B-2A accident investigation board

Flying Safety, August, 2003

10. HUMAN FACTORS ANALYSIS

Human factors played a significant role in this mishap.

Supervisors in the A/R shop were unaware of any procedural shortcuts being used by maintenance technicians while working on the B-2A landing gear. One supervisor stated that he believed it was nearly impossible to take shortcuts with this aircraft. If the supervisor had been aware of this shortcut used to adjust the sensors, he would have "put a stop to it," Although supervisors saw the results of MMT1's work, they had not trained him for this particular job as he was trained by other airmen in the A/R shop. The A/R shop's work schedule is divided into shifts, often making consistent supervision difficult. There were frustrations expressed by some maintenance personnel regarding the lack of job continuity and the inability to schedule formal courses for teaching maintenance tasks to inexperienced technicians caused by the need to supply maintenance trainees as force protection augmentees. Therefore, maintenance technicians only received on-the-job training as actual maintenance was performed on an aircraft. The quality of maintenance training was determined by how quickly the bomb squadron needed the aircraft returned to flight status and there was "a lot of pressure to fly."

When a shop supervisor was asked by the AIB about Operational Risk Management (ORM), he said it was just coming on line in the maintenance squadron, but that the ORM meetings held before the mishap were basically for the purposes of organization and how to properly use ORM forms. When asked whether safety was emphasized on the job, the same supervisor stated that it was "a given" and usually not mentioned for specific tasks. He did state he tried to mention safety generally in weekly shop meetings.

Witnesses told the AIB that there had been one inspection with nothing notable. One maintenance supervisor stated that the unit performed monthly self-inspections using UCI checklists, but problems were being corrected as they were discovered with no specific trends identified. However, another supervisor felt there was a trend for his technicians to fail Quality Assurance evaluations during routine maintenance practices due to lack of continuity and experience in the A/R shop.

Supervisors perceived dissatisfaction among the A/R shop personnel with squadron leadership and the appearance of being the "stepchild." In general, the A/R shop felt it didn't have a vote when told to participate on troubleshooting teams; they were just told what to do. Both supervisors and maintenance technicians from the A/R shop expressed frustration arising from their repeated warnings regarding unnecessary maintenance. Throughout the morning of the mishap, the A/R technicians, including MMT1 and MMT2, expressed reservations about doing unneeded maintenance, but these concerns appeared to be brushed off by maintenance supervision present at the tiger team meeting.

On-the-job training was the primary means MMT1 was trained. It appears that this training, however, did not emphasize the use of T.O. job guides. Although MMT1 knew about the job guides and took them to the mishap aircraft, he was unable to recall actually referencing them or using them for this particular job. He was also asked if he read the job guide prior to the mishap and stated he was using the procedures he was taught in on-the-job training. When asked again, he stated he glanced at the T.O. in the past, but had never read it.