Author Topic: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007  (Read 12801 times)

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Offline Good2Golf

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #25 on: January 09, 2008, 18:01:05 »
The only examples I've seen where disciplinary action was taken against an individual after involvement in a flight safety incident was for willful disobedience of universally known regulations.  Such cases still can be a perception issue of timing more than anything -- because the flight safety system responds so quickly (minutes to hours after an event) many people infer that it was that flight safety system that reported (or "ratted out") the individual -- that is never the case.  When someone is charged, you can rest assured that the individual was going to be charged anyway due to their willful irresponsible actions, it's just that the formal disciplinary system takes longer to visibly respond than does the flight safety system. 

In this particular case, the aviators in this thread are saying is that it appears that there was no willful disobedience of procedures or policy on the part of the technicians not to fully comply with the engine wash procedure.  If the technicians knowingly shortcutted the procedure, sure, then that would be a different issue.  If there was cause for leadership to direct disciplinary action, then there is no doubt that appropriate disciplinary action would be taken.

G2G

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #26 on: January 09, 2008, 19:31:05 »
A good part of the reason why we have the excellent (yet still not perfect) flight safety record that we have is precisely because of the openness, honesty, and trust within the system. It encourages everyone to step forward with the slightest problem, in order to educate others and thereby prevent more serious situations from occurring. Should that spontaneous reporting ever stop, through generation of suspicion within the system by nailing everybody who made a mistake, then our accident rate would soar.

I will echo the statements of my fellow Fliegers: I willingly put my life in the hands of our techs, who are incredibly dedicated, concientious, and professional and are backed up by a proven system of supervision and checks. There are still far too few of them having to do far more than they should with aging fleets and far less experience overall than they collectively had a decade or two ago - when exactly the same things were being said.

Offline Not_So_Arty_Newbie

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #27 on: January 10, 2008, 00:55:35 »
First of all, I don't know of any instances where a watch was found during a walk around or B Check.

About 4 years ago there was an article in safety digest where a tech in Trenton, I think it was Trenton anyway, nevertheless, he discovered that an hour or so after doing maint on an aircraft noticed his watch missing,  he telephoned ops upon noticing, grounding the flight before it had the chance to become an issue. His watch was found inside the aircraft, not in a place where it could have caused any damage. But his dedication in a different situation could have saved lives,  Only one word for it, complacency and it exists everywhere, in my new trade, in my old trade, and I will say again, the maintainers on the seakings (the only maint guys I've sailed with) are some of the hardest working folks in the fleet.

Offline beenthere

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #28 on: January 10, 2008, 20:10:21 »
I wouldn't think of the incident regarding a watch to be an example of complacency. In 30 + years around aircraft 25 of which were as aircrew I saw a lot of mistakes made and made a few myself but I don't recall any incidents or accidents that were caused by complacency. No doubt some have happened where complacency has been a factor but it certainly isn't common.
There was always a problem with inexperience which I attribute to the system of moving people around in a way that never seems to make much sense. The system posts someone to a Squadron or maintenance unit where they go through a whole lot of training after which they spend a whole lot more time getting to the point where they are proficient and able to do good work. With the next posting they get moved to a new aircraft where the cycle starts all over again or to someplace where they do little or nothing related to all of the training and experience that they have gained.
Complacency usually only happens when people mistakenly believe that they have become so good at their job that they can do it without making mistakes and they loose the element of caution that is necessary.

But not lately. If I could do it all over again I would  change one thing.

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #29 on: January 11, 2008, 08:58:17 »
About 4 years ago there was an article in safety digest where a tech in Trenton, I think it was Trenton anyway, nevertheless, he discovered that an hour or so after doing maint on an aircraft noticed his watch missing,  he telephoned ops upon noticing, grounding the flight before it had the chance to become an issue. His watch was found inside the aircraft, not in a place where it could have caused any damage. But his dedication in a different situation could have saved lives,

This is a good example of how and why the system works so well.

If we nailed people like that, he would quite likely have waited until the aircraft returned - praying throughout the flight that it would in fact do so - and then gone looking for his watch, hoping that nobody would notice. Chances are that no harm would befall the machine, but given enough similar incidents, harm would eventually come to some aircraft and crew somewhere, sometime, through something similar. By stepping forward, knowing that he would embarrass himself but nothing more (and embarrassment is enough of a negative motivator for techs, other support crew, and aircrew alike), he not only insured that his watch would not cause a problem, but that the incident would be a reminder to everyone involved in flying operations to be more vigilant.

Statistically, the more such minor incidents are reported, the fewer major incidents and accidents occur, which is why honest and open reporting is encouraged. To that end, he was more likely praised for his actions, rather than berated. This approach may seem bizarre to many of you, but it works extremely well in our environment.

Only one word for it, complacency

Not necessarily. although that is a possible cause factor. "Distraction" is another, and seems more plausible to me (not knowing the full story, obviously). He could have been called away by his supervisor in the middle of his work and the rest of it finished up by colleagues. Similar situations have occurred, and will continue to occur so long as we have too few people with too little experience (as compared to "The Good Old Days"*) trying to do as much work on as many aging aircraft as they can. As part of the educational and prevention process, should something like I described have happened, it would also be a reminder to supervisors to avoid distracting their guys when they've got a broken aircraft stripped down, with parts and tools in play, and it's supposed to go flying thirty minutes ago.

This is why determining the correct cause factors for every incident and accident and using them to educate others is the sole purpose of the investigation. Now, supposing that, at some point, somebody had cause to suspect negligence or something worthy of disciplinary action, a separate collateral investigation would be initiated. NONE of the evidence gathered by the Flight Safety team can be used in that investigation whatsoever, in order to preserve the integrity of the Flight Safety system. None of the Flight Safety evidence can be used in any civil proceeding, either (such as law suits). The courts recognize the reason for this, too.

the maintainers on the seakings (the only maint guys I've sailed with) are some of the hardest working folks in the fleet.

Our techs put in a fair amount of overtime, too, on a regular basis and more often than not they pick up hazards that really should have gone unnoticed as the signs are so subtle that no ordinary person should be able to spot them. That is a good indication of the calibre of our techs and part of the reason that I am willing to trust them with my life (although I do a pretty thorough walkaround nonetheless).

* Five years from now, THESE will be The Good Old Days.

Offline ExPtePhillips

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #30 on: March 04, 2008, 05:32:36 »
maybe they were just too busy having to get the A/C serviceable and being pressured that they forgot to do it....I used to be with 423 and they used to try to pressure all the time expecially the flight crew
« Last Edit: March 04, 2008, 05:35:37 by ExPtePhillips »

Offline Inch

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #31 on: March 04, 2008, 06:19:32 »
maybe they were just too busy having to get the A/C serviceable and being pressured that they forgot to do it....I used to be with 423 and they used to try to pressure all the time expecially the flight crew

If you were with 423 you would know that washing engines is part of a normal shutdown, ashore as well as embarked. It's not maintenance like you seem to imply and as far as that goes, in my 900 or so hours of flying Sea Kings I have never seen any pressure put on the techs to cut corners while doing maintenance. No aircraft, no fly, no big deal.
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Offline Good2Golf

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #32 on: March 04, 2008, 16:19:35 »
maybe they were just too busy having to get the A/C serviceable and being pressured that they forgot to do it....I used to be with 423 and they used to try to pressure all the time expecially the flight crew

Post #1 with an accusation like that is a very interesting way to start your interaction on Milnet.ca, ExPtePhillips.

Is it possible you were reading more into what you thought were pressures, than others intended?

G2G

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #33 on: March 04, 2008, 17:42:59 »
and they used to try to pressure all the time expecially the flight crew

Ah yes the big bad aircrew people. Always trying to screw the techs around by wanting servicable aircraft to go flying "just for the hell of it"

 ::)


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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #34 on: March 04, 2008, 17:57:00 »
When I wore blue and we had operational birds in the Q, they were always serviceable, as were the two backups that didn't fly while they were in that spot. As to the rest of the flight line, pressure be damned. They got the birds when we signed off the snags, or they didn't get them. Besides no aircrew would be stupid enough to pressure the techs into giving out an unsafe bird. They have to fly in them.

I think the username says alot. Ex-Pte. Perhaps he's an ex because he couldn't convince the military to bend and come around to HIS way of doing things, in the short stay he had with us.
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Offline beenthere

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #35 on: March 04, 2008, 20:07:57 »
For someone who isn't familiar with what goes on in air operations it would be very easy to mistake some queries as to the status of an unserviceable aircraft as pressure. The users (aircrew) often have a planned flight which won't get of on schedule because of a snag but they usually have several options to work on and as they work on the options may make some queries to the maintenance/snag desk as to possible fix times or to the possibility of using the aircraft without the snag being rectified until after a flight.

An example would be where ops had a scheduled flight for today but the crew determined that the radar was unserviceable and wrote it up as a snag and delayed the trip for 24 hours.  Also there was a local trainer scheduled but the aircraft for that flight was determined to be unserviceable because of a prop leak and the fix time was 24 hrs. Ops calls snags and asks how much longer it's going to take to fix the radar. Reply is 2 hours. The local training crew say they don't need radar for their trip. Ops calls and says don't do the radar repair because we want to use the aircraft for 4 hours and you can fix it later.

Now if you were the guy who was about to fix the radar you would have no idea what is going on and would probably be kind of wizzed off at these guys who can't make up their mind about if they want things fixed now, later or never and you could think that they were using pressure or deciding to fly with out waiting for repairs.
What you don't know is that a whole series of events have taken place and that at least one crew will be doing what they had planned for that day. It happens all of the time.
But not lately. If I could do it all over again I would  change one thing.

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #36 on: March 04, 2008, 20:39:47 »
And more often than not, it is not the crew who wants to go flying. HHQ directs WOPS to send an airplane out. WOPS in turn directs SQN OPS who sends a crew out. I dont like working on weekends any more than the techs do but giving me grief because "f'ing aircrew wants to go flying" is just plain stupid. We all get paid to do a job, lets all just concentrate on that.

Offline beenthere

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #37 on: March 04, 2008, 20:46:04 »
I did most of my flying on transports. Weekends were not observed.  ;)
But not lately. If I could do it all over again I would  change one thing.

Offline mr peabody

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #38 on: March 04, 2008, 21:10:37 »
When we have a good Sgt/WO running the desk, often that back and forth with Ops never even makes it to my level; direction comes from the desk and we jump on an aircraft.  I'm usually happy not knowing what goes on between the desk and Ops.
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Offline Baden Guy

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #39 on: March 04, 2008, 21:31:42 »
As has been mentioned aircrew don't pressure groundcrew. Maybe not but commitments do!
Got to get flying hours in, got to get aircraft up for an exercise,  there are operational commitments that we do our best to meet.
When maintainers work under the gun of time to meet the aircraft commitment mistakes can occur.


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Starfighter 104749 served with 439 Squadron at CFB Baden Soellingen, West Germany which is where this photograph was taken. Unfortunately '749 fell victim to a hangar fire on 2 March, 1984 and was subsequently struck off strength on 29 August of the same year, just two years prior to the majority of the remainder of the fleet being retired and transferred to Turkey.

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Offline mr peabody

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Re: Investigators 'Baffled' by Sea King Engine Fires on March 7 2007
« Reply #40 on: March 04, 2008, 21:53:24 »
The 'gun' we sometimes work under is most often held by our own tech middle management. 

I've spent a fair but of time working directly for FE's and pilots and not one of them has ever leaned on me the way some of my supervisors have in the past.   

It's not worth the risk to wind everything up into panic mode, my problems start and stop at the aircraft, the rest sits higher up the chain.  It's that can-do attitude that is both a powerful motivator and the cause of many of our problems.
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