HomeMediaArticle Display

Commentary: Lack of supervision, communication can lead to dire situations

NELLIS AIR FORCE BASE, Nev. -- "MOC, Dog 3!" the master sergeant screamed into the radio. "We have an Airman trapped between the flaperon and aircraft fuselage!"

The maintenance operations controller, startled by the communication, asked the master sergeant to repeat.

"We have an Airman's arm trapped between the flaperon and the aircraft fuselage! We need fire and rescue here immediately!"

That afternoon started like any other. It was Friday, there was a ton of work to do, we were undermanned, and our 12-hour shift had just begun. In my aircraft maintenance unit, I was one of two experienced maintainers on shift. My counterpart, in the other flight, was a carbon copy of me: worn thin from the week's adventures. That morning I had prayed to the sortie-production gods to be kind to us. They did not listen.

My counterpart and I were reviewing the day shift workers' forms when we heard that frantic call come over the radio. Immediately, we ran to the aircraft and saw the Airman with his right arm pinned. I could not believe my eyes. How did this happen?

The Airman was an up-and-comer, but had already shown that he was capable of going places in the "Big Blue." He was a top-notch crew chief and was involved in multiple activities outside of work. However, the Airman was going through a divorce. He was having trouble sleeping and paying attention to the task at hand. Consequently, his supervisor pulled him from the flightline temporarily. After a short while, our unit recognized the Airman's desire to return to his normal duties, so we assigned him to work with our technical sergeant trainer. We wanted to ensure that the Airman was performing at his required level before we let him work on his own. It was his fifth day back on the flightline when the accident occurred.

The trainer and a few others were conducting the left main landing gear brake operational check when the Airman, who had been observing the operation, placed his right arm on the top of the flaperon. At that moment, the trainer told the hydraulic test stand operator to "kill the power." Unfortunately, everyone involved in the check was using the same communication headsets and, instead of the hydraulics being shut down, the senior Airman in the cockpit of the aircraft turned the main power switch off. In an instant, the flaperon, which had been held in place under 3,000 pounds per square inch of pressure, shot back to its neutral position, pinning the Airman's arm against the aircraft.

After getting the call and running over to the Airman, I found the courage to ask how he was doing. The Airman was not bleeding, but was in tremendous pain. It looked as if the hydraulic pressure from the flaperon had pushed all the muscle, tendons and ligaments in his arm into a single mass, about the size of a softball, and deposited this mass at the bottom of his palm.

In the chaos that ensued, the maintainers' first reaction was to try to beat the flaperon down with a sledgehammer. My counterpart and I quickly realized that beating on the flaperon would do nothing, so we got the maintainers to stop and to focus on taking care of the Airman, who was clearly exhibiting signs of shock.

We started to hear sirens in the distance and knew that help was coming, but we had to come up with a plan. We knew the fire department would most likely cut off the flaperon if we couldn't find another way to unpin the Airman. My counterpart suggested that we remove a panel on the fuselage, which was a great solution, so we began working.

We were half way through the de-paneling process when the fire department arrived on scene and the commander ordered his personnel to get their saw. Fortunately, an emergency medical technician noticed that the ambulance had not arrived, so they could not cut the flaperon yet. We kept de-paneling as we heard the ambulance approach.

As the ambulance arrived, the panel came free. Medical technicians positioned a gurney under our Airman and, after sliding free, he passed out from shock. As the medical personnel whisked him away to the hospital, I surveyed the aftermath of what had just happened. The scene was a mess: uniform tops had been strewn everywhere, tools were scattered all over the place, and in the 100 plus degree heat, everyone was covered in sweat and sheer exhaustion.

The investigation that followed revealed two main issues. First, no one had eyes on the Airman. There was an expectation that because he was a good crew chief he would be fine after five days back on the flightline. Second, unspecified communication on the head sets was dangerous. Telling someone to do something without clear, concise instructions is what led to the wrong person "killing the power" that day.

These findings caused me to ask a number of questions. Who was watching the Airman? Who was overseeing the training? How many people passed by and saw the Airman with his arm on the flaperon and said nothing? Could a simple suggestion have prevented this from happening?

I realized that when we become so task-saturated and we allow a situation to manage us, trouble comes quickly. The Air Force has given us many tools and instructions on how to manage and lead our work centers and personnel, but to me, the only time we know that we have a safe culture in our work center is when everyone feels empowered to stop an operation that is unsafe, or seems unsafe, at any given time.

Eleven minutes - that is the total time that passed from when the call occurred to the when the Airman was carried away on a stretcher. But those 11 minutes have had a lasting impact. After several surgeries, the Airman separated from the Air Force with some disability in his arm and hand. The last time I spoke with him, he was working with a movie production company and doing fine. The aircraft, after being severely beaten, also survived. The flaperon passed the necessary inspections and is still in working order today. For me, those 11 minutes will stay in the forefront of my mind as a reminder that accidents do happen and that it is up to everyone to look out for each other and to remain vigilant at all times, regardless of how busy or tired we may be.

Original content found here.
USAF Comments Policy
If you wish to comment, use the text box below. AF reserves the right to modify this policy at any time.

This is a moderated forum. That means all comments will be reviewed before posting. In addition, we expect that participants will treat each other, as well as our agency and our employees, with respect. We will not post comments that contain abusive or vulgar language, spam, hate speech, personal attacks, violate EEO policy, are offensive to other or similar content. We will not post comments that are spam, are clearly "off topic", promote services or products, infringe copyright protected material, or contain any links that don't contribute to the discussion. Comments that make unsupported accusations will also not be posted. The AF and the AF alone will make a determination as to which comments will be posted. Any references to commercial entities, products, services, or other non-governmental organizations or individuals that remain on the site are provided solely for the information of individuals using this page. These references are not intended to reflect the opinion of the AF, DoD, the United States, or its officers or employees concerning the significance, priority, or importance to be given the referenced entity, product, service, or organization. Such references are not an official or personal endorsement of any product, person, or service, and may not be quoted or reproduced for the purpose of stating or implying AF endorsement or approval of any product, person, or service.

Any comments that report criminal activity including: suicidal behaviour or sexual assault will be reported to appropriate authorities including OSI. This forum is not:

  • This forum is not to be used to report criminal activity. If you have information for law enforcement, please contact OSI or your local police agency.
  • Do not submit unsolicited proposals, or other business ideas or inquiries to this forum. This site is not to be used for contracting or commercial business.
  • This forum may not be used for the submission of any claim, demand, informal or formal complaint, or any other form of legal and/or administrative notice or process, or for the exhaustion of any legal and/or administrative remedy.

AF does not guarantee or warrant that any information posted by individuals on this forum is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. AF may not be able to verify, does not warrant or guarantee, and assumes no liability for anything posted on this website by any other person. AF does not endorse, support or otherwise promote any private or commercial entity or the information, products or services contained on those websites that may be reached through links on our website.

Members of the media are asked to send questions to the public affairs through their normal channels and to refrain from submitting questions here as comments. Reporter questions will not be posted. We recognize that the Web is a 24/7 medium, and your comments are welcome at any time. However, given the need to manage federal resources, moderating and posting of comments will occur during regular business hours Monday through Friday. Comments submitted after hours or on weekends will be read and posted as early as possible; in most cases, this means the next business day.

For the benefit of robust discussion, we ask that comments remain "on-topic." This means that comments will be posted only as it relates to the topic that is being discussed within the blog post. The views expressed on the site by non-federal commentators do not necessarily reflect the official views of the AF or the Federal Government.

To protect your own privacy and the privacy of others, please do not include personally identifiable information, such as name, Social Security number, DoD ID number, OSI Case number, phone numbers or email addresses in the body of your comment. If you do voluntarily include personally identifiable information in your comment, such as your name, that comment may or may not be posted on the page. If your comment is posted, your name will not be redacted or removed. In no circumstances will comments be posted that contain Social Security numbers, DoD ID numbers, OSI case numbers, addresses, email address or phone numbers. The default for the posting of comments is "anonymous", but if you opt not to, any information, including your login name, may be displayed on our site.

Thank you for taking the time to read this comment policy. We encourage your participation in our discussion and look forward to an active exchange of ideas.

Department of the Air Force does not exercise any responsibility or oversight of the content at external link destination.

The appearance of external hyperlinks does not constitute endorsement by the United States Department of Defense of linked web sites or the information, products, or services contained therein. For other than authorized activities such as military exchanges and morale, welfare and recreation sites, the United States Department of Defense does not exercise any editorial control over the information you may find at these locations. All links are provided consistent with the mission of this web site.