Is It Time to Rethink Human Error? Hearing Loss: You Have the Power New Radar to Prevent It Prevents Bird Strikes 360° Approach

2017, Vol. 1 No. 2

ApproachThe Navy and Marine Corps Aviation Safety Magazine Is It Time to Rethink Human Error? Hearing Loss: You Have the Power New Radar to Prevent It Prevents Bird Strikes 360° Approach

CONTENTS

The Navy & Marine Corps Aviation Safety Magazine 2017 Volume 1, No. 1 Allan Lewis, Acting Commander, Naval Safety Center CAPT John Sipes, Acting Deputy Commander CMDCM(SW/AW/IW) James Stuart, Command Master Chief 8 Maggie Menzies, Department Head, Media and Public Affairs Naval Safety Center (757) 444-3520 (DSN 564) Publications Fax (757) 444-6791 Report a Mishap (757) 444-2929 (DSN 564) Approach Staff Nika Glover, Editor [email protected] Ext. 7257 Aviation Safety Programs Editorial Board Kimball Thompson, Acting Director [email protected] Ext. 7226 CAPT William Murphy, Aircraft Operations [email protected] Ext. 7203 GySgt Ernesto DelGadillo [email protected] Ext. 7239

All Analyst [email protected] Ext. 7811 Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces and put them in hospitals, wheelchairs and coffins. Mishaps ruin equipment and weapons. They diminish our readiness. This magazine’s goal is to help make sure that personnel can devote their time and energy to the mission. We believe there is only one way to do any task: the way that follows the rules and takes precautions against hazards. Combat is hazardous; the time to learn to do a job right is before combat starts.Approach (ISSN 1094-0405) is published bimonthly by Commander, Naval Safety Center, 375 A Street Norfolk, VA 23511-4399, and is an authorized publication for members of the Department of Defense. Contents are not necessarily the official views of, or endorsed by, the U.S. Government, the Department of Defense, or the U.S. Navy. Photos and artwork are representative and do not necessarily show the people or 6 10 equipment discussed. We reserve the right to edit all manuscripts. Reference to commercial products does not imply Navy endorsement. Unless otherwise stated, material in this magazine may be reprinted without permission; please credit the magazine and author. Send article submissions, distribution requests, comments or questions via email to: [email protected] and [email protected]

Pages

2. Approach Bravo Zulu 4.Reconsidering Human Error byLT Andrew Miranda 6. 2,200 Pound Block of Swiss Cheese by AD1 (AW) Patrick Ward 8. Only You Can Prevent Hearing Loss by LT Nicholas Meyers 4 10. The Safety Win by LtCol Jesse Janay 12. Bird Detecting Radar Reduces Strike Damage by Rod Hafemeister 12

On the cover: A pilot climbs into the cockpit of an F/A-18F Super Hornet assigned to the Fighting Swordsmen of Strike Fighter Squadron (VFA) 32 on the flight deck of the aircraft carrier USS Dwight D. Eisenhower (CVN 69) (Ike). ( Photo by Airman Courtney Leavitt) CONNECT WITH US

2 Approach Online FROM THE EDITOR Sailors and Marines We have moved!Preventing Mishaps We have gone digital. While this is bittersweet for those of us in the NAVSAFECEN BravoMedia Zulu group, we plan to continue bringing you in-depth articles and relevant mishap- prevention information. By now, most of you have received the final printed copies of Approach, MECH, Decisions, and Sea Compass. We understand the value of a printed format in certain aspects of your job, but we also know you understand our effort to reduce cost. We are increasingLCDR CHRISTOPHER our presence on the GLENN web so you can still read your favorite stories – whenever and wherever you want. Our transitionLCDR from Christopher print to digital L. is Glenn, a work inUSN, progress a flight and instructorwe appreciate with your VT-10 patience.at We NAS will Pensacola,leverage electronic demonstrated and social exceptionalmedia to give initiative,you quicker knowl access- to each currentedge, andissue, technical printable articlesacumen and while past researchingissues. Our digital a critical magazines safety are availableaspect on http://safety.navylive.dodlive.mil of the T-6A Texan II emergency. oxygen system. An You can alsoaircrew find membercurrent and on archived a T-6A issues training on flightourwebsite: noted www.public.navy.mil/ an illumination NAVSAFECEN/Pages/media/mag_index.aspxof the on-board oxygen generation. system fail warning light. Email us yourThe feedback crew executed and questions their emergencyto [email protected] procedures and. activated emergency oxygen systems We in thank accordance you for understanding. with the T-6A NATOPS. After this action, the instructor pilot’s emergency oxygen supply lasted only one minute and the student’s three minutes instead of the— expected The Editorial 10 minutes. Staff After learning of the issue, LCDR Glenn took it upon himself research the dilemma. He found that there was no check valve to prevent emergency oxygen from flowing back into the main oxygen supply line after actuation. Though not a critical action item in the T-6A NATOPS, he discovered it was time-critical to disconnect the main oxygen supply hose after activating the emergency system to maximize the available duration. He immediately communicated his findings with the chain of command. Through LCDR Glenn’s initiative, the command identified a significant procedural blindspot in the T-6A NATOPS resulting in submission of a detailed hazard report and an urgent NATOPS change to address the deficiency.

SGT RENE RAMOS

While performing the aircraft acceptance screening of a newly received MV-22B, Sgt Ramos noticed a critical tracking error within the optimized organizational maintenance activity program that tracks aircraft component life cycles. In this case the nose landing gear drag strut actuator installed was only being tracked in one of the two metrics required. Noting the discrepancy, Sgt Ramos immediately took action to correct the error. Upon further investigation into the component’s history, it was determined that the part required removal from the aircraft. Due to Sgt Ramos’ attention to detail, and knowledge of the tracking requirements, the squadron was able to rectify an unsafe condition which could have led to landing gear failure, injury, or catastrophic damage to the aircraft.

Vol. 1, No. 1 3 360° Approach

BY LT ANDREW MIRANDA, NAVSAFECEN his year marks the 70th anniver- sary of one of the most influential Tpublications in human factors. In 1947, psychologist Paul Fitts, along with Air Force Capt. Richard Jones and support from Lt. Col. A. P. Gagge and Col. Edward Kendricks of the Aeromed- ical Laboratory at Wright-Patterson Air Force Base, researched results of hundreds of non-combat aviation accidents. The causes of the accidents were originally categorized as pilot error, but the authors were unsatisfied with these conclusions. The title of their report was “Analysis of 270 ‘Pilot-Error’ Experiences in Reading and Interpreting Aircraft Instruments.” The quotations around pilot-error were intentionally ironic, suggesting the authors would not use this term to classify the failures. They concluded that the actual source of failure was poorly designed instruments. What makes The Fitts and Jones report so influential goes beyond design error being a substitute for human error. It was the scientific approach they applied to understanding performance. They gathered pilot performance data by studying various types of errors, interviewed pilots about their experiences and considered human strengths and weaknesses of how we process information. They analyzed errors as the result of interactions between multiple components in the cockpit and determined errors can result not from a single component working in isolation Reconsidering (i.e. the human), but by the interaction of multiple components. For example, the incongruent motion between the turn needle used in one instrument and the bank indicator appearing in a separate Human Error instrument was a source of confusion not previously discovered. should have a panel in which he can shift the latent conditions that put human opera- As a result of this lack of uniformity, from one instrument to another without tors in positions of failure. Each of these the pilot must change his mental set each conflict. entities emphasize what Fitts initiated, time he shifts his eyes from one instrument Paul Fitts went on to become a human which is understanding that performance of to another. He can undoubtedly learn to factors pioneer. The influence of his work aviators, and all human users of technology do this in time, as is shown by the skill is still around today, whether in cockpit for that matter, is the result of the relation- attained by experienced instrument pilots. design or size and location of buttons on ship between the human and the work. In fact, the shift in reference may become a smartphone. Wright-Patterson AFB still Despite his legacy, and the ongoing efforts so automatic that experienced pilots are hosts research efforts advancing human fac- of many human factors researchers, human unaware that it is happening. tors in aviation, including the Navy Medi- error is still a prominent causal factor dis- But the necessity of constantly changing cal Research Unit-Dayton. Other areas of cussed within safety communities. mental attitude certainly makes for more efforts include numerous divisions of naval The statistic often cited when discuss- difficulty to learning instrument flying aviation and the Department of Defense ing safety and human performance is that and may lead to occasional reversal during Human Factors Engineering Technical an estimated 80 percent of accidents are emergency conditions. It cannot be over- Advisory Group. Mishap investigators also attributable to human error. If only it were emphasized that the pilot who must use his use the Human Factors Analysis and Clas- that simple. The statistic implies that most full set of instruments in critical maneuvers sification System, which intends to identify accidents can be traced to the solitary

4 Approach Online 2nd Lt. Seth Montgomery, a student pilot assigned to Training Squadron 28 (VT-28) straps himself into a T-6 II turbo prop plane. (Photo by Mass Communication Specialist 2rd Class Victor R. Navarrete)

Reconsidering Human Error human component within a complex the human component alone and over- challenges. system and that the remaining accidents simplify the interactions occurring within These are solvable problems. But we are attributable to mechanical failure. Sep- complex systems. They often do not take owe it to ourselves, and certainly to the arating outcomes into distinct categories into consideration strengths and weakness future generations of aviators, to first and deprives us of a deeper understanding of of human being as performers in such foremost correctly identify the problems. the interaction between these components. systems. Humans have natural tendencies Seventy years after Fitts and Jones, it is and limitations, especially in demanding time once again to challenge the notion of situations. But we are amazingly creative, human error as being a useful concept. adaptable, and resilient. The Bravo Zulu LT Andrew Miranda is If Fitts and Jones had been satisfied section of this magazine commemorates an aerospace with pilot error as the decisive factor in these very strengths when aviators over- experimental psy- the accidents they analyzed, they may come such difficulties. chologist at the Naval have recommended more training as an The next 70 years will continue to pres- Safety Center. He intervention to improve performance, or ent new challenges in aviation and human earned a doctorate in encouraged pilots to maintain adequate factors. If the progress made during the human factors psy- situation awareness and to avoid compla- last seven decades is any indication, we will chology from Wichita cency. These solutions, however, focus on continue to embrace and conquer these State University.

Vol. 1, No. 1 5 360° Approach 2,200-Pound Block of Swiss Cheese BY AD1 (AW) PATRICK WARD, VFA-37

6 Approach Online hat started out as a normal workday for the powerplants was empty and the shift supervisor confirmed that it was in fact work center, actually turned out to be a hectic night. empty. That was missed opportunity No. 5. Fortunately, the results were not near as dire as they With a mistakenly empty fuel tank ready to be dropped, the couldW have been. Unfortunately, the event could have been com- supervisor positioned himself at the front of the drop tank and pletely avoided had we just followed proper procedures. We did, locked arms with his partner on the other side, and the other two however, answer a very important question. personnel positioned themselves in the back and locked arms. What do you get when you combine a routine maintenance Due to a previous hand injury, I took my spot at the weapons action with miscommunication and maintenance not done by the rack to unlock the release mechanism. I yelled the requisite, book? A 2,200-pound block of Swiss cheese crashing to the deck! “Ready front? Ready back?” My crew replied accordingly, signi- In preparation for a functional check flight (FCF) for the fying they heard me and were ready to receive the weight. At this following morning, the night check desk chief tasked our work point, I unlocked the suspension rack and the external tank fell center with dropping the inboard wing drop tank from aircraft through their arms and landed squarely on the pallets positioned 401 at the evening maintenance meeting. underneath. Our work center was sidetracked with a higher priority As soon as the tank fell, I immediately checked to ensure no job and after four hours, we were asked by the desk if we had one was injured. After determining that no one had been hurt, I completed the drop tank removal. Just to be sure about the opened the fuel tank lid and discovered the tank was completely maintenance evolution the shift supervisor and I, the leading full of jet fuel.

As soon as the tank fell, I immediately checked to ensure no one was injured. After determining that no one had been hurt, I opened the “fuel tank lid and discovered the tank was completely full of jet fuel. petty officer (both collateral duty inspectors [CDIs]), went to We learned many extremely important lessons from this” maintenance control to confirm which aircraft needed its station unfortunate event that we should have never had to learn. First seven-drop tank removed. After asking the maintenance control- and foremost, work center leadership failed from the beginning ler to confirm the aircraft and station to be dropped, we found by not putting the maintenance action into an in-work status. If him working another jet issue and responded, “Yeah, 402, since the proper time had been spent ensuring proper documentation, it needs an FCF tomorrow.” There were many missed opportuni- maintenance would not have been performed on the wrong air- ties that should have been avoided. craft (401 vs. 402) and the miscommunication between the work Missed opportunity No. 1: Wrong aircraft— 401 or 402. center and maintenance control desk would have been easily We immediately headed back to the work center and told the identified. shop to start checking out the appropriate tools for a drop tank Second, the publications checklist (LWS-460) was not with removal and meet us on the flight line. us at the time of the evolution. Had it been, maintenance would Missed opportunity No. 2: Neither the LPO, nor the other have been done by the book. The fuel level would have been CDI qualified mechanic, checked the in-work status of the main- correctly checked by removing the fuel cap and visually verifying tenance action in NALCOMIS. that the tank was empty instead of simply slapping it on the side Missed opportunity No. 3: Neither of us brought a checklist to hear if it was empty. for drop tank removal to the flight line. Third, even with these multiple mistakes made, we com- Missed opportunity No. 4: We never established who would pletely circumnavigated the quality assurance process of prevent- lead the evolution and who would inspect as CDI. ing maintenance mistakes by not establishing the leader of the By the time we made it to the jet, our young Sailors had evolution and CDI to verify proper maintenance was achieved. completely prepared the job site. The aft mount and I-cable were Since the incident, intensive training was conducted about already removed and wooden pallets were placed under the tank the mishap and steps to be taken to prevent a reoccurrence. (we did not have a drop tank cart available at the time). With Work center leadership created a maintenance evolution brief, a jet turning both engines directly adjacent to aircraft 402, the highlighting assignment of team lead, team members, and CDI noise level was pretty high. for each event. The most crucial aspect of the brief is that it When the shift supervisor went up to the tank, he incorrectly translates to all maintenance actions. This ensures clear commu- verified the fuel quantity by knocking on the outside to see if it nication between personnel and promotes safety by eliminating sounded empty. The supervisor was unable to hear any sound and mitigating risks. Overall, the squadron is lucky this had not coming from the tank since the adjacent aircraft was turning, happened before and steps have been put in place to ensure it but deemed it empty and carried on. I asked him if the tank does not happen again.

Vol. 1, No. 1 7 360° Approach Only You Can Prevent Hearing Loss BY LT NICHOLAS MEYERS, VAW-121 aval Aviation is a noisy business, and as aviators it’s a hazard we have come to accept and mitigate through the use of hearing protection. With the introduction of new platforms and technologies there comes a time when we Nhave to re-evaluate traditional hearing protection methods and adapt accordingly to prevent permanent disability. Since the initial flights of the E-2D Advanced Hawkeye, aircrew recognized noticeably higher noise levels and increased crew fatigue throughout different regimes of flight. Many of these flights have led to hazard reports being generated and post-flight audiograms being performed to evaluate hearing change for that duration. The VAW-121 Bluetails conducted a noise study to collect additional data to help support the HAZ- REPs and give fleet feedback to assist the PMAs in allocating resources to address these issues. While collaborating with industrial hygiene specialists at Naval Medical Center Ports- mouth, Va., the squadron was able to both collect this data and learn additional lessons about noise exposure that are applicable to all platforms fleetwide. The scope of this study was to evaluate the magnitude of E-2D noise exposure to aircrew through multiple regimes of flight and determine if current hearing protection methods are sufficient across all frequencies in the aircraft. The Bluetails answered these questions throughout three flights, during with the proper wear of current hearing protection, there are which personal noise dosimeters were utilized and noise levels circumstances where aircrew are subjected to peak noise levels throughout the aircraft were evaluated with various handheld exceeding the exposure threshold for permanent hearing loss noise measuring devices provided by the industrial hygiene spe- while utilizing the recommended PPE. For instance, with a cialists. The flights were two to three hours long and conducted high power setting, straight and level at 200 KIAS, measure- in various operating areas on the east coast. Some of the flight ments taken at the pilot and co-pilot stations were 113 dBA and profiles evaluated were: max power in a climb, straight and 108 dBA respectively. During this noise exposure it is common level flight, left and right flat turns, and max power descent. for aircrew to remove hearing protection to adjust fitment or Samples were taken during these profiles at various locations in switch from helmets to their alternate David Clark headsets. the cockpit, forward equipment compartment (FEC), and the Additionally, within the same flight regime at 210 KIAS, noise Combat Information Center. levels at the FEC avionics rack reached 118 dBA. This area of The U.S. Department of Health and Human Services states the aircraft is often occupied during trouble shooting of avionics that noise levels at or above 85 decibels can cause noise induced and radar pressurization systems or while utilizing the relief hearing loss (NIHL). To put this in perspective, a typical run- tube. To put these exposures in perspective, with no hearing ning vacuum cleaner produces 88 decibels. NIHL is the only protection it will take 56 seconds at 112 dBA to cause perma- type of hearing loss that is completely preventable with the nent hearing loss. proper use of personal protective equipment (PPE) and expo- The study concluded that the noise exposure levels can be sure time mitigation. The study concluded E-2D aircrews are mitigated through the proper wear of double hearing protec- being exposed to a time weighted average of 100 dBA, which tion; however, given the thin margin of protection afforded by requires an attenuation of 16 dBA to reduce personnel exposure current PPE, correct wear cannot be emphasized enough. The below DoD criteria. While these average levels are acceptable question regarding the cause of increased crew fatigue has yet

8 Approach Online Lithographer Seaman Jared Benner, participates in an annual hearing test in an aviation medicine lab. As part of a vast health care system, the hearing conser- vation program is designed to monitor Sailors’style hearing abilities when their working environment is considered a high-level noise area. (Photo by Mass Communication Specialist 3rd Class Jason T. Poplin)

to be answered and has led Naval Air Systems Command to investigate the possibility of the HGU-68 and HGU-84 helmets amplifying at-ear sound at low frequencies due to vibration. The biggest takeaways for aircrew are to ensure you are following the manufac- turers’ recommendations when installing earplugs to maximize effectiveness. Also, it is imperative to maintain the integrity of your hearing protection through proper fitment of flight equipment. Finally, aircrew must manage noise exposure by limiting the time PPE is removed and prioritize quieter regimes of flight if removal is necessary. Noise induced hearing loss is com- Kurt Yankaskas, the Office of Naval Research Noise-Induced Hearing pletely preventable. Wear the correct Loss program officer, watches as Jacob Thompson, of United Sciences, hearing protection, wear it right, and demonstrates an in-ear scanning solution. The company has developed wear it when needed. Only you can a technique for scanning and 3D-printing custom-molded hearing protec- prevent your hearing loss. tion for noisy environments. (U.S. Navy photo by John F. Williams)

Vol. 1, No. 1 9 360° Approach

From left to right: Recovery teamlead Cpl Sean Gutzmer (HMLA-167), aircraft commander Capt Gil McMilliann (HMLA-467), and airframes collateral duty inspector LCpl Brian Jennings (HMLA-167 stand next to the UH-1Y that made a precautionary emergency landing near Prescott, Arizona on Sept. 18, 2015. (Photo by Co-pilot ,Capt Ferrell/USMC).

The Safety Win BY LTCOL JESSE JANAY n Sept. 17, 2015, Capt Gil “Pebble” McMillian and his 23, 2015 at Twentynine Palms that killed both pilots. The UH-1Y Huey crew had a transmission chip light and un-privileged summary from The Marine Corps Times article Othey made a precautionary emergency landing (PEL). is that “About 34 minutes into the 49-minute flight, the pilots Not a big news story in itself, but there is a bigger win here: a noticed that their oil pressure gauge fluctuated and then possible mishap did not occur because the safety management plummeted to zero. system worked. While the warning lights typically indicate an emergency, It was day four of four on a cross-country from North Car- the pilots likely assumed the problem was due to a faulty olina to Arizona to deliver the aircraft for the next weapons gauge, not actual fluid loss, because of recent maintenance and tactics instructor (WTI) course in Yuma. This particular issues. With Twentynine Palms Calif., more than 15 minutes leg was through the canyons of Sedona on the way to the last away, the pilots decided to continue flying. They passed two fuel stop at Lake Havasu. When the transmission chip caution airports where they could have landed safely before the trans- light illuminated, there were no suitable landing zones; noth- mission froze, the investigators found.” The actual SIR goes ing but canyons on the left, and a mountain range blocking into great detail and I’d highly recommend all aircrew read it. the nearest divert to Prescott. Back to Pebbles PEL and his transmission chip. The gauges showed no secondary indications and the Within minutes, the crew spotted a power line slash and crew’s initial instinct was to press over the mountains to the found a small field next to it to execute a PEL. Safe-on-deck. divert, but right at that specific moment, right during the No crash. Phone calls were made, a maintenance recovery make risk decisions part of the risk-management process, team was launched, and the local sheriff was on scene shortly the crew remembered a ready room brief from their squadron thereafter. A confirmed transmission chip and two nights aviation safety officer two weeks prior of a safety investigation later in that same field, the aircraft and crew made it to Yuma report (SIR). It was the HMLA-169 Class A mishap on Jan. safely. Throughout this process, squadron, group, and wing

10 Approach Online The Safety Win BY LTCOL JESSE JANAY leadership supported and applauded the aircrew’s risk man- a mishap. How can one capture a non-eventful; safety wins? agement application and decision-making ability. We always focus on the bad and how this pilot did this or that Normally, this kind of story would never have seen the wrong. There is great merit in this approach... learning from light of day because it was just a PEL. It only did because others mistakes, but we can do better. several weeks later, as the wing director of safety and stan- Our reporting systems are geared to report mishaps and we dardization (DSS), I just happened to go flying with the same rarely hear about the near-mishaps. There needs to be a culture pilot and he told me that the SIR saved him and his crew’s shift that the safety department is not here just to talk about lives. what pilots did wrong, but also to talk about what pilots did Because of a safety program that worked, we are able to right— for making the right call, executing the correct proce- hear about this and not read another mishap report. This pilot dures, and not pushing it—the safety win. was briefed on a previous mishap with similar circumstances, Here’s an idea put into action: Higher headquarters buy-in learned from the causal factors, and it entered his decision and support are essential to the success of the safety win. The loop at a critical moment. We rarely, if ever, hear about these 2nd Marine Aircraft Wing DSS team has done this by briefing safety wins. We only hear about the bad ones. a weekly safety win to the commanding general (CG) and his It is hard to know when your safety management system staff, posting them on the digital billboards across the base works, but it is definitely easy to see when it does not; hence weekly, and staffing a quarterly CG’s safety award (borrowed our almost religious tracking of our mishap statistics. Both that idea from a Navy counterpart from the aviation safety civilian and military aviation professionals track them, but the manager’s course) that really incentivizes the safety win by problem is that they are a lagging metric. In safety, we need giving time off to the winning squadron. The safety culture better leading metrics. One proposal: The safety win. shift in the wing is certainly noticeable because everyone likes We seldom know when our safety program has prevented a win.

Vol. 1, No. 1 11 360° Approach Bird Detecting Radar Reduces Strike Damage BY ROD HAFEMEISTER, NAS KINGSVILLE PAO student pilot is on final approach when he sees a flash of something feathered pass in front of him and then feels A an explosion. Bird strike! The single engine on his T-45 Goshawk jet trainer has failed, turning the aircraft into a 5-ton glider. At Naval Air Station Kingsville, that scenario is more than a training exercise – it happened in 2005 and again in 2007, forcing the student and instructor to eject and destroying two $29 million aircraft. Today, the air station and the flying training wing are using technology to better understand the threat of bird strikes and adjust flying hours to minimize it. Based in South Texas near the Gulf Coast, NAS Kingsville is home to half of the Navy and Marine Corps strike pilot training. It’s ideally situated for such training, with large, uncongested training areas and more than 220 days of sun- shine annually. But the Coastal Bend area has another attribute: It’s the southern United States end of the Central Flyway, the largest migratory flyway in North America. Every spring and fall, millions of birds pass through the area. “In the fall, it’s the raptors – hawks and falcons,” said Eddie Earwood, a Department of Agriculture (USDA) biologist. “In the spring, the problem is especially birds that migrate in the evening, after the sun goes down.” the base’s Bird Aircraft Strike Hazard (BASH) program under Earwood is stationed at NAS Kingsville as coordinator of an agreement between USDA and the Department of Navy. He was brought in as a result of a Class A mishap that destroyed a T-45 in 2005. In 2007, a second bird strike led to ejections and the loss of a T-45. “The 2005 crash was a collision with a single turkey vulture,” he said. “In October 2007, it was a large group of migrating broad-winged hawks. “We decided to see if radar could be used to identify birds before the planes find them. We wanted to identify large groups of birds, such as the migrating hawks, before they entered our critical or most used airspace.” The focus was on the tower pattern, where dozens of sorties Photo courtesy of NAS Kingsville a day practice approaches and landings. U.S. Navy personnel inspect the site of a T-45 Goshawk crash after it struck a bird.

12 Approach Online ABOVE: LCDR Danny Cook, Training Air Wing Two safety officer, and Eddie Earwood, USDA bird aircraft strike hazard coordinator, exam- ine the Merlin radar at NAS Kingsville. The radar is changing the way the Wing plans training, adjusting schedules to avoid flying during the periods of greatest bird strike hazards. (U.S. Navy Photo by Rod Hafemeister) LEFT: Training Air Wing Two duty officer checks the Merlin radar to determine the current bird hazard condition: low, moderate or severe. At Severe, flights are curtailed until the hazard condition goes down. (U.S. Navy Photo by Rod Hafemeister)

Vol. 1, No. 1 13 360° Approach

The answer was Merlin, a spe- cial bird-detection radar. “As a direct result of those two bird strikes in the pattern, we got the Merlin radar,” said LCDR Danny Cook, safety officer for Training Air Wing Two. The radar was put through tests in 2008 and 2009 and was leased for the first time in 2013. It sits between the air stations runways, taking images in three axes. “Our initial thought was that it would let us see large birds at a distance,” Earwood said. Merlin can pick up large groups of large birds out to about four miles. But it turned out it also does a good job of picking up large groups of small birds at shorter distances – which has resulted in changes in how the system is used. Before the radar, tower personnel would set a bird hazard A T-45 Goshawk struck a bird condition and restrict flight oper- resulting in a Class A mishap. ations based on what wildlife they (Photo courtesy of NAS Kingsville) could see from the tower. But adding bird radar was problematic because of manning and logistics. tion necessary to make that decision.” “It was determined that the wing duty officers would be Having pilots in the flying wing determine the bird hazard better suited to make the bird hazard decision, if they had condition was a first, Earwood said. good situational awareness to do so,” Earwood said. The radar was set up to display in the wing duty office – “The radar became their eyes on the airfield. Combined and now can be streamed live to computer screens. with communications with the tower and wildlife detection “Over the years, we’ve gotten a better program,” Cook said. and dispersal team observations, it gives them the informa- “The wing duty officer can directly monitor bird activity. He’s able to set a BASH condition based on what he’s seeing in real Merlin Aircraft Birdstrike time.” Avoidance Radar positioned The wing has established three between the runways at levels of bird hazard condition: Naval Air Station Kingsville, low, moderate and severe. Texas. The air station sits Severe means “no fly” – air- in the middle of the busiest craft on the ground stay there and migratory bird flyway in North aircraft needing to land come in America, with millions of birds with a high-angle approach that ranging from tiny humming- minimizes the chance of a bird birds to large raptors passing strike and maximizes the odds through every fall and spring. of landing safely if a bird strike (Photo by Rod Hafemeister) happens. “Since we’ve integrated the Merlin radar, we haven’t lost an aircraft to a bird strike,” Cook said. “We’ve had some damages, but no lost aircraft.” Earwood and the wing also are using the Merlin radar to develop historical data of the patterns of BASH threats, including times of year, times of day and weather

14 Approach Online conditions. “We have daily reports of the number of tracks, the amount of bird activity at different times,” Earwood said. “The wing sees that real-time data in a scrolling graph that measures bird activity. A red line was implemented at 70 percent of the historic peaks to help standardize setting of bird hazard condition. “Approaching the red line, the condition is moderately elevated, at or above is severely elevated. “As of September 2015, anything above that red line is a full stop – which resulted in a more than 45 percent reduction in overall bird strikes for September, which historically has been the peak month for bird strikes at NAS Kingsville. “The wing is participating in the BASH program in a real A T-45 Goshawk struck a bird way – it’s a cultural change.” resulting in a Class A mishap. While the fall raptor migrations are generally a daytime (Photo courtesy of NAS Kingsville) threat, the spring migrations include many small birds that take flight just after dark, avoiding predators and feasting on spring flying insects. likely. That is helping greatly with habitat management to Spring 2016 marked the first time the BASH condition reduce the threat, Earwood said. settings were fully used at night. “This allows us to make recommendations on ways to “This spring, we’ve hit ‘severe’ and ordered full stop on mitigate the threat from wildlife without adversely affecting landings,” Cook said. mission accomplishment,” Earwood said. “Our plan is to study and adjust the condition thresholds “At the end of the day, we’ve got to work together to train annually; spring typically hits ‘severe’ almost every night for Navy and Marine Corps pilots safely.” nearly a month. Cook said the radar is a great tool, but it’s not going to “So now we’re looking at adjusting our training schedules prevent every bird strike. to minimize evening operations here at NAS Kingsville during “Even with the radar, there’s going to be birds out there that period. We can be smart about it to continue our produc- that don’t meet the ‘severe’ threshold,” he said. tion of new pilots.” “We’ve managed the threat – that’s all we can do. The radar also has revealed the hot spots where birds are “The only way to eliminate it is to not fly.”

A helicopter removes a a T-45 Goshawk from a crash site after it struck a bird. (Photo courtesy of NAS Kingsville)

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16 Approach Online CONTENTS The Navy & Marine Corps Aviation Safety Magazine 2017 Volume 1, No. 1 Allan Lewis, Acting Commander, Naval Safety Center CAPT John Sipes, Acting Deputy Commander CMDCM(SW/AW/IW) James Stuart, Command Master Chief Maggie Menzies, Department Head, Media and Public Affairs Naval Safety Center (757) 444-3520 (DSN 564) Publications Fax (757) 444-6791 Report a Mishap (757) 444-2929 (DSN 564) MECH Staff Nika Glover, Editor [email protected] Ext. 7257 24 Aviation Safety Programs Editorial Board CDR Robert, Beaton, Division Head [email protected] Ext. 7265 CWO3 Charles Clay, Branch Head [email protected] Ext. 7258 GySgt Ernesto DelGadillo [email protected] Ext. 7239 All Analyst [email protected] Ext. 7811 Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces and put them in hospitals, wheelchairs and coffins. Mishaps ruin equipment and weapons. They diminish our readiness. This magazine’s goal is to help make sure that personnel can devote their time and energy to the mission. We believe there is only one way to do any task: the way that follows the rules and takes precautions against hazards. Combat is hazardous; the time to learn to do a job right is before combat starts.Approach (ISSN 1094-0405) is published bimonthly by Commander, Naval Safety Center, 375 A Street Norfolk, VA 23511-4399, and is an authorized publication for members of the Department of Defense. Contents are not necessarily the official views of, or endorsed by, the U.S. Government, the Department of Defense, or the U.S. Navy. Photos and artwork are representative and do not necessarily show the people or equipment discussed. We reserve the right to edit all manuscripts. Reference to commercial products does not imply Navy endorsement. Unless otherwise stated, material in this magazine may be reprinted without permission; please credit the magazine and author. Send article submissions, distribution requests, comments or questions via email to: [email protected] and [email protected] 23 Pages

20. Crunch in the Junkyard by PO2 Clifford Lonesome 22. Look Out Below by LTJG Weston Henderson 23. Do It Right or Dont Dot It at All by AO2 Thomas Besa 24.The Tale of Two Beanies by AE2 Christopher Hill 26. MECH Bravo Zulu 22

On the cover: Aviation Boatswain’s Mate (Handling) Airman Matthew Kuhns uses a tractor to relocate an MH-60R Sea Hawk helicopter assigned to the “Battlecats” of Helicopter Maritime Strike Squadron (HSM) 73 in the hangar bay of the aircraft carrier USS Theodore Roosevelt (CVN 71). (Photo by Mass Communication Specialist Seaman Bill Sanders) CONNECT WITH US

Vol. 1, No. 1 17 360° MECH Crunch in the Junkyard BY PO2 CLIFFORD LONESOME, VFA-195 fellow aviation ordnanceman (AO) and I were preparing ously there and that the damage must have been caused while our aircraft for the day’s flight schedule during the com- moving the ordnance skid. As I returned to the flight deck, I A mand’s fall Western Pacific patrol onboard USS Ronald was told to immediately contact our FDC. The maintenance Regan (CVN 76). The flight deck coordinator (FDC) called departments of both squadrons were notified and our qual- over the radio for us to reposition an MHU-191 ordnance skid ity assurance shop began an investigation. At this point, the in the support equipment holding area of the flight deck, an realization that the IMER had scratched an antenna on the area commonly referred to as the junkyard. The ordnance helicopter began to set in, turning what should have been a skid we were moving carried four bomb rack unit (BRU- routine move into a potential mishap. 41) improved multiple ejector racks (IMERs), used to carry Due to the sensitivity of damaging an airborne sensor, the practice bombs on the F/A-18. The skid was located in the helicopter squadron could not determine if the scratched junkyard next to an MH-60R helicopter, lined up port-to-star- antenna would need to be replaced until the aircraft flew and board on the ship instead of the standard parking orientation the antenna could be evaluated. Fortunately, the following day of forward-to-aft. Our job was to move the skid to a position the helicopter did fly and the antenna checked good airborne, where it was resting in the proper forward-to-aft alignment. requiring only cosmetic repair despite the damage. This time, As the name implies, the junkyard is extremely crowded luck was on our side, but the whole event could have been with support equipment, complicating our task. We decided to avoided through better operatinal risk management of the move the skid to a small space between the front of the heli- move evolution. copter and an aircraft external fuel tank dolly that was located This crunch taught me some valuable lessons. My fellow closely beside it. As we worked to reposition the skid, my AO and I thought this would be a routine move of our support fellow AO guided the aft portion of the skid while I pushed equipment in the junkyard. However, nothing we do on the against one of the IMERs to keep it from hitting the helicop- flight deck should ever become routine. I did not properly ter. After starting the move, we realized the skid would not fit assess the risks involved, especially since the skid was parked into the narrow space available with the IMERs still on it. At so closed to an aircraft. Had we taken a few extra minutes this point, we were about halfway done with the move and I prior to rushing into the task, we could have gathered help left for the work center to get additional AOs to help remove from the work center and removed the IMERs from the skid the IMERs from the skid. prior to executing the move. As we gain experience operating While I was gone, the PO3 assisting me noticed some on the flight deck, it is easy to develop a false sense of pro- scratches on an antenna on the forward portion of the helicop- ficiency and comfort. This near-miss taught me the conse- ter. As she was trying to determine if we caused the damage, quences of complacency when operating in such a dynamic the FDC from the helicopter squadron came over and took and dangerous environment, and how to avoid them in the a look as well. He confirmed that the scratches were not previ- future.

18 MECH Online An aviation ordnanceman uses a skid to transport munitions to an aircraft. (Photo by Mass Communication Specialist 2nd Class James R. Evans)

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Look OutBY LTJG WESTON Below! HENDERSON, VP-45 he P-8A Poseidon is not your typical Boeing 737 aircraft. to operate this machine with attentiveness and caution. As The unique mission of the P-8A requires unconventional the rider moved cautiously downward, the jolting of the cart maintenance that is still relatively new to the commu- caused a tilted unstable platform. nity.T The P-8A has multiple antennas, mission equipment, This abrupt motion caused a speed handle to fall of the and sensors installed on the outside of the aircraft. This cart. The speed handle fell downward and struck the tail cone sensitive mission equipment must be flawlessly maintained causing minor superficial damage to the skin of the aircraft. in order to keep the aircraft fully mission capable. Late one Although the damage to the aircraft was minor, the potential morning, the aircraft division sent an experienced mainte- for greater damage or injury to maintenance personnel was nance team to the aircraft to conduct a routine replacement substantial. of the inmarsat radome. The inherent risks and dangers of flying, operating, and The inmarsat radome is located at the top of the verti- maintaining naval aircraft will continue to be a significant cal stabilizer, which is 43 feet above the ground. In order to factor in mishaps. We must continue to monitor these risks accomplish this task, the maintenance team must use a Genie and continue to implement controls to maintain safety and man-lift to reach the inmarsat radome. The Genie man-lift mission effectiveness. At a glance, the simple idea of a man- comes with a cart that has weight restrictions. With these lift that provides an unstable cart movement does not seem to weight restrictions, the individual maintainer cannot bring an be the likely cause of a mishap. entire tool kit. This event proves that there are hidden and unknown The maintainer must bring the required tools loosely on dangers everywhere in our work environment. These types the floor of the cart. When operating the Genie man-lift, the of hazards can cause problems for the most experienced movement of the cart up and down tends to create jolting and qualified maintainers in the U.S. Navy. operational risk and unstable movements for the rider and the tools. These management, NATOPS, SOPs, quality assurance and the unstable movements are a known hazard and risk accepted command’s safety department must stress the importance of for personnel operating this particular man-lift. Five months identifying risk and hazards that can lead to the prevention of into deployment, these seasoned maintainers have learned damage to equipment and injury to personnel.

20 MECH Online have been catastrophic if it had hit and destroyed someone’s property or, even worse, if it had hit someone as this surely would have resulted in a fatality. Luckily, this did not result in Do It Right or any property damage or personal injury; however, this incident was entirely avoidable had I done by-the-book maintenance. All of this was a result of my negligence to do the job by the Don’t Do It At All book. Proper procedures and instructions are established by BY AE2 THOMAS BESA experts for all of us to follow. Mishaps have happened in the omeone once told me, “Doing it wrong is as good as not past because maintainers have not followed simple instruc- doing it at all.” Right off the bat that message is what tions, and it has resulted in the damage of personal property Syou should get out of this story, as it is a very important and/or injury; and even worse, death. They are easy to read lesson we must all learn from, regardless of rating or rank.¬¬ and simple to use, so there should be no reason to not follow On a rainy Tuesday morning, my fellow ordnancemen and I the specific steps as written in the publications and check- were on the flight line preparing the aircraft for daily flight lists. operations. I was the collateral duty inspector (CDI) in charge CDIs are the people in the work center that the command of overseeing the installation and torqueing of 16 ALE-47 trusts to oversee that the job gets done properly, but, more magazine dispenser buckets on four F/A-18E Super Hornets. I importantly, we are the people that the junior Sailors look had all the required tools, but I did not have the actual check- up to. They seek guidance and knowledge from us, and are list in my hands. relying on us to do it right ourselves and to train them if they Over time, I got so relaxed with the repetitiveness of this are not doing the job correctly. They are our replacements and specific job that I missed a very important step. I should the future of our Navy. What kind of future are we providing have read the checklist step-by-step, without rushing. Even if we don’t teach them to do the right things now? Equally as though I thought I had verified the torque on all the buckets important, how can we as CDIs and supervisors keep our Sail- in an x-pattern, in accordance with A1-F18EA-LWS-000, I ors safe and the jets flying safely if we are not following the obviously missed something. The aircraft returned from its book at all times, on and off the flightline? The term “by-the- flight and during the turnaround of the aircraft another ord- book maintenance” is something we’ve all heard hundreds nanceman found one of the four ALE-47 magazine dispenser of times that can sometimes go in one ear and out the other. buckets missing from the aircraft. The bucket had fallen off in Please use this incident as a reminder of what can happen if flight! The aircraft had flown over residential areas where kids we choose to not take that to heart by letting that phrase fully were at school and where people were in their homes. It could sink in.

Aviation Electronics Technician 1st Class Jeffrey Caleb, right, and Aviation Electronics Techni- cian 3rd Class Adam Chenevert conduct an ALE-47 airborne countermeasure dispensing system inspection during routine pre-flight checks on an F/A-18F Super Hornet. (Photo by Mass Communication Specialist 2nd Class Kilho Park)

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that the night was rapidly turning into the worst-case scenario two down aircraft and a busted flight schedule. Feeling the pressure of everything that was going on, I told maintenance it would be faster to remove the main rotor de-ice distributor (aka beanie) from 710 and temporarily use it on 703 while troubleshooting continued on the door. I was given the go-ahead, and after installing the distributor, 703’s black The Tale blade lockpins worked, pitch locks retracted, and the problem was fixed! The crew stopped working on 710 and began the process of closing the door, and finishing 703’s preflight checks for the flight schedule. I got down off the helicopter with the part in hand, gathered my tools for a proper “All tools accounted for, and was on my way to turn the repairable part into supply. Finally, at 2:50 a.m., flight quarters were set and the crew con- of Two ducted a preflight of the head and launched at 3:30 a.m. Now this sounds like a story of great perseverance by the book maintenance in the face of adversity. Not so. Let us now

BeaniesBY AE2 CHRISTOPHER HILL, HSM-74 During month three of a seven-month deployment, day- to-day maintenance and flying had the days running together. August 21 was a day, however, I will never forget. Vixen 703 had a 1:45 a.m. launch in support of Operation Inherent Resolve and it was maintenance’s job to give the pilots the best helicopter possible on time. It was 11:30 p.m. and we had finished pulling the bird out to the maintenance line to spread. We unfolded the tail and performed the blade spread as we always had. The only difference was the black blade lockpin was engaging and retracting continuously and all the pitch lockpins were still engaged. The blade lockpins drive in to ensure the blade is locked and the pitch lockpins drive out to allow the blades to make pitch adjustments. The system is meant to ensure the integrity of the rotor system prior to and in flight. As a proud naval aviation maintainer, I know the importance of meeting the flight schedule. I grabbed an IETMS and a toolbox, and with a great sense of urgency, sprang into action. Looking at the time, I knew that I would have to act expedi- tiously. Flight quarters would be set at 1:15 a.m. and somehow it was midnight already. I would have to push myself more than usual to meet the mission. Luckily, shift change was going on simultaneously so my counterparts were there to lend assis- tance. We feverishly began to troubleshoot and step after step, produced no results. We spent over an hour and a half making minor progress just to come up short every time. Launch time had come and gone; and now, the pilots were scratching their heads and asking questions. With the flight schedule in jeopardy, maintenance control made the call to go to the spare. This is not what a maintainer wants to hear. During most days, this call would have been simple enough, and would have only taken an hour. It just happened this was not most days. The hangar door for our second aircraft was broken and the rapid securing device (RSD) had a nitrogen leak. This door required three shop technicians and took 30 minutes to open. We would have to charge the RSD system to traverse, which can further delay launch. Additionally, we would still have to find a way to fold 703 and get it off deck. As the rest of the crew began to prep 710 for flight, they discovered the rotor head accumulator required servicing. It was clear

22 MECH Online talk about how this impressive maintenance feat took a turn during a high-stress evolution, it is important to take a moment for the worst into a maintenance catastrophe. While on my to gather and regroup. Consider the operational risk manage- way to turn in the beanie I had limited space to get in the ment of the situation. Perceived pressure can cause you to hangar. I could not go through the hangar door, as they were make mistakes and skip critical steps jeopardizing the safety still attempting to close it, so the only option was the hatch of the aircraft and crew. If the flight schedule does not happen next to it. The ship’s technicians were working on closing the on time every time, it is acceptable. Rushing procedures and hangar door allowing me a sliver of room to sneak by. The tools not properly stowing gear is not. It has the potential to waste filled my hands, so instinctively and foolishly, I set the beanie money and cost lives. Additionally, you must ask yourself , what down on a ready service locker outside of the hangar bay hatch. is different today? We had the hangar, the RSD, and several This locker just so happened to be by the side of the ship. parts of two aircraft requiring maintenance all at the same After going in and out of the hangar a few times, I realized the time. Next time, I will recognize this as a high-risk evolution beanie was missing from my inventory. Once it hit me where I and help my shipmates understand the potential risks. If the thought I had left it, the search began. After 12 long hours with flight schedule starts 10 minutes late because we did pro- no distributor to be found, it was concluded the part fell over cedures properly, I will be able to sleep just fine. When your the side, off the ship, and down to Davey Jones’ locker. Only adrenaline is going, it is easy to lose sight of the situation and later did I find out this part cost approximately $100,000. make a careless mistake. Beware the tale of the two beanies! So what did I learn through this ordeal? First, sometimes

Seaman Joseph Kelley conducts maintenance on the tail rotor of an MH-60S Sea Hawk helicopter (U.S. Navy photo by Seaman Christopher A. Michaels)

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Sailors and Marines Bravo Zulu Preventing Mishaps AN CHANDLER REYNOLDS

While on board the USS Ronald Regan (CVN 76), AN Chandler Reynolds went beyond his normal job responsibilities while serving as the brake rider for Liberty 603 during an aircraft move on the flight deck. During the aircraft move evolution, the towbar separated from the aircraft which left 603 free-rolling towards an F/A-18E Super Hornet and various avionics pods positioned nearby. AN Reynolds quickly reacted by relying on his training, applying the brakes and setting the emergency parking brake, which prevented potential loss or damage to the aircraft and injury to the personnel involved with the move. AN Reynolds’ attention to detail, initiative and dedication to safety identified a major hazard and averted a potential mishap.

AM1 MHAYNARD DIONIDO

While performing a thorough quality assurance inspection prior to flight for Liberty 603, AM2 Mhaynard Dionido discovered a large crack on the forward starboard side of the arresting hook stinger assembly. Recognizing this as a downing discrepancy, AM2 Dionido notified the flight deck coordinator along with maintenance control and the faulty component was replaced. His quick efforts and keen attention to detail prevented a potentially catastrophic failure of the arresting gear system, preserving aircrew and aircraft safety.

AT3 ELIJAH WALKER

While actively engaged in propeller guard duties onboard USS Ronald Regan (CVN 76), AT3 Elijah Walker noticed two jets man up and begin to taxi near the turning Liberty 602. As the second aircraft taxied, a hydraulic servicing unit (HSU) began to slide toward the spinning port propeller of 602. Utilizing superb operational risk management, he quickly assessed the situation and determined that he could safely intercept the HSU. He got down on one knee and successfully regained positive control of the gear. His quick reaction prevented possible injury to his shipmates and damage to 602. AT3 Walker’s attention to detail, initiative, and dedication to safety identified a major hazard and averted a potential mishap.

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