usaf flying safety

June 2002, VOL 58, NO 6AIR FORCE RECURRING PUBLICATION 91-1

U N I T E D S T A T E S A I R F O R C E

M A G A Z I N E

4 Heads Up On Heads-UpA plea for counter-pointer HUDs

10 Fatigue: Insidious Tool Of The Grim Reaper A tale of “microsleep”

12 CRM Anyone?A tale of a failure to communicate

14 Old Habits Die HardA rare but preventable error

16 The NVG FactorOh say, can you see?

18 We’ve Done This Task So Many Times!Doing it “by the book”

20 Communication: Key To Modern Maintenance A timeless topic

23 I Learnt About Stress From ThatThe rage of the “flight line maniac”

26 Ops TopicsLittle things mean a lot

28 Maintenance MattersPower, or lack thereof

30 Class A Mishap Summary

31 The Well Done AwardAirman First Class Ryan L. Moore

Cover: HQ AFSC Photo by TSgt Michael FeatherstonPhoto Illustration by Dan Harman

June 2002 ● FLYING SAFETY 3

GENERAL JOHN P. JUMPERChief of Staff, USAF

MAJ GEN KENNETH W. HESSChief of Safety, USAF

COL MARK K. ROLANDChief, Safety Education and Media DivisionEditor-in-ChiefDSN 246-2968

JERRY ROODManaging EditorDSN 246-0950

CMSGT JEFF MOENINGMaintenance/Technical EditorDSN 246-0972

PATRICIA RIDEOUTEditorial AssistantDSN 246-1983

DAN HARMANElectronic Design DirectorDSN 246-0932

TSGT MICHAEL FEATHERSTONPhoto EditorDSN 246-0986

Air Force Safety Center web page: http://safety.kirtland.af.mil/Flying Safety Magazine on line:http://safety.kirtland.af.mil/magazine/htdocs/fsmfirst.htm

Commercial Prefix (505) 846-XXXXE-Mail — [email protected] Changes —[email protected]

24-hour fax: DSN 246-0931Commercial: (505) 846-0931

DEPARTMENT OF THE AIR FORCE —THE CHIEF OF SAFETY, USAF

PURPOSE — Flying Safety is publishedmonthly to promote aircraft mishap prevention.Facts, testimony, and conclusions of aircraftmishaps printed herein may not be construedas incriminating under Article 31 of the UniformCode of Military Justice. The contents of thismagazine are not directive and should not beconstrued as instructions, technical orders, ordirectives unless so stated. SUBSCRIPTIONS— For sale by the Superintendent ofDocuments, PO Box 371954, Pittsburgh PA15250-7954. REPRINTS — Air Force organi-zations may reprint articles from Flying Safetywithout further authorization. Non-Air Forceorganizations must advise the Managing Editorof the intended use of the material prior toreprinting. Such action will ensure completeaccuracy of material amended in light of mostrecent developments.

DISTRIBUTION — One copy for each three air-crew members and one copy for each six main-tainers and aircrew support personnel.

POSTAL INFORMATION — Flying Safety(ISSN 00279-9308) is published monthlyexcept combined Jan/Feb issue by HQAFSC/SEMM, 9700 G Avenue, SE, KirtlandAFB NM 87117-5670. Periodicals postagepaid at Albuquerque NM and additional mailingoffices. POSTMASTER: Send addresschanges to Flying Safety, 9700 G Avenue, SE,Kirtland AFB NM 87117-5670.

CONTRIBUTIONS — Contributions are wel-come as are comments and criticism. The edi-tor reserves the right to make any editorialchanges in manuscripts which he believes willimprove the material without altering the intend-ed meaning.

CRM: CELLULAR RESOURCE MANAGEMENT

Courtesy ASRS Callback #249, Mar 00NASA’s Aviation Safety Reporting System

Commercial airline passengers are reminded during everypreflight briefing to turn off electronic devices that may inter-fere with aircraft systems—including cell phones. Now here’s areport that suggests what’s good for the cabin, is good for thecockpit, too.

The Captain filed the flight plan late so I could not pick up the clear-ance until just before the passengers showed up. We were issued theSID with transition. I did not have time to look up the SID becausethe Captain was in a hurry to taxi. He was making calls on a cellphone while he taxied out so I still could not talk to him. Tower put usin position and hold on Runway 30L while I yelled for the Captain toturn off his cell phone. He finally did when they cleared us for takeoff.We never did brief the takeoff or the SID.

Once airborne, the Captain asked me what we were supposed to do.I tried reading the text and gave him some of the instructions as I readthem. I got confused at one point about how to join the transition andtold the Captain. He turned the wrong way. ATC asked what radialwe were trying to join. They told us to turn right 140˚ to continue theSID and to call Approach once on the ground.

This would never have happened if the Captain had not been in sucha hurry to get going, and if he had been paying attention to flyingduties while taxiing out, instead of talking on his cell phone.

We’re sure this type of event is rare, but it nonetheless illus-trates the importance of effective cockpit management skills(and training). In effective CRM, flight crews make flyingduties their first priority, and First Officers participate con-structively in resolving problems.

4 FLYING SAFETY ● June 2002

MAJ JEFF LONG12 FTW/SEFRandolph AFB TX

Spatial Disorientation (SDO) has been killing fighterpilots for many years. This time it claimed a student ofmine (for his family’s privacy, let’s call him Steve, acompletely fictional name). Steve died at night in an F-16 shortly after takeoff. Although he had planned toaccomplish night intercepts, he died before his FlightLead even said "Fight’s On." The Flight Data Recordershows he became spatially disoriented during abenign navigational turn and remained so all the wayup to his belated ejection attempt.

It saddens me when I hear about any fatal acci-dent, even more so when the fallen aviator is a peeror acquaintance. The emotion reaches a differentlevel, I’ve found, when the victim is someoneyou’ve taught to fly. At SUPT graduation, Steve’sclass presented me a plaque with a class photo onit. Now, whenever I look at it, I wonder what myfellow instructors and I—or the Air Force as awhole—could have done to save his life.

Reducing SDO MishapsFrom a training standpoint, the Air Force already

does much to minimize the effects of SDO. Aerospacephysiology specialists train students in equipmentthat produces vestibular illusions. Instructor Pilotsteach unusual attitude recoveries in both the T-37 andT-38, not only in the aircraft but also in the simulator.We use vision-restricting devices in the aircraft tosafely give students experience in trusting theirinstruments more than their inner ear. The Air Forceis currently looking into buying newer and betterSDO trainers. Given the impressive efforts alreadybeing made, there don’t appear to be easy any waysleft to make huge strides via training.

Another approach through which the AF is striv-ing to reduce SDO deaths is by improving how weequip our fighter pilots. This article will focus onthat effort by explaining how improvements to theway Head -Up Display (HUD) airspeed and alti-tude information is displayed should make the F-22 and F-35 safer than the older-technology aircraftthey replace. These new aircraft use Counter-Pointer (C-P) displays rather than the Moving-Tape(M-T) displays found in the F-15, F-16 and A-10.

Like most groups of people, fighter pilots can beresistant to change. Resistance is usually fiercestwhen people don’t understand the reasons thechange was initiated. My objective in writing is toinform fighter pilots and fighter/bomber-track SUPTinstructors about why the "Military Standard" HUDfound in the F-22, F-35 and T-38C looks different fromolder HUDs (see F-22 HUD in figure 1).

Before I begin, let me add one caveat: My com-ments are intended to relate primarily to combataircraft and to the training of pilots who fly them. Iknow very little about the air mobility business,but enough to point out that mobility aircraft arenot designed to fly at extreme attitudes, to pullhigh-G turns, or to be flown by only one pilot. Allthree factors make mobility pilots’ SDO risk expe-rience different. Some mobility aircraft now haveHUDs, and I will defer comment on what symbol-ogy is appropriate for them to people more knowl-edgeable about the mobility business.

Many readers may be asking, "If it ain’t broke, whyfix it?" In answering, I’ll cover both general flightsafety information and Human Factors (HF) infor-mation, and then I’ll tie the two areas together byexamining a mishap in detail.

SDO HAZARDS FROM MOVING-TAPE HUD SYMBOLOGYHQ AFSC Photo by TSgt Michael Featherston

Photo Illustration by Dan Harman


I found two things particularly noteworthy. Firstwas the large proportion of fatal mishaps causedby SDO. In fact, SDO turns out to be the numberone killer of F-16 pilots. Second, although most ofthose SDO mishaps occurred during "tactical"phases of flight such as night delivery of Laser-Guided Bombs, an alarming number (12 of 36)occurred during "admin" portions of the mission—benign events such as a fluid turn prior to "fight’son," or an instrument approach. Some things fight-er pilots do are inherently dangerous; that listshouldn’t include admin.

Speaking of deadly admin, let’s get back to Steve.He entered a fluid turn. He looked too longthrough his Night Vision Goggles (NVGs) at hisflight lead and failed to adequately cross check hisHUD or head-down instrument panel. He becamedisoriented, and eventually reached approximately70 degrees nose low and 150 degrees of left bank.

Flight Safety InformationShortly after I learned of Steve’s death, I started the

Flight Safety Officers’ Course at The Air Force SafetyCenter at Kirtland AFB. I resolved to use theresources of the safety system to learn more aboutthis mishap. While there, I met AFSC’s leadingAerospace Physiologist, Lt Col Don White, who, as itturned out, had already done a relevant analysis. Hisexamination of long-term mishap trends (see Table 1)

reveals a downward-sloping trend for G-InducedLoss of Consciousness (GLOC), but an essentially flatone for SDO. This suggests that the aggressive cam-paign the Air Force has been waging against GLOCis meeting with some success, and that we need asimilarly aggressive campaign on SDO.

Lt Col White’s study, combined with the fact thatSteve had died in an F-16, motivated me to reviewevery fatal F-16 mishap from 1 Oct 1991 to 1 Jul2001 (see Table 2).

continued on next page

F-22 HUDFigure 1

Table 1

Table 2


Fortunately, an auditory altitude warning broughthis attention back inside the aircraft. It did so atsuch a high altitude that recovery to level flightwas easily within the jet’s performance capabili-ties. Although the NVGs played a large role in get-ting Steve to this undesirable situation, from thenon it should have been a simple unusual attituderecovery—not much different than the countlessones he had done since the beginning of SUPT.Why, then, did this not end in a "There I Was" storyin the squadron bar? Why did it end in a funeral?That is a mystery that the NVG factor alone cannotsolve. To understand it, let’s start by examining thebody of work produced by HF experts.

Human Factors InformationThe HF community now knows vastly more

about the best way to display HUD informationthan it did in the 1970s, when the F-15, F-16 and A-10 HUD formats were designed. During that peri-od, most designers chose M-T displays, but therewas no standardization of exactly how to imple-ment the M-T. The builders of the A-10 and the F-15 (see figure 2) chose to put the smallest airspeed

numbers on the top of the tape. The F-16 folksselected the opposite solution (see figure 3). Adecade or so later, the designers of the F-15E decid-ed that trend information was not worth the cost inHUD "real estate," so they chose to omit it entirely.

By the end of the 1980s, the AF-wide HUD situa-tion was far from standardized. Pilots transitioningfrom one fighter to another had to waste trainingtime learning a new symbology set, and also had towork hard to "unlearn" deeply-rooted habit pat-terns (such as which direction to move the throttle

in response to upward motion on the left side of theHUD). Decision makers recognized how undesir-able that situation was, in terms of both wasteddollars and flight safety. They chartered a FlightSymbology Development Group (FSDG) to exam-ine not only existing HUD formats but alsoresearch concepts and to assemble the best ele-ments into a single Military Standard (MILSTD)format. In 1989, the Chief of Staff of the Air Forcesigned a memo1 directing all agencies to complywith the FSDG recommendations and to adopt theMILSTD. The other services agreed, and the direc-tive acquired "thou shalt" status at the Joint level—new DoD aircraft and upgrades to existing aircraftnow incorporate the MILSTD.

Given that it’s not easy to convince all four ser-vices to change, readers won’t be surprised to learnthat there is a wealth of objective, quantitative dataunderpinning the MILSTD effort, not mere subjec-tive opinion. In 1992, DoD, NASA, FAA and NATOjointly published a HUD State of the Art Report(SOAR). It reviewed the HUD literature since 1946,summarizing, "Moving tapes are bad news."2

Shortly thereafter, the Armstrong Laboratory at

Brooks AFB published a particularly well-designedset of studies comparing HUD formats, studies thatcollected data in both simulators and aircraft. Theyfound performance with C-P displays was better(p<.01 for you statistics majors out there) than boththe M-T format and the pure digital format.4 (As aformer F-15E pilot, I found it particularly interest-ing to note that pure-digital format gave the worstperformance of all five formats and that this inferi-ority applied to both airspeed and altitude trackingperformance.) By the late 1990s, the weight of sci-

F-15 HUDFigure 2


concluded that the other airplane was hiddenbehind HUD symbology, and named this clutter asone of the "causal" findings.11

(b) At night, some of the light from inside thecockpit internally propagates through the canopyand gets reflected back into the pilot’s eyes.6 Manyhave reported such reflections as disorienting. Themore pixels illuminated on the HUD, the morelight there is to reflect, hence the more chance ofdisorientation.

90° Bank ConfusionJCO paragraph (c) speaks to this phenomenon. A

disoriented pilot who has gotten into a near-90°bank has enough to worry without "latching onto"the airspeed tape, confusing it with the horizon lineor a pitch ladder marking, and then wonderingwhy that symbol doesn’t roll despite the lateralstick pressure they are applying.

Trend Direction/Trend Rate ConfusionTo understand JCO paragraphs (d) and (e), imag-

ine a disoriented pilot pointed nearly straightdown, moving at over 600 knots, and getting dan-gerously close to the dark ocean below. If this pilotwere flying an F-15E or F/A-18, there would be notrend direction information on the HUD—perhapsthe first noticed indication of the crew’s predica-ment might be the wind noise over the canopybow. (A few years ago, one F-15E aircrew memberdied in circumstances very similar to this.11) In anF-15C or F-16, the M-T displays might be movingso quickly as to make them just a blur, with no dis-cernible information about the direction or rate ofmotion. In an F-22, however, these flight parame-ters would cause the altitude C-P to "unwind" at a

entific evidence in favor of the MILSTD was suchthat the DoD Joint Cockpit Office (JCO) pro-nounced its official position: Counter-Pointer for-mat is superior.5,8 To quote the JCO:5

These evaluations indicate that the counter pointerformat significantly enhanced pilot performance whencompared with conventional vertical tape and pure digi-tal presentations. The relative merits of the counter-pointer format are as follows:

a. It takes up less space (causing less clutter) than thevertical scale.

b. The moving tape-fixed pointer scale is inherentlyharder to read because the numbers on the tape are mov-ing and not always in the same place.

c. There is some evidence that the scales might beinterpreted as horizontal pitch lines when viewed by adisoriented pilot in a 90-degree bank.

d. The dial format provides trend information clearly,with no confusion about direction (clockwise is more),and is directly analogous to the round dials with whichpilots learn to fly.

e. During extremely rapid descents, rate and direction ofmovement of vertical tape scales can be hard to distinguish.

ClutterNote JCO paragraph (a). It tells us that you have

to illuminate more pixels to show trends with M-Tdisplays than with C-P displays. Consider two rea-sons such clutter is bad:

(a) Objects in the real world can "hide" behindHUD symbology. Not only is this phenomenonexceptionally well-documented in the HF litera-ture, it has appeared in the findings of USAFmishap investigations. For example, there was apilot who landed on another airplane because hefailed to notice it. The Safety Investigation Board


F-16 HUDFigure 3


rate of about one rotation per second.12 Not onlywould the rate be discernible, the direction wouldbe unmistakable. (In every airplane I know of,counterclockwise motion of an airspeed or altitudepointer means the parameter is decreasing.)

Roll VectionThe concept of roll vection can be found in a dif-

ferent section of the same JCO document.7 It alsoappears in the HUD SOAR. See figure 4 for a graph-ic borrowed from the SOAR.3 Like the exampleHUD found there, the F-16 HUD puts the largestairspeed and altitude values at the top of the tapes.Suppose an F-16 pilot flying IMC looks away from

the HUD for a moment (reading an approach plate,pressing buttons, etc.) and unknowingly enters aslight descent. The descent would probably beaccompanied by an increase in airspeed. The lefttape (airspeed) would slide downward, and theright tape (altitude) would slide upward. The pilotwould detect this motion in his peripheral visionand might interpret it as movement of the horizonline caused by a right roll. If so, the pilot may sub-consciously input left aileron to "compensate."Given the shortcomings of the human inner ear,such a scenario may very well lead to spatial dis-orientation.9,13 Note that F-15C and A-10 HUDs canalso cause roll vection, but would be likely to do sofor a shorter portion of a typical sortie. This isbecause those HUDs put small airspeed numbers atthe top, leading the M-T displays to move in oppo-site directions during accelerating climbs (e.g.,immediately after takeoff) and in deceleratingdescents (e.g., final approach). Counter-pointer for-mat is not susceptible to roll vection.

Summary of Four Hazards Posed by HUD M-TDisplays

We’ve covered a lot of information already, sobefore we move on to Steve’s mishap, let’s recap.There are at least four major mechanisms by whichM-T displays can contribute to mishaps:

1. Cluttera. Obstructing pilot’s view of outside worldb. Worsening canopy reflections at night

2. 90° bank confusion3. Trend direction/trend rate confusion4. Roll vectionNow let’s apply that information to Steve’s last

flight.

Mishap NarrativeSteve’s was a night sortie, and more than one F-16

pilot has commented that internal canopy reflec-tions are an issue in that aircraft. During part of thetime during which Steve was struggling to regainhis spatial orientation, his F-16 was near 90° of bank.

Steve left his power at an inappropriately highsetting for a very long time. In fact, a Wright-Patterson AFB PhD who examined the informationtaken from the flight data recorder estimates thatfor almost 10 seconds, Steve failed to act on theneed to pull back the throttle.14 The high power set-ting contributed to a massive sink rate, and thatsink rate was a major reason Steve’s ejectionattempt proved fatal. Had his HUD been equippedwith C-P displays, perhaps he might have per-ceived the increasing airspeed sooner.

Steve’s initial roll was to the left. It may well haveled to at least three separate illusions (two vestibu-lar, one visual). The roll rate was slow, probablybelow the vestibular detection threshold. The fluid

Roll Vection3

Figure 4

TapeMovingDown

TapeMoving

Up


inside his inner ear would have acquired momen-tum in that direction. As Steve began to realize hisperil, he initiated a rapid right roll but set hiswings without eliminating all of the left bank.When he stopped the roll, the fluid in his semi-cir-cular canals kept moving, providing a compellingsensation his aircraft was rolling to the right,toward the desired wings-level attitude (somato-gyral illusion). Moving his skull to look away fromhis flight lead and inside his cockpit may well havecaused the motion in the fluid of one canal to carryover to the remaining canals (coriolis illusion),compounding his disorientation.

Now let’s tie in roll vection. In his rapidly-accel-erating descent, the left tape would have beenmoving upward and the right tape downward (seefigure 5 for a general idea of what his HUD proba-bly looked like). Viewed peripherally, this motionmight have provided a compelling sensation ofright roll—a sensation consistent with some of thefalse information that may have been coming fromhis inner ear.

Operational Risk ManagementI do not mean to infer that anyone can say with

absolute certainty what contributed to any of the13 SDO mishaps I referenced. Tragically, nonelived to warn their fellow pilots. It is possible thatHUD format never played a significant role. Noone, however, can be sure it didn’t contribute to atleast one mishap.

The first principle of ORM is "Accept no unnec-essary risks."10 Both Human Factors and FlightSafety data give cause to be concerned about the

moving tape format of the F-15C, F-16 and A-10HUDs. Those same sources also give reason forconcern about the complete lack of trend data onthe F-15E HUD. DoD is already applying theselessons learned by purchasing the F-22, T-38C andF-35 (USN, USMC and USAF versions alike) withthe MILSTD HUD installed.

Might it be time to consider retrofit of "legacy"fighters? Perhaps. I recommend that readers whoseduties might include membership on a SafetyInvestigation Board (SIB) be aware of the reasonswe are moving away from the M-T and pure-digi-tal formats. If the facts of a future mishap suggestone of the four mechanisms outlined above playeda role, then the SIB should say so in their mishapreport. Over time, the data collected will allowdecision makers to perform ORM, asking: "Wouldthe potential savings in lives and equipmentgained by retrofitting the fleet justify the moneyand effort needed to do so?"

For the average reader, however, my recommen-dation is more succinct: know that the MILSTD is

coming and realize thatthere are compellingflight safety reasonsbehind the change.

It’s too late to saveSteve, but we may saveothers.

(Maj Long is a SeniorPilot with over 1700hours in the F-15E andT-38. He has both a B.S.and an M.S. in HumanFactors Engineering,and he holds the HFAFSC. His thesis workon HUD and glasscockpit design has beenpublished nationally.He is assigned toRandolph AFB, wherehe teaches T-38 PilotInstructor Training andserves as a Wing FlightSafety Officer.)

Footnotes1. Memo dated 10 Aug 1989, signed by Gen Larry D. Welch, CSAF.2. Crew Systems Ergonomics Information Analysis Center SOAR 92-2, Human Factors Issues in Head Up DisplayDesign: The Book of HUD. Weintraub, D. J., PhD. and Ensing, M. Jointly published by DoD, NASA, FAA andNATO, 1992, p. 125.3. Ibid., pp. 125-127.4. "Standardization of Aircraft Control and Performance Symbology on the USAF Head-Up Display." Weinstein,L. F., Ercoline, W. R., McKenzie, J., Britton, D. F., and Gillingham, K. K., Armstrong Laboratory, Brooks AFB, TX,1993, page 20.5. Military Standard 1787C, Aircraft Display Symbology. DoD, 5 Jan 2001, p. 56.6. Ibid., p. 41.7. Ibid., p. 59.8. Military Standard 1472F, Human Engineering DoD, 23 Aug 1999, p. 24.9. Aviation Safety: The Human Factor. Alkov, R.A., PhD. Endeavor Books, 1997, p. 11.10. AF ORM Pocket Guide https://rmis.saia.af.mil/tools.asp11. This privileged mishap data is available from your Wing Flight Safety Officer.12. 600 knots = 600 NM/ hr = 600 NM/ 3600 sec = 6 NM/ 36 sec = 36,000 ft/ 36 sec = 1000 ft/ sec = 1 C-P revo-lution/ sec13. Gateway, Volume XII, Number 3. DoD Human Systems Information and Analysis Center, 2001, page 3.14. Telephone conversation with Michael Snow, PhD, AFRL/HEC, 13 Mar 2002.

Estimated HUD view during SDO(Note: example HUD is similar but not identical to the F-16)

Figure 5


LT COL ROBERT BEISWENGER514 AMW/SEMcGuire AFB NJ

I fell asleep behind the tanker!Sky conditions were clear and the air

was calm as I gradually approachedthe pre-contact position behind theKC-135. With over 6000 flying hours inthe C-141, I was comfortable with mysurroundings. My last refuelingbehind a ’135 had gone rather well,giving me personal satisfaction andrenewing my confidence. However, Ilearned long ago that the flying gamehas a way of humbling pilots backinto reality, and I was determined toavoid the pitfalls that come frombeing overconfident. Besides, I wasvery tired and I could feel the effectsof fatigue working on me. Our brief-ing at 0800 seemed a long time ago asI entered the dim conditions associat-ed with dusk.

The previous day I watched a video-tape on fatigue produced by the NASAAmes Research Center. It was about asleep study conducted by scientistsusing airline pilots as their subjects.While flying long, through-the-nighttrips, these professionals were continu-ously monitored with sensitive elec-tronic equipment. As their duty daycame to an end, these experienced pilotswere periodically caught falling asleepfrom descent to landing! The durationof their sleep was only three to five sec-onds, therefore labeled "microsleep." (Iviewed this as a more tactful way todescribe simply falling asleep behind thewheel.) But when flying close to theground, three to five seconds count! Mysubconscious ego comforted me. Thatwas about them; I, of course, was abovesuch failings.

As I moved closer to the tanker, Istruggled to stay alert. I mentally talkedto myself as part of an effort to safely

I was very

tired and I

could feel

the effects

of fatigue

working on

me.


position and was attempting to stabi-lize; my next view of the tanker was farfrom there. "Microsleep," that tactfulterm for falling asleep behind the wheel,was the true explanation for this grossdeviation. Like the pilots in the video, Ihad fallen asleep for a few seconds,allowing the still out-of-trim plane todrift out of position.

Fortunately, no one was physicallyhurt, though my self-confidence receivedsome damage. In fact, there was nothingbut silence in the flight station, leavingme free to critique myself and the eventsthat had just transpired. I was gratefulthere would be no repercussions resultingfrom this experience. It was not a checkride; no hazard report would be filled outto broadcast my error. This time it wouldsimply be a "lesson learned," free ofinjuries and public humiliation. "Howcould that be?" you ask. Because I was inthe ARPTT, the air-refueling simulator.

Two months previously, I agreed toparticipate in a sleep deprivation studydeveloped by Dr./LtCol Michael Russoand implemented with the help of histechnician, Dr./Capt. Sandie Escolas,both from Walter Reed Army Institute ofResearch. Together they were perform-ing a study designed to reveal, in mea-surable terms, the mental and neuro-physiological changes that occur whenone is deprived of adequate sleep.

I had successfully demonstrated myown limits and shocked myself in theprocess. However, this was a very valu-able lesson, even though I received it latein my career. It quickly reminded me ofmy own fallibility. Falling asleep underthese conditions was NOT somethingthat just happens to "others"—it can hap-pen to me, too. More importantly, itmade it easy for me to understand andclearly see the consequences of a mindand body that has been degraded by thelack of proper rest. My limits would haveto be reset and, without a doubt, be at themore conservative end of the gauge.

I hope that those with whom I share thisexperience will also benefit from it.Fatigue is insidious—it approaches quietlyand without fanfare, but the consequencescan be fatal. Whether flying, driving orworking on the flight line, it is importantto learn our true limits and take action tomitigate the power of fatigue. Don’t wakeup wondering what just happened, or youmay not wake up at all.

approach the tanker that loomed grace-fully in front of me. "Trim, trim, trim…still need some nose-up trim… keep theeyes moving, don’t fixate on one point…move in slowly… small power adjust-ments," I said. Finally in the pre-contactposition, I worked to stabilize every-thing before moving in for the contact.But my eyes were moving slower asfatigue set in; my eyelids felt like heavyweights were attached to them. I con-sciously used the muscles surroundingmy eyes to hold them open. "Still needssome nose up trim," I told myself.

That was the last thought I remember.The next thing I recall was seeing thetanker—still in front of me, but about ahundred feet or more above me! It wasstill stable, like a rock; I had obviouslyfallen out of position, big-time. But how?

I was stunned that this could possiblyhave happened to me, but the evidencewas clear—I had fallen asleep behindthe tanker! I had been in the precontact

"Microsleep,"

that tactful

term for

falling asleep

behind the

wheel...USAF Photo by MSgt Bill Kimble



LCDR JON BRADY, USNVR-54

It was a calm, moonless night in theAdriatic Sea. More than half of our six-month cruise was over, and we had justhad the opportunity to shore-base ourSH-60B while the guided missile frigatewas in port for two weeks. Throughwork-ups and the first half of cruise, wehad become very familiar with thehabits and skills of each of the otherpilots in our detachment. We had theadded benefit of practicing emergencyprocedures while shore-based. And so,there we were…

We were engaged in the demandingtask of querying passing vessels toensure they were not breaking theembargo against the former Republic ofYugoslavia. I was flying, and the OICwas sitting in the Airborne TacticalOfficer’s seat. Not too many ships werepassing through, and we had goneabout 60 miles south of the ship whenthere was the sudden bright flash of theMaster Caution light, and the mastercaution panel lit up like a Christmastree. I found myself struggling to main-tain control of the aircraft. Based on theforces required to manipulate the collec-tive and the rudder pedals, I knew thatthe hydraulic-powered pilot-assist ser-vos had failed. In the Replacement AirGroup, this had proven to be my mostdifficult practiced emergency. Evenpracticed at an airfield, this was a toughone for me. The pilot assist servos

hydraulically boost rudder and collec-tive inputs and provide elements of theAutomatic Flight Control System(AFCS) and the Stability AugmentationSystem (SAS). Without them, collectiveforces are significantly increased andrudder inputs may require as much as75 pounds of pressure.

With the flashing lights and increasedcontrol force requirements, I foundmyself struck dumb and unable to com-municate with my copilot as to exactlywhat was happening. Fortunately, heknew. He secured the flashing MasterCaution light (which seemed somewhatredundant at the time: I was pretty surewe had a problem!). We settled downand immediately called the ship foremergency flight quarters and had themstart driving toward us. They wereagreeable, and we began to close the gap.

On the way, I decided that I needed tohave the pedals a bit closer to me forlanding when the rudder forces wouldbe the greatest. So, I released the cyclicand reached up to grab the rudderrelease handle and allow the rudders tomove to a closer, more comfortable dis-tance. Mistake! Without the aid of theAFCS and the SAS, there was nothing tostabilize the flight controls. When Ireleased the cyclic, the aircraft rolled toabout a 30-35 degree angle of bank andled to some curious remarks from myfellow flight crewmembers. I stabilizedthe aircraft and explained what I haddone to my somewhat skeptical crew.

We considered and discarded the idea

When I

released

the cyclic,

the aircraft

rolled to

about a 30-

35 degree

angle of

bank.

USN Photo by PH1 (SW/NAC) Spike Call


beach because of the calm sea state, andwe discussed how to close the distanceto the ship. We also chose to do a cleardeck landing. The approach briefingwas not much more inclusive than that.The descent to landing is the least stableaspect of flying without the pilot-assistservos. On the beach, the idea is to allowthe aircraft to drift slightly forwardwhile landing to lessen the inputsrequired. This was not an option land-ing on the ship because the parkingbrake must be on. While an unstableapproach, hover or landing may devel-op during any approach to the ship, thepossibility was much more likely on thisoccasion, due to the nature of our emer-gency. Even so, we neglected to briefhow we would handle that eventualityshould it occur. Further, we never dis-cussed how we would complete thewave-off should that have become nec-essary. These are essential elements ofthe before-landing brief that should becompleted prior to each approach, andespecially prior to an approach duringan emergency. We were fortunate not toencounter either situation.

Repositioning the helicopter to thebeach for the two-week ship-mainte-nance period was a significant factor inthe successful outcome of this emer-gency. The ability to practice emergencyprocedures at an airport that cannot bepracticed underway gives the aircrewrecent practical experience in aircraftcontrollability and response under vari-ous system degradations. This experi-ence increases the aircrew’s confidencein their ability to handle the aircraft witha malfunction and greatly increases theprobability of a successful outcome.

As a whole, this was a fairly uneventfulemergency situation. Better communica-tion and more complete planning wouldhave led to an even less eventful emer-gency return to the ship. CRM cannot beoveremphasized. Crewmembers mustcontinuously communicate with eachother to ensure there are no surprises.One crewmember may know or sensesomething that the others don’t, and thatmay be a critical element in bringing asituation to a successful conclusion.

Also, letting the crew know whatyou plan to do prevents boneheadslike me from releasing the controlswhen there is no stabilization in theflight controls!

of landing at a distant airbase in Italy.The ship was in sight, and we discussed(in somewhat sketchy details) how thelanding would be conducted. As the shipapproached, we instructed them to turn,giving us winds slightly to the port. Theyturned at the perfect distance, and welined up right on final. We instructed theLanding Signal Officer to remove theRapid Securing Device (the normalmethod for landing an SH-60B) from theflight deck, giving us a clear deck forlanding. I flew the approach to the deckwith a momentary hover to stabilize andthen continued to the deck in an anticli-mactic conclusion to a challenging emer-gency. My copilot treated me to a pat onthe back and a "Nice job!" We secured theaircraft and retreated into the hangar,never so glad to be back on the ship.

There are elements of this story thatwere well done and some that obvious-ly were not. The most striking elementmissing from this event is my lack ofcommunication and crew coordination.At the onset, I did not alert my crew thatI had an emergency (although it wascertainly obvious) or specify what theemergency was. Under the circum-stances—wrestling with the aircraft forcontrol—this may have been excusable.However, I knew what the problemwas, and my copilot quickly determinedits exact nature as well. That left the air-crewman in the back without a clue asto what was happening in the front.Again, this was not a huge obstaclebecause we are to fly the aircraft firstanyway, but this was just the beginning.

We move now to preparation for land-ing on the ship. Here is yet anotherexample of a self-induced problem exac-erbating an already stressful situation.As if I were in a single-piloted aircraft, Itook it upon myself to maintain controlof the aircraft while attempting to adjustmy rudder pedals (notifying no one ofmy intentions). A simple application ofCRM would have remedied this situa-tion without upsetting the aircraft orsurprising the other members of thecrew: "Hold the cyclic while I adjust mypedals." Crew coordination and com-munication eliminate this situation bysharing the workload and keeping thecrew informed of what’s going on nowand what’s coming up next.

The approach briefing was incom-plete. We decided against going to the

I took it

upon

myself to

maintain

control of

the aircraft

while

attempting

to adjust

my rudder

pedals.


MAJ BRUCE "FM" EDWARDSUSAFSAM/GEBrooks AFB TX

The old adage says "train the way youfight." This sounds like a good idea, butit means that your training had betterbe squared away and it should bereflective of the way you want to per-form in a crisis situation.

This article examines the way somedesign and training practices mayhave contributed to loss of aircraft.The shutdown or pullback of thewrong engine in twin engine aircraftduring an emergency procedure canbe corrected in some instances, but canlead to total loss of the aircraft underother circumstances.

The story about how we set ourselvesup for this human factors problem is athree-part one: design, training andinterference.

The design issue is one that we haverecognized for many years. The throt-tle quadrant on twin-engine USAF air-craft is pretty standard and has notchanged despite many different jetsand many different missions. Thisdesign is found on the A-10, A-37, AT-38, FB-111, F-4, F-5, F-15, F-22, F-101, F-111, OV-10, T-37, T-38 and SR-71. Theissues relate to the placement of themicrophone button and speedbrakeswitch. The buttons are found on theright throttle only—this means single-engine flight and approaches are mucheasier with the left engine shut downor in idle and the right engine beingmanipulated for flight. The difficultyarises when you shut down the rightengine. You now have to adjust thethrottle with the left control and moveto the right throttle for radio calls andspeedbrake usage. Pilots are generallyquick to figure out that one method,

When under

stress,

many avia-

tors revert

to habits.

USAF Photo by SSgt Jeffrey AllenSource Drawing: Flight Manual, USAF Series A-10/OA-10A



and I also noticed that sim single-engineapproaches were almost always flownwith the left engine in idle. I began towonder (and I needed a research topic),so I went to the Safety Center andlooked at the database. My hypothesiswas that if this never occurred, theimproper engine shutdown wouldshow an equal amount of left and rightengines accidentally shut down, leadingto loss of the aircraft. There was no dataon the times when pilots recognized theproblem and shut down the correctengine, or the times when they figuredout the mistake in time to recover thegood engine and shutdown the bad one,because these events are not tracked. Ilooked at 2095 USAF class A mishapsfrom 1971 to 3 April 2001. Of the 994mishaps which met the aircraft criteria,99 were engine-related. Out of the 99,three were found as "definitely" andthree were found as "probably" havingthe wrong engine shut down. So thiswas a rare occurrence, but it still causedthe loss of life and six USAF aircraft.

Now here is where it gets interesting.All six airplanes had the left engine shutdown or pulled back when the rightengine was the one that was affected. Sothis means that perhaps there is a linkbetween the design, training and habitpattern interference.

Now you ask, "How can we fix thisrare but preventable error?" Well, youcan attack any of the three factors:design, training or habit pattern inter-ference. The design is one that we arestuck with. It would cost enormousamounts to retrofit the fleet withmicrophone and speedbrake buttonson the left throttle, and how likely isthat? I think the term "obese probabili-ty" fits. The training issue is easilytackled—just practice an equal amountof left and right sim single-engine pro-cedures and make aviators aware ofthe reasoning behind the change. Dothis from the earliest phase of twin-engine pilot training and continuethroughout the flying career.

The interesting part is this: If you fixthe training issue, you eliminate thehabit pattern interference. You cannotrid yourself of the habit pattern interfer-ence without changing the design ortraining; the habit patterns are a directand predictable result of the two.

Old habits don’t have to die hard.

flying with the left engine shut down,is much easier than the other. Thisleads directly into the training aspect.

The way that we currently train andstay proficient in single-engine opera-tions is to log events for currency pur-poses. Being the intelligent type, wetend to do most of our single engine opsin the way that makes sense—the easyway. We typically simulate the leftengine as failed and conduct a flawlesssingle-engine approach and landing. Wego back to the squadron and log sim sin-gle-engine on the event tracker, andeveryone is happy. Here is where theinterference plays a part.

Habit pattern interference is wherehabit patterns interfere with some pro-cedure. "Sounds simple enough," yousay, "What does this have to do withemergency engine shutdown?" If youhave been paying attention, you cananswer the question yourself. If not,here you go. The critical actions thatmust be quickly accomplished undertimes of severe stress tend to revert backto learned behaviors—habits. Thesehabits can be very helpful because theyrequire little conscious thought and canbe quickly carried out. They can bedeadly if applied to the wrong situation.This is habit pattern interference.

When a pilot sees a fire light duringlow level flight ops, multiple actionsmust occur almost simultaneously tosafely recover the aircraft. Groundavoidance and flight path deconflictionare just two, but the proper boldfaceprocedure must also be applied to theaffected engine. When under stress,many aviators revert to habits; in thiscase they have practiced pulling the leftengine to idle/off and also pushing orpulling fire buttons/agent discharge,firewall shutoff, etc., to accomplish theboldface. When you have an engine onfire and you shut the other engine off,you don’t produce a lot of thrust, andyou don’t keep flying very long. If youhave enough altitude or smash, youmight be able to fix the problem beforeresorting to the silk descent. If you areout of thrust and options, you may haveto give the jet back to the taxpayers in itsprimitive form—molten metal.

Now that you know how you can beset up to make this mistake, you mightwant to know why and how I knowabout it. Well, I saw some mishap data

All six air-

planes had

the left

engine

shut down

or pulled

back.


MAJ NATE KELSEYHQ AFSC/SEF

Since the USAF began using nightvision goggles in earnest in the late ‘90s,we’ve experienced 14 NVG-related ClassA mishaps. As I attempted to find rootcauses or factors relating to these NVGmishaps in the Air Force Safety Center’sextensive database, I realized severalthings. But before I get to that, let megive you some of my background.

The first time I flew with NVGs wasback in the early ‘80s. I flew variousaircraft with large rotating fans on topof them in another branch of theArmed Forces. To say night visiontechnology was crude back then wouldbe an understatement.

The two things that impressed memost about NVGs back then was theamount of weight I could tolerate on topof my cranium for long periods of time,and how well I could see the groundevery time my IP rolled the throttle toidle during the final approach phase oflanding. Practicing my touchdownautorotations at night was actually moreenjoyable to me than during daytimetraining. Looking back, however, thereason I liked doing "autos" at night wasI don’t think I was seeing things as wellas I thought I was.

Fast forward 16 years to the latter halfof the ‘90s. At that time I was a Cat IIILANTIRN instructor at Luke AFB in the310th FS (Cat III is self designated LaserGuided Bomb low altitude loft deliver-ies). The motto of the LANTIRN com-munity was "Turning Night into Day."Well, the system was good...but not that

good. The squadron eventually startedflying with the newer generation NVGsduring LANTIRN training missions,and life was good! The synergy of thetwo systems more than made up fortheir individual weaknesses. It got tothe point that anytime any of the IPswere flying at night, either in the frontseat or "riding in the pit," we’d wear ourNVGs. That included the initial "nay-sayers" who thought NVGs were "novalue added."

The more I flew with NVGs the more Iliked them, but the more I began to real-ize their limitations. Rewarding NVGsorties started with the preflight and thefocusing. Not the time to pencil-whipprocedures. Then while flying, it wasabsolutely imperative to keep your headon a swivel. We humans tend to moveour eyes until we reach our Mk1 eyeball"gimbal limit," then we’ll move ourskull to maintain visual contact withwhatever object has our interest. Notthe best technique while wearing NVGs.Consciously forcing yourself to do adeliberate overlapping scan patterngives your brain the opportunity to fillin the blanks that monocular vision isproviding you. Real basic stuff here.Several times I was lulled into thinkingI was seeing better than I really was.

I remember one night instructing fromthe pit and my "stud" was rejoining inthe working area to RTB. The flight leadwas about 40 degrees left with zeroaspect and about four miles ahead of us.Well, junior started the rejoin without aradar lock—not the best move, day ornight. After some prodding from me inthe backseat, he established a radar lock

The pilot

was defi-

nitely

enamored

with the

NVGs’

incredible

image.

US Marines/AF photo by Carlos Cintron


execute a planned climbing safe escapemaneuver. This resulted in a shallowerclimb angle and lower-than-intendedrecovery altitude prior to a turn off-target.The result was an undetected overbankand descent during a turn. The MP didnot attempt to eject, and the MA impact-ed the ground in a near-vertical attitude.

There should be no doubt that spatialdisorientation and perhaps G-excess,combined with an inadequate instru-ment crosscheck, was the most probablereason for this tragic loss of a fellowfighter pilot and a valuable combat asset.Once again, that great image NVGs pro-vide you has some severe limitations.

• Just after entering the area, a pair of F-16s had a midair. MA1 collided with MA2with about 180 knots of overtake. MA1experienced dual hydraulic failure andentered into an unrecoverable stall. Bothpilots successfully ejected. Remembermy story? Sounds very similar.

• The mishap sortie was a two-shipNVG upgrade sortie. During the mishapsequence, the MP had a closure speed of350 knots. During the last portion of theintercept, the MP had his attention onthe radar tube for 6-10 seconds. No, thisis not a reprint of what I just said; theseare two completely different events.

• The mishap sortie was planned,briefed and flown as a night basic sur-face attack mission with NVGs. Duringthe sortie, the NVG case fell off the leftpanel and the NVG case strap snaggedon the unguarded Manual FlightReversion Flight Control Switch. Themishap pilot ejected and the MA wasdestroyed upon ground impact.

Some pilots might initially say "poorcockpit management." I say it gets busywhen you’re flying single-seat fighters,especially at night.

What can be said about NVGs? Theyprovide you with an enhanced ability tosee at night. They also provide you withopportunities to become spatially dis-oriented while maneuvering, and withthe ability to fly into IMC conditionswithout realizing it and run into otherairplanes, if you’re not keeping youreyes outside when you’re within 10 NMduring your intercept. Back up whatyou think you see with another onboardsystem. Keep your head on a swiveland check six!

"Deliberate with caution, but act withdecision."

on lead. Well, this young fighter pilotwas so amazed at the visual clarity pro-vided to him by the NVGs that hestopped referencing his radar and HUDairspeed! As we got within a mile oflead, I asked "Studly" what his overtakeairspeed was. After a pregnant pause, hesaid, "About 450." Since the briefedrejoin airspeed was 300 knots, we wereclosing fast and the words "excessiveovertake" come to mind. I took control ofthe jet at 3000 feet and maneuvered ourjet away from lead, winding up about9000 feet in line-abreast formation.

The lesson learned that night wasalways back up what you think you seewith another on-board sensor, whetherDME or FCR data. By keeping mySituational Awareness of lead from thebackseat, I was able to let this upgradingNVG student learn a valuable lesson.That young student, by the way, was amajor with over 1700 hours in the F-16.Channelized attention? You bet. The pilotwas definitely enamored with the NVGs’incredible image. A potentially cata-strophic situation complete with fatali-ties was avoided, not to mention addinga few more gray hairs to my nugget. Mygoing-in position with this article is: Noone intentionally flies into the ground orruns into another airplane on purpose,whether wearing NVGs or not.

Let’s look at some NVG-relatedmishaps and try to glean some lessons.

• The mishap aircraft (MA) was leadof a two-ship NVG syllabus mission toaccomplish Cat-1 NVG currency. Theflight entered the working area at 200feet AGL with the IP in a 2-3 NM trail.The mishap pilot (MP) was describingseveral geographical features and man-made targets to his wingman IP. Whileoverflying and describing a target, theMP inadvertently entered IMC condi-tions. While attempting to determinethe MA attitude, the MP became spatial-ly disoriented and ejected. The MA wasdestroyed upon ground impact.

Two things come to mind initially.First of all, it is very difficult at times torecognize when you are flying, or areabout to fly, into certain atmosphericconditions like clouds while wearingNVGs. Secondly, it may be surmisedthat the MP may have been overconfi-dent in what the NVGs were providinghim as far as visual acuity is concerned.

• The MP of an A-10 did not properly

NVGs pro-

vide you

with oppor-

tunities to

become spa-

tially disori-

ented.


TSGT JOSEPH RICHARDUSAF Air Demonstration SquadronNellis AFB, NV

It was your ordinary day in theinspection section at Nellis Air ForceBase, and four of us were getting readyto do a 1200-hour inspection on thelanding gear system on one of our eliteF-16s. This inspection requires all land-ing gear and their components to beremoved so all the bearings, races,mount pins and such can be checked bymachine shop for excessive wear.

So far this year the inspection sectionhas completed seven of these inspectionsand we felt comfortable with the task athand. It was a hot Monday in July andwe were anxious to start this in-depth,four-day project. We already had theAFTO Form 781 preprints filled out, thenew gear and all the consumables wereon hand, so we were ready to go!

The team jacked the aircraft andeveryone was assigned a section towork on. Scott was working on the leftmain gear with Chad, while Craig and Iworked on the nose gear. We removedthe nose gear without any trouble, and

the left gear was coming along at a goodpace. It was almost noon when wedecided it would be a good time tobreak for lunch. We cleaned the area,put away the tools and went into theoffice for a needed break. After lunch,we were back to work and ended theday with all three landing gear removedfrom the aircraft. After we cleaned thearea we had our normal end-of-the daysection meeting. This is where wereview the day’s work and brief wherewe will be concentrating the next day.

We all came in the next morning readyto get the landing gear prepared for themachine shop inspection. Craig disas-sembled the drag braces and other com-ponents of the main landing gear. Iswapped components from the old tothe new nose strut. Scott cleaned thebearing areas on the airframe, since themachine shop was on the way to per-form their inspection.

Later on that day, I started to cleansome of the components in the partscleaner before we took them over to themachine shop. Everything was goingwell and we were ahead of schedule.

I was

shocked to

see Craig

sitting on

the floor in

a pool of

red fluid.


Why did the strut just blow apart? Idiscovered the strut had not beendepleted of its 1900-PSI nitrogen chargeduring the removal process. On pageone of T.O. 1F-16-C-2-32JG-10-1 Task 2-4-1, Removal of the Main Landing GearShock Strut Assembly, there is a warn-ing before step 3 that states "Shock strutshall be depressurized completely.Failure to comply may result in injury topersonnel." There is also another warn-ing in the tech data (prior to step 16) tomake sure the strut is depressurized priorto removing the landing light bracketfrom the strut.

Now we had to figure out what wentwrong. Were the people involved quali-fied and did they have a T.O.? Yes. Werethey hurried? No. All the workers havedone this job plenty of times in the past,and they actually finished the same taskjust a couple of weeks prior to thisevent. So what went wrong in this chainof events? Two failures to observe keytech data warnings.

First—A failure to deplete the maingear strut prior to removing it from theaircraft.

Second—A failure to verify that thepressure was depleted prior to removalof the light bracket.

In either case, maybe they thoughtsomeone else had depleted the strut orthat they would get to it later. In each sit-uation an important Tech Data warningwas missed. The missed warning couldhave caused Craig to be seriously injured.

The lessons we learned (or relearned)from this were:

•Always read and follow the T. O.•Don’t assume someone else followed

"The Book" when "The Book" asks youto verify something is done.

•It doesn’t matter how many timesyou have performed a task, alwaysreview the T. O. for any changes thatmay have been incorporated since thelast time you read the procedures.

The Thunderbirds and the Air Forcegot lucky this time and avoided a majorincident and injury to key personnel,but next time it could be different. Makesure your landing gear maintenanceprocedures are by "The Book."

Editor’s Note: TSgt Richard is currently theNCOIC of the Thunderbird MaintenanceOperations Center and at the time of the inci-dent was the Inspection Section Flight Chief.

Then, there was a thunderous explosion.It was so loud that everyone came fromhis or her office to see what had hap-pened. I quickly turned around, startledby the noise, and was shocked to see Craigsitting on the floor in a pool of red fluidwith a stunned look on his face. A millionthoughts were going thorough my mind.Was he injured? Was that blood orhydraulic fluid? What had happened?

Craig looked as if he just saw a ghost. Irushed over to see if he was okay and tofind out what had happened. It was dif-ficult for Craig to talk, as he was in a def-inite state of shock, sitting there in a poolof (thankfully) hydraulic fluid. After acouple of seconds of looking at the mainlanding gear shock strut, I pieced togeth-er what had just happened to him. Hewas disassembling the main landinggear shock strut and was in the process oftaking off the landing light bracket. (Thelight bracket being mounted to the maingear strut has been changed after theBlock 30 F-16 aircraft.) He had one of theretaining bolts removed and the secondone halfway out when the strut cameapart in front of him.

Don’t

assume

someone

else followed

"The Book."

HQ AFSC Photos by TSgt Michael Featherston


G. ARLEIGH DOMCustomer Service DepartmentThe Glenn L. Martin CompanyAircraft and Maintenance Review,February 1956

Editor’s Note: This article is reprinted fromthe February 1956 issue of AircraftAccident and Maintenance Review.Despite the fact that many maintainerstoday are women, the article shows thatsome messages are timeless. Communicationis still the key to modern maintenance.Maintenance professionals must alwayscommunicate with each other, AFETS,MAJCOMs, depots and the manufacturersto ensure our high-tech modern aircraftalways fly safe.

When a new aircraft has been built,and the Air Force has given it finalapproval, there begin for the producttwo allied but distinguishable lives. Oneis the life of operations, the other is thelife of maintenance. In both of them, thecompany that brought the aircraft to

you can play an extremely importantrole, but only if it is helped by you whodo the actual operating and maintain-ing. What I’d like to discuss here are themethods we now use to carry out ourfunctions, and the ways you can help usto improve them.

Let’s look at the situation. The mannerin which an aircraft is operated andmaintained is determined by what wecall “rules.” By “rules” I mean all theinformation, orders and policies thatsurround any work that is done by indi-vidual Air Force people. They are theguides without which the aircraft couldneither be operated nor maintained. Now,where do these rules come from and whathappens to them in actual service?

The rules for operating an aircraft ormissile are suggested by the contractor,for he knows the best design capabilitiesof the product and has extensively test-ed it before sending it out. But when theproduct reaches the field, these “rules”are modified and strengthened on thebasis of Air Force flight experience. So

The diffi-

culty is not

in having

time-worn

rules

replaced by

new ones...

HQ AFSC Photos by TSgt Michael FeatherstonPhoto Illustration by Dan Harman


And when things are done automatical-ly in the air, it generally means thatthere’s a maintenance problem on theground. Proof that this has happenedcan be afforded by a look at the auto-matic and semi-automatic equipmentincluded in today’s aircraft, comparedto the equipment of 10 years ago. Aboutall that remains, actually, is the 1945radio. For each of these novelties—LOX,ejection seats, pressurization and soforth—the pilot has some responsibility,but the maintenance man has to take thebrunt of the work. So the complexity ofmodern aircraft and missiles is cominghome to roost in the hangar. You main-tenance people have to pay for the tech-nical advances we’re making.

This probably comes as no surprise toAir Force men, but there are several pointswhich ought to be brought out about it. Asthis tendency continues, there will be morework, not less; and it’s qualitative as wellas a quantitative increase. Maintenancepeople are going to have to expand theirhorizons, because the Air Force is going toneed more men who are both imaginativeand technically informed in the new andterrifically complex problems. If it were acase of merely quantitative increase, agreater number of men would solve theproblem. But the real problem is in findingmen who are ingenious enough to masterthe new rules that are bound to come up.

This brings us to the central message Iwant to get across. We in the aircraftindustry want to help you improveyourselves and your work, in meetingthe challenge of modern complexity.The aircraft company is, I think it’s fairto say, the focal point for maintenanceinformation on its product. So it’s natur-al that we should all be interested in thecommunications between us. The diffi-culty is that the people who are to main-tain the aircraft or missile are hundredsand sometimes thousands of miles awayfrom the information. How do the AirForce and the Air Force’s contractorspass the word?

The bulwark of the communicationsbetween us, of course, is the TechnicalOrder. All the latest information on theaircraft is presented here, and it’s in con-stant revision. Prepared by the contrac-tor and reviewed by the Air Force, thisliterature gives you complete and up-to-date information.

Supplementary to the official litera-

the rules for operating an aircraft or mis-sile are never exactly what we who laidthem down thought they would be.

In maintenance, on the other hand, acompany can be pretty sure that therules it lays down for its customers tofollow today will be good ones to followtomorrow. It looks, on the face of it, asthough maintenance men have an easytime of it; but it just isn’t so, as many ofyou can attest. The difficulty facing themaintenance man is not in having histime-worn rules replaced by new ones,but in having so many new rules in addi-tion to all the old ones. And not only arethese rules more numerous, they arealso much more complex than the oldstandbys. There’s a reason for this, andit’s related, strangely enough, to the activ-ities of flight personnel rather than to any-thing done by maintenance personnel.

There are just so many things the pilotand his crew can handle while they’reflying; when this limit is reached, theaircraft designer has to turn to automat-ic controls to do the rest of the work.

...but in

having so

many new

rules in

addition to

all the old

ones.



ture are a number of special aids.Courses—offered both by the Air Forceand by the contractor—give mainte-nance men an acquaintance with theiraircraft thorough enough to enable themto return fruitfully to their T.O.; MobileTraining units, most often accompaniedby Air Force training units, bring mod-ern methods of visual education to bearon particularly knotty problems. Certainpublications, such as this magazine, dealinformally with problems common to allAir Force maintenance work. Otherbooklets, often prepared by the manu-facturer, help to clarify special difficul-ties in understanding this product.

But the most personal means of com-munication is certainly the field repre-sentative or field engineer. Constantlyavailable for consultation, he is awalking miniature edition of the com-pany he represents: an educator, advi-sor and engineer.

These are ways in which we try toimprove the lines of communication.But they are not, in themselves,enough to ensure what is most impor-tant: That every mechanic be fullyaware of what he is supposed to do ina particular situation. Now, I suppose,the producers of aircraft might writemore T.O.s. and booklets and sendmore field representatives to air bases.But this would be missing the point,which is that men who are maintainingmodern aircraft need a quality ofunderstanding that cannot be obtainedfrom any quantity of information. Thissort of understanding can come onlythrough positive attempts to solvethese new problems. The question nowis, how can we help you? In otherwords, without swamping you withmaterial, what can we give you toincrease your personal efficiency?

Many years ago, this would have beena strange request to make indeed.Aircraft companies were happy enoughto sell the equipment they made, with-out worrying about how the customersgot along with it. Now, every reputablecompany which supplies intricateweapons to the Air Force is glad to pro-vide services in a hundred ways, includ-ing those we have already discussed.There are other services which dependon requests from the users of the prod-uct, and it’s these that you should learnto take advantage of.

The field representative, for example,is someone who is at the base not only torepresent his company but also to advisein every conceivable way the men whoare taking care of the aircraft. It’s up tothe individual mechanic to bring hisquestions to the field rep’s attention.

Ordinarily you should find in the T.O.just about everything you need to know,and it is usually correct, but there aretimes when, for example, the text isunclear or incomplete and perhaps evenmistaken. The mechanic’s responsibilityis to take action, research the problem,ask the field representative, ask otherauthorities. In short, become an activeparticipant to the solution.

The field representative is the properauthority at the base to represent hiscompany. It may be, however, that apuzzle arises and you want more voicesin the discussion. You may be pleasantlysurprised at the attention any manufac-turer will give to your problem. Thereare a couple of reasons for this attention.

For one thing, we who manufacture aweapon are as eager as you are to makeit a smoothly operating piece of equip-ment; any of its problems that can besolved is a step towards making it thatmuch better. But there’s a second rea-son, too, and it goes to the heart of thematter we’ve been discussing.

Have you ever noticed that somesupervisors leave their office dooropen? They’re not just circulating air, ifmy guess is correct. The open door is asymbolic invitation to exchange ideas,and this is communication. Whether it’sthe door of a supervisor, or figurativelyof a large company, I firmly believe it’s agood policy to have the work passed upas well as down. There are very realpractical reasons for the policy, and oneof them is that it’s one of the few waysthe supervisor (or the company) has offinding out what his people are saying.It’s easy enough for us to pass out liter-ature and send representatives around;but it’s difficult to find out what effectthis communication is having unlessthere is another line of communication,from you to us.

What I’ve been trying to say can beboiled down to a few words. We alreadyhave some means of getting informationto you, but this is not enough. You have toseek information, information which theproducers of aircraft are happy to give.

The open

door is a

symbolic

invitation to

exchange

ideas, and

this is com-

munication.


four Sparrow and four Sidewinder mis-siles, pre-flight maintenance carried outand engines run to check various sys-tems and tune the missiles.

The rest of the crew, including the air-crew, are taking advantage of a lull inthe flying to grab some eagerly sought-after hours of shallow sleep, and it is myturn to do the "gases." This is a four-hourly physical check of the variousgaseous systems on the F-4, to top up asrequired and to carry out any minormaintenance required (this in the dayswhen one man could be trusted to carryout aircraft maintenance across tradeboundaries and often did so, hence thenoble Flight Line Maniacs). I have justchecked the left main wheel bay for anyleaks, stumbling around in the dark andcold in the weak light from a fast-failingtorch [flashlight] and notice that the tyrelooks soft. So I dig a pressure gauge outand check the pressure. It is low, so Ihave to get the tyre inflation kit. Noproblems; the accumulator will be fulland I will not need to drag the nitrogenkit to the aircraft.

Wrong. The kit accumulator is empty,so I now have to charge it via the mainbottle set.

The crew room is in darkness andsilent save for muffled snores from themain bedroom where my colleagues areasleep, and the crew room heat was wel-come on my frozen face and fingers as Igathered the spanners [wrenches] andbottle key. The room smells of cigarettesand sweaty socks, the tables in the dark-ness covered with the large F700 main-tenance documents for each of the fouraircraft that are now part of the Q shedinventory. Various games are strewn onother tables, and coffee mugs stand

A Tale of a Flight Line ManiacCourtesy Airclues (UK), 4/2001

Winter in the north of Scotland, andthe weather is living up to a well-found-ed reputation for its ability to be dread-ful. I am on Northern Quick ReactionAlert (QRA or Q) with a well-known F-4 squadron (yes, groundcrew do belongto squadrons as well) for the usualseven-day stint, and it is halfwaythrough the duty. It is 1975, and the fly-ing has been unusually intensive, withQ-birds now lined up outside (no hard-ened aircraft shelter in those halcyondays) on "the point" in the Siberia-likeconditions, with howling winds anddriving sleet and snow. The aircraftparked outside are two-tone, with oneside covered in a thin veneer of blasted-on ice and snow, and the other in starkcontrast, being in the lee of the weather.

To venture into the Q sheds in winter,even with the steel shuttered doorsclosed, is to invite exposure and goosepimples the size of eggs. The sounds ofthe storm echo through the dark tinstructure of the sheds, even with thehulking presence of two fully-armedPhantoms lurking in the murk. Freezingwater is trickling under the closed shut-ter doors forming puddles, and thedoors are rattling and banging as thewinds batter and tear at them. It is thefourth day of activity, and we ground-crew are all very tired, having beenactive for the past four days and throughthis night launching and recovering Q1and 2. In addition, we have had to sufferthe storms to get Q3 and 4 on line. Thishas entailed working in the teeth of theweather in darkness, as aircraft werearmed with the standard complement of

I dig a

pressure

gauge out

and check

the pres-

sure. It is

low.


HQ AFSC Photo by TSgt Michael FeatherstonPhoto Illustration by Dan Harman

ready for the morning.Through the heavy steel blast door,

being careful not to let it slam shut,down dark steps, through another steeldoor and into the echoing cavern of theQ1 shed, I duck under the left wingbetween the Fletcher fuel tank and theoutboard Sidewinder, getting my coldweather jacket caught on the fins, rip-ping yet another ragged vent, strug-gling free I crouch beside the tyre.Blowing on my fingers for some heat, Iconnect the bottles up, charge the accu-mulator and connect the charging kit tothe valve on the tyre. The wind contin-ues its blasting, and fresh squalls of sleetare hissing against the tin roof and wallsof the dark and cold shed. Wraiths ofarctic air seep down my exposed neck,making me shiver. It’s surprising howquickly an aircraft can cool down fol-lowing a five-hour sortie, and the air inthe shed must be at arctic levels—if notlower! I am feeling sorry for myself. Asusual, some air escapes from the valveas I struggle to fit the damn thing, nothelped by the fact that it is still "darko’clock" hours, I am very tired, and myfingers are numb from the penetratingcold. My nose is running, my breathsteams in clouds and my many layers ofclothes both under and over my denimsare not helping maintain my core bodytemperature. I am also kneeling in afresh puddle of melted glacier that hasflowed into the shed from the condi-tions outside.

To my utter frustration, the inflationvalve is now stuck on the tyre valvewith the air escaping fast…

…And it was then that I did some-thing that I have not been proud of overthe intervening years. I panicked andlost my temper; a lethal and heady brew.I tried to pull the jammed valve off butmy fingers slipped and I fell backward,catching my head on the way down onthe undercarriage down-lock actuatorand had the breath knocked out of me,landing in an undignified lump underthe auxiliary air door. Strugglingupright, I then caught my collarbone onthe undercarriage door and landed onboth knees, clutching my woundedshoulder and moaning gently whilstrocking slowly to and fro. The languagewould have shocked Lucifer himself.

As soon as I was as upright as possiblein the wheel well, the reaction to my

mounting anger was to lash out with asteel-toe-capped boot. I meant to miss (itbeing an expression of my angst) butcompounded the situation by connectingwith the valve, severing it from the tyrewith a final determined serpentine hiss.

The tyre now proceeded to collapse asthe air escaped with a rush, and I wasleft with Q1, the primary war bird forthe Northern sector, listing to port witha full complement of live missiles onboard. Time for rational thought, but allI could do was panic.

It is strange what the human is capa-ble of doing in situations of danger orstress. I even tried to push the fracturedvalve back into the gaping hole fromwhence it came. Stupid boy!

There was no choice now but tochange the wheel and tyre assembly.Normally a straightforward operationand one that I had carried out almostdaily for my six years as a Flight LineManiac, but at this my darkest hour itsuddenly appeared to be the most majoroperation in the world. The sparewheels and tyres were kept in a wheelchange trolley, an ancient but functionalwooden contraption that could betowed behind a Land Rover. The trolleywas parked outside the main hangar,about 400 meters as the Flight LineManiac flies. The kit consisted of twomain wheels, two nose wheels, a jackand various tools and weighed…well, itwas sufficient to give one a nasty case ofthe ruptures.

I stood in the darkness for an instantdeciding on options. Wake up thesnecko (SNCO) (not wise), get one of myassociates (again not wise) or do it all onmy own. Fed in part I suspect by embar-rassment at my stupidity, I elected forthe third option.

I ran full tilt to the hangar (easy goingwith the gale and snow behind me) andpulled the full trolley by hand to the Qshed with the storm full in my now-seared and wind-blasted face. I openedthe shuttered doors, wincing at everysqueak and squeal, jacked the aircraft(probably way over the max massallowed on the tiny bottle jack), changedthe wheel assembly and had everythingsquared away within 20 minutes.

I could no longer stand, my handswere like a grease-covered hamburger,my legs were shaking, I felt nauseous, Iwas bathed in a cold sweat and had


The tyre

now pro-

ceeded to

collapse as

the air

escaped

with a rush.


achieved nothing, and in fact could onlybe negative in its end result.

I learned that faulty equipmentshould be reported as soon as itbecomes faulty and should never be leftfor others to find; likewise they shoulddo the same. This of course involveschanging cultures. Sometimes we mustaccept the cost in fiscal terms.

The following day, after I had relatedthe tale to my SNCO and the "guys," andafter they had stopped their hystericallaughter, it was found that the thread onthe charging valve was worn out andextensively damaged, hence the continu-al troubles with getting it on and off. Itcame as no surprise that others of myhonorable trade then began to relate sim-ilar tales of woe with the valves on otheritems of ageing equipment. We then car-ried out a check of equipment availableto us, changed torch batteries, replacedworn or damaged earth leads, replacedworn and damaged covers and locks,replaced worn and damaged tools,replaced or fixed broken head sets andlong leads and re-applied paint to vari-ous and sundry items. It came as a shockto realize the number of rounded nutsand fasteners on pipe and hose ends, andhow badly damaged other vital items ofground support equipment were. Thesewould take longer to replace.

We had drifted into a comfortable butnegative frame of modus operandi, wehad omitted to question the viability ofthe tools of our trade, we had taken forgranted the vagaries of equipment, hadoperated with a substandard set of pro-cedures and tools, and had "got by." Wehad been totally task-oriented and hadforgotten the team and the individual.We had not considered the expert opin-ions of our own most importantresource, our people, and had been con-tent to work with tools that were, by anystandard, substandard.

How many of the readers today can,hand on heart, say that all tools theywork with daily on our very expensivefrontline aircraft are fit for their pur-pose? How many shift managers cansay who out of their charges are suffer-ing the onset of stress-related illness orare displaying the symptoms of stress?Stress is insidious and its effects can bedevastating to both the sufferer andthose with whom he or she has to com-municate daily.

taken the skin off both sets of knuck-les—not from dragging them along theground as some thought we wereinclined to do (or was that the armor-ers?) but from the speed and desperateenergy with which I had applied myselfto the task. And all the time dreadingthe sudden banshee wail of the scramblehooter. (I grew to hate the sound andeven now, almost 27 years later, myheart still skips when I hear anythingsounding remotely like that hooter.)

I learned about stress from this.I learned that people are vital

resources and should, in times of greatstress, be given the chance to sleep andto follow as near to proper shift patternsas operations will allow. Not justsnatched hours but quality sleep awayfrom disturbance. A lesson here formanpower and shift control duringheavy periods of work: It is dangerousto assume that people can cope, and asmanagers it is incumbent on us toensure that we actually check our peo-ple, talk to them and ask them how theyare feeling. It’s great to talk.

I learned that I was as prey to stress asthe next man and that I could not "keepgoing" on the adrenaline rush from theexcitement of the occasion, even asyoung a pup as I was then.

I learned that stores and equipmentthat might be required to support the Qsheds and aircraft should have beenparked close to them for ease of access, orif they were shared inventory then moreshould be purchased to avoid this issue.

I learned that when tired it is impor-tant to step away from tasks that arebeginning to tax and stretch the temper.Take a slow count of ten, take a powderor get someone else to take the mantlefor you or at least help. Once again, it’sgreat to talk, and a problem shared is aproblem halved.

I learned that the tools of the tradeshould be kept in an effective and viablecondition and in this case that the wheelcharging kit accumulator should havebeen charged at all times and not leftempty as usual. The standard of mosttools at the time could be best describedas "well worn."

I learned that to lose one’s temper iscounterproductive and will achievenothing positive.

I learned that taking out my temperon equipment by physical abuse

I could not

"keep

going" on

the adrena-

line rush

from the

excitement

of the

occasion.


THE LITTLE THINGS!

How often do we forget the little things in our daily routines? Unfortunately, in our business the littlethings can become large and expensive very quickly. Look out for each other, and remember the little things!

Was The Intake Inspection Clear?An MH-53M had flown an FCF in the morning

and was returned and released for flight. It wasthen scheduled to fly a night tactical low-level sor-tie. However, the FCF crew had written up the #1engine air particle separator (EAPS) caution lightfor intermittent illumination. The FCF crew and themishap crew had a face-to-face debriefing. Themishap flight engineer completed his preflight,and the mishap pilot also completed the requiredwalkaround inspection.

Now the fun starts. During engine start the num-ber two engine started normally, but the gas gener-

craft, flailing against the aircraft skin. The crewretrieved the wayward items and secured the hatchto the cargo floor. The aircraft then safely landedback at home station.

Did this crew cover all the little things? Was theinspection the crew conducted of the hatch enoughto ensure the hatch was secured? You decide. Thelittle thing of ensuring a latch is in the correct posi-tion, and doing the preflight inspection by thebook, will ensure you don’t have to wonder if thehatch is secure.

Is The Hatch Secure?A C-141C departed on an AMC-directed channel

mission. As the aircraft passed FL250 to itsassigned altitude of FL310, the aircraft experienceda rapid decompression, and there was a loud noise,followed by a vibration. The quick-reacting crewfollowed the checklist and returned the aircraft to asafe altitude. At this time, the crew found the #2emergency escape hatch (located overhead and justaft of the crew entry door) was open, and theescape ladder and survival kit were outside the air-

ator speed (NG) on number one started to roll back.With all other indications normal, the crew abortedthe engine start. The mishap crew then attemptedtwo more engine starts on the number one engine,all with the same results. Dedicated aircrew here,don’t you think?

After giving up on starting the number oneengine, they retuned the aircraft to maintenance.Maintenance then inspected the number oneengine and found severe damage to the first threestages on the inlet guide vanes. Upon teardown ofthe engine, the propulsion backshop found threepieces of FOD that appeared gold/brass/bronze in

Editor’s Note: The following accounts are from actual mishaps. Theyhave been screened to prevent the release of privileged information.


color and appeared to be from the same object.What was the object? We aren’t sure, but could thecrew have prevented the FOD or the extent of thedamage? How many times do you try before youstop and let maintenance check things out? We

need to press on with the mission, but when itcomes to our engines maybe we need to look beforewe try too many times. Another little thing we cando to prevent or limit damage to very expensiveAir Force assets.

Who Is Providing Wingtip Clearance?We all travel to exotic locations, but for a C-5B it

turned into a little bit longer trip than anticipated.The aircraft arrived at the foreign airfield and had tomake two 90-degree turns into its final parkingspace. All guidance showed that the taxiways andairfield were suited for the large C-5B. The aircraftwas cleared to taxi to the USAF-approved parkingramp. Four foreign nationals, who were untrainedin C-5B operations, provided guidance to the park-ing spot. The aircrew noticed that the two 90-degreeturns they had to make would bring them close to

an aircraft hangar and a large semi-rigid tent. The first turn was uneventful, and as the aircraft

made the second turn the right wingtip impactedthe semi-rigid tent. Do you think the tent was on theairport diagram? The crew shut down the aircraftand surveyed the damage to the aircraft. Another“little thing” that caused a damaged aircraft and adelayed mission. We must ensure that our opera-tions around the world are done safely and smartly.When in doubt, STOP! The few extra minutes youtake may save days and thousands of dollars.

How Far Can You Taxi An Aircraft?Once again at a deployed location, a B-1B taxied

to the runway for takeoff, a distance of 3500 feet.Then, due to winds and the maximum weight take-off, the crew elected to taxi to the other end of therunway to take off, another 12,500 feet. All thismovement of a heavyweight aircraft took placewithin about 15 minutes. The aircrew then tried totake off without delay. Unfortunately for them,during the takeoff roll the number four tire experi-enced tread separation, and pieces of the tireentered the number four engine. The aircraft waspast the decision point and the aircrew took off.The airfield folks cleared the runway of debriswhile the aircrew shut down the engine and light-

ened the aircraft for a return to base. Luckily for the Air Force, the crew was sharp and

the aircraft landed without further incident. Whatwent wrong? How much taxi time can you have onan aircraft before you overheat the brakes and sub-sequently the tires? Every aircraft is different, andthe tires you use are designed for a maximum taxidistance. In the case of this B-1B, the tire was onlydesigned for a 10,560-foot taxi distance withoutfirst allowing a cooling time based upon ambienttemperature, taxi speed and tire pressure. If youaren’t sure of the taxi distances at the deployedlocation, stop and ask the experts. Things changerapidly at our deployed locations, but the few min-utes you wait could save your mission.

Didn’t I Tell You Not To Touch Anything?The flight was to be a two-ship incentive ride for

a deserving airman. One of them got the ride of hislife. The aircrew briefed the personnel involved onwhat they were going to experience and the safetyrequirements IAW all MAJCOM and Wing operat-ing instructions. This included cockpit orientation,location of canopy jettison handles, ejections han-dles and the appropriate switches, as discussed inthe step brief. The crew stepped to the aircraft andthe deserving airman was assisted in strapping inby the crew chief. Takeoff was normal and every-thing was uneventful until they were performingthe second G-awareness exercise, at which time thecanopy departed the aircraft. The canopy handlewas in the down instead of the locked position.

The aircrew safely recovered the aircraft back to

home station and the investigation started. Howcould an experienced pilot and an inexperiencedbut deserving airman lose the roof? On the F-15Dthe canopy is a full manual lock canopy. In order tolock the canopy, the handle must be moved to thelocked detent, and this is the only way the canopy-unlocked light will extinguish. The rear seat has anidentical handle to that in the front seat, locatedapproximately three inches below the rear seatcanopy sill armrest. We need to make sure all per-sonnel in the cockpit know what they can and can-not touch! Everyone must understand what theemergency procedures are, and it is up to the expe-rienced parties involved to ensure they cover allparts of the safety briefings thoroughly. The littlethings can and will come back to haunt you at theworst times.


LET’S TALK POWER, OR LACK THEREOF…

Without the engine, an aircraft doesn’t go very far. It seems we maintainers have a knack for findingways to FOD our motors, or just not quite do things the right way to ensure the operators can keep themotors running. In fact, we do it to ourselves time and time again.

Did You Put The Cap On?One of our F-16CG aircraft came home with an

engine exhaust nozzle problem. A Jet Troop anda Crew Chief proceeded to change the engine-driven hydraulic pump servo filter to correct the

the required post-flight intake inspection, andguess what he found? FOD damage to the #4engine fan blades and surrounding areas! Wherecould it have come from?

During the initial investigation a screw wasfound lodged in the #4 engine fan blade’s secondstage outer shroud. This screw matched the twoother screws that were installed in the fan stopperhandle. IAW T.O. 1C-5A-2-1, the fan stoppers are tobe inspected prior to use. However, there is no cri-teria for inspecting the fan stopper.

How could we have prevented the $350,000+repair cost and lost mission-capable time of a criti-cal airlift asset? How about closer attention todetail or more defined directions? Or if you don’thave all the hardware, stop and find out where itwent before you start the engines.

Do You Have All The Pieces?Aircraft maintenance personnel were tasked with

troubleshooting a C-5 #3 engine generator discrep-ancy. Worker 1 performed the outside walkaroundand the required intake/exhaust inspection of allfour engines. During the #4 engine inspection hefound a nut and washer missing from the fan stop-per. The fan stopper is a wooden handle with aheavy rubber tip attached to sheet metal andsecured by three screws. He finished the inspectionof the #4 engine, then re-inspected the #3 engine toensure it was clear of FOD. Finding none, he docu-mented the inspections in the aircraft forms. Goodwork ethic, right?

Worker 1, along with two co-workers, started andwarmed up the engines and performed theirassigned task. After the run, Worker 1 performed

slow-to-close nozzle IAW 1F-16CG-2-78-00-1.The task was completed, and an operationalcheck was performed with no leaks noted, so theaircraft was returned to service.

The aircraft then proceeded to fly the next sortie

Editor’s Note: The following accounts are from actual mishaps. Theyhave been screened to prevent the release of privileged information.


of the day. Unfortunately for the pilot, he got tocome home early as the exhaust nozzle was stuckat 75 percent and the oil pressure was fluctuatingout of limits. The pilot landed uneventfully and theaircraft was turned over to maintenance, again!

“What happened?” you may ask. Post-flightinspection revealed the engine hydraulic pumpservo filter cap hanging by the safety wire, with oilleaking out of the filter. There was no damage tothe threads on the cap, the threaded portion of thehydraulic pump servo, or to the safety wire. Inaddition, the pump checked out good during abackshop bench check. So, why did this happen?

No one knows for sure how the cap cameloose. It was discovered that the F-16 Career

Field Education and Training Plan (CFETP) doesnot directly cover the filter in question. TheCFETP just lists "remove and replace filters." It’sup to the individual and their supervisor toensure they know all the tasks required by theaircraft. We train our people on many tasks dur-ing upgrade, and some tasks have many differ-ent parts. If you need to narrow the field in thetraining record, take the few extra minutes tomake an AF Form 797 entry to cover the addi-tional task. Even better, contact your career fieldmanager and see if you can add the task to theCFETP. The few extra minutes you spend onpaper will be gained back by ensuring the AirForce has fully-qualified airmen.

Was The Seal There Or Wasn’t It?Another one of our F-16s was rejoining on a

tanker and had a little in-flight oil problem. Hesafely returned the aircraft to the nearest landingfield and called for maintenance, as there was oilon the underside of the aircraft. When the mainte-nance recovery team arrived they found all fourchip detectors properly seated, but the numberfour detector was missing one O-ring and the sec-ond O-ring was cut. The MRT then serviced the

engine with 21 half-pints of oil, out of the 47 half-pints total capacity...

What caused this engine event? Simply put, thereare two scenarios that could have happened. Eitherthe O-ring was not installed during the post-flightinspection chip detector check, or the seal blew outduring flight. No one knows for certain whichevent happened. Bottom line…when you do theroutine pre/post-flight task, ensure you checkeverything!

How Much Oil Can We Use Per Flight Hour?In preparation for an over-the-pond deployment,

the mishap unit performed several phase inspec-tions which require the engine AC generator to beremoved, as was done on the mishap aircraft. Afterthe phase inspection, the required leak checks wereperformed to include a hot servicing of the engine.The aircraft forms showed 45 half-pints of oil wereserviced into the engine. The aircraft then flew one.6-hour sortie. In addition to this sortie, there weretwo maintenance runs completed due to a fuel mal-function during the sortie.

The sortie and the two engine runs were accom-plished all in the same day. After the sortie and themaintenance runs, the engine oil was checked andfour half-pints of oil were added and documented.Now, tech data, in this case T.O. 1F-16C-70FI-00-1,states that maintenance should have compared theflight time to the oil consumed, .6-hour sortie/fourhalf-pints. Now T.O. 1F-16C-70FI-00-1 also statesthat if oil serviced exceeds 1.5 half-pints per hour,of engine operating time, then download theengine data and get the exact engine operatingtime. This would then include ground operatingtime as well as flight time. If the oil consumptionrate still exceeds 1.5 half-pints per hour, trou-bleshoot for oil consumption. In this case, the exactoperating time was only 1.8 hours. What oil con-

sumption rate do you calculate?The cost of this maintenance event? The aircraft

flew off into the wild blue yonder for a planned 11-hour across the pond sortie. While enroute the pilotreceived an oil system malfunction message andhad to divert to the nearest airfield, only 247 NMaway, over water, in a single-engine aircraft with anengine oil system problem. The entire four-ship andtheir accompanying KC-10 followed to provide sup-port in case the worst happened over the water.Luckily for the Air Force, the aircraft landed safelyat the divert field, and the other aircraft then contin-ued on their merry way to the original destination.

“What was wrong with the aircraft?” you mightask. Well, the maintenance recovery team arrived aday and a half later and they serviced the enginewith 14 half-pints of oil. During the maintenanceengine run, they found oil leaking from the AC gen-erator O-ring, which had been pinched duringinstallation. What could have stopped this event?We all know the rules on proper documentation ofoil servicing, but have we fully trained our peopleon oil consumption? As professional maintainerswe must ensure even the youngest crew chief andengine troop, or other specialty if they perform oilservicing, know what and where to check to ensurean aircraft won’t run out of oil in the wrong place atthe worst time.


14 Oct ♣ An HH-60 crashed into a river while flying a low-level training mission.17 Oct An F-16CG was severely damaged following an aborted takeoff.25 Oct An F-16C departed the runway after landing.02 Nov ♣ An MH-53 crashed while performing a mission.05 Nov ✶ An F101 engine undergoing Test Cell maintenance sustained severe fire damage.12 Dec ♣ A B-1B crashed into the ocean shortly after takeoff.21 Dec ♣✶ A C-141B sustained a collapsed wing during ground refueling operations.30 Dec ♣✶ An RQ-4A Global Hawk unmanned aerial vehicle crashed while returning to base.08 Jan A C-17 was damaged during landing.10 Jan ♣ An F-16C crashed during a surface attack training mission.10 Jan An MH-53J crashed during a search and rescue mission.17 Jan ♣♣ Two A-10As were involved in a mid-air collision. Only one pilot ejected safely.24 Jan An MH-53 crashed while performing a mission.25 Jan ♣✶ An RQ-1 Predator crashed on landing.31 Jan ♣ A T-37 crashed during a training mission. The two crewmembers suffered fatal injuries.02 Feb ♣ A C-21 crashed while landing. The two crewmembers suffered fatal injuries.12 Feb An F-15 was severely damaged due to an engine fire.13 Feb ♣ An MC-130P crashed during a mission.18 Mar An MH-53 crashed during landing.20 Mar ♣ An F-16 crashed during a training mission and the pilot did not survive.15 Apr ♣ An F-16 crashed into the sea during a training mission.

● A Class A mishap is defined as one where there is loss of life, injury resulting in permanent total disability, destruction of an AF aircraft, and/or property damage/loss exceeding $1 million.

● These Class A mishap descriptions have been sanitized to protect privilege.● Unless otherwise stated, all crewmembers successfully ejected/egressed from their aircraft.● Reflects only USAF military fatalities.● ”♣ ” Denotes a destroyed aircraft.● “✶ ” Denotes a Class A mishap that is of the “non-rate producer” variety. Per AFI 91-204 criteria,

only those mishaps categorized as “Flight Mishaps” are used in determining overall Flight MishapRates. Non-rate producers include the Class A “Flight-Related,” “Flight-Unmanned Vehicle,” and “Ground” mishaps that are shown here for information purposes.

● Flight and ground safety statistics are updated frequently and may be viewed at the following webaddress: http://safety.kirtland.af.mil/AFSC/RDBMS/Flight/stats/statspage.html

● Current as of 29 Apr 02.

FY01 Flight Mishaps (Oct 00-Apr 01)

11 Class A Mishaps4 Fatalities

11 Aircraft Destroyed

FY02 Flight Mishaps (Oct 01-Apr 02)

17 Class A Mishaps6 Fatalities

11 Aircraft Destroyed

✩ U.S. GOVERNMENT PRINTING OFFICE 2002-773-437/53029




Airman First Class Ryan L. Moore325th Bomb Squadron

Whiteman AFB MO

A1C Ryan Moore demonstrated keen situational awareness andsafety practices when the B-2 his ground crew was recoveringexperienced a #2 brake fire in the quick-turn area. Upon taxiingback, the ground crew noticed flames originating near thebrakes, on the lower end of the left main landing gear. As theevent quickly developed, the ground crew made crucial deci-sions and took immediate action to mitigate the risks present toboth the flight crew and aircraft. As the ground crew expedi-tiously contacted the flight crew to notify them of the pendingdanger and assisted them with egress procedures to a safe dis-tance from the potential danger, A1C Moore unselfishlyapproached the aircraft and extinguished the fire. Once it wasout, he remained on scene and monitored the brake until the firedepartment arrived. His safety-focused decisions resulted inonly minor damage to the brake assembly, no loss of life, and nodamage to the aircraft or adjacent components. In the subse-quent investigation, A1C Moore provided critical technicalinputs and findings to assist in determining the cause. Theinvestigation revealed a flaw in brake change technical data,resulting in a maintenance procedural change.

HQ AFSC Photo by TSgt Michael Featherston

We did it again...with your help!