How Maintenance Practices Drive Ground Mishaps
G3, Investigations, Reporting and Tracking
U.S. Army Combat Readiness Center
Fort Rucker, Alabama
The command maintenance discipline program (CMDP) allows commanders to evaluate unit maintenance programs on a day-to-day basis. It is oriented toward combat readiness and sustainability. The overriding principle of the CMDP is the Soldiers’ and units’ abilities to maintain their equipment in any environment. However, when the leader’s vision and expectations drive Soldiers to take shortcuts and circumvent established procedures in order to maintain readiness and sustainability, then there is the potential for a catastrophic mishap to occur. A review of three relatively recent Army incidents highlights the impact the CMDP has on fatal mishaps. Mishap 1
An M2A3 Bradley Fighting Vehicle (BFV) power unit access door (PUAD) fell on a BFV maintainer, instantly killing him. The PUAD was suspended by an improper strap attached to an eyelet on the front of the BFV. The improper strap was used because the authorized “lifting eye” was secured in an internal slingable-container unit (ISU-90) because the unit was preparing for an OCONUS deployment.
In preparation for the deployment, the mishap unit was working around the clock to complete the required maintenance on the manifested vehicles. The investigation into the incident revealed that the unit was improperly reporting its operational readiness (OR) rate leading up to the mishap. In an effort to achieve a 90% OR rate, the unit was placing vehicles on an administrative not mission capable (NMC) report to circumvent them being shown on the equipment status report (ESR) or the materiel condition status report. This essentially was an unrealistic picture of the actual OR rate of the mishap unit.
This mishap was a direct result of the improper administrative NMC status of the BFV. This NMC status, combined with the BFV maintainers’ misplaced motivation in attempting to meet mission requirements and repair the dead-lined vehicle, directly contributed to this mishap. Had the actual status of the fleet/vehicles been provided on the status report, then the command could have planned accordingly and adjusted timelines and suspenses in preparation for deployment. The status report, part of the CMDP, was not an actual representation of the mishap unit’s readiness. Consequently, the BFV maintainers attempted to complete the maintenance utilizing improper equipment and following incorrect procedures. Mishap 2
An M1120A4 Heavy Expanded Mobility Tactical Truck (HEMTT) Load Handling System (LHS) was the trail vehicle in a four LHS movement/convoy on an improved tank trail on the installation. The driver of the trail LHS was following too closely to the vehicle to his immediate front. Additionally, the interval between the vehicles was too close for the limited visibility created by the dust and dusk. As one of the LHS drivers began to slow and pull to the side of the trail, the driver of the mishap vehicle was unable to stop. At the last second, the mishap driver attempted to steer to the left to avoid hitting the LHS to his front. Unable to avoid the impact, the right side of the mishap driver’s LHS struck the left rear corner of the flat rack on the LHS attempting to pull to the side of the trail.
The impact resulted in the truck commander suffering fatal injuries and extensive damage to the LHS. Although the CMDP and maintenance practices did not directly cause this mishap, the investigation revealed that all four LHS vehicles in the movement had faults that should have rendered them NMC, including numerous loose lug nuts, Class III hydraulic leaks, air leaks, and damaged and worn tires.
How is it that all four LHS vehicles had similar faults? Could it be an indication of the CMDP within the organization? In an effort to meet the commander’s intent for the mission, the maintainers and operators were continuously operating unserviceable vehicles and not properly maintaining them to the known standard. Properly maintaining the vehicles would have limited the number of assets available for the mission.
Once again, this mishap highlighted deficiencies in the CMDP. Operators and maintainers were not following traditional maintenance practices. The actual vehicle’s status was not being properly portrayed to the command in violation of the CMDP. Mishap 3
An M2A3 BFV was conducting a movement to a contact training exercise when a loose electrical connection in the turret provided a source of ignition which eventually ignited a pool of fuel in the sub-turret area of the vehicle’s hull. The flames ruptured both fuel cells, resulting in a fire that destroyed the BFV. The fuel leak was a known issue with the mishap BFV. The operators and unit leadership chose to continue operating the vehicle in contravention to the BFV technical manual that states any fuel leak renders it not ready/available. The fuel leak was known for several months and had never been annotated on a historical equipment status report (ESR).
The mishap investigation identified a maintenance culture where the actual OR rate and vehicle condition precluded reporting the actual status. Crews and maintenance personnel found themselves in a situation where the OR rate of 80% directly affected the ability to properly report the status of pacing items. This culture prohibited the maintenance management team from properly annotating faults and correctly tracking NMC equipment on the status report. This mishap is an example of where maintenance practices and CMDP culture directly contributed to the total loss of a BFV. Conclusion
The mishaps referenced above occurred during training exercises or while the units prepared for deployment. None of these mishaps should have occurred had the CMDP and the unit leadership been more actively engaged in the daily and weekly activities of their respective maintenance programs. The OR rate is a goal. However, when the OR rate becomes unattainable given the equipment, time and qualified Soldiers available, leadership influences have the potential to unknowingly steer Soldiers in a direction contrary to traditional CMDP principles.
Have you ever considered what happens when the actual maintenance status and OR rate conflict with the goal of 80-90% fully mission capable? Inevitably, maintenance practices and procedures are circumvented to achieve the leadership’s goal. Leaders at all levels need to ask themselves the following question: “Could my emphasis, guidance, focus and goals cause Soldiers to take shortcuts?” If the answer is “Yes,” then a maintenance refocusing needs to occur within your CMDP. When the OR rate and status reports cause maintainers and operators to delay, overlook or disregard known standards and procedures, then an unwanted maintenance culture exists.
Historically, units with a poor maintenance culture tend to have more mishaps than those that do not. Although this sounds simplistic, failure now to take immediate action within your unit and formation will undoubtedly be identified in a future mishap investigation. Ensure your leadership, guidance and Soldiers’ maintenance practices do not drive and contribute to future mishaps. Review your maintenance practices and status reports and ask the tough questions.