Work zone: reducing mishaps by 50%

Mech, Winter, 2003

Maintenance-Related Mishap (FY94-93)

The Cost:

* $873,009,104

* 18 Shipmates, Marines and friends dead.

* 37 aircraft destroyed and many more unavailable for extended periods, dramatically affecting readiness.

Which Communities Are at Risk

* Fighter: 8 destroyed and 1 dead

* Attack: 19 destroyed and 8 dead

* Helos: 5 destroyed and 7 dead

* Trainers: 3 destroyed and 2 dead

* Other: 2 destroyed and 0 dead

When aircraft crash because of maintenance malpractice?

Sun-30, Mon-61, Tue-84, Wed-88, Thu-96, Fri-81, Sat-51

What are common causes (reason and number of events)?

* Supervision--270

* Failed to manage/supervise personnel/assets--96

* Failed to demand adherence to technical doctrine--77

* Inadequately inspected--59

* Production--360

* Failed to follow technical procedure--130

* Improperly installed--65

* Lost situational awareness--46

How can we fix these problems?

* Ensure every job is supervised.

* Use the book every time and make sure every Sailor is taught to avoid shortcuts and follow the step-by-step procedures in the maintenance manuals.

* Do thorough in-process and final inspections.

* Make sure Sailors and Marines are rested and are focused on their duties.

* Do self-assessments and asks for safety surveys.

* Use the information in this magazine, messages and other media to help maintainers work to reduce mishaps.

These charts show the relationship between injury classification and mishaps or incidents caused by maintainers and aviators. Remember, some incidents can involve a maintenance and aircrew causal factor (double reporting). Aircraft and events are included to show that some single events involve multiple aircraft and to correlate the number of events to injuries or deaths. Lost-work day (LWD) and first-aid injuries are included.

Maintainers are responsible for more ground incidents and their related injuries than those caused by aviators (no surprise). However, it is interesting to note the number of fatalities and lost-work day injuries linked to maintenance causal factors in the ground and in-flight categories. The number of first-aid injuries reported in the intent-for-flight category is significant higher than ground, in part because a maintainer is unlikely to report a first-aid injury. Aviators are more likely to report these types of injuries because it is part of the hazrep culture to do so. It is important for maintainers to see the range and severity of injuries caused from maintenance error. We must do better to prevent mishaps and incidents.

No Intent for Flight (Ground Incidents)
Jan. 01, 1980 to Sept. 30, 2003

     Injury                     No. of People
      Class                  Maint   Aircrew

A--Fatal                        27       8
B--Perm Total Disability         1       0
C--Perm Partial Disability      46       4
D--5 or Greater LWD            499      27
E--1-4 LWD                     411       5
F--First-Aid Injury             41      16

Totals                        1025      60

No. of events:
Maint. 1602
Aircrew 225

No. of aircraft.
Maint. 1689
Aircrew 271

Intent for Flight (Takeoff, In-Flight or Landing Incidents)
Jan. 01, 1980 to Sept. 30, 2003

     Injury                     No. of People
      Class                  Maint   Aircrew

A--Fatal                       89       815
B--Perm Total Disability        3         7
C--Perm Partial Disability     10        53
D--5 or Greater LWD           104       300
E--1-4 LWD                     77       256
F--First-Aid Injury           177       725

Totals                        460      2156

No. of events:
Maint. 950
Aircrew 2177

No. of aircraft:
Maint. 978
Aircrew 2561