For this series, I’ve drawn inspiration from the comedy Groundhog Day, which was released by Columbia Pictures in 1993. In this classic movie (classic to me, anyway), cranky weatherman Phil Connors finds himself reliving the same bad experiences over and over.
In my first installment, I introduced the following principles that enable organizations like yours to put problems behind them the first time, thereby avoiding Phil’s experience:
- Find the REAL source of the problem
- Don’t assume the problem is isolated
- Identify solid long-term fixes, rather than band-aids
- Implement fixes promptly and correctly
- Ensure fixes remain in place until no longer needed
Today’s blog will touch on Principle #2: Don’t assume the problem is isolated. But first, a brief story.
Way back in the 1980s, I was making my rounds aboard a US Navy submarine when I ran across something that just wasn’t right. Specifically, a putty-like substance was visible in the overflow port for the purifier, which used centrifugal force to remove impurities from lubricating oil. The resulting inquiry determined that a drum containing paint hardener had been delivered to the boat along with drums of lubricating oil, and the crew had subsequently transferred its contents into one of our four oil sumps. After samples confirmed that the paint hardener had migrated to a second sump, both affected sumps were drained and flushed. Problem solved, right? Well…unfortunately no. During the next plant start-up, a turbine began spinning a whole lot faster than it was supposed to. An alert shipmate promptly tripped steam to the turbine before it catastrophically failed, much to the appreciation of those of us who probably weren’t quick enough to dodge shrapnel. It turns out that a pipe connected to one of the ‘bad’ sumps hadn’t been adequately flushed, allowing some of the contaminants to enter the ‘good’ sump supplying the turbine’s control system when a cross-connect valve was opened.
In the decades since I stopped poking holes in the ocean, I’ve encountered quite a few similar situations where organizations were unpleasantly surprised when a new problem came to light after they thought they’d put an issue to bed. In some cases, the organization simply assumed the problem was a lone wolf rather than confirming it, while in others, their efforts weren’t thorough enough to find the rest of the pack.
The term ‘Extent of Condition’ is used by many organizations when referring to how widespread a problem is…so I’ll use it here. The value of determining the Extent of Condition is this: It’s a safe bet that the problem we found (or found us) isn’t the only one that its cause(s) created. Said slightly different, it’d be very convenient if the roach I just spotted in my kitchen was alone, but it’s far more likely that he’s brought some buddies along to partake of the food I left out overnight.
Extent of Condition reviews should be performed whenever the problem we’ve encountered impacted safety, quality, or reliability…or easily could have had the circumstances been slightly different. The first step in the process is identifying which condition(s) are important enough to determine the extent of. We’d then perform a separate review for each distinct condition to see if it was present in identical and similar entities. Let’s say we determined that a circuit breaker failed to operate on demand because an understrength spring was installed in its operating mechanism. The Extent of Condition, in this case, would involve determining if the same non-conforming spring was present in the operating mechanism for other circuit breakers. If our incident were instead triggered by a mechanic’s work practice, we’d need to determine if the same work practice was used by other mechanics performing the same or similar tasks. You get the idea…
The level of effort we’d expend determining Extent of Condition should align with the risk the condition poses. For our circuit breaker example, we’d definitely want to identify if the understrength spring was present in other breakers that are important for safety or reliability. Conversely, there’s probably limited value in checking out those breakers that don’t meet this criterion, which we’d typically run to failure anyway!
Extent of Condition reviews are often completed by the team assigned to perform cause analysis for an incident. That can work fine when the level of effort needed to check it out isn’t too great. In cases where there’s an urgent need to nail down how widespread the problem is AND doing so could take considerable effort, consider forming a separate Extent of Condition team to work in parallel with the team analyzing the incident. If determining Extent of Condition isn’t urgent, consider deferring portions of the review until after the incident report is issued. For example, the action plan for the circuit breaker incident could include an action for Amy or Bob at your company’s other facility to identify whether the understrength spring is present in their important circuit breakers.
I’ve partnered for several years with Fisher Improvement Technologies (FIT) to develop Cause Analysis approaches that integrate solid methodologies with the practical application of HOP principles. We’d love to help if your organization is stuck reliving the same old problems and, like Phil Connors, would like to get it right so you can move on. Please visit www.improvewithfit.com to learn more about the products and services FIT offers, including how to enroll in our upcoming Cause Analysis Workshops. You can also contact me directly via LinkedIn or by sending an email to firstname.lastname@example.org.