CH-53 report

Walt,
Excellent report, sir. Although I would expect no less from you. It's clear that the crew did all they could.
Most of us have worked many, many hours on our birds at one time or another...but how many days did these guys do it??? Sounds like you've gotta be pretty whipped to need help holding your hand still! I've got to sympathize with them, trying to get the job done..and then the unthinkable happens! I know that feeling....and it ain't good.
Semper Fi
Joe

CH-53D ACCIDENT

Makes one wonder where QA (Zero and Stripes) was, or was not. Working hours in excess of 17 hours per day for a mere three days is nothing new. I well remember our night crew at HMH-463 in K'Bay working more than that on "short" weeks. Our engine shop at H&MS-32 (prior to MALS) worked 23 consecutive days at minimum of 16 hours per day; but, QA was ever present doing their job. We went from 17 "Bare Firewals" to having three spare engines during that period. Could site more instances like this than I have fingers and toes. And, I quite well remember working those hours when I was just a pup in Nam, especially during Tet of '68.

A.G. Friend
"Alfa Golf"

Who's acft? wasnt 265 still in NC at rhe rime. Org sqd 463?? Alpha U agree where was QA??17 hour day was routine on floars.

Hello Alpha Golf! Without knowing what kind of maintance process the Corps is currently using I cannot say where this process broke down....but....I do remember the Maintenance control procedures in place when I ran Maintenance control for you in HMH-463 and for Bull Wemheuer in HMH-363. It was my responsibility to certify every aircraft as "safe for flight" prior to a pilot accepting it. This process consisted of verifying that all maintenance actions had been performed according to written instructions and signed off by the required personnel. Any maintenance action taken on a flight control system required a Quality Assurance department signature and a post maintenance test flight. We had many "test and go" flights due to this process. The process was designed to consider fatigue of the mechanics by this system of checks and balances. Back then 12 hours would be considered only half a day. Gunner Anderson's night crew was well conditioned to 3/4 days being the norm. I would have to hold myself accountable. Even with this system some H-46 "Jesus" nuts were left off. Those were the days my Friend! SF L R Gilton

HMM262 and HMM265 are stationed at Futema Okinawa. When I was Maint Control Chief of HMM 262 HMMT 302 and HMX that was the same guide lines we used. Any work on any flight control required QA and a test hop sometimes they where test and go though. I have no idea what system is in use today.We worked long hours all so sometimes it seemed I met my self going to work. SF

It has been my experience that these mistakes are usually overlooked by many eyes

There are three different and distinctive signatures required when a flight control system is worked on; all three are highly trained, well informed personnel. They all understand the seriousness of the Flight Control System and their roll in the test procedure.

Any work on any Flight Control System must have a Quality Representative Inspection that would be the first signature.

The Crew Chief pre flighting this Helicopter for the test hop would be well aware of the maintenance that was performed and his signature is required after the QA rep, that is the second signature.

The third signature would be the Test pilot, while it is true that he signs off the yellow sheet before the preflight, he is still well aware of the maintenance performed and is responsible for a thorough preflight of the area worked on prior to taking off for the test flight.

All three of these positions report to the Aircraft Maintenance Officer and all three were responsible to have inspected the cotter pin during their inspections.

In my experience, test and go was never authorized when a flight control system was worked on.

This inident seams like Complacency to me.

George, I think 2 more signatire are needed, a CDI for tq]s and tools, snd Maintenance Control as Safe for Flighr. I think computer are now used vice signatures. on MAF's.

QA

One of the basic principles in the design of Aviation QA systems is that if a mistake can be made, somewhere, sometime, it will happen. Anything connected with flight controls is potentially catastrophic and the levels of signoff required in this case show that. All of us who served in War Zones can tell stories of hours that under normal circumstances would considered excessive but were worked without complaint or comment. Following the QA procedures becomes even more important: tired people make mistakes. This accident shows an almost incredible failure at many levels of supervision. It points to failure at the top not the bottom.

That said, I expected to read that the crew were all killed. How on earth did they get it on the ground with what can only be described as relatively minor injuries. I'd love to know what they did.

Top A I was told at a reunion at New River that ever thing is in the computer and that paper wasn't used any more . John I agree with you I wouldn't be looking for the Marines that did the job but for who ever was supervising this and for who ever inspected this job. George test and go may not be authorized but I would bet you ever squadron in the Marine Corps did it at one time are another.SF

Thanks Walt, I worked OSS from 91-2000 C9 support and rhey were all cpu data, bur wasnt s8re on ders nowdays. I'd look for amo,aamo, mmco, maint cnrk chiefand QA/cdi's. These folks are one's respomsible for work loads amd final producr. Aksi what BS from the Barrackd, firld days etc. duroung off rime.

There were mistakes...

I know this is an old thread and I don't really see this going anywhere but I want to set the record straight.

I'm an active duty Airframer and I was part of this entire mess. The cause of the mishap was, indeed, faulty rigging procedures. I worked on that plane the day before it crashed. I spent three days, without rest, at the crash site at Ginowan City Univesity as the ERT leader.

Bottom line: I know the guys that caused the mishap. Good men, good maintainers and good Marines. Don't be too quick to judge. Don't be holy. Don't quote me the 4790. We were caught up in a goat rope and they were pressured more than anyone else. If anyone is tempted to point a finger, point it at the brass that thought it would be a novel concept to put together a slew of personnel across MAG-24 on short notice and throw them out in the (eventual) sandbox. The idea of sitting back in a high chair and judging them for their actions disgusts me. I saw controllers come and go while I and the Flight Line guys put in 18-20 days (contrary to the piddly 14 in the "official" report) for the work-up to the Essex. Stop checking the morning report and grab a wrench, get back to the reality of Marine Corps aviation maintenace. It's unforgiving, without accolades and built on pride. Those guys made a mistake based upon the "gray" areas of the MIMS. I was there right after the stinger batallion showed up. Funny enough, the one guy I saw "sweating it" the most (right after the crash) was the senior SNCO and maintenace controller of the det (53-wise). Although we all followed his word, he never once set foot on the flightline, nor did he put in the same hours as the rest of us. I'm not blaming him. I'm blaming the command element in general. We were undrstaffed and inexpierenced. I'm just happy that no one was killed.

Judging Marines?

Hilock,
I don't think anyone here is judging you or your Marines. We've ALL been there on too little sleep/rest and too many committments. For Walt and me and many others it was Viet Nam, combat conditions. You're correct when you say s**t happens, Always has, always will. NONE of us are perfect, but we did certainly try and and give it our best as you and your Marines did.
Semper Fi, Sir!

It all comes down to check and recheck, especially when flight controls are involved. I did it in the Corps and for 35+ years in civilian aviation. You check your own work, an inspector checks it after you and the pilot is the final set of eyes that checks it all with signatures and license number. The military also has a crew chief responsible to do a pre flight inspection. Lots of eyes missed that missing cotter pin, maybe it was there and not bent over, but when flight controls are involved you look a little harder especially where the work was done. No excuses! I know about working long hours for many days in a row both in combat with HMM-262 (with Walt) and in civilian jobs. I would have lost my A&P license for something like that and other heads would have rolled + there would be lawsuits. OooRaah to the crew on a somewhat safe landing.
S/F
Tim

Maint procedures re:

It had always been drilled into me, that as a Post-Maintenance-Inspection Pilot, your acceptance of that a/c for test, and certification for release from maintenance status was your responsibility.

Henceforth, if there was maint done, that required a "test flight" then there was an officer pilot's signature that it was such.

I cannot itemize or describe the range of things that were not right, maint-wise, on the birds that I tested, nor did I ever blame the crew chief or the maint poges, but never ever, was one signed off for flight, unjless it was ready to be so. No blame, anywhere...when the PMIP signed it off, it was good to go.

Hooper

010+
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