While on a maintenance test flight, a unsafetied retention bolt for the main rotor pitch change rod vibrated free from oscillatory loading and was thrown from the aircraft. The unrestrained upper pitch change rod resulted in complete loss of control over the main rotor system and, ultimately, an inflight breakup of the aircraft. The aircraft impacted in an open field. All three personnel on board were fatally injured. A postcrash fire destroyed the major portions of the aircraft.

History of Flight
While executing completion of a maintenance information message to install phenolic washers to PC rod end bearings and dampers, work was started but not completed and write-ups were signed off. During the maintenance procedure, three dampers and one PC link were found to be unserviceable. The crew chief did not remove them; a decision was made to leave the PC and damper bolts loose and unsafetied. Due to haste, the aircraft maintenance test flight was rescheduled for four days earlier than planned. Due to the reschedule, several other maintenance personnel were assigned to finish several other maintenance actions on the aircraft. Once the aircraft maintenance actions were thought to be completed, the technical inspector arrived and conducted his inspections, during which he failed to thoroughly inspect the logbook and verify what work had been completed and required signoff. Due to this lapse, he signed off that the PC rod had been re-torqued and safetied. Following the work, the aviation maintenance officer and pilot (PI) failed to complete the preflight inspection in accordance with the technical manual, resulting in failure to find the PC rod retaining nut was not torqued or safetied. The aircrew departed the airfield en route to the maintenance test flight area. At approximately 3/10 of an hour into the flight the PC rod came loose and the aircraft broke up in flight.

Crewmember Experience
The maintenance test pilot (MP) had 469 hours in series and 469 hours total time. The PI had seven hours in series post flight school.

Commentary
Army aviation maintenance is a demanding and high task-saturation environment. It is inherently unforgiving of even minor errors. As maintainers operate in this high OPTEMPO environment, it is critical supervisors and unit leaders maintain the standards. When we see failures occur, such as in this mishap, we had three levels of failure: the executor, the quality control system and, finally, the aircrew. To catch the errors, leaders must be visible on the maintenance floor — not only just milling about to be visible, but actively visible and engaging the maintainers on what task they are completing, verifying the technical manual is on hand and open to the procedure being completed, querying the technical inspectors on the status of the aircraft and verifying aircrews are conducting proper preflight inspections.

As you can see from what leaders should be doing to maximize safe maintenance operations, this visibility requires each level of supervision and leadership to be visible: the floor sergeant, the technical inspector, the aviation maintenance officer, the production control officer, the platoon leader, the first sergeant and the commander. Implementing leader visibility is an active process and the one sure method to catch errors before they become a mishap. Supervision by multiple levels breaks the accident chain. Enforce high standards. Get eyes on the operation so you have situational awareness of how well the maintainers perform, who excels and who requires more supervision or training. Deploy an aviation maintenance training program with your commander’s guidance and manage it. A standardized program will assist in preventing errors and mishaps.