This is an interesting story of how not to fail using alarm systems. A case like this is interesting to us from a number of perspectives, including alarms, employee training, and “doubtsourcing”. This is sort of like “outsourcing” but not really.
I have a few dog years’ experience in Quality Management, I have had past and current experience consulting with outsourcing entities. A lot of these companies need to become ISO certified, and the story below is exactly the reason.
Who am I to be Telling You This?
I also worked for one of these companies a long time ago. I was a “grunt worker” and have stories about the nasty, dangerous, repetitious work that these people do, because I did it.
How Not To Fail: Alarm Systems Back Story
According to the report, a janitorial service, working at Rensselaer Polytechnic Institute. This service, in upstate New York, is being sued because one of its employees flipped the circuit breaker. This shut up an annoying alarm.
The alarm was attached to a freezer, which housed a 20-year long research experiment. The lawsuit is for more than $1 million in costs associated with the lost research.
According to the report, when the event happened, the researchers did a risk analysis. They somehow and determined that the freezer could be kept running. A possible contributing side factor is the fact that they had to wait for a manufacturer’s technical service people to schedule a repair.
They posted a variety of signs on the freezer to the effect of “yes, we know the alarm on this freezer is annoying but please don’t shut it off.”
The janitor, working for Daigle Cleaning Systems, an outsourcing entity, ignored the signs, flipped a circuit breaker, and shut off the alarm and everything else, compromising the experiment. So, there is a lot to unpack.
The Alarm System
Here is a video about this topic:
I happen to like this one a lot.
It basically says that we’re living in a world where alarms go off, and nobody does anything about them.
Regarding the alarm, there are four possible outcomes, only two of which are good.
The condition you’re alarming against happens, and the alarm goes off. Also, if the condition doesn’t happen, the alarm needs to not go off.
The other two possibilities are that the alarm goes off without the condition happening, which is a “false alarm.” These happen nowadays so often that alarms are frequently ignored. This is thought to be something on the order of 99% of the time.
The other condition is that the condition happens, in this case the freezer malfunctions, and the alarm doesn’t go off.
Reacting to Alarms
Once this first level of complexity is passed, the alarm goes off, and there needs to be some kind of reaction.
Presumably the employees in the area need to be aware of what to do. That’s a training issue, and it should have been ironed out as part of the plan to install the alarm.
You’d be surprised how many people install an alarm on a piece of equipment, without a plan as to what to do when it goes off. If you’re in a medical situation, which this potentially is, there’s an expectation to document any kind of investigation, and if the conscious decision is made not to take action, that is documented. That way, at least the proper authorities are engaged in the problem.
So, in this case, the alarm went off (correctly.) There was an analysis as to the action plan, and the researchers thought they were good.
Doubtsourcing
As we said above, doubtsourcing is a lot like outsourcing, but not really. Here is another video.
Here’s the story.
Some of these world-class organizations have world-class workforces. There’s an underlying expectation that these jobs come with high pay, and nice benefits.
At some point, probably at the same time of the disempowerment of the unions, it became the style to have “outsourcing” for some of the “support” activities. This is a good example. The management of this world class organization decided that they could save a few dollars by “outsourcing” their “less value added” activities, such as emptying the trash. That job doesn’t require a world class education or qualifications.
I actually work with a few of these companies. There is an “outsourcing” management, that coordinates this, and there is a pool of labor that shows up more or less every day, and does the work. The work is done on a contract basis, and there is savings in it enough in it so that the “outsourcing” company can make a profit doing exactly the same job as a former employee of the main company.
But, what happens is that the actual work falls to “low wage workers.” Also, the workers in essence get reduced pay and benefits, but for a certain type of worker, they’re willing to do this.
We’ve also talked about these people in the past. Some of them are there for a reason.
Training of Outsourced Workers and/or Temps
Okay then, here is the problem, as it applies to this case.
These outsourcing organizations experience huge turnover. The jobs are often boring and unpleasant. The workers themselves are very often not your best workers or employees.
They may not even be able to read signage in English.
So in a case like this, where there is a complicated experiment, an annoying alarm, and some signage, there is no assurance that the worker will understand it or deal with it in the right way.
It’s also possible that the engineers or whoever put up the signs made the wrong assumptions regarding the employees’ ability to understand written communication.
If I were the lawyer for the defendant, that’s what I would do. I’d go to the contract between the University and the Cleaning Service, and ask the simple question of whether reading in English is a job requirement.
That’s also what I would do if I were an ISO auditor, by the way, which I am.
Another side issue: It is possible, and maybe likely that the freezer was purchased 20 years ago, and it never occurred to the management at the time that the janitorial service would be outsourced. That’s not an excuse, since as part of the risk assessment someone should have picked up on this and come up with a plan to train the outsourcing people.
A third issue is that turnover is so high in these places, that this might have been done by the “new guy” without sufficient training or understanding of what he was doing.
That is, of course, other than “empty the trash.”
The Cookie Story
I have this story about an incident I had a few years ago regarding signage as a work instruction. The simplest work instruction, three words, is only about 20% effective without additional hand holding and training.
It is possible that if the supervision for the cleaning service sat down with the engineers, and brought in the cleaners, and said “whatever you do, don’t shut this freezer off” that would have been better. It wouldn’t have been foolproof though. Some people don’t understand spoken English either.
A clever lawyer would look for training records to this effect, and then say “see, you, the “plaintiff” didn’t adequately train or communicate to anybody. You just put up a few signs and called it good.
We have a quality systems expert willing to testify to the effect that this is no way to communicate to anybody.
Alarm Systems: The End Result
The lawsuits are going to fly on this one, and it looks to me like the cleaning service has a leg to stand on in this case.
A “reasonable jury” might conclude that despite the signage, the University didn’t sufficiently communicate this to the cleaning service, particularly in light of the lack of a requirement to read English, if there is a lack of requirements.
But that doesn’t help the situation regarding the poor lab test. Twenty years of research down the drain. I hope it didn’t have a cure for cancer in it.
I, a quality systems professional, could be an expert witness in this case. You know where to find me.
The Importance of Records
This is a side point, but not really, because documentation of all of this is going to be critical.
The contract between the cleaning service and the University will be evidence. It will have in it, the minimal qualifications for an employee to work in this outsourcing service.
If there are written training records on either the outsourced cleaning people or the decision to temporarily allow the freezer to run, that will be important.
The training records for the cleaning employee will be submitted as evidence.
All of these things are requirements of a sufficiently constructed ISO-conformant management system, for this very reason.
How Not To Fail Alarm Systems
So here you have it, how not to fail if this were to happen again.
- Install a better freezer. 20 years is a good lifetime for a freezer, but apparently not good enough.
- Make a management decision about what to do if the alarm goes off. This should be thought of when the alarm is installed, and documented.
- Once that management decision is made, if it affects the behavior of “support personnel” make sure everybody in the system is aware of the fix, and do training, and retain training records. Sticky notes and temporary instructions are not really very good means of communications.
- Extend training into the outsourcing organization. Many outsourcing organizations have a training function that does this very thing.
- In addition to that, if this is an outsource situation, make sure communication ability is a job qualification, and keep records of that too. Also, retain employee hiring records to confirm that the employees were properly screened before working in this area.
We’d first of all hope that the problem never happens and the system works.
But, if the system doesn’t work, we will want to know what the story was, and that’s why the records are critical.
Side note: We’re sad that the experiment was ruined, but glad it wasn’t something like dynamite or nuclear waste, which it could easily have been. In many of these cases, the experiment you save could be your own.
You know where to find me.
PS If you’re an outsourcing organization, and want to set up a system where you maintain documentation and records to protect you from silliness like this, let me know because I do that kind of work as well.
Here is my link to Udemy course, “How Not to Fail at ISO9001”
https://www.udemy.com/course/how-not-to-fail-at-iso9001/learn/lecture/34733460#content
Here’s the link to my Quality Systems Training. You can hire me to give this training in person, complete with questions and answers, and along with a few decades worth of horror stories about product quality, dangerous products, and why people don’t do their job.
And, here’s the link to my book “How Not to Fail at ISO9001” available at Amazon.
The Spanish version is also available.
Links and References
