What is on my mind at the moment is how people investigate “equipment malfunction” which is the catch-all lame excuse that is quite often used when there is some sort of otherwise unexplained incident.

Aside from the two space shuttle disasters, and the collapse of the Tacoma Narrows Bridge, and possibly the Hindenburg disaster, quite possibly the most famous equipment malfunction in history was this one, which occurred during the 2004 Super Bowl Halftime Show.

The Real Root Cause of Equipment Malfunctions

I’ve done about 300 ISO audits. In those, I’ve looked at about 5 non-conformity investigations per audit. In that 1500 investigations, probably zero have actually gotten to the actual root cause of an equipment malfunction.

I believe the definitive work on this topic is being done by Dr. Mark Hannah from Iowa State and summarized in the following video:

To summarize, of the ten biggest causes of machine failure, about nine of the ten have one thing in common, which is that they really represent human failure of various types.

Equipment Failure During the Planning Stage

I have to tell you a story about this, which I can do because most of the people involved are not around anymore. Also, the plant that this took place in is now a vacant lot that is well on the way to turning into some nice condos.

The company I was working for used big intensive mixers that were the three story version of this food processor. Ingredients went in the top, there was a high pressure hydraulic ram that rammed it all together, and when the batch was done, it dropped out the bottom and into some downstream equipment.

The mixer body in those things gets all the wear and tear, and it got to be time for a replacement. At that same time a company came forward with an idea to increase capacity. They could make the mixing chamber 15 percent bigger, and, even better, it had the same physical footprint as our antique mixers. This meant that they wouldn’t have to replace the ram, motor, or discharge equipment.

The Technical VP bought into the idea, and without any validation, made the very expensive decision to put one of these mixers in. They threw the keys to the process person, namely me, and started counting their extra profit.

A Problem Arose

Although the mixer did fit into the footprint perfectly no one took into account the support equipment and there were nothing but problems. There was 15% more strain on the motor, which blew fuses. There was 15% more strain on the ram, which was not set up for it and broke down repeatedly. There was 15% more volume for the discharge equipment to handle, and it caused additional scrap. The thermal efficiency, and circumferential rotor speed, and a lot of other factors were also way off.

The way we figured out how to deal with the problem is slow the mixer down. The net productivity of the operation was negative after the investment in “bigger” equipment.

The Plot Thickens

So the root cause of this series of equipment malfunctions was a questionably effective validation and purchasing process. But, since the decision was made by the VP, who was one of those people who learned slowly if at all, there were no repercussions.

We eventually figured out a way to compensate for the slower mixing: Cut down on the mix cycle so that the batch would mix faster, but have poorer dispersion, and worse performance. This was a “stealth” charge to the customer in diminished quality.

Nobody in the system could see or admit to the failure. Stuff runs down hill, however, and it was obvious to me. Over time, the motor, discharge equipment and ram were quietly replaced with newer models. The free market had its way. The business eventually was sold to a rival. I don’t know what happened to the mixer.

So now what?

Even I myself occasionally buy the wrong piece of equipment for a job. I’ve also been known to use a tool inappropriately for the job at hand. I had just an example the other day with an old circular saw I had which I expected to cut an arch. Those things are meant to cut straight. I accepted the risk knowing the consequences. The smoke coming out of the motor was not too serious.

I am about the same age now as my VP Boss was then. Don’t discount this as a contributing factor. He thought he knew better and I might have made the same decision at this point had I managed to convince my boss, the President that I was an expert at something. The difference is, I would have knowingly accepted the risk, acknowledged the possibility of failure and would have been prepared for the consequences.

Clause 6.1 of the ISO standard wants you to do this. ISO9001 was about 10 years away from being invented.

The real root cause of this series of equipment malfunctions was under-estimation of risk, which by any other name is called “hubris”. No one could call it what it was. How to investigate equipment malfunctions is to look at the human factors involved.

Side Point

Justin Timberlake’s net worth, 15 years after that incident, is now estimated at $250M. Janet Jackson? about $190M according to estimates. The $550,000 fine, which was appealed all the way up to the US Supreme Court, could very well prove to be one of the greatest investments in history. That pretty much says it all about the “malfunction” aspect.

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