Two maintenance personnel in a training squadron were completing a 224-day inspection of an ejection seat that was reinstalled in the aircraft without drogue chutes. After the seat was installed and armed, the maintainers began installing the chutes. Just prior to the mishap, one of the aviation structural mechanics (equipment) was seen standing in the ejection seat leaning over the headbox. The seat fired and propelled the maintainer who was leaning over the headbox into the hangar overhead, striking a steel I-beam and falling back to the floor of the hangar beside the aircraft, killing him. The other maintainer sustained first-aid injuries.
The Safety Investigation Report (SIR) stated the following:
• Reinstallation of the ejection seat with the drogue chute removed, while previously allowed, had been prohibited by policy for more than six years.
• The squadron commanding officer, despite a verbal commitment to “by the book” practices, created a longstanding command climate, which placed undue priority on meeting operational commitments.
• The squadron maintenance officer took insufficient action to discourage complacency and unauthorized maintenance practices.
• Several members of the maintenance organization, including collateral duty inspectors, quality assurance representatives, the work center supervisor, and others failed to follow, or allowed others to deviate from, published procedures.
You ain’t gotta be a bloodhound to smell what’s rotten on this one. This tragedy has ol’ Gramps so ticked off that I can’t even see straight. The old man set a tone that wasn’t healthy, the maintenance officer turned a blind eye, and others charged with making sure we do it right took the easy way out and what’s our result? The loss of one of our finest. That, kids, is just plain unacceptable.
If, when you started reading this, you asked yourself, “Self, I thought Gramps wrote about tales of derring-do in the air, what gives here?” the answer is: I think that when in a leadership position, every durned thing you do is watched by your folks. So what did the fledgling aviators learn when they saw how things ran in this squadron? Did they “learn” by the example that was set for them that cutting corners is acceptable? Did they carry that attitude to the cockpit? The first day you step into your squadron, you are in a leadership position, and folks are watching you. Are you going to be the one that lets your folks get away with corner cutting? Words don’t mean nothing unless they are backed up by action and leadership.
So, like a hoot-owl, here’s my question: Who? Who says “by the book” but doesn’t really demand it? Who puts demands on their folks, then turns a blind eye when they cut corners to deliver? Who doesn’t speak up when they know things ain’t being done correctly? Kids, that “who” better not be you.