The question 'WHY' is the first tool of a successful manager

We frequently experience undesirable events and experiences, we don't know why they happened and wish they would not happen in the future.  Simply wishing or blaming people doesn't help. But systematically, patiently and persistently diging around and down into those events, uncovering their root causes with an open mind and eliminating them, works. We can save our time, energy, costs and reputation.  Let us explore this in depth by looking into a few reallife case studies. 

CASE STUDY 1: Two stainless steel bolts in the paper machine broke at night and caused downtime

The stainless-steel bolts were holding the bracket of a roll to a column in the paper machine. Their failure caused 4 hours of machine downtime. 

The "non-why" approach

Well, the broken bolt stopped the machine and quick action is needed to minimize production loss. We had to replace the bolt and hand over the machine to production, go home, sleep for a few hours and go back to the plant in the morning half sleepy.  After a few months or years, similar event takes place and the same process is repeated.  No questions raised. 

The "why" approach 

The broken bolt was replaced by the technicians not the Engineers. What then is the role of the Engineers who go to an Engineering institute (a polytechnic or a college) for a few years studying a variety of engineering subjects? Is it only to arrange the technicians and materials and supervise the job? I think their job is also to make sense of what they see happening. If what they see, is not making 'Engineering sense' they need to keep asking questions and generate answers like the following,  prompted by their engineering knowledge.  In these cases, I followed this process prodded by my internal boss "Mr. WHY".

Q: Is any bolt supposed to break at all? 

A: Not under normal conditions because it is a routine engineering practice to design the cross section of a bolt with a factor of safety of say 4 so that the bolt safely withstands four times the normal running load.  A bolt does not break unless the forces are more than 4 times their normal running load.  What happened doesn't fit into my Engineering knowledge!

Q; The machine was running smoothly until these bolts failed and the roll came down. There were no unusual forces on them. Then why did they break?

A:  These bolts were always exposed to slightly acidic water and might have been corroded, causing a reduction of the load bearing cross section which might have led to their failure even under normal forces.   

Q: Did you carefully scrutinize the failed bolts? If you did, did you find any corrosion on them?

A: I did look at them. There was no visible corrosion on their bodies. On the other hand, the cut sections had clean sharp edges as if a new bolt was cut by a laser!

Q; Then why did they fail?

A: Honestly, no idea. I wonder what was the cause for their failure. This is an  ABNORMAL failure that doesn't fit my concept of how a stainless bolt should behave. Someone apparently used stainless steel bolts when they found the carbon steel bolts corroded and difficult to open when needed.  I need to study a book on stainless steels to resolve this anomaly.  If I don't, there are bound to be more such downtimes and I am already exceeding my budget, attracting criticism from the management.

I entered this in my task list and after a couple of days, went to the Design office library and pulled out a handbook on stainless steels. In that book I read that stainless steels are susceptible to 'stress corrosion cracking' which occurs under particular conditions - Material. Environment and Stress. Carbon steels don't fail in this manner. I still remember reading about the tragic incident in Switzerland in 1985 in which the roof over a swimming pool collapsed and killed 12 people. After learning about this, I think we probably substituted the 304 by 316 bolts which is less susceptible to such failures but when I checked online now, even 316 grade is susceptible to 'stress corrosion' failures.  It looks like super duplex stainless steels are recommended for such duty conditions. 

CASE STUDY 2: Stainless steel pipe burst open causing downtime

One day a stainless-steel pipe of 304 grade carrying stock to the head box burst in the paper machine and caused downtime. There was no surface corrosion inside the pipe. But following a similar thought process, a close examination revealed fine cracks on the weld joints. That was unusual. Again, the book on stainless steels explained that welded stainless steels should not be 304 or 316 but must be 304L or 316 L grade. The 'L' designation means the steel has extra low carbon. The pipe material as well as the welding rods must have 'L' designation to avoid such failures. The relevant information is in this page,

CASE STUDY 3: My blunder in using titanium in dry chlorine line

When a drawing for the inner parts of a valve in the dry chlorine line in the pulp mill were being made, I changed the original material 'Hastalloy-C' to titanium because it was the material for the pipe line carrying chlorine dioxide which is more corrosive than wet chlorine, thinking titanium will give a better life. To my shock, when the line was opened to dry chlorine the titanium parts exploded! Luckily there was no major damage to the equipment or people. Referring again to the book on stainless steels, I learned that titanium ignites if the moisture in the chlorine is less than 1% . Here is a link which mentions this phenomenon.

CASE STUDY 4: Proposal for a one crore rupees of investment dropped (year 1982)

I was working in the Industrial Engineering Department of in Heavy Engineering Corporation.  I read a book on application of method study and was itching to apply it to a real life problem. Soon after, the Director of my division received a proposal from the utilities HOD for expansion of the gaseous oxygen generating plant on the ground that the oxygen pipe line pressure was falling below the acceptable level because the demand had gone up. In view of the high cost and may be he felt that production had hardly gone up to justify the higher consumption. He passed on the proposal to my HOD who in turn handed over the file to me to check out as I was pestering him for such assignments. I used the systematic analysis using the "WHY chart for problem solving'. I defined the problem as 'Low pressure of oxygen at the consuming end of the pipe line'.  I collected the information to gain qualitative and quantitative clarity about the problem - what was the expected pressure vs the actual pressure, at what times was the pressure normal and what times it was below the normal, which consuming unit was experiencing this problem and for what time period etc,    ...........(to be continued).    

Conclusion

If a failure doesn't fit into our 'Engineering sense', we need to ask 'WHY', study authentic sources till we get satisfying answers and take necessary steps to prevent recurrence of such failures. Going routinely by past experience is unprofessional and will lead to recurring failures, downtime, unsafe conditions and economic loss. There is no substitute to referring to authoritative books on any issue when faced with a problem which looks unusual or abnormal. These days, up-to date knowledge can be accessed from one's palm!

Postscript

I have been applying the same approach to studying and understanding of the pervasive problem of 'Domestic Abuse (Violence) that has been going on foe generations in all classes of people - rich/poor, less educated/highly educated, irrespective of their religion, nationality,  male/ female …so on.  The salient aspects of the knowledge gained so far are in this web page "Domestic Abuse 101".  The process of understanding the root causes of this horrific behavior within the family is continuing.