Rough one
https://www.afjag.af.mil/LinkClick.aspx?fileticket=dxoQ_pf1qG8%3d&portalid=77

Incredibly sad and entirely preventable. Someone needs to be charged with manslaughter.

Standard practice is to use a Portable Maintenance Aid (PMA) for this maintenance task. In contravention of standard practice, the multi-functional display (MFD) in the cockpit was used to actuate the desired functions. There is no line-of-sight between the cockpit ladder and the rightside weapons bay, and the maintenance team chief retracted the CRL when all personnel were not clear; MM was in the bay and his head was impinged between the plume deflector and the bulkhead, causing fatal head trauma.

Didn't digest the whole report, but this bit from the Executive Summary seems to sum it up. TO guidance is to use the PMA (a laptop hooked into the aircraft) to actuate the launch rail. Instead, the team lead sat in the cockpit and used the cockpit controls (in violation of TO guidance). When sitting in the cockpit, there is poor visibility to the weapons bay. There was some confusion amongst the team members, and the launch rail was retracted by the maintainer in the cockpit while another maintainer had his head in the way. That poor soul had their head fatally crushed.

11 hours ago, Sua Sponte said:

Incredibly sad and entirely preventable. Someone needs to be charged with manslaughter.

Maybe. I want to know more about how JBER personnel got to the point where they were actuating the launch rail from the cockpit instead of the laptop, in violation of TO guidance.

The report indicates this was something that was "routine" at JBER, so it would be interesting to know how that came about. Sounds like classic "normalization of deviance" going on.

Contributing, but they were doing this work in a hangar, with the APU running. So couldn't communicate verbally due to the noise, and had to rely on hand signals. Maybe I'm showing my ignorance of these things, but is that normal? Don't you typically have power in the hangar you can hook up to, or other ways to avoid running the APU?

17 minutes ago, Blue said:

Didn't digest the whole report, but this bit from the Executive Summary seems to sum it up. TO guidance is to use the PMA (a laptop hooked into the aircraft) to actuate the launch rail. Instead, the team lead sat in the cockpit and used the cockpit controls (in violation of TO guidance). When sitting in the cockpit, there is poor visibility to the weapons bay. There was some confusion amongst the team members, and the launch rail was retracted by the maintainer in the cockpit while another maintainer had his head in the way. That poor soul had their head fatally crushed.

Maybe. I want to know more about how JBER personnel got to the point where they were actuating the launch rail from the cockpit instead of the laptop, in violation of TO guidance.

The report indicates this was something that was "routine" at JBER, so it would be interesting to know how that came about. Sounds like classic "normalization of deviance" going on.

Contributing, but they were doing this work in a hangar, with the APU running. So couldn't communicate verbally due to the noise, and had to rely on hand signals. Maybe I'm showing my ignorance of these things, but is that normal? Don't you typically have power in the hangar you can hook up to, or other ways to avoid running the APU?

In my experience, if power is on and hydraulics are powered, headset communication was used.

Beyond violation of TO procedures, voice comm isn’t required/a factor here. This is all avoided by guy in cockpit not touching anything until someone on ground gives him the thumbs up to do so (and that guy has 1. visually cleared the area surrounding moving parts and 2. Has signaled to others what’s about to happen so they don’t go into any “danger areas.”) So this is a major, double fuck up.