Sea Dragon safety investigation

53' ACCEPTED muss FACTORS HumanFaclur 7 Smoke and Heal Due 10 Cabin Fire Ova Mhe\med Mvshap Fvlots Anelys's Acourding In pain-mishap 72 hour and the MFE OHM sheet, (here were r'o farm's indicated mat would have predisposed the MC '0 spafial disnnemahon or a loss of SA Based on mficokogy scveemngs peflormed on aumpsy, were no inaicauons that any M0 were under the Influence |1f any unaumoflzed substances. The M00 and MCI Sta|sdlhalpflor1oma eruption of five "1 [he cabm me awrclafl was heing flown wmhin ms expeckeu normal operanng paramekers' According In interviews, and M81 reported no matluncfions of me radar amde hold leamre 0' the AFCS that 15 used durmg AMCM opetauons. The MHAC and MCP ware expsnarwed AMCM piles, having was a and 163 5 flight hams under mw respecuvelyA According to the MA El there was extenswe ewnencs or me damagex mcluding 120" of dueling with is epoxy vesm bu med out. Accommg to lab tests In support at me El, the epoxy resin gm of! large amounts of dense mack smoke as combusuon pmaums, The MA also common mm cockpu space was filled mm dense mack smoke from the 2 ma swam us; am TM rs meme. \nvasnam'm mm, uHhe ("m-mum mm Nacn'mma' amuse Ind unnumbumummzumm Cam: Mmmanslm Mat/Human Incmlovmnuun muvunnm my":qu snobs-nos uva personne' sum: mm In maplmw man may 5 USE was wasMailed, M01: or pan, mm In Comm. um may new ceiling down to the level at the instrumem panel. in addmm to obscuring smoke, observations indicate the presence of extrema treat in the as a result at the cabh trre. The MHAC helmet was covered in seat and showed eyidenoe or savsis thermal damage to multiple components. Autopsy results revealed mat the MHAC snfleled partial thickness bums to the law and hands. Fligfl surgeon analysis at MHAC iniflnes $119ng that the burns a; the lace wele sufficiem to cause an shutting reflex and ternpumry blindness i'n at least one eye. The MCC and Nict both stated that Vislbility inside the MA was reduced to near zero shonly following the eruption 0| file in the Cabin. According to the MA and ers Els. the structural damage and recovered GPWS data indicete that the eircrelt impacted the wcterteii iirst at a somewhat ievel attitude with a slight iolt bias. 'ms indicates that the MP3 were most likely aflempting to ditch the MA. Ultimately. the smoke the cockp'n space due to the cab in lira was suflicient to cause extreme Irritation, obsmire outside vefsrenos tn the horizon. and at least pamallv obscure relererice to the instrument panel Additionally. the heat Ilia cabin Illa caused severe physiual distraction to the We in the term ct bum injurieS. Based on the above analysis. the AME concludes "ml the cabin lire produced smote and heat in the cockpit that overwhelmed the MP5 and prevenlsd from saieiy controlling the MA during in attempt to ditch. (3) Act' AE300 - Perception error. MFS failed to safely the MA due to spatial disorientation arid extme physical distraction. Preconditions: (1) FE206 - Workspace incompatible with operation Thick smoke and extreme heat in the cockpit caused MPs to sulier spatial risorientaticn and extreme physical disilao'on. i o. HumarlFactor - MC railed to use adequate CHM (1) Analysis: The Nice stated that the oreokout of tire No the cabin lotlcwed closely his mmplefion oi caom security checks. Pilots will typically treat initiation oi cabin security checks by the crew as i prompt to also (fleck gauges in the cockpit, including luel state. Theretore, iciicwing a cabin secunty checx is the most time lor pilots to notice a need to iraneler tool to balance the tanks. Neither ihe MOO not me repented nearing the pilots announce their intention to trensier lust over the ICS The MHessE NATOPS does not contain any procedure or mandatory voice reports tor translerring tool in liight. though it is common During the MP, the cabin heater flamed out muln'ple times. When the cabin heater flames out, there is no instrument. caution light or advisory light indication to the crew. According to NATOPS, a heater that has timed out could result in excessive luel accumulation and a potential hazard. The MCC and observed the file in the cabin emanating from an area in 1hS vicinity Ol the cabin heater luel supply line. The fuel tube that was tound In be the true source 01 the leak is routed in the same vicinity as tie cabin heater fuel supply line, Once the tire started, tine primary means at eliminating the source at the file would have been to secure the loci Iianslar pumps, Acixmiirlg to interviews with the MCCV the MCC did not call tor the termination oi luei transter tire bmka out in the cahln. The NATOPS Emergenw Procedure tor Fuselage Fire does not mm the crew to secure tuei traneter The race isporled that his lirst respcnee to address the tire was to call tor the pilots to secure the cabin heater. In his interview, the MCC reported that when the pilots inquired as to lhe lccatlcn oi the lire. he responded by telling them It was in the cath and tn "hang on Although the MCC inlended I0 use the purlable lite extinguisher and call tor a cinch il neoessury. the iron recalled being overwhelmed by the smoke pelcrc he could to tight the tire. Mei reported in his interview that the crew indicaled to the that they were attempting use the portable lire i roe use ONLV trio is concord, i use, caroly invest-ether. report. unamuzerr nimmum rn inc nimmawi minis recon or is entlnairesby mmiy peconnd is a oitersc and [Minnie we Artcic 92. Union Cone on MM Jufltm llmilltluiund mocha ct in. mlqmiuton in mic report one mcmums py crviiprr percomci wrii moot them to discolinery am" urinvS use 7502. not. 751:4, 75in. rizi. mi. 7102. was this <<pull not hl tile-Nd. in truce or in can by me Nluzl Satay center, eidinguisiier Based on orew inierviews, neitherilie MOO nor Moi reporiied caning iorihe pilots lo dlinh lrie Neilher me illcc nor incl recalled hearing me pilois say anything about diiching ilie sher ihe lire broke out in his inlervievi, recalled thal when ihe iire broke out ihe MCC said, "Hey, we have a huge oall oi lire and lore ol smoke in die cabin" The reeurring iiameoul of die healer oredlsoosed ihe crew in focus lhsii silueuonal awareness on me healer oi ils polenlial no cause is lire. The leilure oilrie MCF lo announce ihe inlliallon oi lransler severely degraded lhe SA olirie MGC.eflec1lvely prevenling ihe horn oorreoiiy diagnosing the source oi the lire and responding appropriaiely. The MCC porirayed lo me pilots a shuau'on in vvhidr me cabin line we oomrollabie. but due 10 lne rapid prugieissian oi me lire ihe MAC was unable lo update ihe pilols' porceplion of (he sliusiion. This delayed any adeinpl in diroh [he airmail lielere the pilots were overwhelmed by smoke and heal resullirig (he Ille. Based on Ills above analysis, The AME concludes lhal We MC lailed to communlcate elieciively heiween lhe cockpit and the cabin redua'ng lne SA oi the entire crew and conlriliuiing in line mishap Aci: A5301 -- inoorreci response is a mispercepiion. Aircrew called ior pilois in secure healer instead iuel transfers Precondiliors: (1) -- Failure lo ensure inlenlions/sciions were underslood and iollowed. Pilots did not communicate imemorl (a luel 10 me aircrew Fl. HuinanFamor NAVAIR Failed to specify Sulliciem lnspemians lo Pravenl a FIIE (ll Analysis: The AME inspecied several MH--53E sircreii a! born meMS and sisler squadron and discovered dial many oi inern had wire bundles ohaiing sgsinsi lines as suspecied in the MA Stalemenls [rem maintainers who servin (he MA demunslrafied Ihal all procedures were oompleled IAW approprisle pubiicailons. There are procedures in plane ror various mainlenanoe rulings Ia rnspecl die aircrah ohsling and inose procedures are ouilined in die Phase, Daily, and Special decks. These inspeorions lhai oover dialing do nor include cabin wiring and are specific lo oerlein components on both the imlen'or and exisnnr of me airframe. Per H53 ISST, Operallonal and Depul level inspeoiinns do nu! speoiiy corrprehensive inspeciion oi cahin area eleclrissl Wiring and bundles lor damage, proper mlm'ng, clamping, or minimum clearances - espeoidly irorn liuid carrying lines. AME research imo Intarmsdiab lsval revealed mat there are no al that level that would ideriuiy wiring or line placemenr discrepancies such as lhe one moi led lo mishap. Based an die above analysis, rhe AME concludes mar overafional, lnierrnediaie. and level malnienance inspections are insuilicierii lo prevent key precondnions for an airmail cabin lire. Act: - . Organilalional: (l omoa >vaided inadequaie procedural guiuarioe or publications. No inspeedon oriieria oxide lo leak ior discrepancies suoh es die one lhai caused inis mishap s. HumanFaolor NAVAIR Failed in Mirigaie Risk or Wires Near Aircra't componenis Analysis' The AME inepecied several Nil-165E aircrail al the MS and sisior squadron and discovered liial many of ihem lied WIre bundiss chafing against transiel lines as suspecled llie MA. AME review oi MA ADE revealed no malmenance sciinns involving ihe suspecl wire hundls or Iransler line. AME review of all Alrframes Changes, Niciaft MndilicafionsV and Ali'lrames Bulletins revealed no required nieinrenance tn ihe suspect wire oundie or osrsier line The Jolru Service Fan OFFICIAL us: arm Thisu solidi-m iirnuendisniuiicn. area/invesnpviion repsn via ins iconicrirseuiuvnneaneiosuiesoy mnnei is dcmiimi Mmmim Mimich 92' unliun. cod. dmiiraiydusm unsuvniizsddiscissuie dissimimniicnn hisrwun urns :mWiliig Enclimlu oy mun Wm wil nmlaci Irwin in Mummy unders usc ism. ms. 7?i3,7?ui 7121,7lm m2, me. his moon-nay noi s. Velnised, v. whole or in pan exam by ihe Novel samy c-riisr i i General Wiring Malnhenance Manual specifies that wire bundles shall be maintained in euch a way mat they do no: oorne inlo oonlaoi with lluld tubes. However, the Join: Semce General Wiring Maintenance Manual also slates that original manirlaciurer wlre routing hes preoedenoe over the manuals guidance. The original manulaorurers wrre routing drawings lor suspect wire bunde placement allows rorthe wire bundle id be routed as suspected in the MA, The AME concludes mm guidance regard to wire bundle routing allowed for a wire bundle to he placed and maintained in close to a critical aircraft component and ultimately Conflibutsd lo the mishap. Acx: - . in) Organizational. t1) opooa - Provided inadequate procedural guidanoe or publications. No inspection criteria exists to lock for discrepancies suoh as the one that caused this mishap T, Maherlal - Wires Chafing Against Fuel Transfer Line Caused a Cabin Analysis' Crew imervlerus with the and M01 revealed ma! an extensive hre broke out in the cabin or Ihe MA during the MFE just prior |0 the crash. The MCC and MCI observed flames shooting me port cabin bulkhead and reaching all the way across me cabin U12 starboard bulkhead. MCI) and M01 described the shape oi the llames as that of a lrluw loich (very directional). MCI recalled that the llames were extenslve enough that they bledred M83 lrorn saler transiting romerd through the cabin irom his position on one rarnp. The smoke in the cabin quickly spread such mat M01 reported rhai no oould not see out or the windows. The Mac reported that by the lime he reached lor the portable lire extinguisher he could no longer breathe the air in the bin An examination or the salvaged oornponenls revealed considerable evidence or he throughourthe MA The three mash attenuaan (fool) sears (CATS) along Illa IGVWEM port bulkhead between 5131an 222 and 282 shnwed severe heel damage. other iisnrs showing evidence ol extreme thermal damage included ihe port lonrrard ICS station. MGB chip looator panel, nylon vent lines. and a helmet bag Cabin overreed soundproofing also showed evidence or exposure in his. MAC injuries were consistent the presence or lire in fire heficcpter: MCC exhibited bums to the has and the MHAC had partial burns to the lace and hands MAC llighi geer also showed evidence ol lire mmughoui the helicopter. The MHAC helmet was covered in soot and showed evidence ol severe thermal damage In multiple components. El of the MHAC drysuit and survival ves1 showed evidence ol exposure to smoke. MCI '3 helmet showed minor evidence at smoke, Locadon ol the lire was determined lrorn orerr interviews and an analysis dl rhe lire damage in the helicopter. Both M00 and met ooeenred the names in the cabin smanallng rrorn the upper port bulkhead just an ol the GO-NOGO fillar(HlFR1llher). MC1 rationed that he was sitting in a CATS againsl the part bulkhead near slalinn 282 when he lell Intense heal over shoulder and mulled to get out of the way. The pen bulkhead al Slallnn 282 nuntalns multiple ruel lines including engine leed lines, pressure reiueling lines, the cabin healer suppry line, and tuet lransier lines The pattern oi the rnial damage to CATS horn the port bulkhead that heat was most intense at Stalin" 282, lessening towards (he flex! seat lorwald and less! 33th forward most seal. Troop steals aft of station 282 show less severe dieimal damage than those lorward oi station 232. indicahng that the tire was less ii-rlense in lhe all direction. Earningan 01 the part bulkhead a! slafian 282 showed evidence 0' dlrecl thermal damage. Whlle lhe nylon hiding on the soarboard bulkhead in die vicinity on station 232 exhiblled highly looused heating, selectively melting the tubing. The MA El ebnmuded trial the direclionalily ml the hottest spots in lire forward cath were omilmtable to the port bulkhead at stalion 292. ran orncilu usE GNU ma isa primed. iinred use. madam". sens lmnfigifinn report oi lhe Inlamullun his report ems mommy alumni" ey pertain/lei a minimal unenmmr nunaheoie under mice ea unirorrn CM. (1 uravrhenea arrows er the melmim his mum uris swimmer personnel re use wade 7405, 1613 van. 712'. mums. no: no legal nayner be ordered in when or e. um. emu in die Cammlmal Naval seer, career, in me vicinity oi scarier. 252. only lhe iuel iransier llne has me polendsi lo schism posilive iuel pressure. Fuel irensier lines became posiriveiy pressurized durlng pressure reiuellng (ground or l'nlligm) and riansier cperzrions An examinallon oi die reiuel inasrer panel in lhe coukpil ieveeled Ihanhe luel rransier source lank puehbuilons ior lire Number 2 and Number 2 Led iuel tanks were depressed. The iuel rianeier source rank puenhuhons on me reiuel masnei panel open ruel rransrer valves and energize rhe iuel pump in lire corresponding sponsdn, pressurrzind fuel iransierand pressure iefuel lines in me Depressing individuel ruel lrarsier source pushbunons lo balanne luel loads la a manual fuel transfer: in which case Ihe luel lransiei pump(s) slanwhan [he pushbuhon is depressed and siwr off aulomaiicaliy aller so seconds No dalmatian rank iuel lrerisier puslibuilons were depressed according lo a visual inspecllen oi ihe reiusl masler panel The MA El coniinrred rhez ihe rigm and left iuel were in me open posiridn el Impact, and ihal me pressure reiuel valves were in hie closed pasflionr which coincides will. his posirion of lhe lemel psnei pushbunons. The Fuel Transier Pressure Tube El revealed mel lhe iuel nensier line from rhe eon bulkhead had Mo dlslinoz holes: one hole lhal cia hole caused Dy a chafing nylarl 21p he as was commonly used In bundle alec'mcal wiring, the Dlhel hole Gunslan wilh that oi a hole caused by an eiecirical are, The ehaiing hole in rhe iuel rransler line would have allowed pressurized iuel emer irie cabin oi me helicoprsr. Evidence ol en eleolrical are In very close proximiry ro iuel leak likely provided lhe source io eian the lire. To runner confirm his suspscied oi lhe wlre bundle in me vioinily oi me liansier line, me AMB inspeered severei other MHASSE airsiair al rhe ms and discovered rhal many oi mom hard wire bundles ohaimc against luei lransier lines as suepeoied in the MA. Based on the above analysis, lhe AME concludes ml in cheling wlre bundle weakened me well oi lhe porr ruel ~lransier line, and rhen pressurized ruel breached rhe weakened iuel lransier line, causing an elecirleol arc lrorn en unshielded poninn oi a nearby eleonicel bundle end slaning an cabin iire. (2) Componemi FUEL SYSTEM, ENGINE FUEL SUPPLY SYSTEM. (3) Mode: Hole in lube cue lo chafing (4) Agent: Chaan Electrical Wires 9. Fiscornmendelione: A, Recommerwaiion, #1 (1) Deseriplion: Change H53 NATOPS rd incorporare iuel lieneier checklis1 (2) Remarks: Fuel mansier operaridns in the libs aircrair result in lines inside me cabin becoming pressurized. Any leak in a luel line liial becomes pressurized has lhe poxeniial lo inlmduce iuel inro lhe cabin and poses a irre hazard. The ourrem conlains no procedures iuel irom one rank lo amber and no holes, or warnings man would alerr aircrew to lhe rislrs posed by pressurizing iuel lines within lne cabin oi the aircrail. in lhis mishap, lhe MC incorrecny idcused lheir iniliel ahenrlon on line healer as the source ci lhe fire. The lull-lan NATOPS manual clearly states that his healer has me pmenilal to cause a cabin lire arid the cabin heater maliuncrioned rii-nes lhroughourlhe MFE. Mcsi imporuanlly, none ci me crew oulslde oiihe cockpil was aware mat the MP3 had a lual dansier, Given lhese clrcurnslanees, crew SA wirh regards lo possible sources oi cabin rlre was diminished. The irrecrporalion of a pressure reiueling checklist mandatory voice repn ris serve to enhance crew SA and eiieclive panrcipelion in any similar cabin fires in the iucure. Acrlon Agency: N53627 MINE COUNTERMEASUHES SQUADRON IA 7 Hid-14 FOR us: DNLV me surely irweeudaiiori recon. unmmoilzec durlomre on his r. mam at is .ncloruier by wire-y plasmid >3 Mime am punananie uridermcis 91 docs pi iwiiwryiierice. "ruminant oi vie midirnuleri in his reconer in mooning. ciicicsvwa av perxnnel will lo creep-inn new under 5 use 7508 ms lele may m7| an i-ieascd. ma: ci rn mil, exwpl h: comm-ii samv corner i i i i lAi Applies To: Type: HUMAN FACTOR Statement: Smoke and Real Due to Cabin Flre Overwhelmed Mishap Pilots to) Type: HUMAN FACTOR (oi Statement: Mc lalied to use adequate CHM R, Reoornmenrlalion #2 Description; Assess adequacy or Recurring Mormenanoo inepeclron intervals (2) Remarks; A lhoreugir mvesligalmn ol all recurring maintenance on Ihe H53 at the organizational level reveaierl virtually no inspecrion ior wire bunle I arrlrerne interlerence. lnspemjon oi Wirlrig is limited Io lwuoieshooling discrepancy maintenance and broad lnspeolion criteria such as -eondilron and securin While this may. in some instances. uncover areas of wire Chafing agarnar eririsal portions oi the aircrait (light control cables and tones, pressunzee fuel lrnes and lines), ii is lneuilicient to prevent a similar cabin lire in the tuture. Specific Maintenance Requrrernant cards must be developed to sysuernaiically arid muroughly inspem rhe aircrall lor wire Dundie chalrng against critical alrciafl components on recurring oasis. (3) Action Agency N00019 COMMANDER NAVAL SYSTEMS COMMAND (4) Applies To: Type: HUMAN FACTOR in) Statement; Smoke and Heat Due to Caoin Fire Overwhelmed Mianep Fliers Type>> MATERIAL FACTOR Statemenl Wires Chafing Against Fuel Transler Line Caused a Cabin Fire Type, FACTOR (ll Smemanl; Ferled to Specily Sullicienl inspections to Prevent a Fire 0. Recommendation: #3 (I) Assess the Adequacy of Dspcil Level crrleria (2) Remarks, MA was on its third tour. it had undergone 14 Aircrah Service Period Adjustment evaluations and two Standard Depot Level Mainlenanoe (5mm events. A thorough irnresiigelion into lhe specification lor porn lhe ASRA ano SDLM work packages revealed no specific inspection olwlre bundle placement with regards to crilical aiicvafl components. ASPA ana SDLM present an opportunity lor a more ltrorougn inspection of eirorah wire bundle Iairirame interlerence as maror components are removed. Speoilio inspection crilerie should no developed ler incorporation irm ASFA and SDLM events to inspem lor wire ounole clearance wiln struc1ure,h.rei and hydrauiic lines (3) Action Agency: N00019 COMMANDER NAVAL SYSTEMS COMMAND l4) Applies To: Type: HUMAN FACTOR (bi Statemeno Smoke and Heat Due to caprn Fire Ovenunelmeo Mishap Pilots (C) Type FACTOR stalement. Wires cneling Against Fuel Transler Line Caused a Cabin Frre Type: HUMAN FACTOR (ii Stalemeni: Failed lo epeuiy Sufficient lnspecfions to Freuenr a D. Recommendation #unwizgefl. "muse. limit-Manipuran, seven rrwosupam rapcn unaurnonsed ahcmure 01 in. Wuimllmi in INS repel or its summing wmmifi in may personnoi rs nominal mo>> and ounisnaeie under Anini: 92, iran Code oi Justin. Unnumuu axiosur. clu- imam-Mn in mt: Inboun- la swarming enclosures cl sic--n 91ml will map-1.1 mam ro dshwiinity achmi wire. a use 7m 7405.1le rm 7121,7701i7102i 77m, Tub wan ire rehasad where or in pan. evun' twine Conrrunuer Naval Salary qulm, (1) Description investigate engineering solutions to physically isolate wire bundles- (2) Remarks; investigation into the placement at the suspect wire bundle revealed no maintenance actions that would have requireo its removal and reinstallotion Furthermore there are no Airirantes Bullelns, Airframes Changes or Aircraft mat [equired me removal and reinstallalion oi the suspeet bundle. The laglcal conclusion is that the handle ptaoementevident in this airoratt. as well as otherairoratt in the is per the manulaclurel's original specilioation, write this bundle plaoernent is oorrtrary to airoralt wiring guidance iound in Joint Service General wi ring Maintenance Manual, the literaroiy oi wire muan guidanoe iuiind in that manual pisses original rnanulacturer wire routing ehove all other guldance. This would have resulted in the wire hundie being lett In piaoe during any maintenance action in the suspect area at the aircralt, While this bundle rooting may have posed minimal risk early in the service tile 0! the and therelore not met the original manulactiirers threshold tor rerouting; it poses a significant risk in an aging aldi'ame. Inapeelion criteria alone will serve to eliminate rnuch ot the risk oi wire bundle ainranie intertarerioe. bot physioaliy isolating aircialt wiring ironi all critical aircraft components is necessary to prevent catastrophic oiiatirg between maintenanoe Intervals. (3) Amiofl Agency- N00019 WMMANDER NAVAL NR SYSTEMS COMMAND (4t Appli'es To: Type: HUMAN FACTOR Siatement Smakis and Heat Due ll) Cabin Fife Overwhelmed Mishap Type HUMAN FACTOR tdi Statement: NAVAIR Failed to Mitigme RISK orwtres NearAirotart Components Type MATERIAL FACTOR I (0 statement, wires Chafing Against Fuel Transter Line Caused a Cabin fire E. Recommendation: are (I) Description: Complete Full Risk-Analysis of Aging Fleet. (2) Remarks, With proper incorporation oi the previous recommendations. this pamouiar made of laiiure is not likely to present itself in lhe [units However. the discovery of Helen is a leading indicator that other age-related disciepancifi that some lead to loss at aireratt and crew in the tuture may be present There is no planned replacement for (he MH-53E and the fleet is expected in uperale Waugh 2025 A thorough risk analysis at other areas at the aircraft that are prone to age related degradation a necessary to safely operate the through the planned end oi its servioe (3) Action Agency: NOODIQ COMMANDER NAVAL AlFl SVSTEMS COMMAND i4) Applies To' Type. HUMAN FACTOR lb) Statement: NAVAIH Failed lo Mitigate Risk oi vinres Near Alreratt components Recommendation: #6 (1) Description: latter this to all rotary wing aircrew and maintainers (2) Remarks. This mishap has salient lessons tor all realty wing airerews and maintenance professionals. First, it is evident that the crew/s lack oi knowledge oi luel being transterred may have oontributed to their misdiagnosis oi the souroa oi the lire. Sound cam is crucial to building the high level at crew SA necessary no combat oompoond and complimle airerart emergencies. Aircrew and pilots should ooileetiveiy assess their own level or CRM and develop strategies tor any areas this is a iirriihodistnmon. salary .nvestpaten disclosure otrhe in mis rapon or its mum/'9 measures by military vllsumel is unmirai Meme and pomsnaoia onoar Aman 52, Unlmm Owe omiitary tomes, immunized disciosw. otota imam-m in ms room or its mooning anaiosiires by when paryxmel will stopat them to oasiptnary soon onus. a use 150:, ms. 7513. rsu. net, 7701 me. me the rated nay rial be rel-coed. in whole or oi pan emem ovate commander Nun] eatery Cullen weakness. Funhetmore, WhlIe II I5 tncumbem upon NAVAIR and FST to prawns inspection ClIlefla that minimlze the nak at mechanical tam-re: [hat alone is only one piece at the equaliun is equally tncumbant upon all atrcrew and maintenance-protessmnals '0 lhomughly tnspect the aircrafl they are preparing to put on the Itth line or preparing to operate, If something doesn't rock nght, ask questions and demand answer; II guidance IS uncIeal, ask qussflons and demand answers. (3) Action Agency: ALL ROTARV WING AIHCHAFT ACTIVITIES Applies Tn' (al Type. HUMAN mow-on Statement: Smoke and Heat Due to Cfibln File overwhelmed MIshaD (O) Type: HUMAN FACTOR smalament: NAVAIH Failed .0 Mt'n'gate Risk cl Wtres Naav Almrafl Components Type. MATERIAL FACTOR 1 Slalemenl' Wt'rss cnaung Mains! Fuet Transter Line Caused a Cabin FIle I (9) Type: HUMAN FACTOR Statement MC Vajled to use adequate CHM Type: HUMAN FACTOR Statement NAVAIR FalIed to Specify Sumciam Inspections to Prevem a Flle my Airman Mishap Board: A. Position. Memher (1) Name 8, Past'lt'on: Airman Operatmns InVEsItgafing oflicer c. Fosmon. Amcrafl Maintenance lnvesfigatmg Officer (1) Name. Olituer <mt Surety emu.