Overconfidence, Complacency and Checklist

Aviation Machinist’s Mate 3rd Class Neiven Torres, assigned to Strike Fighter Squadron One Nine Five (VFA-195), cleans grease out of an F/A-18C Hornet engine cover. (U.S. Navy photo by Mass Communication Specialist Jimmy C. Pan)

Aviation Machinist’s Mate 3rd Class Neiven Torres, assigned to Strike Fighter Squadron One Nine Five (VFA-195), cleans grease out of an F/A-18C Hornet engine cover. (U.S. Navy photo by Mass Communication Specialist Jimmy C. Pan)

STORY BY AD2(AW) ALVIN PRAKASH, VFA-195

As an aviation machinist’s mate and collateral duty inspector (CDI) for work center 110 (power plants), I had performed enough engine removals on the F/A-18 Super Hornet to feel very comfortable briefing and leading my team on what seemed to be a routine engine removal evolution to facilitate other maintenance on the aircraft. Before starting the evolution, we briefed the engine drop at the night check maintenance meeting and ensured that my team members knew their responsibilities. Both team members had prior engine removal experience and I had removed a F414-GE-400 engine from a Super Hornet within the past month.

Having completed the brief, my two team members checked out all tools required for the job and I placed all three of us in work on the maintenance action form (MAF). Next, we positioned the engine removal cart under the aircraft, ensuring the guide rails were lined up properly to transfer the engine during removal. Once the cart was in place, we ensured that the proper procedure for the job was open in the interactive electronic technical manual (IETM) computer we had on hand at the work site. I instructed my team members to remove all the necessary engine accessories for the evolution. Once they were complete, I inspected the engine to make sure all steps had been completed prior to lowering it from the aircraft engine bay.

After completing the pre-removal inspection, we raised the cart and locked it to the engine. With the engine mounts disconnected from the aircraft, I instructed the team members to begin lowering the engine and cart. As they did this, I heard an abnormal sound and told them to stop. I began to inspect the engine cavity and then looked under the engine fan. It was then that I saw the engine anti-ice clamp was still attached to the line coming from the aircraft at the forward fire wall of the engine bay. The anti-ice ducting line was bent, cracked, and broken. We had failed to remove the clamp as we disconnected the engine from the aircraft.

As the team lead for the evolution, it was my responsibility to make sure my team members were following the checklist and to verify all steps had been completed. Instead, I let them complete the engine removal steps from memory without using the personal electronic maintenance aid (PEMA) to verify they had done each item on the checklist. For an engine removal, the IETMs procedure states: “Loosen nut, open duct coupling clamp halves, and separate forward anti-icing duct and inlet device aft anti-icing duct flanges.” Once this step is performed, a noticeable gap will develop between the two sections of ducting. When I conducted the visual inspection of the engine to make sure all steps were complete, I failed to notice that the gap did not exist.

After further investigation, we determined that the damage to the engine and aircraft would cost more than $30,000, making it a Class D mishap. Because of my complacency and the overconfidence of my team, we thought we could do a routine engine drop without following the checklist. I definitely learned that no matter how many times I have done a specific job, I need to follow the procedure. Failure to do so puts our people and equipment at risk and leads to preventable mishaps.