Posted on Jul 10, 2016
Navy: Human error to blame for incident injuring 8 sailors on carrier Ike
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NORFOLK, Va. — Navy investigators say human error is to blame for an incident that injured eight sailors on the Norfolk-based aircraft carrier USS Dwight D. Eisenhower in March.
The sailors were injured after a cable used to catch a landing of an E-2C Hawkeye snapped on the carrier's flight deck.
A Navy report obtained by The Virginian Pilot in a public records request says workers missed at least one and possibly two "critical steps" while performing maintenance.
As a result, the report says an engine that controls the flight deck cables didn't slow the aircraft and the cable broke.
The report says the sailors' injuries included a fractured ankle, wrist, pelvis and legs. One sailor suffered skull and facial fractures and another suffered a possible traumatic brain injury.
From March:
The sailors were injured after a cable used to catch a landing of an E-2C Hawkeye snapped on the carrier's flight deck.
A Navy report obtained by The Virginian Pilot in a public records request says workers missed at least one and possibly two "critical steps" while performing maintenance.
As a result, the report says an engine that controls the flight deck cables didn't slow the aircraft and the cable broke.
The report says the sailors' injuries included a fractured ankle, wrist, pelvis and legs. One sailor suffered skull and facial fractures and another suffered a possible traumatic brain injury.
From March:
Navy: Human error to blame for incident injuring 8 sailors on carrier Ike
Posted from navytimes.com
Posted >1 y ago
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I read it, I heard. Someone screwed the Pooch on the PMs and that is the worst thing you can do. Ideally there is a fair degree of auditing and second checking in the process just because this is what can happen if PMs are not conducted correctly. Lot of People are going to take a fall on this one. XO being head of the PM program could easily be relieved.
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It is very sad when a preventable maintenance failure results in the injury of 8 US Navy sailors or anybody else for that matter SFC Joe S. Davis Jr., MSM, DSL
Hopefully those workers who missed "one and possibly two "critical steps" will be disciplined appropriately.
Hopefully those workers who missed "one and possibly two "critical steps" will be disciplined appropriately.
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Read the article from the Virginian Pilot it goes into more detail. This happened after troubleshooting and corrective maintenance, not PMS. Here is an excerpt:
"In the March 18 incident, personnel that were troubleshooting a fault code from a previous arrested landing with the Eisenhower’s No. 4 arresting gear engine were using an approved Navy procedure when they missed steps that led them to misprogram a valve that controls the gear engine’s pressure and energy absorption, according to the report. But that procedure lacked warnings, other notations and wasn’t “user friendly,” Navy investigators found. As a result, while those personnel failed to comply with a “technically correct written procedure,” the Navy found their error understandable because the procedure didn’t explain the basis for its steps, lacked supervisory controls and “failed to warn users of the critical nature” of the valve’s realignment."
Not sure how things are in the air community, but on the surface side we don't always have the same checks and oversight for troubleshooting/corrective maintenance that PMS receives. The procedure probably made complete sense to an engineer.
Another lesson learned in blood.
http://pilotonline.com/news/military/local/navy-human-error-to-blame-for-march-cable-break-aboard/article_c4675c54-6cdc-5882-867a-68f961145c9d.html
"In the March 18 incident, personnel that were troubleshooting a fault code from a previous arrested landing with the Eisenhower’s No. 4 arresting gear engine were using an approved Navy procedure when they missed steps that led them to misprogram a valve that controls the gear engine’s pressure and energy absorption, according to the report. But that procedure lacked warnings, other notations and wasn’t “user friendly,” Navy investigators found. As a result, while those personnel failed to comply with a “technically correct written procedure,” the Navy found their error understandable because the procedure didn’t explain the basis for its steps, lacked supervisory controls and “failed to warn users of the critical nature” of the valve’s realignment."
Not sure how things are in the air community, but on the surface side we don't always have the same checks and oversight for troubleshooting/corrective maintenance that PMS receives. The procedure probably made complete sense to an engineer.
Another lesson learned in blood.
http://pilotonline.com/news/military/local/navy-human-error-to-blame-for-march-cable-break-aboard/article_c4675c54-6cdc-5882-867a-68f961145c9d.html
Navy: Human error to blame for March cable break aboard USS Eisenhower flight deck
A Navy investigation obtained by The Virginian-Pilot faults maintenance personnel for failing to reset a valve for a March incident in which eight sailors were injured when a cable used
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