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

  • Published
  • By Master Sgt. Anthony Smith
  • 57th Maintenance Group
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.