Kenxxxx x xxxx xx
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Incident at Boeing simulator operations

by Kenxxxx x xxxx xx

This report is to bring forth the incident at Boeing Simulator Operations on May 18th, 2008. It is a work related accident and in reviewing the key points that I hope to bring out with this report, it will show that it should not have happened and could have been prevented; as a result of this accident my future has been altered and very uncertain with permanent injuries and a forced changed way of life. First I’ll explain the events leading up to the accident, how the accident happened, the aftermath of the accident, and then how it should have been prevented, as well as, pointing out major flaws in the operation and procedures happening at Boeing Simulator Operations. I was just hired on to Boeing As a Simulator Device Technician Level III on April 25th, 2008 after being away from Simulators for about 2½ years and writing Technical manuals on simulator operation and maintenance for 5½ years before that; See Figure 1 for picture of a Simulator. We were on the second week of doing overtime on the weekends to do hydraulic oil flushing on 2 different simulators that are considered extremely old and the flushing was years overdue; when finishing up on the second simulator (the 757, oldest), all of the hydraulic pumps had been turned ‘ON’ to circulate the oil through the system and after a little while, a pretty bad leak was noticed on one of the Control Loading servo actuator/valve components. The Control Loading system hydraulic oil pump pressure was turned ‘OFF’ so the actuator could be removed and repaired; as someone was removing the actuator, I noticed another new leak dripping from under one of the Motion leg servo actuators (See Figure 1, Call out #2) so I went to investigate and clean up the puddle. That was the last thing I remember because just as I went over there, the Motion pressure hydraulic hose swivel joint (approximately 1700 psi, See Figure 2), broke loose hitting me 4-5 times knocking me unconscious onto my back & hitting my head. The next thing I remember is opening my eyes and being asked questions, but I was covered in hydraulic oil and I spit out a tooth and was trying to comprehend what happened. They had to cut off my clothes and take me by ambulance to the nearest Emergency Room and showered the oil off of me (sort of); they ran different tests and determined that I had to go to Harborview to see a Jaw reconstruction specialist.
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As a result of the accident my jaw was fractured in over 20 places (pieces), I lost 6-7 teeth, chipped and broke 3-4 other teeth, knocked all teeth out of alignment, now have TMJ syndrome, face spasms, disfigurement / scarring (have to keep a beard cover), a broken rib, right shoulder/neck trouble causing quite a few headaches, a very big blood clot and bruise on lower abdomen, hit my lower left leg, lower back lumbar injury, which is actually now worse AFTER a laminectomy surgery that was supposed to help it, memory loss problems, attention and learning disabilities, and a very hard time being around the simulators (PTSD?). I also ended up fighting an addiction problem to the pain medications (admitted to rehab) and still have to worry about that as my medical fight is not done yet. I constantly have to combat chronic pain and suffering, but can’t use effective medications; currently I’m only using suboxone and gabapentin for pain, as well as, bupropion for depression and both don’t seem to be helping much anymore. I have become known as having the worst simulator accident ever known and recorded. Before the accident I had perfect teeth and never even had a cavity; I was known as a very fast, quick learner, able to undertake and handle ANY job, and have moved through promotions very fast and strove to climb up and higher all the time. I always had a positive attitude and was a people person always ready to crack a joke and have fun, as well as, being serious when necessary. They do have me medically covered under their L&I insurance (Broadspire/Sedgewick) but they have already tried to IME (Independent Medical Exam) me once to try and close the claim, one of the nurses recently tried to close the claim, and I seem to be starting to get a certain percentage pay of the bills. This will not cover the future and as soon as they can, they will try to close my case out. Now it will be very hard or impossible to find future jobs as I’ll now have a broken work history and will be blacklisted by Boeing and other companies that hear about this lawsuit thereby losing a yearly salary, Medical Insurance, Dental Insurance, Life Insurance, Disability Insurance, the company 401K accruals, and mostly the Retirement Pension money due for future completion of said employment. At work for a while after the accident, they seemed really scared to say or do anything to me and as a result they had me there working under the influence probably when I shouldn’t have been, my work standard got lazy and now that it’s getting closer to the 3 year statutory time limit, they are cracking down on me and counseling me for almost next to nothing (sometimes for things that everyone else does, but no problem for them, or things that have been existent for years then I’m supposedly the one that messed up and has to fix it) following me around, literally, trying to watch every little minute detail waiting for every little mistake or assumptions, and making documented records while also trying to remove me as the Visual System Focal, even though I have fixed numerous visual problems that have been non-functional since before I was hired and have kept the visual discrepancies to a minimum and all equipment 100% operational and running smoothly. I think they are getting ready to let me go at that 3 year mark because I do have problems at work after the accident especially how I feel when being next to the simulator for too long, and I definitely can’t go under the simulator or I start freaking out. They even put negative marks against me for leaving work a couple of hours early sometimes when I just couldn’t take being around the simulator more than usual, but I can’t tell them that or something immediate would be done and I probably wouldn’t like it and lose some pay. It feels like I’m being discriminated against in a hostile work environment and then finding out that my secret [(the drug rehab) to be kept by the supervisor (the same supervisor at the accident)] had been told to just about everyone, among other things (behind my back) making it just that much worse; defamation of character? Now I will point out why the accident happened and how it could have, and should have been prevented from happening. First of all everyone knows as common fact, and it is clearly in every technical manual written for flight simulators as a ‘WARNING’ that before turning ‘ON’ the Motion pump motors under the simulator, you are supposed to check that the Motion operating envelope is clear of personnel and obstructions; you DO NOT ENTER the operating envelope while the Motion system is in operation. Due to the outdated age of this Rediffusion Simulation brand simulator, the 3 Motion pump motors on the HPU (Refer to Figure 1, Call Out 10 – Hydraulic Power Unit) can actually be ‘ON’ and running (at full pressure 1700psi) without the simulator ramp going up and the simulator going up to the idle position. All new, current, and upgraded simulators do not do this. When we went to investigate the Control Loading leak problem, the Control Loading pump was turned ‘OFF’ (separate pump/motor), but the Motion pump which was placed in ‘BYPASS’, was still running and if I had known the operation of this system at the time, I would not have been under the simulator; we followed the direction of the Lead Supervisor there heading up the operation and followed him under the simulator. All simulators where I used to work and even the newer simulators here at Boeing have a flashing strobe light underneath the simulator that activates when the Motion pumps are running; this simulator does not! Also, at other training centers there is a boundary barrier around the simulator with a gate signifying the Motion envelope; this simulator, and the other simulators at Seattle, did not! Some training center boundary barrier gates even have a switch that will turn ‘OFF’ the Motion when opened to prevent accidents! The technical manuals even mention wearing protective equipment like hard hats and safety glasses, but these were not existent at the time of my accident; they did put safety equipment (including an eye wash station) and a temporary kind of barrier around the simulators really fast, AFTER my accident! Before my accident they didn’t have any training or equipment for lock out, tag out of power and energy either; that also happened really fast AFTER my accident! Other training centers also have safety flooring under the simulators where oil accumulates, or raised rough deck flooring, but at Seattle, it is just a smooth painted floor that gets really, really slippery with just a drop of hydraulic oil. (Different flooring or protection and I may not have been knocked backwards on my ass so hard). I also should mention that earlier that same day, me and one other person had been inside the HPU (Hydraulic Power Unit, Refer to Figure 1, Removable Hatch) being very stuffy, cramped, and oily without the proper Confined Space training. Aside from this basic safety training, this training center also lacks the basic technician equipment familiarization training to get newer personnel familiar with and up to par on knowing all the different simulator systems and subsystems basic knowledge on how to power up and down, loading different software etc…newer technicians here are just thrown into the fire and have to learn on their own, which results in quite a few breakdowns, money wasted on parts, and training time lost for pilots that should not happen. They previously had a training program and qualification sheets for the technicians but stopped in 2005. Even looking on past records, it looked like some technicians were more qualified on the equipment than the supervisors. All Safety violations aside, something to add along with the careless Supervisor on the job is that he performed a certain procedure wrong and not as shown in the technical manuals thereby causing undue torque stress on the swivel joint (where it separated, split, and broke – See Figure 2). He had me helping him with two spanner wrenches to remove the pressure hose#3 from the swivel joint instead of removing the swivel joint from the transfer block#4 underneath the servo-valve#1; it took a lot of muscle pushing and pulling to loosen the junction. The first preferred method was not to remove the swivel joint at all but remove the servo-valves and install flushing blocks (always supplied with the simulators) on the transfer block for complete thorough flushing; it was talked about but they couldn’t find the flushing blocks so they went with the alternate method (Lack of Proper Equipment?). The alternate method shows to remove the swivel joints from the transfer blocks under the servo-valves and join the swivel joints together with a flushing adapter which does not cause any stress on the extended thin part of the swivel joint, but the (Qualified and Experienced) supervisor said to torque on the junction removing the hydraulic hoses from the swivel joints, him pulling one way and me pulling the other way. I believe this to have caused the swivel joint to break due to excessive stress; if the procedure had been performed correctly, this particular accident may not have happened, but with the other items mentioned it’s hard to say that nothing would have happened then, or later. Even with the wrong procedure, if proper safety precautions were met, it wouldn’t have ended in injury, just equipment failure. It has come into question about flight simulator age; how old is too old for a safe flight simulator? When we have our FAA Simulator Certifications every year, they check the functionality of the simulator if it’s able to do what it’s supposed to and qualify the pilot, but they don’t look or inspect the physical part of the simulator. This simulator is over 20 years old. Is a Simulator Quality Management system needed for simulator inspections and technician training?
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I have had 4 jaw surgeries and 1 back surgery so far and still have more to go. I need Orthodontia work started, possible bone grafting needed (bone from hip), lots of basic dentist work needing done that I never worried about before, and then after all of that putting in implant teeth to replace the missing ones. The back surgery failed miserably and needs something more, but not sure what and scared to do it. Shoulder / neck off and on problems with accompanying headaches and disturbing memory loss problems where I can just blank out and not remember a combination that I’ve used a hundred times or someone saying they told me something that I totally can’t remember. Really starting to lose concentration very easily; I’ve been actually trying to finish my degree and had no trouble studying before, but really troublesome now and difficult.
Specific WARNINGS that are listed in many different sections of the Technical Manuals for the Hydraulics, and in all capital letters, are:

• To prevent injury to personnel and damage to equipment, the following general safety precautions shall be observed at all times during simulator operation and maintenance.

• HYDRAULIC PRESSURE IN THE SYSTEM IS SUFFICIENTLY HIGH TO CAUSE SERIOUS INJURY OR DEATH. BEFORE ATTEMPTING TO WORK ON OR REMOVE ANY HYDRAULIC COMPONENT, ENSURE THAT THE SYSTEM IS COMPLETELY DEPRESSURIZED. ALLOW AT LEAST 15 MINUTES FOR THE HYDRAULIC OIL IN THE ACCUMULATORS TO COMPLETELY DEPRESSURIZE. THE PRESSURE GAUGES ON THE HYDRAULIC POWER UNIT MUST INDICATE ZERO. THE SAFETY ISOLATE KEYSWITCH ON THE MOTION ELECTRICS CABINET MUST BE SET TO ‘ISOLATE’ AND THE KEYSWITCH REMOVED TO PREVENT THE SYSTEM FROM BEING INADVERTENTLY STARTED.

• ALL REASONABLE PRECAUTIONS MUST BE TAKEN WHEN INSPECTING FOR LEAKS IN THE HYDRAULIC SYSTEM. THESE MAY CAUSE INJURY.

• SAFETY HELMETS MUST BE WORN BY ALL PERSONNEL WHILE WORKING UNDER THE MOTION PLATFORM. EAR PROTECTORS SHOULD BE WORN IN THE HYDRAULIC POWER ROOM WHEN THE SYSTEM IS OPERATING.

• CHECK THAT THE MOTION OPERATING ENVELOPE IS CLEAR OF PERSONNEL AND OBSTRUCTIONS BEFORE ATTEMPTING TO OPERATE THE MOTION SYSTEM.

• DO NOT ENTER THE OPERATING ENVELOPE WHILE THE MOTION SYSTEM IS IN OPERATION.

• BEFORE ATTEMPTING MAINTENANCE TO MOTION SYSTEM ENSURE THAT THE HYDRAULIC SYSTEM IS OFF AND OPERATING KEY REMOVED.

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Removable Hatch

FIGURE 1

Flushing Adapter

Swivel Joints

FIGURE 2