Keeping the mission moving
By Maj. Ken Ernewein, 39th Air Base Wing Safety
/ Published November 07, 2006
INCIRLIK AIR BASE, Turkey -- In 1999, I was the investigating officer of a major mishap that took place at Tinker Air Force Base on the KC-135 Stratotanker depot maintenance line. We were asked to figure out how a KC-135 in its final stages of quality checks prior to reentering the operational inventory could explode during a routine pressurization check. In fact for the first couple weeks of our investigation senior Air Force staff were so concerned about the catastrophic nature of this mishap that they grounded all KC-135s and AWACS aircraft until we could provide analysis ruling out materiel or design failure. This decision grounded more than 600 Air Force, Air National Guard, and Air Force Reserve Command aircraft.
The Bosnia Conflict was just kicking off and Air Force leadership was more than a little concerned about not having the ability to use their tanker and AWACS aircraft. Boeing sent a team of metallurgists and scientists that pored over every inch of our aircraft wreckage nonstop 24/7 for over a week. Despite having some really big brains and cool equipment, a - la CSI, they were unable to produce any indication of materiel or design failure.
The rest of our investigative team continued to dig hard into the human, training and procedural aspects of the mishap. We interviewed everyone involved, and with regard to the maintainer at the controls during the mishap, we were consistently told he was "the most qualified," and "the preeminent expert" on the task that they were performing. Moving further up the chain we checked training records, talked to supervisors and even looked at past inspection results. Everything was in order. In fact the Tinker depot line had recently passed a major inspection which focused on their training documentation with flying colors.
The individuals were the best at what they were doing and the training was perfect ... so how did that fit with these other facts that we uncovered? The facts showed that this maintenance team had committed nine major deviations from technical order guidance which combined to create the exact conditions for a perfectly good aircraft to burst like a balloon during a routine ground pressure check.
If I haven't raised enough questions yet, consider this ... despite the numerous T.O. violations, in the end we did not find the individual maintainers at fault for this mishap. It turns out they had been trained and certified to do exactly what they had been doing that day. Unfortunately their training, certification and quality assurance oversight had become only "good on paper." This underlying problem had started 10 years earlier during the implementation of cost saving measures within depot maintenance.
In the early 1980s depot supervision and Quality Assurance Evaluators had been reduced. As a result supervisors and QAEs that were not qualified to perform specific tasks were allowed to sign off others on those same tasks. These types of flaws in safety oversight were not intentional and did not happen overnight. Instead, over time (in this case about 10 years) as experience retired and procedures changed the previous level of oversight maintained to mitigate hazards was no longer in place. The good news is this non-fatal mishap prompted leadership to correct the problem. However, they did not go to the old manning levels...instead they found a way to correct the problem with the resources available. They did it smarter.
The Air Force over the last 20 years has transformed tremendously. During the last two decades we have experienced continual cuts to our resources and yet have steadily become more safe, agile and lethal.
The trick is in the implementation. Air Force Smart Operations is the Air Force's articulation of this goal. Stay with me here...I'm not saying that getting behind a catch phrase like AFSO 21 or ORM is some type panacea. In fact I've intentionally left AFSO and ORM out of this discussion until now so that I could keep you from going into AID (Acronym Induced Disgust). However, from time to time the AF gives us the ability to tell our bosses what needs to be fixed and how to fix it. Have you ever wondered what step in the ORM process tells you to inform your boss when they're about to do something just plain wasteful or harmful to the mission? That's right...step 3--Analyze Control Measures. If you tell your leadership how to fix what's broke instead of just complaining about it to coworkers it will get fixed. AFSO 21 is a blunt invitation to provide this same information. It is our duty to make it possible for our leadership to eliminate wasted processes, make the necessary cuts and continue to improve our warfighting capability. How well we enable our bosses to make the right force shaping and transformation decisions today will determine whether we're getting the mission done or watching it pass us by.