om15

[propersplitbrainme]

When you are faced with an incorrect risbridger in the OM15 can, and an unkown number of replens carried out using it, what the liney should have done becomes largely immaterial. What they did do is put the wrong oil in a number of jets!
Disciplinery action against the individual after the fact may sate the blood lust of those who believe infallability to be keystone of a good techie, but you are still faced with a whole heap of work to recover the contaminated jets.
Surely that is the point?

 

[Get Tae]

You techies must be a knightmare when shopping, do you all go to buy a tin of beans, but buy a tin of peas instead? or do you read the label!

ONCE MORE I SAY AGAIN, YOU ARE A ******!

 

[Hook]

Hyd Oil vs Eng Oil

Hyd Oil vs Eng Oil

How have we managed over the past 30 plus years when entering the POL store to be confronted with all the confusing tins and tubes? Loctite in little red bottles but different grades, greases in small white squeezable tubes, but not the same type, paint in 1 litre tins but different colour paint inside and PRC in white foil bags but again different grades inside. Now OM15 reverting to square tins! Surely the foolproof answer is to read the label and if the label is not there don't use it!

 

[propersplitbrainme]

Now OM15 reverting to square tins! Surely the foolproof answer is to read the label and if the label is not there don't use it!

There is NO foolproof answer, even when we had different coloured and different shaped cans people still screwed up. Screwing up is what makes humans human, and no amount of orders, instructions, rules, threats of punishment or simplistic thinking (i.e. just read the label) are going to prevent it from happening. Making similar things easier to tell apart, particularly if doing so is important to flight safety, is one of the ways to mitigate the effects of human fallability.
This isn't PC tree-hugger thinking either, its just plain common sense. 'Why didn't you just read the label' is of no use whatsoever when you are faced with recovering several jets stricken with a dose of the wrong fluid.

 

[Harry B'Stard]

OM15 solutions.

OM15 solutions.

In my second line environment the OM15 is locked away in POL stores, There are two seperate lockers one for hyd oil, the other for eng oil. The risbridgers are kept in tool stores and all OM15 tins and boxes of tins have a dayglo OM15 sticker applied (yes I know stickers come off... but not always).

Yes it's a pain in the arse to do a simple hyd top up, as you have to sign out a risbridger, sign out a locker key, and sign out POL keys before even considering doing the job. Obviously not ideal for 1st line , hurry up the crew are walking type tasks.

We also waste loads of oil as you rarely put exactly 5 litres in a jet and we then have to disconnect the risbridger to return it to stores... remaining oil goes into waste POL.

I understand the decision was not to save money but because the supplier of OM15 said we no longer make round tins full stop.

Even going back to making it a purely rigger only task for hyd top ups would cause problems when short of manpower, people getting pressured around to get stuff done faster with less manpower will make mistakes.

There is no easy answer... just be careful out there boys and girls!DT_Xtremez_19:

HTB

 

[MAINJAFAD]

I understand the decision was not to save money but because the supplier of OM15 said we no longer make round tins full stop.

That's what the flight safety mag said and its most likely true, anyhow most POL is lifed is it not, you should check the label to see if its in date anyway. Failure to do so is just being lazy, nothing more, nothing less.

 

[roverboy]

Haven't experienced OM15/OX26, but had our engines contaminated with OX24 (apparantly a marine engine oil) in Cyprus one year. Yes the tins wre thje same colour and shape, but as has been said in this thread, "READ THE LABEL" was always knocked into me and I knocked it into my students when I was instructing.

 

[Tech-tonics]

Simple really 'read the firkin label'. In the mob we have many things that come in the same shape / size bag, packet, box and I haven't seen many chinny rotor heads fitted to puma's (yes I know it's an exaggeration).

On a more realistic note all of Tesco's value canned foods have the 'value' blue and white lable but I don't here of many people buying pinapple cubes instead of beans!

What we really need to do is get the cnuts reading the label. On Sqns yes we always have a can fitted to the risbridger but every one (with the exception of a few armourers who would'nt be near it anyway) can read.

I know of many instances of cross contam now in the various fleets but it comes back to doing the job properly and reading the label.

No matter whether the tins are the same or different shape cross contam will happen. In my days as a smally tech-tonics some buffoon connected a waxoyl tin to the eng oil risbridger, and latterly a releasing oil tin (same tin shape, both in the POL store).

Fcuk this softly softly, nicey nicey a few strategically placed charges will get people reading the tin and maybe get people thinking about what they are doing now not what they are going to do tonight / tommorow etc.

 

[MontyPlumbs]

I've read the comments on this subject with a mixture of amusement and bewilderment.

Firstly, to all the non-technical trades, there are the so -called "Dirty Dozen" of Human Factors that are now taught to aircraft techies. Human factors is comes from the CAA and is a pretty wide brush to tar things with but basically it's saying that people make mistakes, no matter how good their training is (due to varying factors which i can't be bothered to explain haha).

It's all very well saying read the label before attaching the can to the risbridger - and I completely agree, but again, human factors comes into play - people make mistakes (even Armourers ffs).

Surely, the best way to ensure 100% safety in a critical arena like aviation engineering is to make the different cans physically different, thereby ensuring (as far as possible) that a catastrophic fcuk up can't occur.

I'm always 100% extra careful when dealing with anything that may get the other aircraft trades angry (dropping bolts down the engine bay, leaving the aircraft battery on etc), and topping up the hyd system or the engine oil is no different - I always read the label. However, it only takes someone to have an "off day" and we could all be in the mire....

NOTE: The above is 100% my own opinion, feedback is welcome (unless you're a fairy).

 

[propersplitbrainme]

Fcuk this softly softly, nicey nicey a few strategically placed charges will get people reading the tin ....

If you want to prevent nugatory work or flight safety incidents then no it won't, not when they are getting in the ear to have the jet ready for the next wave or whatever. It hasn't before, it won't now and it won't in the future, not unless we start employing robots who can be programmed to 'just read the label'. It's simplistic thinking like this that has seen errors made in the past, and its continuance will see similar errors made in the future.
You can cajole, threaten, fizz 'till they glow, write orders/procedures and train as much as you like, you will not eliminate human error from humans.
This does not excuse culpable negligence which SHOULD rightly be punished but its a shame that many cannot see the difference.

It's all very well saying read the label before attaching the can to the risbridger - and I completely agree, but again, human factors comes into play - people make mistakes (even Armourers ffs).

Correct. Its a shame that too many people lack the perspicacity to see the point being made.

 

[Realist78]

Simple really 'read the firkin label'. In the mob we have many things that come in the same shape / size bag, packet, box and I haven't seen many chinny rotor heads fitted to puma's (yes I know it's an exaggeration).

On a more realistic note all of Tesco's value canned foods have the 'value' blue and white lable but I don't here of many people buying pinapple cubes instead of beans!

What we really need to do is get the cnuts reading the label. On Sqns yes we always have a can fitted to the risbridger but every one (with the exception of a few armourers who would'nt be near it anyway) can read.

I know of many instances of cross contam now in the various fleets but it comes back to doing the job properly and reading the label.

No matter whether the tins are the same or different shape cross contam will happen. In my days as a smally tech-tonics some buffoon connected a waxoyl tin to the eng oil risbridger, and latterly a releasing oil tin (same tin shape, both in the POL store).


Fcuk this softly softly, nicey nicey a few strategically placed charges will get people reading the tin and maybe get people thinking about what they are doing now not what they are going to do tonight / tommorow etc.

Not so with OM15/OX26. The round, shorter OM15 can required a different risbridger. I don't recall one instance of cross contamination when we had this murphy proof system. As for reading the label, some guys have trouble breathing!DT_Xtremez_28:

 

[Tech-tonics]

Realist - OK OM15/OX26 cross contam is a new threat to Tornado due to the shape change and yes, I appreciate it was not possible before with this combination. It is only due to the fact other oils are not available that another type of cross contam did not happen. As I said in my little 'when i' it did happen where other oils are were available.

An additional factor at ISL is that on every Flight Serv the batch number of the OX26 (if used) should be recorded on the aircraft docs thus preventing some 'human factors' (other goaters terms) event happening. For cross contam to happen it theoretically it can only happen to the person who fits the oil to the risbridger, as from then on it should be logged and checked by many. Judging by the rumours from around the fleets there are a lot of people suddenly suffering 'human factors' incidents which are probably more due to familiarity and conformity i.e. square can engine oil, round can hyd oil.

OK maybe a charge is harsh (my previous refers) but there is also a level of corporate / management culpability. When the cans changed everyone predicted we may encounter some cross contam but in most of the places I have seen / encountered very little was done to prevent it. OK batch number checks in the 700 and a few posters, but why not make it harder to get the OM15 in the 1st place. Management could see it coming but in many cases did little to prevent it.

The new cans have been in circulation now for over 18 months and people are still fitting the wrong can to the risbridger. I believe we are now past the odd 'human factors' / recognition problems and in to basic incompetance.

 

[propersplitbrainme]

Judging by the rumours from around the fleets there are a lot of people suddenly suffering 'human factors' incidents which are probably more due to familiarity and conformity i.e. square can engine oil, round can hyd oil.

Familiarity and conformity errors which are human factors! Like taking the wrong turn on your drive home because you are going to your old house and not your new one!

The new cans have been in circulation now for over 18 months and people are still fitting the wrong can to the risbridger. I believe we are now past the odd 'human factors' / recognition problems and in to basic incompetance.

So what is your solution to overcoming this basic incompetence? And thats a serious question by the way.

 

[MattBombHead]

Realist - OK OM15/OX26 cross contam is a new threat to Tornado due to the shape change and yes, I appreciate it was not possible before with this combination. It is only due to the fact other oils are not available that another type of cross contam did not happen. As I said in my little 'when i' it did happen where other oils are were available.

An additional factor at ISL is that on every Flight Serv the batch number of the OX26 (if used) should be recorded on the aircraft docs thus preventing some 'human factors' (other goaters terms) event happening. For cross contam to happen it theoretically it can only happen to the person who fits the oil to the risbridger, as from then on it should be logged and checked by many. Judging by the rumours from around the fleets there are a lot of people suddenly suffering 'human factors' incidents which are probably more due to familiarity and conformity i.e. square can engine oil, round can hyd oil.

OK maybe a charge is harsh (my previous refers) but there is also a level of corporate / management culpability. When the cans changed everyone predicted we may encounter some cross contam but in most of the places I have seen / encountered very little was done to prevent it. OK batch number checks in the 700 and a few posters, but why not make it harder to get the OM15 in the 1st place. Management could see it coming but in many cases did little to prevent it.

The new cans have been in circulation now for over 18 months and people are still fitting the wrong can to the risbridger. I believe we are now past the odd 'human factors' / recognition problems and in to basic incompetance.

Ok, fair point, but if the Supp Serv is signed up AFTER the wrong oil has been used, the Jet is still dead.

I think the point has been made, even idiot proof systems aren't. But, you can go a very long way to making them as idiot proof as possible, ie DIFFERENT SHAPED TINS.

And as an aside, i'm sure i remember at least one cross contam incident on Tonka's, but i couldn't give any specific details.

 

[Tech-tonics]

Mattbombed - Am fairly sure there may have been some cross contam but I will not give fact because of possible unwated trolls who we do not want to get the info.

ProperSplitbrain - Serious answer - Honestly I'm not sure. Obviously with regard to the OM15 problem the ideal would be what we all know, round short cans. Although historically a total fcukwitt on buccs finding a short tin just (ie om15) just dipped the pickup tube into the tin and started pumping. fortunately he complained about a short stubby tin on return to the line and after his 're-eduction' the problem was sorted. BUT round short tins will not happen unless the manufacturer is prepared to comply. A practical answer would be OM15 unopen cans only in the oil store not hangar floor POL lockers etc. One OM15 risbridger with a can fitted that must be tagged on each use in a Locked POL locker which only Mech (riggers) have routine access to. In the main POL store the OM15 must be well separated from the OX26. I would suggest OM15 toward the back, Eng oil toward front as 'human factors' say jo fcukwitt will not go further than necessary to get oil. Re-education regarding oil is now fruitless as two years in we are still having near misses despite numerous briefings, posters etc.

The main problem that seems to be reported recently is when units are deployed/detached with near misses occuring. Obviously we all need to practice what we do at home when away. This problem however only seems to have come to light again in big numbers since the OM15 cans have changed. I know other fleets have used different hyd oil for years that comes in square cans (I have been told skydrol (vc10's??)) it would be interesting to see how that is/has been managed.

I still believe we are past the initial phase of events that could possibly be put down to pressure/human factors mix and now we are just down to incompetance / ignorance / lazyness. Ultimately, if filling the oil it is an intrinsic part of the procedure that you check what you are putting in, regardless of trade or experience. This is enforced from basic trade training. By not complying with this an individual is breaching basic trade principles and practices and should be treated thus. Each case should be judged individually, although I am sure if similar happened outside the mob the consequences would be more than a chat with boss and donuts for the boys, and in some cases I feel you could be looking for a new job. A note on the individuals file may be pertinent and considered at assesment time not just glossed over as so many things seem to be these days.

 

[Realist78]

It appears that this argument is going round and round and will undoubtedly appear again. It seems there are 2 ways around this problem...a) change the tins design back to murphy proof (unlikely) or b) start fizzing those responsible? feckwits!! What's it to be???DT_Xtremez_17:

 

[monobrow]

R78, Hows about another option.....

Publish fleet wide supps, posters to go everywhere, and re-print the 5B1 with Check the tin before filling

Well I made the last one up, but the 2 options you gave just ain't gonna happen.

 

[Realist78]

R78, Hows about another option.....

Publish fleet wide supps, posters to go everywhere, and re-print the 5B1 with Check the tin before filling

Well I made the last one up, but the 2 options you gave just ain't gonna happen.

Bet the last one will!!

 

[monobrow]

You mean responsible for the incedents or those who changed the can? I was under the impression you meant the latter...

 

[kinners]

maybe fizzing is the way forward, because there is no reason for it to happen just lame excuses. we've had a recent example on my sqn of engines being faintly polluted with om15, when a om15 risbridger was fitted to a ox27 can. there have been other cases too of the wrong oil being used...
i think most of the time its down to stupidity, the amount of times the fackin lineys leave the oil caps off is beyond the joke!