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 There was some confusion amongst the team members, and the launch rail was retracted by the maintainer in the cockpit while another maintainer had his head in the way.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.

I did a CDI once for a group of maintainers who had sucked up the engine covers into the engines of a kc-135 during an engine run at night. This was a group of five maintainers, all of whom had forgotten to bring a flashlight, and so instead of either finding a light source or just walking up to the engine to see if they were covered, they just skipped every procedure and rule to prevent this mishap fired them up.

Sadly this is completely believable. I hope he went quick.

After an incident like this MX will get anal probing. Back in the 90's the F-15 had a known discrepancy in the tech order on how to rig the stabilators, these were rigged backwards, and pilot didn't notice it until he tried to takeoff from Spangdahlem, it was a fatal mistake. The following actions where the tech data was finally fixed and maintenance personnel whose name was in the 781 were court martialed, later one committed suicide and the MXG guys refused to sign any red X off in the forms because the witch hunt that was going on. The mission of that wing slammed to a stop because mx folks were in full career preservation mode and screw the sortie count. I bet JBERS will go through some painful soul searching, lives destroyed, careers scuttled, MX actions going into slow crawl mode.

Mueller v. US Dept. of Air Force, 63 F. Supp. 2d 738 (E.D. Va. 1999) :: Justia

PLACING BLAME AT ANY COST | TIME

Edited 13 hours ago13 hr by Prosuper

1 hour ago, Prosuper said:

After an incident like this MX will get anal probing. Back in the 90's the F-15 had a known discrepancy in the tech order on how to rig the stabilators, these were rigged backwards, and pilot didn't notice it until he tried to takeoff from Spangdahlem, it was a fatal mistake. The following actions where the tech data was finally fixed and maintenance personnel whose name was in the 781 were court martialed, later one committed suicide and the MXG guys refused to sign any red X off in the forms because the witch hunt that was going on. The mission of that wing slammed to a stop because mx folks were in full career preservation mode and screw the sortie count. I bet JBERS will go through some painful soul searching, lives destroyed, careers scuttled, MX actions going into slow crawl mode.

Mueller v. US Dept. of Air Force, 63 F. Supp. 2d 738 (E.D. Va. 1999) :: Justia

PLACING BLAME AT ANY COST | TIME

Way back in the day at a PACAF base, we were getting ORE'd to death after coming back from having kicked off OIF. 4 months straight of surge for a week, fix over the weekend, then right into a week long phase 1/2. Rinse and repeat. ORI rolls around and MX/OPS leadership was on our ass for writeups received during generation phase so everyone went out and during ORI generation did our job to the letter of the TO. 2 jets generated. I think there were 5 horizontal stab changes and 2 vert changes just in our squadron. WG CC called all the crew chiefs in to talk. We got to vent for a bit and he actually made some shit happen. We got to by name request a few more 7 levels and they diverted a bunch of 3/5 levels.

They preach by the book but don't want it by the book. Doesn't take too much of a leap to get into fatal consequence level when you veer too far from the book though. Alot of common sense shit that doesn't get done but you get by without reaping the effects. It'll get you eventually.

12 hours ago, brabus said:

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.

Except the AIB points out the dude in the cockpit couldn't have seen the guy by the CRL on the right side of the jet. However, they could've activated the CRL via their laptop, which was under the jet on the ground, on the wrong TO checklist (APU start) to the maintenance they were doing. Since their laptop could actuate the CRL, there was literally no reason why the guy was in the cockpit doing it via the MFD.

8 hours ago, Lord Ratner said:

I did a CDI once for a group of maintainers who had sucked up the engine covers into the engines of a kc-135 during an engine run at night. This was a group of five maintainers, all of whom had forgotten to bring a flashlight, and so instead of either finding a light source or just walking up to the engine to see if they were covered, they just skipped every procedure and rule to prevent this mishap fired them up.

Sadly this is completely believable. I hope he went quick.

I remember seeing that when I was in OGV. The best part was the CVR recording the idiots in the cockpit making fun of the kid at the firebottle for not having being able to see due to no one having a flashlight.