In Full Health
CHIEF WARRANT OFFICER 2 CORY SMITH
2nd Battalion, 238th Aviation Regiment
Wisconsin Army National Guard
West Bend, Wisconsin
During a short stint as the state safety specialist for the Wisconsin Army National Guard, I had many eye-opening experiences. One, in particular, really grabbed my attention due to my previously held military occupational specialty — a 15D aircraft powertrain repairer. Even though I spent just three years as a mechanic in an aviation unit, I’ve always related to maintenance practices and procedures. The mishap I’m sharing in this article took place in a ground maintenance shop.
I first learned of this incident through one of the many reporting channels within the state and read the details. A vehicle mechanic working as a full-time technician was replacing the output seal on the rear transfer case of an M1120A4 HEMTT. During the procedure, a propeller shaft fell and crushed his finger between the shaft and vehicle frame. After receiving the initial Abbreviated Ground Accident Report (AGAR) from the shop supervisor and technician, it was apparent something was missing. An accident report in general, no matter what type, is intended to capture the facts and ultimately uncover the root cause so Soldiers and leaders may prevent similar mishaps. The initial accident description cited that the propeller shaft fell “unexpectedly.” It further stated that the technician performed the procedure many times in the past without incident.
Early on it became apparent that the proper way to uncover the root cause of this accident would be to sit down with the technician and walk through the procedure step by step. Even though I was somewhat familiar with aviation maintenance procedures, I had never opened up a maintenance manual for ground equipment. Since I was already scheduled to perform a standard Army safety and occupational health inspection at the site, I decided to use some of my time afterward to visit the technician.
Before we talked about the accident, I reassured the technician that my objective was to obtain the facts and root cause to prevent similar incidents in the future. In my opinion, doing this sets the stage for an open conversation focusing on solutions to an issue rather than punitive actions. The first thing I asked him to do was pull up the maintenance manual on one of the shop computers so we could compare what he did that day versus what the manual states. Upon opening the work package for the task, I saw several Warnings, Cautions and Notes that were laid out prior to getting into the first step of the procedure. We read through each of them together. Afterward, it was apparent to both of us where the so-called “mistake” that contributed to the accident was made.
The technician had failed to heed the Warnings, Cautions and Notes displayed at the beginning of the work package that stated a lifting device or a second individual should be used to support the propeller shaft to ensure it does not fall. The technician confirmed he did not follow these instructions. He said he’d performed the procedure multiple times and never had a propeller shaft break free and fall like it did that day. As I continued reading, I also discovered there was another step that mentioned the importance of supporting the propeller shaft to avoid injury.
Once the analysis of the maintenance manual was complete, we discussed the importance of adhering to Warnings, Cautions and Notes, as they are key to avoiding injury, death or equipment damage. We also talked about the availability of tools, such as a crane to support the driveshaft, or having a second individual available to assist with this procedure. In other words, I used this opportunity to educate rather than place blame on the technician. Lessons learned
Several important lessons can be learned from an accident such as this one. The first one is to always follow the technical manual for whatever piece of equipment on which you are working. This is important because procedures sometimes change or Warnings, Cautions and Notes are updated because of an event significant enough to warrant the creation of new processes or safeguards. Following the manual will greatly reduce the risk of injury or equipment damage during maintenance procedures.
The next lesson learned is to never become complacent. Complacency is the cause of a majority of accidents. An individual may perform a procedure incorrectly several times before it either injures or kills someone. Again, Warnings, Cautions and Notes bring awareness to the potential for an incident to occur.
Another takeaway from this event is how important safety culture is to mission completion and accident avoidance. More than 75 percent of the accident reports I receive are lacking detail in such a way that it is apparent the individual fears reprisal for the mishap. Receiving report after report that states “no mistake was made” will not improve safety within an organization. It is incumbent upon our safety professionals and leadership at all levels of the Army to ensure Soldiers understand the purpose of accident investigation and reporting so they do not hesitate to reveal the complete details related to a mishap.
The final lesson is education, education, education! One of the most effective ways to promote safe behaviors is to educate individuals on the potential consequences of their actions or inactions. When an individual understands they could be injured or even killed by performing a procedure incorrectly, it tends to hit home or pull on their heartstrings. The overall intent of education in relation to safety matters is to put a reason as to why we must operate the way we do. The goal of the safety program is for every member of the Army, Soldier and civilian alike, to accomplish the mission and, equally as important, return home to their families in full health.