Unit Mixups

www.us-metric.org/unit-mixups/

Here are some incidents that involved confusion between units or systems of measurement.

They vary in significance and seriousness, but in each case, the problem would have been avoided had there
not been a mixture of measurement systems. Using the metric system doesnt guarantee that such problems will
never occur, of course, but the metric system is so much simpler than other systems that errors are much less
likely. And using dual units further increases the chances of errors over using a single system of measurement.
As long as inch-pound units survive in an otherwise metric world, these types of conversion problems are likely
to continue.

Contents
Expensive rice
Escape of the 250-kilogram tortoise
Winning long jump record lost
Loss of Mars Climate Orbiter
Roller coaster derailment at Tokyo Disneylands Space Mountain
Gimli Glider: Boeing 767 emergency landing
Olympic triple jump loss
Korean Air MD-11 crash
Medication dose errors

Expensive rice
An American company sold a shipment of wild rice to a Japanese customer, quoting a price of 39 a pound. But
the customer thought the quote was for 39 a kilogram, so the actual price was more than twice what the
customer expected.

In the interest of maintaining a long-term business relationship after the misunderstanding, the seller discounted
the rice to his cost, and ended up making no money on the deal. [The customer] had to explain to her boss.
Everyone was embarrassed. We both ended up losing money on the deal.

(See the 6 July 2001 San Francisco Business Times story, Manufacturers, exporters think metric.)

Escape of the 250-kilogram tortoise

What happened

In February 2001, the Los Angeles Zoo lent Clarence, a 250-kilogram, 75-year-old Galapagos tortoise, to the
Exotic Animal Training and Management Program at Moorpark College in Moorpark CA.

The first night in his new home, Clarence wrecked it: He just pushed one of the fence poles right over, said
Moorparks Chuck Brinkman, quoted in a 9 February 2001 Los Angeles Times story.

Why it happened

The L.A. Zoo warned that Clarence was big, and needed an enclosure for an animal that weighs in at about 250,
so thats what the college built.

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Unfortunately, they thought the zoo meant 250 pounds, so the enclosure wasnt adequate for holding a 250-
kilogram beast.

Winning long jump record lost

What happened

University of Houston sophomore track star Carol Lewis made a record-breaking long jump at the NCAA Mens
and Womens Indoor Track Championship, 1112 March 1983 in Pontiac, MI.

However, her jump did not qualify as an official record.

Why it happened

To be considered as official records, college sports track and field measurements must be metric. However,
officials hosting the games refused to use metric tapes. As a result, the non-metric measurements dont qualify
as official records. For record-setting purposes, measurements cannot be converted to metric after the event.

[Source: American National Metric Council Metric Reporter, May 1983.]

Loss of Mars Climate Orbiter

What happened

Mars Climate Orbiter (MCO) was launched on 11 December 1998 on a mission to orbit Mars as the first
interplanetary weather satellite and to provide a communications relay for another spacecraft, the Mars Polar
Lander. MCO was lost on 23 September 1999 when it failed to enter an orbit around Mars, instead crashing into
the planet, destroying the $125 million craft, part of a $328 million mission.

Why it happened

The root cause of the failure was a computer program that was supposed to provide its output in newton
seconds (Ns) but instead provided pound-force seconds (lbfs). From the mishap investigation report:

Angular momentum management is required to keep the spacecrafts reaction wheels (or flywheels) within their
linear (unsaturated) range. This is accomplished through thruster firings using a procedure called Angular
Momentum Desaturation (AMD). When an AMD event occurs, relevant spacecraft data is telemetered to the
ground, processed by the SM_FORCES (small forces) software, and placed into a file called the Angular
Momentum Desaturation (AMD) file.

The JPL operations navigation team used data derived from the Angular Momentum Desaturation (AMD) file to
model the forces on the spacecraft resulting from these specific thruster firings. Modeling of these small forces is
critical for accurately determining the spacecrafts trajectory. Immediately after the thruster firing, the velocity
change (V) is computed using an impulse bit and thruster firing time for each of the thrusters. The impulse bit
models the thruster performance provided by the thruster manufacturer. The calculation of the thruster
performance is carried out both on-board the spacecraft and on ground support system computers. Mismodeling
only occurred in the ground software.

The Software Interface Specification (SIS), used to define the format of the AMD file, specifies the units
associated with the impulse bit to be newton seconds (Ns). Newton seconds are the proper units for impulse
(force time) for metric units. The AMD software installed on the spacecraft used metric units for the
computation and was correct. In the case of the ground software, the impulse bit reported to the AMD file was in
English units of pounds (force) seconds (lbfs) rather than the metric units specified. Subsequent processing of
the impulse bit values from the AMD file by the navigation software underestimated the effect of the thruster
firings on the spacecraft trajectory by a factor of 4.45 (1 lbfs = 4.45 Ns).

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As a result of the incorrectly computed trajectory, the spacecrafts initial periapsis (low-point in the Martian orbit)
was only 57 km; the minimum survivable periapsis was 80 km.

Wouldnt an error that large a factor of 4.45 have been noticeable? Yes, as it turns out: Almost
immediately (within a week) it became apparent that the files contained anomalous data that was indicating
underestimation of the trajectory perturbations due to desaturation events. However, for a variety of reasons, the
source of the inconsistencies wasnt determined until after the loss of the spacecraft.

For the details, read the Mars Climate Orbiter Mishap Investigation Board Phase I Report, issued on 10
November 1999.

(The other half of the mission Mars Polar Lander also crashed into the surface of Mars due to a computer
program bug, but that incident was not related to measurement.)

Roller coaster derailment at Tokyo Disneylands Space Mountain

What happened

On 5 December 2003, the Space Mountain roller coaster at Tokyo Disneyland derailed when an axle broke just
before the end of the ride; there were no injuries.

Why it happened

According to a 21 January 2004 report from Oriental Land Co., which built and operates Tokyo Disneyland, the
diameter of the broken axle was found to be smaller than its design specification. As a result, the gap between
the axle and its bearing, which should have been about 0.2 mm, was actually over 1 mm, resulting in excessive
play that caused more vibration than normal, eventually causing the axle to break.

The broken axle was one of 30 axles received in October 2002, all of which were found to be thinner than the
design specification as a result of an error when they were ordered in August 2002.

That error arose from improperly maintaining the design drawings. In September 1995, the design specifications
for the axle bearing had been changed to metric units, and the specification for the axles was therefore changed
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as well. As a result, there were two sets of design drawings. In August 2002, the old drawings were mistakenly
used to order 44.14 mm axles instead of the correct, 45 mm parts.

The company confirmed that other orders for axles used the correct dimensions.

Gimli Glider: Boeing 767 emergency landing

What happened

On 23 July 1983, Air Canada flight 143, a Boeing 767 flying from Montreal to Edmonton via Ottawa, ran out of
fuel about an hour into its flight. At an altitude of 41,000 feet the crew received its first indication of low fuel
pressure in one fuel pump, and a few seconds later, in the other fuel pump. (Aircraft are assigned altitudes that
are multiples of 1,000 feet. 41,000 ft is about 12,500 m.)

An initial decision to divert to Winnipeg had to be abandoned when both engines failed. Luckily, the first officer
was aware of a decommissioned air force base in Gimli, Manitoba, about 20 kilometers away, and the captain
was an experienced glider pilot; they managed to land the 767 on the runway now a drag strip. The partially
extended nose gear collapsed on landing, stopping the aircraft before it hit anyone on the ground. Two
passengers suffered minor injuries using the emergency slides to evacuate the aircraft.

Why it happened

The aircrafts fuel quantity indication system had begun malfunctioning three weeks before the incident. It failed
completely the night before the flight. The mechanic investigating the failure was told that no spares were
available, but he discovered that pulling a circuit breaker brought it back to life, so he left the breaker open, the
flight was fueled, and it flew from Edmonton to Ottawa to Montreal without incident.

In Montreal, a maintenance worker was assigned to manually check the aircrafts fuel levels, due to the problems
with the fuel monitoring system. While waiting for the fuel truck, he decided to investigate the problem, although
he had no training or authority to do so.

Curious about the open breaker, he closed it, causing the fuel gauges to again go blank. He left, and the crew,
seeing the blank gauges, decided to resort to manually calculating the amount of fuel required for the trip back to
Edmonton and on to Ottawa. (The problem was later determined to be a cold solder joint on an inductor
combined with a design flaw that prevented the unit from switching to a backup.)

The maintenance workers performed a test that estimated that 7,682 liters of fuel were in the tank. They knew
they needed 22,300 kilograms of fuel for the remaining flight, so the question was, How much fuel, in liters,
should be pumped from the fuel truck into the aircraft? They were forced to resort to a manual calculation:

1. They multiplied 7,682 L by 1.77, the density of the fuel provided by the refueling company on their
documentation: The aircraft, according to their calculations, currently had 13,597 kg of fuel.
2. Subtracting from 22,300 kg, they decided they needed to add 8,703 kg of fuel.
3. Dividing by 1.77 the same density used in the previous calculation yields 4,916 L, which was
pumped into the aircraft.

However, 1.77 was the density of the fuel in pounds per liter (lb/L), not kilograms per liter (kg/L); the correct
figure for kg/L would have been 0.80. As a result, they ended up with less than half of the required amount of fuel
on board. (The fuels density depends on characteristics of the fuel, so its not a constant, and the value must be
taken from documentation accompanying the fuel.)

The ground crew didnt notice the discrepancy because 1.77 was typical of numbers theyd seen before. They
assumed the number was in kg/L, not realizing that this was the first aircraft in Air Canadas fleet to measure fuel
in kilograms; density figures on paperwork hadnt yet been changed from lb/L. The refueler didnt notice the
discrepancy because he had no idea where the aircraft was headed, so he had no reason to question the
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relatively small amount of fuel the crew asked for.

In addition, fuel amounts hadnt been calculated by hand since the days of three-man cockpit crews, where the
flight engineer was responsible for checking the fuel load. That process was normally handled by computer on
an aircraft like the 767. What if the computer wasnt working? In 1983, that question hadnt been adequately
addressed.

On aircraft with a two-man crew, tasks formerly assigned to the flight engineer were either automated or
assigned to ground staff, so theoretically the ground crew was responsible for ensuring adequate fuelling if the
automation couldnt handle it. But maintenance crews had never been trained on how to calculate fuel, so they
assumed the flight crew would handle it. But the flight crew had never been trained in this process, either.
Furthermore, Boeing documentation at the time was inconsistent as to whether the aircraft could safely fly with a
malfunctioning fuel monitoring system.

Media coverage at the time pointed out that this was Air Canadas first aircraft to use metric measurements, but
thats only partially true. Although it was the first to measure fuel mass in kilograms rather than pounds, fuel
volumes were already metric, in liters.

Olympic triple jump loss

What happened

At the 2004 Olympics in Athens, triple jump champion Melvin Lister was eliminated in the qualifying round.
Although he had jumped 17.75 m in Sacramento the previous month, his top jump was only 16.64 m in Athens.

Why it happened

A Kansas City Star article quoted Lister as saying, Nobody told me they were only going to have metric out
there. I couldnt figure out what my mark was. And from the 21 August 2004 Los Angeles Times :

Lister blamed his problems on trackside officials refusal to allow him to use his measuring tape, which measures
distances in feet and inches and serves as a guidepost for him. He said he was told the tape might hurt
somebody because of a spiked attachment and was told to use a metric tape, but he didnt have one and
couldnt work with the metric tape organizers supplied.

Nobody told me I need one, he said. Coming down, I need my running speed and to trust in my approach.

Teammate Walter Davis, who advanced with a leap of 16.94 meters, scoffed at Listers excuse. When youre
coming overseas, youve got to have a metric tape, he said. Mine is in feet and meters. Youve got to come
prepared.

Korean Air MD-11 crash

What happened

On 15 April 1999, Korean Air flight 6316, an MD-11 freighter on a flight from Shanghai to Seoul, crashed shortly
after takeoff from Shanghai Hongqiao Airport. The aircraft was destroyed, its three crew members and five
persons on the ground were killed, and 37 on the ground were injured.

Why it happened

The flight was initially cleared to an altitude of 900 meters, then instructed to climb to 1,500 meters. After
reaching about 1,400 meters, the crew erroneously concluded that they had misinterpreted the altitude. Having
decided that they should be at 1,500 feet, rather than meters, they began a rapid descent.

During the process, they lost control of the aircraft and crashed.
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Note that aircraft altitudes are in feet throughout the world, except for China, Mongolia, and the CIS (former
Soviet states), which use meters.

Medication dose errors

What happened

In 2004, a baby was given 5 times the prescribed dose of Zantac Syrup, a medication for reducing stomach acid
production, until a doctor pointed out the error a month later. Fortunately, the child was not injured, although
doctors say there was a risk of seizure or stroke had the incorrect dosing continued.

Why it happened

The doctor prescribed a dose of 0.75 milliliter twice a day, but the pharmacist labeled the bottle, Give 3/4
teaspoonful twice a day. A teaspoon is about 4.9 mL.

Note that an additional source of error, given a prescription in teaspoons, is that consumers might use teaspoons
from the silverware drawer instead of measuring spoons.

See Pharmacy makes another potentially dangerous prescription mistake from WFTV for more details.

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Copyright 20062009, U.S. Metric Association (USMA), Inc. All rights reserved.
Updated: 2009-01-05

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