Whose Stupid Idea Was this?? [Archive]

InTgreen

31st May 2006, 16:23

Ratty, come on! There have been very few incidents of this nature while the cans were different shapes, and on one DASC report just out there are 3!! (Or so.. not got the report in front of me!) It must have cost the MOD more on cancelled sorties/recalled aircraft already than it would to continue to purchase different cans for the job! It is very similar to the change in fire extinguisher design in the last few years! Why change something that works and that people understand?? It is easy to not read/misread labels when tired or at night or working in bad weather in field conditions! WHY TAKE THE CHANCE???:ugh: In my view its just dangerous.

Rant over..

snowball1

31st May 2006, 17:24

Contract has been changed, hence different shape can. Techies shouldnt be relying on shape anyway to ident type! next you will be telling me that batches are not checked either! and cans have to meet strict united nations (dangerous goods) regulations hence cant have different size caps per oil type.

MightyGem

31st May 2006, 17:41

Can be really nasty those square cans. Perhaps you could read what it is, if you look close enough it might even be printed on the side of the square can as to what the contents are. Accident averted. Wow that was easy.

Yeah, and mechanical bits are made so they can't be fitted the wrong way just for the hell of it.

WPH

31st May 2006, 19:49

There have been a lot more than 3 incidents on the one aircraft type I know about. However, give it 6 months and people will have learnt to RTFL. To purge current stocks now would take even longer. Properties of the two are pretty close, so no long term effects/ damage are likely. Disruption to fly prog not good though I admit! :)

RNGrommits

31st May 2006, 20:11

does not rtfl apply?
It can't be that hard. How do they manage down tescos with all the same stuff in the same packets, with only the LARGE WORDS on the outside to differentiate.
(but then i'm only an air trafficer, and obviously not up on the ins & outs of the complexities of label reading).

umba

31st May 2006, 20:21

IMHO, I think OM15 cans should have remained in round tins but the contract has been let now and it appears we're stuck with engine oil shaped tins.

When enough engines have been contaminated and the whole situation settles down, it'll be interesting to see how many hyd systems are then contaminated with OX27.

Oh, and all this before the introduction of the OM15 replacement, OX19.

Still I presume there will have been plenty of well earned advancements on the back of the highly effective change management programmes implemented to deal with the change in OM15 can shape!!

The Helpful Stacker

31st May 2006, 20:47

ratty1

31st May 2006, 21:02

Ok let me see now.....................:bored: I know why dont you write OX26 on one can and OM15 on the other to save any confusion:cool:. I guess most techies can read numbers and letters.
You could even paint one tin black with white letters and numbers and the other tin white with black letters and numbers. Or even green with white numbers and letters and the other Pink with deep ocean blue numbers and letters............. You see the possibilities are endless. :ok:

r supwoods

31st May 2006, 21:16

Shame some oils were decanted from one shape to the other in one case - just so the pump fitted .... ooops

Then one station posts warning notices all around the place ... and 3 more ac are contaminated within days.

At one time six ac from mixed types were effected in one week.

Fg Off Max Stout

31st May 2006, 22:43

Bloody hell guys. Most of you are just jumping on the gingers because of these incidents but it's a simple matter of ergonomics. Remember back to your elementary trainers and note that the throttle, mixture and rpm levers were not only different colours and positions but different shapes and on many aircraft different textures as well (although wearing leather gloves kills that one). Several layers of defence built in against inadvertant incorrect selections. On the matter of oil containers, we now have a situation where the levels of defence against incorrect selections have been reduced by one. Most of you argue to the effect that the gingers should just read the bloody label but I genuinely think that differentiating between the different oils on as many levels as possible is the right way to go. You may argue that only one preventative measure should be necessary to prevent an incident, and you may be right, but why not have two or three.

I think many of you chaps are being unduly harsh on the gingers (and that's coming from an aircrew mate). Before you shoot your mouth of on this issue have a think about how many fixed-wing guys have cut off the mixture on pfls, and how many RW guys pulled the collective instead of the parking brake, or closed the thottle instead of putting it to idle or moved the throttle instead of the nozzles (http://www.break.com/index/harrierfalls.html) and so on.

The change to oil container designs was unnecessary and degrades safety.

Tigs2

31st May 2006, 22:49

ratty1, RNGrommits

you are sooo sooo wrong. 3.30am loads of pressure on the techies, to get the aircraft up, in the middle of their(the techies) circadian dips etc etc etc. This incident will occur over and over again untill they put the failsafe back in.

Grommits you may be an Air Trafficker but if reading the label is so easy, then why do Air Traffickers f**k up just as often as pilots and techies, for example putting aircraft on converging headings at the same height etc. After all your just looking at a screen where every aircraft is given a label arn't you?? Why cant you just read it? Why the problems Grommits, you are only reading labels after all. Maybe its just down to human error chum, something we are all suseptable to arn't we.

you say
'(but then i'm only an air trafficer, and obviously not up on the ins & outs of the complexities of label reading).'

I do hope that improves. You read labels on console, you read labels on radar, you read chinagraph labels in the tower.

glum

31st May 2006, 23:00

I've put the wrong oil in an engine before. It was on board the transport aircraft I was downroute with, and since engines isn't my main trade - just did the week on topping up oil, emtying the crappers etc - I assumed the oil on board was the oil to use. It was in an identical shaped tin, painted green, with white writing on - just like the can I should have used (only a different OX number)

No serious harm done, just an engine which had to be drained and refilled several days later when someone spotted the wrong oil on board and I got quizzed / bollocked about it.

Of course, I'm older and wiser now, and have learned not to trust anything I'm not familiar with. Never assume...

oldbeefer

1st Jun 2006, 09:27

Judging by the number of Navy incident reports recently, it won't matter which oil they put in 'cos they'll forget to put the cap on and the oil will dump all over the airframe.

WhiteOvies

1st Jun 2006, 09:52

Have been trying to get this one sorted for a while now but have found that those older, wiser and with more stripes have said that the lads will have to RTFL or face the disciplinary consequences:ugh: Is this the open flight safety culture we want to promote or will lads now just not own up after making an honest mistake?

The shape of tin was never mandated on the previous contract or on the current one, it was just that the old manufacturer used round tins whilst the new one uses the standard square ones. Have also had a couple of a/c types pointed out to me by senior types that have always had all fluids in square tins and have not had a problem with cross-contamination.

The principle issue is that hyds fluid has a lower flash point and lubricity than engine oil: bearings get hot due to reduced lubrication - fluid has a lower flashpoint........etc.

Personally I feel that we need to make engineering as fool proof as possible, everyone makes mistakes, especially on the long night shifts in far away places. However meeting with quite high level resistance at the moment. Will see what happens next but til then expect to see more IRs from across the different fleets.:{

Kengineer-130

1st Jun 2006, 16:04

Of course we can read labels :rolleyes: , but it is yet another "foolproof" failsafe to help prevent cross contamination. It is the same reason aircraft emergency systems are painted yellow and black, ie easy to identify quickly. Although its easy to say RTFL, it helps prevent a mishap in ****ty dark conditions, especially when you are doing a big job that involves engine oil and hydrulic oils being filled up, just like a herc K where the prop takes OM15 and the engine takes OX27 :} . These things have been developed over time for a reason, ususally because an accident has happened before :ugh:

Red Line Entry

1st Jun 2006, 17:26

The holier-than-thou comments at the start of this thread were echoed in whatever flight safety publication I was reading about this issue, when RTFL was the officially mandated solution (along with: it's too difficult to change the contract now OR IN THE FUTURE).

There will always be ignorance between the trades but I had hoped that the better integration of the engineers and the suppliers over the past decade would have gone some way to mitigate and avoid these problems. Clearly, we still have a long way to go!

(Or in other words, if you haven't worked in the middle of nowhere, at oh-dark-thirty, outside, in the dark, with crappy lighting, low on manpower, under pressure to meet an op wave, after 12 hours plus on duty, then try to imagine how easy it is to make a mistake reading a label - if you can't, then you sound like the ideal man to go into POL procurement!)

rugmuncher

1st Jun 2006, 18:10

The reason we have gone over to using square tins is because there are no round tins left, all the 'chavs' have used them up sticking them on the back of their peugot 206's exhaust pipes.

glum

1st Jun 2006, 18:15

Lets get rid of anti-lock brakes and airbags in our cars too - read the bloody road!:}

C130 Techie

1st Jun 2006, 19:14

Strange how us knuckle-dragging F&L stackers can tell the difference between OX26 and OM15 when we issue it to sections but the highly-trained folk with fat wallets we give it to can't.
The station I'm at even handed out posters (produced through DFC West Moors I believe) to help those poor souls work it out. Bless.
Of course its never the fault of the line swine just those damned stackers again, expecting techies to interrupt their game of ping pong to actually RTFL.
Never assume, check.

If this is not a 'tongue in cheek response' and I don't believe it is then its an extremely narrow minded view.

I don't care how easy the label is to read - Any small thing that has a positive impact on flight safety particularly in these days of high pressure ops and reduced manpower is clearly worthwhile. Every safety feature put in place dramatically reduces the risk of a mistake/accident.

How many times have the wrong spares been delivered because someone didn't read the label!!!

Go and find something less important on which to get your cheap snipes at the techies.

tonkatechie

1st Jun 2006, 21:35

RTFL???
Yeah ok, except you'll notice from one of the posters doing the rounds at the moment, that there's a problem with the labels peeling off (it used to be painted on, but they discovered there's still a large rainforest to get rid of). Of course, in this case everyone will just throw the can away as an 'unknown' won't they? Except for the thousands of guys who have 'grown up' with the cans being a certain shape etc etc. Remember one of the 'dirty dozen' human factors is "Norms". We're not exactly helping ourselves here are we?:ugh:

Tigs2

1st Jun 2006, 22:20

woptb

1st Jun 2006, 23:04

Do they sell many pegs at your sons public school?
Chav is a corruption of a Roma word 'Chavo',which in Roma means child.

rugmuncher

2nd Jun 2006, 12:29

Rugmuncher
do you actually know what the term 'Chav' actually means?? I would love to know what you think it is, as everybody is now using it and it(the term) comes from the the public school my son attends. What does it mean rugmuncher??

And your problem is.....?

Do you take offence at the fact that your son has a peugot 206 with an OM-15 can for an exhaust or because he is a "cheltenham average" and is being labelled as "white trash" because urban language in the UK has now taken the term "chav" to mean something else.

Put the word into Google and you will read the meaning I was using, and not referring to some public school boy with a father who seems blinkered to modern day lifestyle.

Perhaps you can explain what YOU understand the term "chav" to mean?

Maybe a good idea for a thread in JB "what is a chav?"
:ouch:

Tigs2

2nd Jun 2006, 14:06

Rugmuncher
I had no problem at all. It was a perfectly innocent question, which appears to have recieved a vitriolic reply.I was just asking you what you thought it meant. 'Cheltenham Average' absolutely correct. And why did my question lead you to state that i am blinkered to modern lifestyle:confused:

rugmuncher

2nd Jun 2006, 16:20

"it(the term) comes from the the public school my son attends."

" 'Cheltenham Average' absolutely correct"

So are you saying then that your son is a "chav" in the modern sense of the word, ie, wears burberry, drives a ****e car, and wears bling jewellery from Argos, or his he merely "Cheltenham Average".:ouch:

From Wikipedia:

".Another commonly cited false etymology derives the word from Cheltenham Ladies' College. Here, it is claimed, the term was coined from the words "Cheltenham Average" (Ch-av), used by the young women of the school to describe less desirable young men of the town [6]."
:zzz:

http://www.getlippy.com/play/quizzes/chavquiz/

Either way, back to the thread topic,,, if OM-15 is decanted into a "juniper rig" by a GE maintainer/tool controller, then surely it doesn't matter a bit about what shape, size, colour of can it comes in.

Kitbag

2nd Jun 2006, 23:14

I recall in the good ol' days that OX26, OX27 and OX38 all came in identical containers with only the label differentiating. Now most would say that is not a problem, except of course it is- these lubricants are all produced to seperate specifications for a damn good reason, but no contributor so far has acknowledged that. OX38 has more or less disappeared now I think due to its cost. The point is I recall working on a unit where all 3 where available. There were systems in place to prevent the misuse of one in place of another. Our tradesmen are professional. Let's give them the chance to be, they can read, segregation and labelling of risbridgers is possible as is effective tool control. Granted on Ops things may be strained, but I have to ask who is managing normal UK flying ops. Is pressure being self generated? Is anyone prepared to say 'Stop and Check'? If the 'frame is not ready in the morning and work was stopped for safety reasons I know who I would be trusting, both as a worker and an operator. Just my take on these things.:)

Tigs2

2nd Jun 2006, 23:28

Rugmuncher

Clearly as anyone will read that is not what was meant at all. You are a rude chap in the extreme , please ponder on your out of order comments.

Infact this was edited because of what you said rugmuncher you are in fact a w****r

rugmuncher

3rd Jun 2006, 01:36

:= http://www.stickergiant.com/Merchant2/imgs/450/y7982_450.jpeg

Better to be a chap than a chav,,

Keep smiling tigger,,, you may start to enjoy life better!!

Tigs2

3rd Jun 2006, 02:40

Always smiling mate
Its just the width of the grin that varies!!:D

monkeybumhead

6th Jun 2006, 19:22

Even in the days of different shaped tins I still had some daft tw@t put OM15 into a herc engine instead of the prescribed OX27. At least he owned up to his mistake and showed some integrity, something lacking somewhat in our illustrious leaders. Didn't stop said individual having the pi$$ ripped out of him for the rest of the shift though.:}

fightingchickenplumb

6th Jun 2006, 22:04

hey thought i would stick my humble opinion in seen as am getting ready to start a swing shift at 12am tonight

firstly yes we should all RTFL , however at 4am when you are getting sleepy (and no amount of sleep during the day stops u feeling like you want to sleep) on potentially a cold wet dark pan, its a very easy mistake to make, and anyone who hasnt done a late night/early morning BF feel free to join me. I know there have been two incidents already on my squadron with cross contamination. Secondly we have been told it wasnt a safety feature to have round tins? well if it wasnt designed to be it should have been continued with for just that reason, maybe the MoD could have used the savings on the 3 inch of OM-15 unuasble (the OM15 risbridgers have a shorter pipe than OX26) in each can could have been used to have a contract to keep the tins round.even widely differing coloured tins say dayglo orange and BRIGHT green would be a idea , then it would be "in your face" . My idea is to put to POL cabinets at each end of the HAS annex, each painted diffrent colours, at least then the liney would need to make a concious decision to go to eaither one locker of the other.

Beeayeate

6th Jun 2006, 23:19

however at 4am . . . on potentially a cold wet dark pan, its a very easy mistake to make, . . .

followed by. . .

My idea is to put to POL cabinets at each end of the HAS annex, each painted diffrent colours, at least then the liney would need to make a concious decision to go to eaither one locker of the other.
The different colours would be obvious at 4am on a cold, wet, dark, pan I suppose.

Myself I recall we had mis-identification in the 'good old days'(TM) as well. Used to happen, does happen and will happen for ever more. :hmm:

Anyway, aren't all cans now square because it makes them easier to stack? :E

.

fightingchickenplumb

7th Jun 2006, 09:28

yeah i suppose your right about the tins, but as a well known supermaket slogan says "every little helps"

Monty77

7th Jun 2006, 14:00

I don't think anyone can reasonably argue against the fact that the more layering of oil container identity by size shape and colour, the less mistakes will be made by the weakish link in any aviation process: the human. We've all accidentally spooned the sugar into the kettle/emptied the milk into the sink. It's cognitive failure. That's why experienced pilots will land with the gear up and techies will stick the wrong oil down the wrong hole. Whoever presided over the change of contract that introduced a change of container should really have seen it coming. Unless of course, they were a beancounter who had no idea of how the moneysaving scheme would impact the shopfloor.

It reminds me of the old maxim that starts off with the coal face describing something as a 'crock of sh*t', and by the time the description has reached top management, it's 'a glistening masterpiece of solid gold'.

Pontius Navigator

7th Jun 2006, 19:06

You have been talking about oils, colours, and words as if RTFL is the answer.

Well of course no one ever mixed up the nitrogen trolley, air trolley or oxygen trolley did they?

monobrow

7th Jun 2006, 19:32

You have been talking about oils, colours, and words as if RTFL is the answer.

Well of course no one ever mixed up the nitrogen trolley, air trolley or oxygen trolley did they?

Well I don't know about the air trolley, but the connectors for oxy + nitrogen are different as well as the green pipe for O2 and black for N2. As far as i was aware, you cannot cross connect those, different thread sizes.

Pontius Navigator

7th Jun 2006, 20:01

Trust me, it has been done every which way. Man's ingenuity to achieve a c*ck*p is unbounded.

Safety_Helmut

7th Jun 2006, 21:20

As has already been said on here many times, this is an old lesson. This has been discussed at the highest levels, and the response..........? Read the label ! A decision made by idiots who have no understanding of human factors. Aviation has shown us time and time again, that if things can go wrong, they will go wrong, not just military, but civil aviation too.

People have always made mistakes, and they always will, and that's the reason for putting barriers in place to stop seemingly small mistakes propagating all the way through the system until they lead to accidents.

It's good to see you've got a sound grasp of things as usual by the way Stacker.

S_H

flipster

8th Jun 2006, 01:30

Someone once said

''Nothing is 'fool-proof' - as fools are so ingenious!''

But seriously (and as others have said)

''If things can go worng.... they will." (QED)

That is why we have multiple 'layers of defence' - different colours, shapes, labels, different connectors, different stuff from different shelves etc etc.

All these things help to 'trap' or even 'mitigate' against the 100% chance of an error occuring.....somewhere, sometime.

Therefore, we should all be in favour of

'Another layer of defence'....whatever the cost, or minor inconvenience.

If it saves just one life (or even one aircraft) - surely, it is worth it!?:O :O

Flipster