…and if you’re Canadian you probably know what that means. Don’t drink the water eh?
Well, yeah. Except it’s been nearly 13 years since the outbreak (of E coli from an improperly fixed well, a massive rain storm and a tangle of factors including insufficient chlorination of the water that killed 7 people and sickened some 2,300 – for those just tuning in).
I haven’t found a cheerful way to spin the subject yet. It was awful and many people still suffer. But I chime in in the hope that it will make us all think about it. The book is closed on the inquiry, jail sentences have been set, and most people think of it as over and irrelevant, but (though I hate to be the bearer of bad news) the root of the problem is far from gone.
Even the most embittered and devastated E. Coli survivor would agree that if the citizens of Walkerton had one voice, it would wish that no other town ever go through what they did. A thorough root cause analysis is necessary to understand the origins of the disaster, which we clearly have to do if we want to make lasting changes that will truly prevent something like this from recurring.
The correct verdict for the implicated parties (in this case the Koebel brothers, though it could be argued that it could have been anybody) is important.
But equally necessary though less obvious is an analysis of the system as a whole. This is the only way to serve and protect people well into the future.
Let me switch into an industrial analogy. A factory must send a prescribed number of widgets with no impermissible defects to its customer on a daily basis. The factory has a set companies who sell us the raw components (collectively known as a supply chain) and set of inspection procedures, errorproofing measures, machinery and operators (collectively known as a process) designed to help achieve their mandate.
Let’s say a screw on one of the clamps on one of the inspection machines came loose. Let’s say that that screw got wedged on the face of the clamping pad. Now the screw is positioned so that it imprints each widget housing with a little dint. The product keeps coming out of the assembly line, a little dint on each one. The dint compromises the seal on the leak testing device on the assembly line, but the volume of air escaping is sufficiently small that each unit still receives a ‘pass’ signal from the machine. The dint is undetected by the unloading person’s visual check, who is busy looking for a different defect on a different part of the widget.
You with me so far? Bad parts getting through. No one has noticed yet, and dints are to widgets as poisonous E Coli is to water.
Now the dinted product is being loaded into the carry totes by the thousand, and being shipped to Illinois (or Michigan or Korea) to be assembled onto engines at the customer’s plant. The first 500 dinted units are unpacked and assembled there without notice, but when the first dinted widgets hits the equipment that tests the leak rate of the whole engine, each begins to fail. Customer workers stop their assembly process and discover the dint on the product that we shipped to them, and pronounce it the root cause of the failure. Several things now happen:
1) Sorting: a) Customer workers begin a manual inspection of all product in stock at their facility to determine whether they have the same defect.
b) Workers at the home factory begin a manual inspection of all product in stock inhouse to determine whether they have the same defect.
2) Containment: Appropriate measures are taken to separate good units from bad units.
3) Charging: The home factory is charged for the labour involved in 1a) and b), 2 and sometimes an additional fee. (For certain customers it is $10K automatically for a new Quality issue).
4) Root Cause Analysis and Elimination: The home factory analyzes the defect and brainstorms on where it could have been created. If they are on the ball they will figure it out, check on the assembly line, find the loose screw and tighten it.
5) Systems Review: A team of process experts comes together to investigate the root of the problem to ensure it never happens again. This team would examine such questions as: Why did the screw come loose? Why did we select that type of screw? Where was the vibration coming from that made it loosen? Why wasn’t the loose screw detected? Why wasn’t the dint detected by the leak tester on our assembly line? Why wasn’t the dint visually detected by the operator? Was there not sufficient lighting? Not sufficient time? then follow up to correct them. Through this they might learn that the operator should have caught the defect, that the leak tester’s parameters were mis-set, or that the maintenance mechanic’s failure to do preventive maintenance on the assembly line that day resulted in the screw coming loose. Or perhaps all of the above. Most often, a combination of factors is found to be the root cause of the problematic outcome.
No one factor could have caused the problem and one small fix would not have contained it; yet together those small factors swirled like the perfect storm and caused a disaster.
6) Documentation and Analysis: The findings of 4 and 5 are written down and communicated to the customer. They are interested in 5 more than 4. The findings are also reviewed periodically within our company to allow designers of new processes to avoid similar issues in the future.
Everyone’s going to have their own perspective on this scenario; their own way of weighting the best way to solve it.
If we had a nurse or development worker in this conversation, he/she might automatically gravitate toward #1,2: emergency relief, getting the problem under control. My lawyer friend Sean’s concern rested nearly solely on finding the right sentence (punishment fit for the crime) for the responsible party – which makes sense, since he comes in on #3. As a Continual Improvement/Manufacturing Engineer, I am chiefly involved in #4, 5 and 6, so I switch into that gear automatically when considering any problem.
There is always new product flowing out the door; regardless of what the problem was, it needs to go away.
So back to the not-so-trivial scenario of the contaminated water flowing into peoples houses in my little old hometown. After the old tap fixtures are being disinfected and the E coli-stricken are released from being cared for in hospital (#1, 2), the wrong-doers are sentenced (#3) and the issues are probed in a public inquiry (#4). Unavoidably, new water is soon flowing through the taps. The only way to guarantee (or maximize the chances) that the water is safe is through rigourous and extensive and blameless and tireless pursuit of #5. Then make sure everybody knows about it, all the angles, in #6.
It’s natural to want to raise up and demand crime and punishment when things get this scary and awful. We are human beings and we all deserve to feel safe where we live, work and play. Framing the situation emotionally, somebody must pay.
In the context of problem-solving, however, determining who’s responsible is only useful to the point that now we now how to fix it – and determining which consequences are appropriate is only useful to the point that implementing them truly prevents the problem from recurring.
This is the frame of reference from which I approach the situation, and the basis on which I base my skepticism that the problem has really been solved. Focusing on Stan and Frank Koebel (the much-maligned managers of the municipalities water system at the time) is the equivalent of yelling at the operator who missed the dint and closing the investigation right there.
It provides us no safety, no comfort, no real solace because there no assurance that it will not occur again. The screw could vibrate right out of the machine again and the ride begins anew – with a different schmuck taking the fall, but no real progress made. Incidentally, Stan Koebel did get a year in jail, and many would agree that he should have. The inquiry gave 50% responsibility to the provincial government at the time. No one to represent the tangled web of factors their negligence failed to capture. So we punish the man who held the simplest piece of the puzzle, and convince ourselves we have ‘solved’ the issue. To me, both as a citizen of Walkerton and a citizen of the world, that outcome is simply unacceptable.
