Whose stupid idea was this Part 2
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Originally Posted by The Helpful Stacker
Surely this is a problem of training rather than one of different shaped tins?
How EXACTLY will training prevent someone from making a simple human error they didn't intend to make?
Because if you, or anyone else who thinks that 'training and read the label' are the solution can tell me, then I'm off to become a multi-millionaire.
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...the civil sector won't use them (i.e. round tins)as they take up more room during shipping
But we're civilians so what the **** do we know?
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I'm sure that if a member of a non-technical trade caused damage/unserviceability of an expensive piece of kit through not reading the label of an required for its use the book would well and truly be thrown at them.
One of the many tasks I've had during my service was blending AL48 into F35 to make F34 FSII. Unfortunately the AL48 itself comes in green 205lt drums that look exactly the same as every other green 205lt drum in use, the only thing differentiating them being a small white label with the product details on it. Now considering the majority of blending operations are carried out in operational areas (such as Iraq where all F34 in theatre has been blended to spec by the grubby mitts of a humble stacker) where the workload is high, hours long, temperatures extreme and a whole host of other factors effect human performance it does make you wonder how come they can manage to read the labels correctly whereas it seems quite a task for better paid and apparently more 'skilled' personnel.
I'm sorry, whilst I agree that different shaped/coloured tins could prevent mix up between OX26/OM15 this doesn't account for the fact that other fluids which also come in green rectangular tins aren't also regularly mixed up. Ultimately its a lackadaisical attitude towards working practises and being blasé over the little things that causes these errors, errors who's consequences would have previously been hammered home in personnel when their colleagues who committed them were 'trade charged' for their actions. Unfortunately the no blame culture is a double edged sword. Being nice about errors means that people admit their mistakes but without the threat of serious repercussions some people won't buck up their act.
The other side to this is if mistakes are being made over such a simple issue as using the correct fluids to service an aircraft what other more technical mistakes are lurking within the aircraft of the RAF's fleet?
Yes I have made mistakes before but admittingly there are very few that a stacker can make that directly affect flight safety but this in itself is reflected in our length of trade training and ultimately our level of pay, something that many in the more technical trades crow on about with regularity when the 'threat' of less lofty trades being bumped up to their level of pay is mentioned (see the vitriolic posts on E-Goat with reference to the MT trade pay increase for example). Earn that pay, do the job right and read the label.
One of the many tasks I've had during my service was blending AL48 into F35 to make F34 FSII. Unfortunately the AL48 itself comes in green 205lt drums that look exactly the same as every other green 205lt drum in use, the only thing differentiating them being a small white label with the product details on it. Now considering the majority of blending operations are carried out in operational areas (such as Iraq where all F34 in theatre has been blended to spec by the grubby mitts of a humble stacker) where the workload is high, hours long, temperatures extreme and a whole host of other factors effect human performance it does make you wonder how come they can manage to read the labels correctly whereas it seems quite a task for better paid and apparently more 'skilled' personnel.
I'm sorry, whilst I agree that different shaped/coloured tins could prevent mix up between OX26/OM15 this doesn't account for the fact that other fluids which also come in green rectangular tins aren't also regularly mixed up. Ultimately its a lackadaisical attitude towards working practises and being blasé over the little things that causes these errors, errors who's consequences would have previously been hammered home in personnel when their colleagues who committed them were 'trade charged' for their actions. Unfortunately the no blame culture is a double edged sword. Being nice about errors means that people admit their mistakes but without the threat of serious repercussions some people won't buck up their act.
The other side to this is if mistakes are being made over such a simple issue as using the correct fluids to service an aircraft what other more technical mistakes are lurking within the aircraft of the RAF's fleet?
Yes I have made mistakes before but admittingly there are very few that a stacker can make that directly affect flight safety but this in itself is reflected in our length of trade training and ultimately our level of pay, something that many in the more technical trades crow on about with regularity when the 'threat' of less lofty trades being bumped up to their level of pay is mentioned (see the vitriolic posts on E-Goat with reference to the MT trade pay increase for example). Earn that pay, do the job right and read the label.
Last edited by The Helpful Stacker; 5th Sep 2007 at 08:10.
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S'funny. All the cans of engine oil that I ever poured into an engine were round and opened by punching triangle shaped holes into opposite sides of the lid with a key that had another end that was useful for opening bottles. Oddly enough, I noticed the chap topping up the hydraulics was using exactly the same key to open his cans of hydraulic fluid.
But we're civilians so what the **** do we know?
But we're civilians so what the **** do we know?
I'm not going to argue this point, the bare facts are round tins take up more room than rectangular ones on a standard shipping pallet and hence cost more to move about as shipping costs in marine and the road freight industry is generally based on size of loads not weight. If you are still using round ones then you are paying more for the product than if you were using rectangular tins
I don't own this space under my name. I should have leased it while I still could
F4 out of the shed, linney's did the compass swing but no why could they swing the standby compass. They changed the compass; no deal.
They called me in and, by a stroke of luck we had Alan Snowball from the Greenwich Observatory (I think -what a job for a flt lt). Anyway he had a little gizmo, a magnet in a plastic gimballed cradle.
He checked the F4 canopy arch and found that it was magnetic. he checked further and found the windscreen securing screws were magnetised, or at least some of them.
Then he went to the storage bins and found some of the screws in there were also magnetic. There all looked the same but somehow some were ferous and some were not.
Murphy once again.
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Oil can shape
As an Ex-member of Mrs. Windsor's Flying Circus, I would like to add my tuppence worth to this thread.
As a trainee I and the others were taught, under threat of death or worse, before you unscrew the cap - check the contents. All aviation liquids came in 1,(square) 5, 50, (both round) Imp Gall containers, be it oil - hydraulic - vegetable mineral or synthetic, engine, lubricating, de-icing fluid or whatever. If I recall correctly, the only 'commercially' labelled product was Racasan. All containers were the same shape, mistakes were made e.g. the wrong hydraulic fluid being added to a system.
Later in my service, I spent time as a trade examiner and when testing a young lad, I asked 'You are servicing a hydraulic system requiring OM-15 and you find a gallon can marked OM-15 in the hangar. It is half full with a red fluid but has no cap. Would you use it?' This was a standard question and the expected answer 'No, because it could be contaminated.' The answer I received was 'No, because you said it was half full. That means I would be adding air to the system and I would then have to bleed it.' I carried on with the test and asked him at the end how long was his training and what had he been taught about fluid contamination. He looked at me as though he was seeing water burn. OK 18 weeks is a lot less than three years, but I am certain flight safety was never overlooked.
I have to agree with everyone who puts the oil mix up down to insufficient training. It has nothing to do with suppliers. At the end of the day it is the man/woman who actually does the pouring who carries the can, (no pun intended).
Also as 'The 'tiffy' says in civvy street, all our cans are round except for the 1US gall cans of Skydrol. And, for the man who says it is due to transport costs the round quart cans are shipped in - you've guessed - square boxes. Every manufacturer has a different colour, not every product, but they do have their own identity printed on the can.
My only advice is spend an extra few seconds reading the label. It might not just be the saving of a promising career - just think of the life/lives you have saved and, not the 40 pence and an on-time departure.
As a trainee I and the others were taught, under threat of death or worse, before you unscrew the cap - check the contents. All aviation liquids came in 1,(square) 5, 50, (both round) Imp Gall containers, be it oil - hydraulic - vegetable mineral or synthetic, engine, lubricating, de-icing fluid or whatever. If I recall correctly, the only 'commercially' labelled product was Racasan. All containers were the same shape, mistakes were made e.g. the wrong hydraulic fluid being added to a system.
Later in my service, I spent time as a trade examiner and when testing a young lad, I asked 'You are servicing a hydraulic system requiring OM-15 and you find a gallon can marked OM-15 in the hangar. It is half full with a red fluid but has no cap. Would you use it?' This was a standard question and the expected answer 'No, because it could be contaminated.' The answer I received was 'No, because you said it was half full. That means I would be adding air to the system and I would then have to bleed it.' I carried on with the test and asked him at the end how long was his training and what had he been taught about fluid contamination. He looked at me as though he was seeing water burn. OK 18 weeks is a lot less than three years, but I am certain flight safety was never overlooked.
I have to agree with everyone who puts the oil mix up down to insufficient training. It has nothing to do with suppliers. At the end of the day it is the man/woman who actually does the pouring who carries the can, (no pun intended).
Also as 'The 'tiffy' says in civvy street, all our cans are round except for the 1US gall cans of Skydrol. And, for the man who says it is due to transport costs the round quart cans are shipped in - you've guessed - square boxes. Every manufacturer has a different colour, not every product, but they do have their own identity printed on the can.
My only advice is spend an extra few seconds reading the label. It might not just be the saving of a promising career - just think of the life/lives you have saved and, not the 40 pence and an on-time departure.
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I'm afraid I have to disagree about lack of training.
I'm currently involved with teaching Lineys at a front line base and evey time it comes to teaching how to do oils we repeatedly stress TO READ WHAT IT SAYS ON THE TIN.
I don't think you can necissarily tie it down to a single cause. A combination of habit and complacency. 'If it's in this location it must be OX-26'
I've yet to hear of OX-26 being put into a system instead of OM-15. If anyone knows differently I'd like to know about it.
I'm currently involved with teaching Lineys at a front line base and evey time it comes to teaching how to do oils we repeatedly stress TO READ WHAT IT SAYS ON THE TIN.
I don't think you can necissarily tie it down to a single cause. A combination of habit and complacency. 'If it's in this location it must be OX-26'
I've yet to hear of OX-26 being put into a system instead of OM-15. If anyone knows differently I'd like to know about it.
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Why tins?
Milk does not come in tins.
Car oils do not come in tins.
Translucent, recyclable plastic would be lighter, is moulded to whatever shape and could be manufactured in sealed once-only sizes.
Just send my cheque to . . .
Milk does not come in tins.
Car oils do not come in tins.
Translucent, recyclable plastic would be lighter, is moulded to whatever shape and could be manufactured in sealed once-only sizes.
Just send my cheque to . . .
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About 11 years ago, as I remember it, MoD(N) let a contract for oil in Trade Standard packaging. The Contractor supplied the said oil in plastic containers; and very stylish they were too. When the oil was stacked in the conventional manner in the stowage, the ones at the bottom deformed to such an extent that the stacks began to collapse. We went back to metal containers.
Sitting here in the relative comfort of a not overly warm office, I'm finding it hard to understand how it is difficult to read a label with O-160 and OX-26 or H-515 and OM-15 (as appropriate) marked in 1 inch high digits (as per DEFSTAN 05-52 Part 1). If the problem was the 1 litre tin, then that's very understandable as it isn't subject to the same labelling/marking standard.
Sitting here in the relative comfort of a not overly warm office, I'm finding it hard to understand how it is difficult to read a label with O-160 and OX-26 or H-515 and OM-15 (as appropriate) marked in 1 inch high digits (as per DEFSTAN 05-52 Part 1). If the problem was the 1 litre tin, then that's very understandable as it isn't subject to the same labelling/marking standard.
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GBZ, 5 litre and only 1.5 litres remaining after the one litre 'incident'.
Not sure whether the first 2.5 litres was used orrectly and neither were the engineers which was why they had to check all the jets.
Not sure whether the first 2.5 litres was used orrectly and neither were the engineers which was why they had to check all the jets.
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The reason for the change of can was due to the original "round" can manufacturer ceased trading and the change of supplier of OM15 used square cans. This was looked into and the upshot is "read the label".
I suppose its a bit like which nozzle you pull out when you fill your car up? Diesel or Petrol???!!!
I suppose its a bit like which nozzle you pull out when you fill your car up? Diesel or Petrol???!!!
I remember when the S76 was first operated on the North Sea. The Allison C30 engine was prone to coking and turbine failures were a regular occurence.
Bond helicopters ran a trial to see which oil produced the lowest level of carbon deposits in the turbine bearings.
All six aircraft were operated on different oils, supplied in us quart sized cans and all operating from the same hangar, what fun.
Boeing uses Skydrol in the 737 hydraulic system but it uses Aeroshell 41 (OM 15 equivalent) in the flap gearbox's.
The possibilities for error are endless.
Many helicopters use the same oil in engines and transmissions, others have something different for transmissions. The B0 105 uses engine oil as a hydraulic fluid for the rotorbrake.
Bond helicopters ran a trial to see which oil produced the lowest level of carbon deposits in the turbine bearings.
All six aircraft were operated on different oils, supplied in us quart sized cans and all operating from the same hangar, what fun.
Boeing uses Skydrol in the 737 hydraulic system but it uses Aeroshell 41 (OM 15 equivalent) in the flap gearbox's.
The possibilities for error are endless.
Many helicopters use the same oil in engines and transmissions, others have something different for transmissions. The B0 105 uses engine oil as a hydraulic fluid for the rotorbrake.
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It is incredible just how much 'point missing' is going on here. Of course techies should take the time to identifyt the contents of a can of fluid and I'm most certainly not advocating excusing deliberate negligence which should be punished accordingly, but what about when the guy is not being deliberately negligent, what about when he/she just makes a simple error because of the circumstances of the situation?
When one bears in mind how many seperate replenishment activities are carried out daily, the number of screw-ups made is quite small, so it is not a frequent occurence as had been suggested. This means that technician training must be working, and that 99.99% of the time lineys are taking the time to read the labels and identify the contents.
Its the other 0.01% of the time when the over-simplistic 'my advice is read to the label' doesn't work. And you can repeat it as many times as you like until you are blue in the face, read the label, read the label, read the label, it won't overcome the inherent psychological and physiological imperfections that are part of the human make-up. Perhaps Helpful Stacker has managed to carry out blending operations successfully without cross contamination every time, but then again, I have managed to put the right oil in the right system every time. What does that prove? It proves that both I and THS have never had the misfortune of having the ingredients for a screw-up fall into place all at the wrong time. I'll tell you this though, I do know of stackers who have put the wrong bolts in the wrong bin in stores because they misread the NATO number or the bin number.
Deliberate negligence or purposeful stupidty? Well one things for sure, just telling them 'my advice is read the label'
didn't work for them.
When one bears in mind how many seperate replenishment activities are carried out daily, the number of screw-ups made is quite small, so it is not a frequent occurence as had been suggested. This means that technician training must be working, and that 99.99% of the time lineys are taking the time to read the labels and identify the contents.
Its the other 0.01% of the time when the over-simplistic 'my advice is read to the label' doesn't work. And you can repeat it as many times as you like until you are blue in the face, read the label, read the label, read the label, it won't overcome the inherent psychological and physiological imperfections that are part of the human make-up. Perhaps Helpful Stacker has managed to carry out blending operations successfully without cross contamination every time, but then again, I have managed to put the right oil in the right system every time. What does that prove? It proves that both I and THS have never had the misfortune of having the ingredients for a screw-up fall into place all at the wrong time. I'll tell you this though, I do know of stackers who have put the wrong bolts in the wrong bin in stores because they misread the NATO number or the bin number.
Deliberate negligence or purposeful stupidty? Well one things for sure, just telling them 'my advice is read the label'
didn't work for them.
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Splitbrain, Well Said 
As the eng rumour mill is knackered am I right in understanding Aunty Bettys flying club is thinking/going/gone down the route of techies and lineys aka FLEM's again?????
if so then square can/ round can for replens might be a good idea. With recruitment and retention such a problem and the lowering of standards across the board then I think that project "Prison or Serve" won't be far away...................................
In my crystal ball I see..............????
As the eng rumour mill is knackered am I right in understanding Aunty Bettys flying club is thinking/going/gone down the route of techies and lineys aka FLEM's again?????
if so then square can/ round can for replens might be a good idea. With recruitment and retention such a problem and the lowering of standards across the board then I think that project "Prison or Serve" won't be far away...................................
In my crystal ball I see..............????
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We had an 'incident' here at ISK where an AMM put OM15 into the engines but that is because this particular AMM is maybe a tad slow on the uptake (recruitment issue?).
You cannot legislate for stupidity but there are also plenty of times where HF comes into play.
As for the argument of 'throw the book at him', when was the last time a heavy landing which subsequently causes an untold number of man hours wasted fixing the jet (and then lack of flying hours for other crews) or whoops I seem to have taxied the jet into a building ever resulted in 'lets throw the book at him'?
(I can give plenty of other 'incidents' from the flying side from the past 21 years if you so desire)
Whats good for the goose...........................
You cannot legislate for stupidity but there are also plenty of times where HF comes into play.
As for the argument of 'throw the book at him', when was the last time a heavy landing which subsequently causes an untold number of man hours wasted fixing the jet (and then lack of flying hours for other crews) or whoops I seem to have taxied the jet into a building ever resulted in 'lets throw the book at him'?
(I can give plenty of other 'incidents' from the flying side from the past 21 years if you so desire)
Whats good for the goose...........................
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There are some very stupid comments on this thread ( eh, unhelpful stacker 
), why erode the flight safty barriers we have built up over the years?
We always strive to do the job 100% correctly,I would hope everyone in every trade does, and stupid comments such as "read the label then" & "Stackers don't play a major role in flight safty" show a basic lack of understanding of human factors and flight in general........ as someone said on the previous page, aircraft flightdecks have taken years and years to evolve, hence why emergancy systems are all black and yellow striped, important switches are in a red gate, flap systems have guards, undercarridge systems have lights, warning horns and controls shaped like wheels in a lot of aircraft. It has been evolved over years of painful lessons learnt, crew landed with no gear down, incorrect engine shut down, etc etc etc. Everything is made to make decisions and actions easier to take in times of very stessful/ high workload situations..
The basic fact is that we always find better ways to screw up, make something idiot proof and all you get is a better class of idiot. We all make mistakes, thats why aircraft have redundant systems, ejector seats, and all manor of other equiptment that is used in an emergency... cars have seatbelts and airbags......No one plans an accident do they?? The whole issue of the round can debate is that if all the normal systems fail, the safty net is there as a last chance to prevent cross contamination....
Imangine an engine and prop change On the C-130K. After the Cx, you need to refil the engine oil and the prop oil. The engine takes OX27, and the prop takes OM15, it used to be easy to see the difference in the oil cans just by looking at them, and 99.9% it is nigh on impossible to make a mistake due to reading the label, shape of can etc. Now imagine at dark O'clock on your 10th or 11th nightshift in a row ( not unheard of in theatre), in crap weather, maybe handing the job over to someone else, the oil cans get mixed up due to someone moving staging or whatever reason, and seeing the sqaure can of OX27, in a rush, under pressure, and probably complacent ( happens to everyone) due to having done the job 1000's of times before, you grab the can of oil (which happens to be the new square shape OM15) and start to put it in the engine. As its dark, wet, etc etc, you don't notice the colour until it is too late..... Could have easily been avoided in one simple solution, a different shape can...
Same as the old coloured 731 system, RED= U/S Green= S at a glance, I wager many items have been put back into stock U/S, or even fitted to A/C due to the removal of the simple colour code system
Do we not learn our lessons? There is an old saying that there are no new accidents, just new victims
), why erode the flight safty barriers we have built up over the years? We always strive to do the job 100% correctly,I would hope everyone in every trade does, and stupid comments such as "read the label then" & "Stackers don't play a major role in flight safty" show a basic lack of understanding of human factors and flight in general........ as someone said on the previous page, aircraft flightdecks have taken years and years to evolve, hence why emergancy systems are all black and yellow striped, important switches are in a red gate, flap systems have guards, undercarridge systems have lights, warning horns and controls shaped like wheels in a lot of aircraft. It has been evolved over years of painful lessons learnt, crew landed with no gear down, incorrect engine shut down, etc etc etc. Everything is made to make decisions and actions easier to take in times of very stessful/ high workload situations..
The basic fact is that we always find better ways to screw up, make something idiot proof and all you get is a better class of idiot. We all make mistakes, thats why aircraft have redundant systems, ejector seats, and all manor of other equiptment that is used in an emergency... cars have seatbelts and airbags......No one plans an accident do they?? The whole issue of the round can debate is that if all the normal systems fail, the safty net is there as a last chance to prevent cross contamination....
Imangine an engine and prop change On the C-130K. After the Cx, you need to refil the engine oil and the prop oil. The engine takes OX27, and the prop takes OM15, it used to be easy to see the difference in the oil cans just by looking at them, and 99.9% it is nigh on impossible to make a mistake due to reading the label, shape of can etc. Now imagine at dark O'clock on your 10th or 11th nightshift in a row ( not unheard of in theatre), in crap weather, maybe handing the job over to someone else, the oil cans get mixed up due to someone moving staging or whatever reason, and seeing the sqaure can of OX27, in a rush, under pressure, and probably complacent ( happens to everyone) due to having done the job 1000's of times before, you grab the can of oil (which happens to be the new square shape OM15) and start to put it in the engine. As its dark, wet, etc etc, you don't notice the colour until it is too late..... Could have easily been avoided in one simple solution, a different shape can...
Same as the old coloured 731 system, RED= U/S Green= S at a glance, I wager many items have been put back into stock U/S, or even fitted to A/C due to the removal of the simple colour code system
Do we not learn our lessons? There is an old saying that there are no new accidents, just new victims
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So having a different shaped can would mean you don't have to look at the label right?
What about checking the re-test dates? In the past whilst carrying out POL locker checks I've often discovered sections holding out date stock as still in use, indeed when I pointed this out cans of oil (some of which were out of date up to 12 months) were actually being used. To compound this one section at my last unit was found using OM15 that had been quarantined, even though they had been sent a memo advising them to return it as waste which they had returned signed and stamped as done.
Would a round tin stop out of date/quarantined product being used? No, it just makes it easier to carry on regardless of the state of the product held within.
I know, its terribly unhelpful of me to point out that there are far more things to look at on a can of oil than just what type it is before you use it.
Sorry, I feel we must agree to disagree on this matter. I'm obviously of the opinion that highly trained and well paid personnel should be able to read a simple label (which contains information important to flight safety other than just what the product is) whereas you seem to believe that shape saves all and bugger the age of the product within because that'd involve reading something, a task far beneath someone who is busy and they should be excused for not doing it.
What about checking the re-test dates? In the past whilst carrying out POL locker checks I've often discovered sections holding out date stock as still in use, indeed when I pointed this out cans of oil (some of which were out of date up to 12 months) were actually being used. To compound this one section at my last unit was found using OM15 that had been quarantined, even though they had been sent a memo advising them to return it as waste which they had returned signed and stamped as done.
Would a round tin stop out of date/quarantined product being used? No, it just makes it easier to carry on regardless of the state of the product held within.
I know, its terribly unhelpful of me to point out that there are far more things to look at on a can of oil than just what type it is before you use it.
Sorry, I feel we must agree to disagree on this matter. I'm obviously of the opinion that highly trained and well paid personnel should be able to read a simple label (which contains information important to flight safety other than just what the product is) whereas you seem to believe that shape saves all and bugger the age of the product within because that'd involve reading something, a task far beneath someone who is busy and they should be excused for not doing it.