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Scary problem accidentally found!

Jesse

Jesse

Well Known Member
I had a guy fly up to visit my shop on Saturday. I had talked to him once or twice about how difficult it has been to start his O-360. He was able to get it started on Saturday morning to come visit me (hoping I would be here, which I happened to be). Then he couldn't get it started again to get home, which very possibly saved his life, and very likely saved his plane.

The starting problem appears to be a bad Mag, or at least bad points. We popped in a Slick 4372 that we had on the shelf in place of his 4373 after talking to the Slick guru about he compatibility and how to time it for testing. We out the mag in and it started on the second blade. We ran the engine for about 15-20 seconds. After I shut down my assistants noticed that the firewall was covered with oil. Upon closer examination, this is what we found.

CE05482F-CC99-4607-B188-CF46798810B1_zpsv9opawc1.jpg

Which easily became this with almost no force.
119F9D10-C9BA-4900-B158-45B070009E9D_zpsr3hwotkx.jpg

In this view you can see the oil on the firewall.
6F8A954A-74B4-4BDF-BB98-C5AD6E5C95D0_zpsjwfncts6.jpg

Someone had used an aluminum line with flares to extend the flexible oil pressure line to the sensor. Due to the vibration, the flare had broken and the line started to leak. With the tiny amount of force it took to pull the line out of the flare nut, I am confident that a couple more seconds of engine run with 75 psi of oil pressure would have forced the line out and would have started pumping oil overboard. I don't know how long it would have taken to empty 6 quarts of oil at that pressure and that size line, but I am guessing about the time it would take to taxi and takeoff and get to maybe a couple of hundred feet. Then a seized engine or worse and into the trees. That's scary to me! The owner (who will remain unnamed, if he is on here, it's for the benefit of others) mentioned, after I sent him a picture and a short version of the above scenario, that he had seen the line when he replaced the battery after he ran the first one dead trying to start, and it looked a little weird.

Please, fellow VAFers, if something looks weird, please have someone else (preferably an aircraft mechanic) look at it to see if it is normal or an accident waiting to happen. This brigs to mind Vic's post recently of an oil suction screen packed full of crud. That got my attention. Hopefully this will get someone else's attention who may have aluminum rigid lines firewall forward in a critical engine function.
 
Nice job, Jesse. Close one for sure!

I've always wondered why we don't see more oil level indication/warning systems. It seems like they would be very useful in cases like this.

David
 
👌👍👍👍👍👍👍

Great job Jesse!

You're attention and your assistant's attention to detail is inmeasurable in this case!

Cheers,


Don
 
Whoa! THAT'S frightening.

Did the line at least have a restrictor fitting on the engine-to-flex-line?
 
Please, fellow VAFers, if something looks weird, please have someone else (preferably an aircraft mechanic) look at it to see if it is normal or an accident waiting to happen. This brigs to mind Vic's post recently of an oil suction screen packed full of crud. That got my attention. Hopefully this will get someone else's attention who may have aluminum rigid lines firewall forward in a critical engine function.

---------------------------

And no unsupported T-fittings hanging in mid-space....
 
battery replacement

Is is just an illusion or is it impossible to pull the battery out to replace it with the oil line routed over the top?
 
F1R said:
FWIW the battery hold down strap looks like a potential accident in waiting.
Click to expand...

It just looks like he put heat shrink over the hold down bar. Actually seems like a pretty good idea to prevent accidental shorts while doing maintenance or charging with alligator clamps.
 
Somebody trying to save a buck used a hose they had lying around that was too short so they went to the used fitting bucket and cobbled together an extension. See this kinda stuff on experimental all the time. Accident looking for a happening. Sure am glad someone caught it before the inevitable accident.
 
Thanks for sharing, it is brave for anyone to share stuff like this to everyone, for the benefit of all, Thanks! I too am looking at the battery hold down and it looks like only a couple of mills of heat shrink stopping a direct short across the battery, I think that hold down needs a visit to the band saw for reshaping to clear the battery posts!
 
Restrictor Fitting

With that much oil, it may not have and need a Restrictor Fitting installed at the engine.
 
This looks like a classic Red Green (Canadian comic) "This is temporary, unless of course, it works" scenario.
The 18" hose you ordered was only 12" but as this is just the first engine start we will make a patch so we can start the engine. Then we make a couple of ground runs, gotta get a new hose.... Then a few more, then a flight and before you know it the issue is forgotten.
One would have thought that somebody else might have noticed this but good catch Jesse.
We are All, capable of this type of thing and that is why you need extra eyes to check your work on an ongoing basis
 
I am sure there are other issues that could be considered unorthodox or unkosher. I have not inspected the engine compartment for these things. The plane just happened to be stranded here so I am doing some troubleshooting for him on the hard start. This oil issue just scared me at how close this plane was to a likely engine failure and a potential crash and all that can go along with that. I will take a quick look over the other areas of the engine compartment to see how it looks.
 
That almost looks like it was never flared! I am sure you must have found the flare still in the fitting?
 
Jesse, talk him into a full redo of lines and wiring. It all needs looking at and some rework. In just the pics you show there are half a dozen things that are subpar.
 
I am planning to go over the unkosher things I see with him.

This begs another question for the other mechanics on here. When a plane comes to you for a mag swap or something specific like that, what is the scope of the mechanic's responsibility legally, ethically, in regards to liability, etc? Then, regardless of that, how far do you go normally in doing a quick once-over even when it wasn't requested?
 
Jesse said:
I am planning to go over the unkosher things I see with him.

This begs another question for the other mechanics on here. When a plane comes to you for a mag swap or something specific like that, what is the scope of the mechanic's responsibility legally, ethically, in regards to liability, etc? Then, regardless of that, how far do you go normally in doing a quick once-over even when it wasn't requested?
Click to expand...

Speaking from the auto/truck side...

Always write a work order describing the customer's request, and get it signed. You're much less likely to be held responsible if you fail to discover unrelated issues not on that work order.

It's generally considered to be good business to look for other problems. Frankly, it is selling service, i.e. increasing shop revenue. At the same time, you satisfy your own moral issue. Some of the labor time will be uncompensated, as the customer will decline the additional work. Some will pay well. Nothing ventured, nothing gained.

Always inform the customer of what you found in writing, on a work order. Get him/her to initial it, give them a copy, and be darn sure you keep a copy.

Break.

It was nice to see you last weekend. And Annabelle is a doll!
 
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I always look over a plane for errors, and ALWAYS point them out to the owner. I sometimes make enemies that way, but so be it. I wish I had the personality and speech qualities to make it not sound so "preachy" but I don't.

Jesse said:
I am planning to go over the unkosher things I see with him.

This begs another question for the other mechanics on here. When a plane comes to you for a mag swap or something specific like that, what is the scope of the mechanic's responsibility legally, ethically, in regards to liability, etc? Then, regardless of that, how far do you go normally in doing a quick once-over even when it wasn't requested?
Click to expand...
 
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Jesse said:
I am planning to go over the unkosher things I see with him.

This begs another question for the other mechanics on here. When a plane comes to you for a mag swap or something specific like that, what is the scope of the mechanic's responsibility legally, ethically, in regards to liability, etc? Then, regardless of that, how far do you go normally in doing a quick once-over even when it wasn't requested?
Click to expand...

Jesse - when I sign off a logbook, I describe in precise terms the work that was performed, then sign the release on THAT WORK ONLY. I'm essentially saying my work is airworthy. We are fortunate that Canadian regulations actually require this.
 
Thread Drift - Delivering an awkward message

DonFromTX said:
I always look over a plane for errors, and ALWAYS point them out to the owner. I sometimes make enemies that way, but so be it. I wish I had the personality and speech qualities to make it not sound so "preachy" but I don't.
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Don:

My approach:
1. Be sincere.
Genuinely caring about the person you're with comes across. Talking to a person is "preachy."
[Yep, posting internet advice is preachy... I promise to look you in the eye and say the same things if I ever get to La Feria.]

2. Be tactful.
One on one reduces potential for embarrassment. Have a quick quip ("Yep, Bob was telling me what he wants to do...") when others ask.

3. Be direct.
"Me to you, I'm scared at how close this is to a likely engine failure and a potential crash..."

4. Be helpful.
"We could do A, or B, or C... " as you reach for tools, parts, etc.

6. Be calm.
 
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esco said:
Don:

My approach:
1. Be sincere.
Genuinely caring about the person you're with comes across. Talking to a person is "preachy."
[Yep, posting internet advice is preachy... I promise to look you in the eye and say the same things if I ever get to La Feria.]

2. Be tactful.
One on one reduces potential for embarrassment. Have a quick quip ("Yep, Bob was telling me what he wants to do...") when others ask.

3. Be direct.
"Me to you, I'm scared at how close this is to a likely engine failure and a potential crash..."

4. Be helpful.
"We could do A, or B, or C... " as you reach for tools, parts, etc.

6. Be calm.
Click to expand...

To the above, I would add
7. If the customer is unwilling to take excellent safety-based advice to heart, in a constructive manner, be prepared to tactfully tell the potential customer that you have to decline his business.

This last one has been difficult for me, but I have learned the hard way to politely say "no, thank you" when some people ask if I will work on their aircraft. If I've said "no, thank you" to you lately, it's because I've opted to spend my limited free time working toward completion of my own aircraft, so please don't think I declined because your airplane is a rat's nest and that you're intractable! :)
 
Saville said:
Yes I'd be interested in knowing how the connection failed.

Thanks.
Click to expand...

I imagine there are several here who do not understand what happened here. This is an example of one of the risks one takes when engineering or fabricating something versus assembling something. For anyone who does not understand what happened here, I would recommend you have someone look over your FWF design. Most experienced in the trade can help identify improper design or use of materials.

Larry
 
lr172 said:
I imagine there are several here who do not understand what happened here. This is an example of one of the risks one takes when engineering or fabricating something versus assembling something. For anyone who does not understand what happened here, I would recommend you have someone look over your FWF design. Most experienced in the trade can help identify improper design or use of materials.

Larry
Click to expand...

Larry,

Not sure your response answered Savilles question. If you have the know how share it. After all, most people here are building for the FIRST time and are learning something new every step of the way, including myself. Jesse started this thread to teach a valuable lesson, and drove his point out the field (home run). I'm quite certain how this happened but would be great to hear it from people who "are experienced in the trade". After all, this is a forum where builders come to learn, everything related to build these wonderful travel machines we call RVs.

Jesse,

Thanks for posting this. The poster that mentioned the temporary fix story seems likely but would love to hear what the owner said. Was the owner the builder? Glad no one got hurt. Is that battery hold down bracket really as close to the battery post in person? Seems if the the bracket loosens just enough to wiggle closer the to the posts, the bracket covering would wear in no time and short.:eek: Let us know how the FWF once-over goes with the builder or at least share (time permitting) if you find other learning topics. THANKS again!!
 
LuisR said:
Larry,

Not sure your response answered Savilles question. If you have the know how share it. After all, most people here are building for the FIRST time and are learning something new every step of the way, including myself. Jesse started this thread to teach a valuable lesson, and drove his point out the field (home run). I'm quite certain how this happened but would be great to hear it from people who "are experienced in the trade". After all, this is a forum where builders come to learn, everything related to build these wonderful travel machines we call RVs.

Jesse,

Thanks for posting this. The poster that mentioned the temporary fix story seems likely but would love to hear what the owner said. Was the owner the builder? Glad no one got hurt. Is that battery hold down bracket really as close to the battery post in person? Seems if the the bracket loosens just enough to wiggle closer the to the posts, the bracket covering would wear in no time and short.:eek: Let us know how the FWF once-over goes with the builder or at least share (time permitting) if you find other learning topics. THANKS again!!
Click to expand...


For the record, I am not in the trade, but have been wrenching for quite some time. My primary point was to alert the community to the risks involved in going too far without support. This community is a fabulous learning tool, but it can occasionally build over confidence. I was hoping people would think about each time they did something FWF that was new and not documented somewhere and have someone experienced validate it.

At a high level, whatever that hose and tee attaches to needs to be able to support the weight of that hose assembly. The longer and heavier the hose, the more force the fitting needs to support. Grab a hose at the end and shake it around. Due to leverage, it applies more force than you would expect. Now grab the fitting and apply that same force and imagine it happening millions of times. Do you trust what it is attached to?

That aluminum line can support no meaningful weight or force. It is simply not designed for that. It's primary application is to connect two rigidly supported fittings. The aluminum does not have a lot of strength compounded by the fact it will work harden and loss it's ductility (i.e. become brittle) with extended movement.

Larry
 
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Maybe I'm crazy to say this, but I personally don't see the problem with the Tee fitting. If I didn't have the Van's pressure sensor manifold and wanted a pressure switch as well as the pressure sensor, I might use a Tee. Then if I removed whatever I used the pressure switch for, I could just cap the tee.

Larry hit the nail on the head regarding the aluminum line. The only rigid lines I am aware of firewall forward are the oil lines for rear-mounted prop governors and the flow divider to cylinder lines for fuel injection, and I'm pretty sure they are both stainless, and both are mounted rigidly on both ends to the engine or a hard-mounted engine accessory.

I would never ever use any aluminum rigid lines firewall forward.

I will take the nut off the Tee today to see if the rest of the flare is there.

And no, the battery terminal is not as close to the strap as it appears. It is in a recess. It still wouldn't hurt to trim the strap down a little on the positive end.
 
A bit off topic, but if we're to address scary things not everyone knows about....

The photographer is wearing a wedding ring. That's ok if he is indeed just a bystander with a camera. However, if you actually work in a shop, be sure to pocket all rings and watch bands before walking in the door.

Frankly, it's better to not wear one at all. Patti agreed to keep my wedding ring in her jewelry box about 35 years ago, after I almost degloved my own ring finger while working on the house. I'm no less married without it.

Google "ring avulsion", "finger avulsion", or "wedding ring injury".

If you just absolutely have to wear a ring while working, try one of these:

http://www.ebay.com/itm/9mm-Mens-Si...-Crossfit-Best-Flexible-Durable-/271870402255
 
Jesse said:
Larry hit the nail on the head regarding the aluminum line. The only rigid lines I am aware of firewall forward are the oil lines for rear-mounted prop governors and the flow divider to cylinder lines for fuel injection, and I'm pretty sure they are both stainless, and both are mounted rigidly on both ends to the engine or a hard-mounted engine accessory.

I would never ever use any aluminum rigid lines firewall forward.

I will take the nut off the Tee today to see if the rest of the flare is there.
Click to expand...

Thank you Jesse..very informative.

As LuisR said there are builders and owners representing a very wide range of knowledge and skills. So explanations of this sort are extremely useful.

Thanks
 
DanH said:
A bit off topic, but if we're to address scary things not everyone knows about....

The photographer is wearing a wedding ring. That's ok if he is indeed just a bystander with a camera. However, if you actually work in a shop, be sure to pocket all rings and watch bands before walking in the door.

Frankly, it's better to not wear one at all. Patti agreed to keep my wedding ring in her jewelry box about 35 years ago, after I almost degloved my own ring finger while working on the house. I'm no less married without it.

Google "ring avulsion", "finger avulsion", or "wedding ring injury".

If you just absolutely have to wear a ring while working, try one of these:

http://www.ebay.com/itm/9mm-Mens-Si...-Crossfit-Best-Flexible-Durable-/271870402255
Click to expand...

I can't think of a single entry that I have read a post from Dan H and have not learned some valuable lesson. I do like to tinker around the garage, cars and and airplane and with the exception of when I rock/ice climbed, never took off my ring. Not any more.
 
DanH said:
A bit off topic, but if we're to address scary things not everyone knows about....

The photographer is wearing a wedding ring. That's ok if he is indeed just a bystander with a camera. However, if you actually work in a shop, be sure to pocket all rings and watch bands before walking in the door.

Frankly, it's better to not wear one at all. Patti agreed to keep my wedding ring in her jewelry box about 35 years ago, after I almost degloved my own ring finger while working on the house. I'm no less married without it.

Google "ring avulsion", "finger avulsion", or "wedding ring injury".

If you just absolutely have to wear a ring while working, try one of these:

http://www.ebay.com/itm/9mm-Mens-Si...-Crossfit-Best-Flexible-Durable-/271870402255
Click to expand...

Dan: I practiced Emergency Medicine for many years and I agree 100% with this advice. These injuries are devastating.
 
DanH said:
A bit off topic, but if we're to address scary things not everyone knows about....

The photographer is wearing a wedding ring. That's ok if he is indeed just a bystander with a camera. However, if you actually work in a shop, be sure to pocket all rings and watch bands before walking in the door.

Frankly, it's better to not wear one at all. Patti agreed to keep my wedding ring in her jewelry box about 35 years ago, after I almost degloved my own ring finger while working on the house. I'm no less married without it.

Google "ring avulsion", "finger avulsion", or "wedding ring injury".

If you just absolutely have to wear a ring while working, try one of these:

http://www.ebay.com/itm/9mm-Mens-Si...-Crossfit-Best-Flexible-Durable-/271870402255
Click to expand...


I almost lost my ring down the backside of BBJ 737 bulkhead when I was wiring some equipment. I think the job hour budget was 20 hours to remove that bulkhead. I doubt as I was a vendor that I would have ever seen that ring again if it had slipped off that last knuckle. It's been on the night stand ever since.

I guess I took it a bit more off topic.
 
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DanH said:
A bit off topic, but if we're to address scary things not everyone knows about....

The photographer is wearing a wedding ring. That's ok if he is indeed just a bystander with a camera. However, if you actually work in a shop, be sure to pocket all rings and watch bands before walking in the door.

Frankly, it's better to not wear one at all. Patti agreed to keep my wedding ring in her jewelry box about 35 years ago, after I almost degloved my own ring finger while working on the house. I'm no less married without it.

Google "ring avulsion", "finger avulsion", or "wedding ring injury".

If you just absolutely have to wear a ring while working, try one of these:

http://www.ebay.com/itm/9mm-Mens-Si...-Crossfit-Best-Flexible-Durable-/271870402255
Click to expand...

Amen! That lesson was beat into me by my mentor at about age 7. Luckily I never had to learn it the hard way. There are enough ways to whack yourself in the shop (I've tried many of them). I haven't seen my wedding ring since the day we got married, 16 glorious years ago, and have never gotten any flack for it.
 
DanH said:
A bit off topic, but if we're to address scary things not everyone knows about....

The photographer is wearing a wedding ring. That's ok if he is indeed just a bystander with a camera. However, if you actually work in a shop, be sure to pocket all rings and watch bands before walking in the door.

Frankly, it's better to not wear one at all. Patti agreed to keep my wedding ring in her jewelry box about 35 years ago, after I almost degloved my own ring finger while working on the house. I'm no less married without it.

Google "ring avulsion", "finger avulsion", or "wedding ring injury".

If you just absolutely have to wear a ring while working, try one of these:

http://www.ebay.com/itm/9mm-Mens-Si...-Crossfit-Best-Flexible-Durable-/271870402255
Click to expand...
I have an Uncle without a ring finger on his left hand. He lost it one day hauling hay. He was in a hay barn loft, reached out for a rafter to hang onto, slipped and fell down from the loft to the barn floor below. His wedding ring had snagged a nail on the rafter. He was on the ground. Twenty five feet above him was his left hand ring finger dangling by his wedding ring on that nail!
 
Rings are good conductors

Yes, rings will do unbearable damage to the finger when caught on something. Being of gold and other precious metals, they are also great conductors and will heat up faster than you can blink if contact is made with a live circuit. They should not be worn in the shop at all. In the Air Force we were never allowed to wear nay jewelry while on the flight line---rings, watches, ID bracelets (for those who remember them), etc.


Vic
 
Having been an EMT and a LEO for years, I can attest to the "de-gloved" fingers. After seeing it, the only time I wear a ring is on a social occasion. There's too many tree stands, wrenches, lawn mowers, etc. in my daily activities.
 
Bavafa said:
I can't think of a single entry that I have read a post from Dan H and have not learned some valuable lesson. I do like to tinker around the garage, cars and and airplane and with the exception of when I rock/ice climbed, never took off my ring. Not any more.
Click to expand...

Google "degloving" and you'll be afraid to wear a ring *ever again*, let alone in a shop :)

Seriously...take everything off but your work clothes. A colleague recounted a story of one of her fellow students who, while in a lab, didn't take off a metal bracelet, which contacted a battery (for a small spacecraft), which then welded the bracelet to something nearby and nearly burned her hand off at the wrist because she couldn't get the bracelet off.

Not to mention things in pockets falling out and causing FOD damage...
 
jchang10 said:
I dont even want to think about nose rings, eye brow rings, belly button rings, lip rings, and such. :eek:
Click to expand...

Everytime I see somebody with all these facial piercings that are popular now, I just want to grab a battery charger and start touching points and watch them twitch...
 
airguy said:
Everytime I see somebody with all these facial piercings that are popular now, I just want to grab a battery charger and start touching points and watch them twitch...
Click to expand...

I can't stand metal studs. I prefer a traditional bone through the nose. Non conducting.
This thread has certainly turned.....

As an electronics tech and a father in law de-gloved by catching his ring on a drapery hook, I have never worn my wedding ring. Either marriage.
 
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