F-117A Accident During Air Show Flyover Caused by Omission of Fasteners in Wing-Support Structure

FLIGHT SAFETY FOUNDATION Aviation Mechanics Bulletin SEPTEMBERÐOCTOBER 1998

F-117A Accident during Air Show Flyover Caused by Omission of Fasteners in Wing-support Structure FLIGHT SAFETY FOUNDATION Aviation Mechanics Bulletin Dedicated to the aviation mechanic whose knowledge, craftsmanship and integrity form the core of air safety. Robert A. Feeler, editorial coordinator

SeptemberÐOctober 1998 Vol. 46 No. 5

F-117A Accident during Air Show Flyover Caused by Omission of Fasteners in Wing-support Structure...... 1 Maintenance Alert ...... 9 News & Tips ...... 13

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Bart J. Crotty Aviation Consultant

On Sept. 14, 1997, the pilot of a Lock- Force said that no one on the ground heed Martin F-117A felt an abnormal was seriously injured; news media re- vibration when he initiated a climb ports said that 12 people suffered during a flyover at 700 feet and 380 minor injuries. knots at an air show at Martin State Airport near Baltimore, Maryland, The Air Force said, in its investiga- U.S. The U.S. Air Force stealth fight- tion report, that the accident was er then abruptly rolled to the left and caused by the omission of four fas- pitched nose-up. teners, which resulted in failure of the brackets that attach a wing-support A large section of the left wing sepa- structure to ribs in the left wing. rated from the airplane and struck the ground between the runway and a The aluminum wing-support structure, taxiway. The nose section also sepa- informally called a Brooklyn Bridge, rated from the airplane. The pilot measures 18 inches by 5 inches by 5 ejected, and the airplane descended inches (45.7 centimeters by 12.7 cen- and struck the ground in a residential timeters by 12.7 centimeters). The area. structure spans the outboard-elevon integrated-servo-actuator (ISA) bay. The airplane was destroyed, and three The structure braces the wing and houses were damaged by fire. The serves as a platform for attachment of pilot sustained minor injuries. The Air the outboard-elevon ISA. (An elevon is a primary control surface that com- rigidity of the left wing and allowed bines the functions of an aileron and the support structure and the out- an elevator.) board-elevon ISA to move within the outboard-elevon ISA bay. This al- Figure 1 shows the wing-support struc- lowed uncommanded movements of ture. Figure 2, page 3 shows the loca- the elevon to begin as the airplane tion of the wing-support structure. began to climb during the air show flyover. The Air Force said that four Hi-Lok fasteners (bolts) were omitted from The intensity of the elevon oscilla- one of the support structure’s attach- tions increased and resulted in ment brackets. Omission of the fas- structural stress that ultimately teners resulted in reduced structural caused the wing to fail and separate

Lockheed Martin F-117A Accident, Sept. 14, 1997 Left-wing Support Structure

Top Cap

Location of Four Missing Fasteners D OAR AFT OUTB Source: U.S. Air Force Figure 1

2 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 about 2.5 feet (0.76 meter) inboard had been performed between 1992 of the outboard elevon, at the no. 11 and 1996 on the support structures in wing-rib position. both wings and the outboard-elevon ISA in the left wing. The accident airplane was built in 1983 and had accumulated 2,585 The wing-support structures in the flight hours. The Air Force said that F-117 fleet had a history of mainte- the pilot’s preflight inspection on the nance problems that began in 1988. day of the accident had revealed no The problems were caused by loose discrepancies. A review of mainte- Taper-Lok and Hi-Lok fasteners; nance conducted during the previous elongated bolt holes; and cracked 30 days (14 items) revealed nothing support “T” (T-shaped) brackets. that could have been involved in the accident. Two T brackets, four “L” (L-shaped) brackets and several fasteners affix A further review of the airplane’s each wing-support structure to the no. maintenance history by the Air Force 14 wing rib and the no. 15 wing rib showed that substantial modifications in the ISA bay. Fasteners also affix

Lockheed Martin F-117A Accident, Sept. 14, 1997 Left Wing

Inboard Elevon

Outboard Elevon

Location of Wing-support Structure

Outboard Elevon Integrated Servo-actuator

Source: U.S. Air Force Figure 2

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 3 steel caps to the top and bottom of staffing situation had on the events each support structure. leading to the accident.

During a scheduled (no. 3 phase) in- The Air Force found no record in the spection in January 1996, the support computer database (the core automat- structures in both wings of the acci- ed maintenance system [CAMS]) of dent airplane were found to flex up the removal, repair, reinstallation and and down. The aircraft manufacturer inspection of the wing-support struc- recommended removal and repair of tures by Air Force technicians. A the structures. The manufacturer pro- record had been made on paper, but vided on-site technical assistance and had been discarded; such paperwork tools, and Air Force structural-repair is not required to be retained beyond personnel removed, repaired and re- three months. installed the structures at an Air Force field maintenance facility. Maintenance personnel from at least four different Air Force technical The repairs consisted of stripping groups, an Air Force engineering tech- paint; resizing holes; conducting non- nical service representative and the destructive inspections; installing aircraft manufacturer’s representative new, oversized fasteners; and repaint- had been involved in the removal, re- ing. The repairs required two weeks pair, reinstallation and inspection of to complete. the wing-support structures.

The Air Force said that when the Structural repair personnel had in- structural-repair personnel reinstalled stalled the wing-support structure in the wing-support structure in the left the left wing. The aircraft’s crew chief wing, they apparently failed to install or wing phase-inspection personnel four Hi-Lok fasteners on the upper then had installed the outboard- inboard L bracket that attaches the elevon ISA and the steel cap. With structure to the no. 14 rib. the cap installed, the wing-support structure and its rib attachments no The Air Force said that two people in longer were visible. key maintenance-management positions at the field maintenance facili- Air Force aircraft are maintained, in ty were in transition (that is, they had part, according to procedures in spe- received new job assignments) and cific technical orders (TOs). There that no one had been assigned to an- was no TO for removal, repair and other key maintenance-management reinstallation of the wing-support position at the facility. The Air Force structure. Therefore, submittal of did not say what effect, if any, this a maintenance-assistance request

4 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 (MAR) by the field maintenance fa- two technicians conducted the in- cility and approval of the request by spection, but Air Force investigators appropriate Air Force authorities discovered that the inspection actu- were required before the work was ally was conducted by three other begun. technicians.

The Air Force said that it found no The inspection required removing MAR or written record of approval the top steel caps, but not the wing- for the work, although some docu- support structures. The three techni- ments indicated that verbal approval cians who removed the steel cap from for the work had been given. the left-wing-support structure said that they could not recall if the four Air Force officials with authority to Hi-Lok fasteners were in place. approve the work said that they were aware that the steel caps were being Records show that no further main- removed, but were not aware that the tenance or inspections of the ISA bay entire wing-support structures would were conducted before the accident be removed, repaired and reinstalled. occurred. Some officials referred to the steel caps as part of the wing-support struc- The accident aircraft was at a depot tures; other officials referred to the maintenance facility between August caps as components that are not part 1996 and November 1996. A time of the wing-support structures. compliance directive (TCD) recom- mending inspection of wing-support- Some maintenance personnel inter- structure fittings was not conducted viewed by investigators said that the during a depot visit. repair of the wing-support structure was complex and normally would be The TCD had been issued in January conducted at a depot maintenance 1996 (the same month that the wing- facility, rather than at a field mainte- support structure in the accident air- nance facility. They said that the de- craft was repaired at the field ficiencies in documentation of the maintenance facility). The directive work resulted, in part, from conduct- recommended inspection of the ing the work at the field facility. Taper-Lok holes, Hi-Lok holes and T brackets in all F-117A wing- A no. 4 phase inspection of the air- support structures. The TCD said that plane was conducted in July 1996. the inspection should be conducted at The left outboard-elevon ISA and the a depot maintenance facility within ISA attachment fittings were in- one year of issuance of the directive spected. CAMS records showed that or whenever parts became available.

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 5 The Air Force said that because Maintenance Errors of contractual and budgetary constraints, the inspection recom- Analyzed mended by the TCD was not conducted when the airplane was at the depot An analysis of the Air Force report facility. suggests events and factors that could have influenced the course of events In June 1997, a major (no. 1 phase) that led to the omission of the wing- inspection was completed. Following support-structure fasteners (readers the inspection, an Air Force pilot with may formulate other possible events three years of flight experience in and factors contributing to the main- F-117s flew a Northrop T-38 behind tenance error). The codes appearing the accident airplane. The pilot ob- in parentheses, in order of priority served that the outboard elevon on the assigned by the author, are explained accident airplane’s left wing was de- in Table 1. flected approximately two inches (5.1 centimeters) upward while the air- ¥ The technicians who reinstalled plane was in level flight. the repaired support structure in the left wing in early 1996 failed The T-38 pilot reported the abnormal to install four Hi-Lok fasteners deflection. No written procedure ex- (W, S, C, P, O); isted for investigating the abnormal- ity. Nevertheless, an exterior visual ¥A postinstallation inspection of inspection was conducted on the the wing-support structure may ground. The Air Force said that the not have been conducted or may maintenance technicians found only not have been conducted prop- 0.5 inch to 0.75 inch (1.3 centime- erly (S, I, P, C); ters to 1.9 centimeters) deflection and concluded that this was acceptable. ¥ The crew chief or the phase in- No further action was taken. spection personnel who installed the top steel cap on the wing- In October 1997 (one month after the support structure did not discov- accident occurred), the TCD recom- er that four Hi-Lok fasteners mending inspection of F-117 wing- were omitted (W, P); support structures was revised to require compliance “not later than next ¥ The omitted fasteners were not depot input.” The Air Force said that discovered during the July 1996 the revision was made because of an inspection of the outboard- administrative error in issuing the orig- elevon ISA and ISA attachment inal TCD, not because of the accident. fittings (I, T, W);

6 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 Table 1 Factors Involved in Maintenance Error

Code Factor Related Elements

C Communications Verbal, written, visual D Design Original, modification E Environment Weather, lighting, indoor temperature, noise I Inspection Preliminary, progressive, final; NDI, duplicate H Hardware Equipment, tools, parts, material, etc. L Limitations (physical), Weight, reach, sight ergonomics M Manufacturer manuals Instructions, service bulletins, aircraft flight manuals, alerts, data, etc. O Organizational structure Division of and/or shared responsibility, and top management support recources, safety commitment and assurance P Paperwork and its systems Logbooks, records, documentation, etc. R Regulations Design, operating, airworthiness, etc. S Supervision and middle Work assignment and oversight, decision management making T Training Basic skills, aircraft technical, administration, human factors W Worker Aircraft maintenance, licensed, nonlicensed, ground-support staff X Physiological, psychological Stress, fatigue, drugs, alcohol, etc.

Source: Bart J. Crotty

¥ Records misidentifying personnel field maintenance facility staffed who had conducted maintenance by personnel in transition, and on the accident airplane, the ab- with another key maintenance- sence of records of several repairs management position vacant, the and inspections of the airplane, opportunity existed for potential- and noncompliance with proce- ly inadequate supervision of the dures for seeking MAR authority removal, repair and reinstallation show that strict control of main- of the wing-support structure (O, tenance was lacking (P, S, C, O); S, C);

¥With two key maintenance- ¥ The decision to conduct the re- management positions at the moval, repair and reinstallation

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 7 of the wing-support structure at Editorial note: This article was based the field facility was question- on U.S. Air Force Accident Investi- able, because the facility lacked gation Report F-117A, SN 81- full management capability and 000793, 7th Fighter Squadron, 49th because the removal, repair and Fighter Wing, Holloman Air Force reinstallation of the wing- Base, New Mexico, 14 September support structure were complex 1997, Near Martin State Airport, tasks (O, S, L); Maryland. The 795-page report con- tains diagrams, color photographs ¥ Discovery that fasteners were and appendixes. The maintenance- omitted from the wing-support error analysis presented by the author structure likely would have been is not part of the report. made when the accident airplane was at the depot mainte- About the Author nance facility, if the TCD had required, rather than recom- Bart J. Crotty is an airworthiness and mended, inspection of the sup- maintenance consultant. He is a port structure when the airplane former U.S. Federal Aviation Admin- was at the depot facility (P, I, S, istration airworthiness inspector and O, C) ; and, trainer, and designated airworthiness representative. Crotty has worked for ¥Following the T-38 pilot’s report, repair stations, airlines, an aircraft the conclusion of maintenance manufacturer, law firms, safety orga- technicians that the elevon de- nizations and several non-U.S. na- flection was acceptable was not tional civil aviation authorities. His based on specific, established career spans 38 years, approximate- criteria and precluded a more ly half of it in non-U.S. locations. He thorough investigation that might has an airframe and powerplant cer- have revealed degraded structur- tificate and a bachelor of science de- al integrity (S, L, C).♦ gree in aeronautical engineering.

8 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 MAINTENANCE ALERT

Wing Component Adjustment with B-747 Location of On Jacks Produces Boeing 747 Right-wing Panel Loss in Flight Fixed Trailing-edge Upper Panel Bart J. Crotty

During climbout shortly after takeoff, the flight crew and cabin crew felt an unusual vibration thought to be com- ing from the right side between doors no. 3 and no. 4 of their Boeing 747.

The vibration could also be felt Fixed through the cabin floor. When the air- Trailing Edge Upper Panel craft reached cruise-flight level, the vibration eventually stopped. Source: Boeing Commercial Several hours later, at the destination Airplane Group airport, an inspection found that a Figure 1 large area of the right-wing fixed trailing-edge upper panel (Figure 1), also holes. Metallurgical examination known as the “flying panel,” was miss- showed that the tie rod had failed being. Inboard areas of the upper surfac- cause of low-cycle and high-stress es of the fore- and mid-trailing-edge bending fatigue, indicating that a cy- wing flaps were badly damaged. clic force had been involved in the failure. Investigation revealed that the flying panel showed signs of hammering An investigation determined that against the fore-flap upper surface, about 160 cycles to 240 cycles had producing two deep grooves. Under- occurred from the start of the crack neath the flying panel, the inboard until failure. It was further determined diagonal tie-rod at the no. 1 rib that the tie rod had been adjusted to was bent and bowed laterally out- extend its length, and that the adjust- board in compression and had frac- ment appeared to have been accom- tured across the lower drain/vent plished using a “Stilson/pipe wrench”

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 9 Boeing 747 Fixed Trailing-edge Upper Panel Substructure

Upper

Fixed Trailing Edge Landing Gear Beam Upper Panel Attachment

Vertical Tie Rod

Lower Forward

Diagonal Tie Rod

Point of Fracture Outboard

Source: Boeing Commercial Airplane Group Figure 2 tool on the larger diameter of the tie and had been performed by an over- rod, resulting from the lengthening seas contractor. A records review did adjustment (Figure 2). not reveal any maintenance performed since then that would have A review of maintenance records involved adjusting the subject tie-rod showed a major repair of the flying length. The aircraft had operated panel, but no evidence could be found for 230 flights since leaving the con- that this repair was less than satisfac- tractor’s facility before failure of the tory, nor were any other material or tie rod. structural defects found that could explain the failure of the tie rod and During installation and rigging of a damage to the flying panel and other replacement flying panel by the surfaces. About five months earlier, operator, an accident-investigation- the aircraft had undergone a heavy authority inspector observed that, in maintenance check for three months the aircraft maintenance manual, in a

10 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 chapter covering removal, installa- Maintenance Errors tion, adjustment and rigging proce- Analyzed dures were difficult to follow and ambiguous in some areas. The oper- 1. Maintenance, i.e., adjusting the ator considered this observation but tie-rod length, was performed decided that changes to the manual but not recorded. (W,S,P) were not required. The manual does caution that adjustments of the fly- 2. The manufacturer’s mainte- ing panel should be made with the air- nance manual requirement for craft “on the gear” (meaning not on tie-rod adjustments to be per- jacks). formed only with the aircraft on the ground was not followed. The investigation concluded that the (W,S,T) inboard diagonal tie-rod failure occurred from compression forces act- 3. A strap wrench, not a pipe ing repeatedly to bend the rod until wrench, should have been used fracture occurred after about 160 cy- during the adjustment. It is very cles to 240 cycles. This allowed the disturbing that a maintenance flying panel to lose its rigged form worker would use a pipe wrench and strike the upper surface of the when it should have been obvi- fore flap. These abnormally high ous that a pipe wrench damages forces resulted from incorrect adjust- the surfaces that it engages. ment to the tie rod, possibly while (W,S,H,T) the aircraft was on jacks. If so, when the aircraft was later placed on the 4. Though not mentioned in the ground, the landing-gear beam may incident report, it is assumed the have induced higher loads than the pipe wrenchÐdamaged surface tie rod was designed to absorb. The area of the tie-rod shaft was not tie-rod fatigue-fracture striation sug- the site of the failure. gested that the incorrect adjustment had occurred during the last major 5. The apparent widespread break- maintenance. downs of correct procedure in items nos. 1, 2 and 3 leaves Several aspects of this apparent doubt that the contractor orga- maintenance-error accident suggested nization’s management and su- lessons to be learned or relearned, based pervision of workers fulfilled on the author’s opinion (see Table 1, basic responsibilities. (O,S) page 12). It should not be inferred that all the following areas were the 6. The possibility that the manu- cause of, or contributed to, the incident. facturer’s maintenance-manual

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 11 Table 1 Factors Involved in Maintenance Error

Code Factor Related Elements

Source: Bart J. Crotty

warning was not explicit or Editorial note: This report is based strong enough, or that other on U.K. Aircraft Accidents Investiga- operator errors have been made, tion Branch (AAIB) Incident Bulle- suggests that a separate alert tin No. 3/97, ref. EW/C96/10/1. The should have been issued. (C, maintenance-error analysis presented M)♦ by the author is not part of the bulletin.

12 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 NEWS & TIPS

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16 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ SEPTEMBERÐOCTOBER 1998 BLANK INSIDE BACK COVER Flight Safety Foundation

11th annual European Aviation Safety Seminar (EASS)

“Flight Safety: Management, Measurement and Margins” March 8–10, 1999 Grand Hotel Krasnapolsky, Amsterdam, Netherlands Among the topics are propulsion system malfunction; rushed and unstabilized approaches; and alertness technology: medication, diet and the scientific findings

For registration information: Flight Safety Foundation, Suite 300, 601 Madison Street, Alexandria, VA 22314 U.S. Telephone: +(703) 739-6700 Fax: +(703) 739-6708 Joan Perrin, director of marketing and development, ext. 109

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