the interior left wing fuel tank pressure exceeded wing structural tolerances, as pressure was unable to vent due to the forgotten fuel vent plug. Over-pressurization resulted in catastrophic failure of the left wing structure at the wing root. We previously discussed another E-8 contractor error at Lake Charles: What a Difference a Hole Makes: E-8C JSTARS $7.35 million Radar Mishap FOD in military converted Boeing aircraft remains topical: US Air Force forces Boeing to make changes after...
read moreFatal S-61N Dual Power Loss During Post Maintenance Check Flight
Fatal S-61N Dual Power Loss During Post Maintenance Check Flight On 6 September 2016 Sikorsky S-61N, N805AR (MSN 61717, formerly V8-UDZ of Brunei Shell Petroleum (BSP) from 1974 to 2010), was destroyed during a post-maintenance check flight after experiencing a dual loss of engine power while in a hover near Palm Bay, Florida. The three persons onboard were fatally injured due to “multiple blunt force injuries”. The aircraft was operated AAR, who had acquired the aviation businesses of Xe (formerly Blackwater). The aircraft had flown 40,296.2 flying hours at the time of the accident and an impressively high 107,600 cycles (consistent with the short sectors offshore Brunei). The Accident Flight According to the US National Transportation Safety Board (NTSB) safety investigation report: …the helicopter’s fore/aft pitch servo had recently been removed and replaced. Subsequently, three functional check flights (FCF) were required to be completed. Two FCFs were completed uneventfully the day of the accident, and the crewmembers were conducting the final FCF when the accident occurred. One of the maneuvers to be performed during the final FCF was rearward flight at a computed airspeed of 20 knots. The crew performed two of these rearward maneuvers during the accident FCF. While the pilot was flying and recovering from the first rearward flight maneuver, unusual sounds were heard, which the flight crew identified as a compressor stall. The pilot then told the maintenance crewmember that they were returning to their home airport; however, after discussing compressor stalls and engine exhaust gas temperatures with the copilot, the pilot changed his mind and told the maintenance crewmember that they were going to try the maneuver again in a different direction relative to the wind (with the wind off the nose). However: While the pilot was recovering from the second rearward flight maneuver, there was a change in background noise, which the maintenance crewmember identified as a compressor stall. About 2 seconds later, there was another change in background noise, consistent with a decay in drivetrain rpm, which was followed by the helicopter descending and impacting the ground. The helicopter came to rest upright [and a] postcrash fire consumed the cockpit and cabin. The tail boom transition section exhibited partial thermal damage, and the tail boom remained intact. The NTSB have published a full Cockpit Voice Recorder (CVR) transcript. Safety Investigation Recent maintenance on N805AR was as follows: The NTSB reviewed a year of Flight Log entries. The entries before the accident were: The aircraft was fitted with a Universal CVR-120. There is no mention of a Health and Usage Monitoring System (HUMS) or Flight Data Recorder (FDR). As the BSP S-61Ns were fitted with Meggitt IHUMS, which integrated HUMS with a CV/FDR, it appears N805AR had been demodified. Although the crew identified the sounds and loss of power as compressor stalls, a sound spectrum study could not characterize the gas generator speed (Ng) behavior, due to overdriven audio on the CVR, to determine the engine anomaly the crew identified as a compressor stall. It is likely that the cause of the overdriven audio is related to an engine anomaly. At the same time the engine anomaly occurred, the sound spectrum revealed Nr quickly decayed due to a dual loss of engine power coupled with a high collective setting. Because main rotor speed (Nr) decayed at the same time the overdriven audio occurred, it is likely both engines lost power nearly...
read moreEverett Introducing S-92A to East Africa
Everett Introducing S-92A to East Africa At HAI‘s HeliExpo 2019 in Atlanta, Everett Aviation signed a lease for their first Sikorsky S-92A from Lobo Leasing. The Tanzanian based operator has put the aircraft, MSN 920140, onto the Kenyan register as 5Y-EXZ. It had pride of place on the Sikorsky stand and is due to arrive in East Africa in mid-April 2019. Simon Everett, CEO of Everett, commented: We’re delighted to be introducing the S-92A… Many regions across sub-Saharan Africa are seeing a tremendous boom in infrastructure and civil engineering projects, and our new S-92A is ideally suited to supporting those missions. This particular helicopter is equipped with a highly versatile utility interior, which can seat up to 19 passengers in standard configuration or mix passengers with stretchers or cargo in a combined configuration. We also see opportunities for the S-92A in the offshore role in our region, and we plan to offer that configuration to our clients soon. 920140 was formerly operated by AAR, who had acquired the aviation businesses of Xe, in Afghanistan in support of US Transportation Command (USTRANSCOM). Sikorsky S-92 Developments Sikorsky has delivered more than 300 S-92A helicopters since entry into service in 2004. Sikorsky say that: In 2018, the fleet flew 175,000 hours, a record for the fleet, contributing to a total of nearly 1.5 million hours flown. Sikorsky launched the planned S-92A+ retro-fit upgrade and the new-production S-92B at the show. Both will feature Phase One of new MATRIX automation technology. This will include Rig Approach 2.0 which will be capable of flying the aircraft to roughly 500m from an offshore installation say Sikorsky. It also introduces, the SuperSearch mode to fly optimised search patterns. The interior will be readily adaptable to SAR and offshore operations. They will also feature the ‘Phase IV’ main gearbox. This is constructed of aluminum rather than magnesium and a different lubrication system. A GE CT7-8A6 engines, as used in the VH-92A Presidential helicopter, are an option, for improved hot-and-high performance. The S-92B variant, to be available in 2022, also will offer a revised cabin entry door, larger cabin windows and titanium side frames. Aerossurance has extensive air safety, operations, airworthiness, human factors, aviation regulation and safety analysis experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreEngine Failure after Inadvertently Being Put Back into Service Incomplete
Arriel Engine Failure after Inadvertently Being Put Back into Service Incomplete (Papillon, EC130B4 N151GC) A pilot made an excellent forced landing in rising mountainous terrain, on 27 June 2017 in Airbus Helicopters EC130B4 N151GC following a loss of engine power near Boulder City, Nevada. The helicopter was being operated by Papillon Grand Canyon Helicopters on an air tour flight. The pilot and 4 passengers were uninjured. Two other passengers sustained minor injuries. The aircraft was damaged. Accident Flight According to the US National Transportation Safety Board (NTSB) safety investigation report: The pilot reported that, as he executed an “S-turn” about 3,000 ft mean sea level, the helicopter made a subtle yaw to the right, which was accompanied by an audible “gong.” The pilot lowered the collective and simultaneously noted a yellow engine parameter failure indication on the instrument display. Moments later, the main rotor rpm warning horn activated and was followed by warning lights on the caution warning display. The helicopter began to descend immediately. The pilot elected to perform an autorotation to a nearby helicopter pad. In the attempt to steer away from power lines, the pilot made a left cyclic input; however, the retreating main rotor blade contacted a power line. The pilot continued to maneuver the helicopter and subsequently made an up-slope emergency landing on rising mountainous terrain. Safety Investigation The helicopter was powered by a Safran Arriel 2B1 turboshaft engine. Postaccident on-site engine examination revealed that both the gas generator and power turbine were seized and could not be rotated by hand and that there was a significant amount of heat damage to the turbine blades and thermocouples. The vehicle and engine multifunction display recorded multiple engine temperature exceedances during the accident flight. Metal particles were found on the accessory gearbox [AGB] magnetic plug. Further, no oil filter was found installed in the airplane [sic]. The NTSB report that: The last maintenance performed on the engine was 109.6 hours prior to the accident at the Safran HE USA facility, Grand Prairie, Texas. On June 30, 2016, the facility received the accessory gearbox for an overhaul. The oil filter was removed and discarded as part of the normal process for arrival inspection. However: During the document review, it was determined that the overhaul was not due, and the operator agreed to have the accessory gearbox sent back as is. The maintenance organisation correctly shipped the AGB with a log card entry “Equipment returned repairable, not repaired, not airworthy as is” and without a serviceable tag. They reportedly did not inform the operator that they had commenced maintenance on the AGB and removed the engine oil filter. That log card entry was subsequently voided, on the instruction of the maintenance organisation Quality Manager, “after being questioned by the operator thus reverting the airworthiness back to the previous entry”. Although not discussed by the NTSB the implication is there was an incomplete shared-understanding of what work had been performed before the overhaul was cancelled. The engine was rebuilt and operated for 109.6 hours without the oil filter installed this… …led to coke pollution that obstructed the oil jet and resulted in the subsequent oil starvation of the axial compressor rear bearing oil and its subsequent failure. Safety Resources Professor James Reason’s 12 Principles of Error Management Back to the Future: Error Management Safety Performance Listening and Learning – AEROSPACE March 2017...
read moreHelicopter Ops and Safety – Gulf Of Mexico 2018 Update
Helicopter Ops and Safety – Gulf of Mexico 2018 Update The Helicopter Safety Advisory Conference (HSAC) has been publishing data on the Gulf of Mexico (‘GOM’) offshore helicopter fleet and its safety since 1995. We have looked at their 2014. 2015, 2016 and 2017 reports previously. Now we examine their 2018 data. Helicopter Operations: GOM Fleet Data HSAC report that flying activity continues to decline, with just over 182k flying hours in 2018, although the rate of decline has slowed (4% down on the 189k in 2017 and vs 196k in 2016, 298k in 2014 and 410k in the peak year of 2007). The fleet is up slightly to 336 helicopters, from 334 helicopters in 2017 (down from 344 in 2016 and 453 in 2013). This was mostly driven by a strong increase in medium helicopters and a fall in all other categories. The number single engine helicopters fell from 182 to 176, down 35% over 5 years. The light twin fleet dropped by 4 to 25 and is down 52% over 5 years. The medium twin fleet went from 80 to 97, 1 more than 5 years ago. The number of heavy twins (mainly Sikorsky S-92As) fell by 5 to 38, a 17% decrease over 5 years. Flying hours, passenger numbers and flights have dropped by 39%, 40% and 41% respectively over the last 5 years. This is indicative of the economic decline in the small ageing coastal fields and delayed investment in deepwater exploration and production due to the drop in oil price from mid-2014 onwards. Average sector length has been creeping up, from 22 minutes in 2016, to 23 in 2017 and 25 in 2018. The number of operators responding reduces from 10 to 9 (vs 13 in 2014). The big three are Bristow, ERA and PHI, with RLC strong in the single engine sector. Helicopter Safety GOM Encouragingly, 2018 was the 5th fatality free year in since HSAC’s records began. There was a single non-fatal accident, 18 February 2018 when N860AL suffered a landing gear collapse during taxy at Acadiana Regional Airport (ARA), New Iberia, LA. We discussed that accident here: S-76C+ MLG Collapsed Due to Pothole Consequently, according to HSAC: The 2018 accident rate was 0.55 per 100k flying hours (vs 1.59 in 2017 0 in 2016, 1.31 in 2015 and 1.35 in 2014) Note: The 2015 rate would be 1.73 per 100k flying hours if all 4 occurrences listed by the NTSB are included. The 2018 fatal accident rate was 0 per 100k flying hours (vs 0.41 in 2017, 0 on 2016 and 2015 and 0.34 in 2014). The 5-year rolling average accident rate is 0.83 per 100k flying hours. The 5-year rolling average fatal accident rate is 0.28 per 100k flying hours. We are aware of one other possible accident: a reported ditching of RLC Bell 206L4 N174RL on 13 January 2018. UPDATE 12 March 2019: A Bristow Bell 407, N577AL, operated for Talos Energy, was lost shortly after take off from Galliano, LA on 10 March 2019. The pilot and single passenger both died. UPDATE 19 November 2020: NTSB Probable Cause: The pilot’s loss of control during cruise flight as a result of spatial disorientation while operating the helicopter in close proximity to terrain in marginal meteorological conditions. UPDATE 28 June 2019: The 2016 stats may have to be revised in light of this belated report: Tail Rotor Lightning Strip Damages AW139 Main Rotor UPDATE 7 December 2019: A Panther Helicopters Bell 407, N79LP, with two persons onboard went missing in...
read moreWhat a Difference a Hole Makes: E-8C JSTARS $7.35 million Radar Mishap
What a Difference a Hole Makes: E-8C JSTARS $7.35 million Radar Mishap While washing a USAF Northrop Grumman E-8C JSTARS at a the Northrop Grumman Lake Charles Maintenance and Modification Center in Louisiana, maintainers covered up three drain holes in the 40 ft (12 m) canoe-shaped radome. This houses the 24 ft (7.3 m) APY-7 passive electronically scanned array Side Looking Airborne Radar (SLAR) antenna fitted to the heavily modified Boeing 707-300 surveillance aircraft. So far so good… Unfortunately these were not uncovered afterwards says a Air Force Materiel Command (AFMC) Accident Investigation Board (AIB) report. It is reported that: …maintainers were required to make sure the drain holes weren’t obstructed as part of the pre-flight inspection process… But pre-flight inspections were conducted four times [at Lake Charles]…without catching the drain hole obstructions. The damage wasn’t caught until the JSTARS was flown back to Robins and maintainers there conducted their own inspection. The AIB describe this as being due to a “checklist error”. Consequently 4.5 in (114 mm) water collected in the radome between 4 June and 27 July 2016. On 25 June 2016, Northrop personnel powered the aircraft’s radar as part of maintenance procedures, cycling the antenna. The combination of electrical current and moisture exposure led to the degradation and damage of many of the antenna’s components, to include 240 circuit cards. This caused $7.35 million damage. Most of those components had to be replaced. Four other aircraft were subject to inspections. It was later reported that one management change had been made at the lake Charles facility. It was commented that: …problems stem at least partially with the Air Force’s confusion over when and if to retire JSTARS. When the service planned to retire the fleet, it kept aircraft from moving into depot maintenance, believing that no further work would be needed before they were mothballed. However, after it decided to keep operating JSTARS, a higher number of planes than expected were rushed to the depot [creating an]…unexpected demand. Improperly installed bolts are also reported to have been found. It was reported subsequently that: Oversight processes had also been relaxed, so maintenance work was not as heavily scrutinized as it had been on previous contracts. …the Air Force has since added some layers of inspections, while Northrop improved training and quality control processes. The parties also modified the incentive structure on the contract to balance capacity and quality, which had languished. A Northrop Grumman spokesperson said: As we had gone through trying to get more airplanes through the depot, we had kind of shifted the incentive to be more on how fast we were able to get them through. Never was it anybody’s intentions … on the part of any of us to sacrifice quality for speed, but unfortunately I think we saw some of that. Other Safety Resources 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 Lost Tool FODs Propeller Blade, Penetrating Turboprop’s Fuselage Micro FOD: Cessna 208B Grand Caravan Engine Failure & Forced Landing B1900D Emergency Landing: Maintenance Standards & Practices Robinson R44 Power Loss: Excessive Lubricant 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...
read moreUSAF Parachutist Fatally Extracted Through Ventilation Door
USAF Parachutist Fatally Extracted Through Ventilation Door (Shorts Skyvan N46LH) On 21 February 2014, a US Air Force (USAF) Tactical Air Control Party Jumpmaster died during an inadvertent parachute extraction from a contracted Short SC-7 Skyvan N46LH, operated at SkyDive Arizona over Eloy, AZ. The fatally injured “mishap jumper” (MJ) was wearing an MC-4 ram-wing parachute. He was a member of the 17th Special Tactics Squadron, Air Force Special Operations Command (AFSOC), assigned to Fort Benning, GA. According to the USAF Accident Investigation Board (AIB) report: En route to the drop zone with the mishap aircraft approaching 9,700 feet mean sea level, the MJ stood and gave the “10 minute” warning and winds call, followed by the “don equipment (rucksack)” command. The MJ opened the Plexiglas ventilation door between the aft cargo door and aircraft floor and sat down on the seat next to the door to don his own rucksack. [It is not clear if he] inadvertently attached his rucksack to the ripcord handle, snagged it on equipment, or inadvertently grabbed [the handle]. [Shortly after] the MJ leaned forward, the spring-loaded pilot chute popped up and fell directly through the open ventilation door taking the reserve parachute with it. In roughly two seconds, the MJ was extracted though the ventilation door opening-tearing off his rucksack, damaging the aft cargo door, and killing him instantly. The MJ landed under a fully inflated reserve parachute …southeast of Eloy, AZ. The investigation concluded that the MJ inadvertently pulling his reserve parachute ripcord while donning his rucksack. The open ventilation door, was of “sufficient size for a parachute to pass through, but not large enough for safe passage of a person”. Opening the ventilation door without also opening the cargo door “did not violate either military or civilian guidance” but was considered contributory. …testimony varied on whether the hazard of an inadvertently deployed pilot chute departing through the ventilation door was briefed as a safety hazard, it appears the personnel interviewed largely failed to identify or underestimated the risk of opening the ventilation door… Investigators also noted that: The characteristics of the MC-4 equipment attachment D-rings, which are similar in appearance, feel, and location to the lower portion of the ripcord handles, make it relatively easy to either (1) attach equipment inadvertently to a ripcord handle instead of the D-ring, or (2) catch equipment inadvertently on ripcord handle while attempting to attach equipment to the D-ring. Safety Resources James Reason’s 12 Principles of Error Management Back to the Future: Error Management AC-130J Prototype Written-Off After Flight Test LOC-I Overstress C-130 Fireball Due to Modification Error 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 MC-12W Loss of Control Orbiting Over Afghanistan: Lessons in Training and Urgent Operational Requirements UPDATE 30 March 2019: Contaminated Oxygen on ‘Air Force One’ Poor standards at a Boeing maintenance facility resulted in contamination of two oxygen systems on a USAF Presidential VC-25 (B747). UPDATE 30 October 2019: ‘Crazy’ KC-10 Boom Loss: Informal Maintenance Shift...
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