On the following pages can be found an example of what happens when we do not pay attention to detail, and do not follow instructions and checklists!

A KC-135 Aircraft was being pressurized at ground level. The outflow valves which are used to regulate the pressure of the aircraft were capped off during a 5 year overhaul and never opened back up. The post-investigation revealed: that a civilian depot technician who, "had always done it that way," was using a homemade gauge, and no procedure.

The technician's gauge didn't even have a max "peg" for the needle and so it was no surprise he missed it when the needle went around the gauge the first time. As the technician continued to pressurize the aircraft, and as the needle was on its second trip around the gauge the aircraft went "boom" - the rear hatch was blown over 70 yards away, behind a blast fence!

Fortunately, no one was reported as being injured.

This was a good "Lessons Learned" for making sure we have trained people, who have the right tools, and who are following detailed procedures. And it should serve as a reminder that just because you've always done it that way, it does not make it the "right" way!