I have a BUTE of a story

Mech, Winter, 2003 by Chris Parham

While working night check, a fellow metalsmith and I waited for one of our C-9s to return, so we could repair a pending gripe on a bracket from the left onboard spoiler. It's the one that holds hydraulic lines away from the spoiler and aileron control cables.

Once the aircraft landed, we told maintenance control that we were going to work on the discrepancy. Instead of taking the whole toolbox out to the aircraft, we grabbed only the necessary tools required for the job--my first mistake--and headed out to the aircraft. We then removed the bracket without incident and brought it back to the shop for rework. We remanufactured the bracket, gathered the necessary tools, put them in our pockets, and headed out to the aircraft, again leaving the toolbox behind--my second mistake.

The new bracket went into a tight area, and it took two people to handle the wrenches, flashlight and needle-nose pliers. After we got the screws installed in the Adel clamps, I put the pliers down on top of the BUTE (bent-up trailing edge) door, and we started tightening the hardware. After we finished, I collected all the tools, or so I thought, and headed back to the shop. A shipmate filled out the VIDS-MAF, and, as the collateral-duty inspector, I signed the "inspected by" and "logbook-entry required" blocks, stating all tools were accounted for. Night check then secured for the evening.

At 0530 the next morning, a day-check AM2 did the workcenter tool inventory and overlooked an empty spot where a pair of needle nose pliers should have been--the third mistake. The maintainer had just returned from 72 hours of SIQ and still was not feeling well. He went home later that day.

That same morning, aircraft 513 had launched on a line flight, returned and went out again later. Just before shift change, day check did a tool inventory. and they noticed the needle-nose pliers were missing. They called me at home, and I told them we had used the pliers in the flap well while installing a bracket the previous night. I said. "If the pliers are not in the shop, they are either silting in the flap well on top of the BUTE door, or they fell out of my pocket while I walked back to the shop."

I came in early to help find the pliers, but that drive was the longest 15 minutes of my life. All I could think about was a pair of pliers sliding around the control cables of an airborne aircraft.

I arrived and immediately started to took for the pliers on the flight line and in the shop. I had no luck and took the next step, notifying maintenance control and QA that we had a missing tool. I told them it may be on the aircraft, inside the flap well, and around the flight controls.

Aircraft 513 was out of range for the base radio frequency. Maintenance control instantly contacted the control tower and had them radio the aircraft to return to base immediately.

I volunteered to block in the aircraft and signaled them to drop the flaps. This step would allow me to inspect the work area. I found the needle-nose pliers wedged under the spring rod of the BUTE door. I showed them to the pilots, maintenance control personnel, and QA.

I am thankful that the only damage done was to my professional pride, but this incident very easily could have ended much worse. While in flight, the pliers could have fallen off the aircraft and hit something or someone on the ground, causing major damage, serious injury or death. The pliers could have been wedged in the flight-control cables, causing the aircraft to lose control.

Several items contributed to this situation: incorrect tool check-out entries in the tool log, improper CDI tool-inventory procedures after the completion of the job, inaccurate night-check post-shift tool inventory, and inaccurate day-check pre-shift tool inventory.

I learned how important tool control is to naval aviation and can't stress it enough. This event clearly illustrates how a series of procedural errors could have created a major mishap and could have cost lives and loss of aircraft. That's people and equipment for which I am responsible.

Petty Officer Parham wrote this article while assigned to the airframes shop at VR-58.