The Risk of Routine
CHIEF WARRANT OFFICER 2 CHRISTOPHER LEE
B Company, 3rd Battalion, 101st Aviation Regiment
Fort Campbell, Kentucky
For a line company pilot on deployment, things can become very routine. We often perform daily operations without being able to account for every step needed to accomplish our final goal. For example, brushing your teeth. Sure, we know we brushed our teeth in the morning, but who can remember how many steps it was to the bathroom or if you capped the toothpaste?
During one deployment, I was part of an aircrew that, upon landing, discovered an open and damaged engine nacelle. My first reaction was how the nacelle latch could fail in flight because I always check them during my walk-around. I asked myself, “I did check them this time, right?”
Thinking back to the beginning of this mission, I recounted conducting my preflight and doing my typical thorough walk-around — to include checking the nacelle latches prior to engine run-up. Once it was determined our aircraft was ready, we waited for our mission time. A few hours later, my crewmember and I returned to the aircraft shortly before our mission and conducted another walk-around and departed. When we landed, we discovered our damaged nacelle.
How could this happen? We always check. As I went over the scenario in my mind, while having blood drawn at the medic station as part of the investigation into the incident, I struggled to recount if I actually did physically check the nacelle a second time. This is one of the tasks we do so often that I could not remember if the task I was so positive I had completed was a memory of the earlier check, the day before or even from earlier in the week.
The lesson learned for me was to always remember to slow down. Ensure every step of a task can be accounted for and nothing is missed. As part of my crew brief, I now assign both crewmembers the job of checking engine nacelles before getting into the cockpit. Additionally, I have included the crew chief in the crew brief and require them to check my engine nacelles before starting the auxiliary power unit. Don’t find yourself flying a mission and wondering, “Did I check that or not?”