Blind To The Big Red Flag

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rhughes's picture
Blind To The Big Red Flag

I broke my leg and had been out of the AME shop for the past six months. When I returned to my shop I was anxious to get back to work. The AME shop was scheduled to reinstall four GRUEA-7
ejection seats in an EA-6B Prowler after completing a 364-Day inspection. A few things remained before we were ready and
I was happy to help. I never expected that I was about to make the biggest mistake of my career.

Arming an ejection seat is a two phase process. The first phase is to “Bottom Arm” the seat which is done in the workcenter. The second phase is “Top Arming” which is completed only after the seats have been installed in the aircraft. The AME shop had finished bottom arming the seats before I came to work. Once at work, one of the PRs asked me to help switch the seat pans between seats.
Removing and replacing seat pans is a routine maintenance function. As long as the seats are not “Armed,” the task does not even require an ordinance qualification. Eager to help, I went over to a seat, assuming it was “De-Armed.” I failed to notice the “Armed”warning flag on the upper ejection handle when I removed the Manual Override Release (MOR) handle safety pin and pulled the
MOR handle—the same way I had hundreds of times before. However, this time the seat was “Armed!” The guillotine CAD fired off, shooting the guillotine blade into the guillotine body. To my horror, I had just inadvertently discharged a CAD!

During the investigation, Quality Assurance found that there were no steps in the publication to remove the seat pan while the seats are out of the jet and mounted on seat dollies. A Technical Publication Discrepancy Report (TPDR) was submitted requesting this addition to hopefully keep this from happening again.

It could have been much worse; the guillotine blade could have come all the way out and hit someone, causing a serious injury or possibly killing a fellow Sailor nearby. Before breaking my leg, I had been a CDQAR and had trained and worked on these seats for over six years. I never imagined that complacency would have led me to make such a dangerous mistake. It’s pure luck that no one
was hurt and luckily my mistake only caused damage to the seat and wasted man-hours. This all could have been avoided except for a momentary lapse of situational awareness. That is all it takes for something to go wrong.

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