I thought it was good to go

Our squadron had completed a successful Western Pacific deployment and now was enjoying a proud sense of accomplishment. We felt untouchable and immune to anything and everything. It took only a tow tractor to rain that high.

The workday had begun like any other one: a fine Navy day. We reported for work at 0630, and the morning maintenance meeting began at 0700. Line-division personnel already had begun preoperational inspections of the support equipment.

Those inspections were good, except for one on an A/S32A-42 tow tractor. An airman inspector noticed the starboard aft wheel was missing all but one of its lug nuts. That airman immediately notified his supervisor, who, in turn, told everyone in the division not to use the tow tractor. The supervisor then called AIMD GSE and passed on the information about the tractor. Ten minutes after that word was sent, maintenance control told the line to tow aircraft 402 to the wash rack.

The supervisor gathered his available people, checked out a tow tractor from a sister squadron, and proceeded to tow 402 to the wash rack.

Thirty minutes had passed, and a mech from power plants needed to leave for AIMD GSE to check out an engine stand. That AD3 walked toward the line shack to check out the tow tractor, but he noticed the line supervisor was at the far end of the flight line. The mech decided to save time by driving the bad tug to the supervisor.

He rationalized that the drive would be quick; the request would be short; and the pick up at AIMD would be easy. He did a quick walk-around of the tow tractor, jumped on, and drove onto the ramp. As the AD3 neared the end of the flight line, he made a sharp left turn, shearing the one bolt holding on the wheel. The starboard wheel completely rolled off, and another one jammed under the tractor, immediately stopping it. No one was hurt, but the mech was humiliated when he had to explain what had happened to the maintenance chief. Trying to explain why he had failed to do a proper preoperational inspection, the AD3 stated, "I thought it was good to go."

The mech didn't do even a quick pre-op, but the line also should have tagged or marked the down status on the tractor. They also should have notified maintenance control.

ORM teaches us to assess and minimize risk by identifying hazards and implementing controls. This low-risk job turned into a major problem because of a failure to communicate. The hazards were identified, but the proper controls (a safety tag and a phone call) were not implemented.

Petty Officer Dixon is the safety petty officer at VFA-195.

COPYRIGHT 2003 U.S. Navy Safety Center
COPYRIGHT 2003 Gale Group