Aircraft 1, headseat 0

Mech, Summer, 2003 by Terry Carroll, Leslie York, Dale Glardon

In most aviation accidents, a number of contributing causes join together like links in a chain or holes in Swiss cheese and allow a mishap to happen. If we remove any link from that chain, an accident will not occur. Human error is the most common cause of any mishap, and this story is about an aircraft that ate a communications headset. You will see the many links that led to our mishap.

Two experienced maintenance technicians just had completed a late-night engine turn and found a communications headset was not working. When the run was completed, one of the maintainers put the headset and cord inside an intake screen and went to another aircraft to do another turn. This was their first mistake because they did not turn in the headset as a broken tool.

The turn operator already had inspected the aircraft and its intakes before the screens were installed. When the screens arrived, the technician and the turn operator installed them, causing mistake number two. The turn operator had failed to complete a pre-op inspection on the turn screens, which would have revealed the headset and cord. The technicians also failed to make sure the work area thoroughly was illuminated with mobile light carts-the third mistake.

Since the headset did not work, the turn took place with the ground technician standing on the boarding ladder so he could communicate with the cockpit. That maintainer noted in his statement that "they were going to be short turns." This meant the technicians had failed to follow procedures for an aircraft ground turn and made mistake number four.

Turn procedures require a headset and a communication cord. Had the bad one been turned in as broken and a new one checked out, the maintainer would not have stood on the boarding ladder with a bad headset stuffed in the turn screen. The headset FODed the engine, and the damage cost $265,913.69.

These type of mistakes and accidents do happen especially given the high operational tempo of naval aviation, but most errors are preventable. This case was no exception. Our maintainers were well-trained and experienced mechanics, but they got complacent.

We have to insist on strict compliance with procedures, to avoid lax attitudes, and to think in terms of doing the mission effectively. When we break the "safety chain," accidents will follow, and, in our case, we proved that theory again.

LCdr. Terry Carroll is the maintenance officer at CTW-1. Leslie York and Dale Glardon work for Boeing Corp., Meridian.