When troubleshooting goes wrong ...|
Last night I saw a very instructive TRUE story on TV. The condensed version goes like this: a highly qualified, intensive-care doctor has appendicitis. So he undergoes keyhole surgery at the hospital where he works. He is now a patient in his own hospital. In the recovery room, post-surgery, he is awake but starts to feel light-headed. A nurse takes his blood pressure and it's way down. This triggers an emergency response.
The medical emergency team arrives at the patient's bedside. Being a doctor, the patient argues with them. He can't believe he's having a heart attack, because he does not have any chest pain. But the attending emergency doctor shows the doctor/patient his ECG. He is indeed having a heart attack. The attending doctor wants to send the patient for a CT scan to establish what is wrong with his heart.
In the meantime, the situation is explained to the patient's wife over the phone. She relays the information to the patient's brother - who's also a doctor. The patient's brother immediately 'gets' what's happening. So he almost screams down the phone to the wife: "don't let them do a CT scan, he's bleeding into the abdomen, get his surgeon!" As an aside, the patient's brother also knows that having a CT scan when you are critically ill is statistically very dangerous. Apparently, this is because the CT scanners are usually located a long way from the equipment and personnel required if the patient crashes.
Anyway, the wife rushes to the hospital and arrives just as her husband it about to be given the dye necessary for his CT scan. She immediately tells her husband what his brother told her. The penny drops. Even though he is gravely ill, the patient/doctor realizes his brother's diagnosis is correct. He refuses the CT scan and demands, in no uncertain terms, that his surgeon be summoned immediately. And he lived to tell the story.
No, it wasn't an episode of Greys Anatomy. This actually happened. Truth is stranger than fiction and all that. And while it is very dramatic, it's nothing more than a story about a troubleshooting mistake.
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... And how to avoid it|
It doesn't matter whether your specialization is medicine or hydraulics, the principles of effective troubleshooting are essentially the same, as Greg Brodie-Tyrrell, one of our members from Balhannah in South Australia explains:
"I've spent 17 years working as an electronics technician and another 20 years at the sharp end of computing, covering all areas with a high degree of technical responsibility. Fault diagnosis is something that I am very familiar with, and a subject close to my heart. It is something that can be taught, of course, but it is also something that requires experience to refine and perfect. Some people never catch on, some take to it well. My experience in a number of fields has stood me in good stead, and as a result I find I can diagnose problems in all sorts of technologies, even if my experience is not necessarily broad."
This is true. Also, as demonstrated in the above medical drama, troubleshooting is often an interactive process. And this can be both help and hindrance. Greg continues:
"To me, the most important thing is to listen carefully to the user's description of the problem. Users can be technically smart, but often they are not; how many people do you know who can tell you intelligently what is wrong with their car? Accept the description, but don't take it as being correct; I lost count years ago of the number of fault descriptions that were so wide of the mark they were useless, and if accepted at face value, seriously misleading. Take the user's description as the description of symptoms, not a description of the problem."
This is good advice. While I don't have enough medical knowledge to know how many heart attacks occur without chest pain, I would have thought this symptom was a very a important troubleshooting clue - to consider a cause other than a blockage; low blood pressure, irregular heart beat, no chest pain, recent abdominal surgery… looks obvious doesn't it? And it almost always does with hindsight.
Ah you say, but it was more complicated than that at the time. It almost always is. Add to this the fact that a lot of troubleshooting occurs in 'pressure cooker' situations - not only in medicine - and it's easy to understand why a mistake is a lot easier to make than an accurate diagnosis.
This is where a procedure or check list can be of enormous help in avoiding mistakes, but it is not always easy to get people to use them, as another of our members Roy Cox, explains:
"Following a procedure to troubleshoot a problem is actually very difficult for those not practiced in this methodology. The desire to correct the problem in the shortest amount of time over shadows the logical approach to arrive at a conclusion. The "perceived probability" (of what is causing the problem) of each individual in the troubleshooting crew has everyone looking in every direction at the same time. Mostly, this kind of action just cancels out any real achievement and makes for a long drawn-out process in the end."
The notion of "perceived probability" is very important. Because it can affect even the most experienced troubleshooter. Perhaps more so. I suspect it was a significant factor in the misdiagnosis of the attending doctor. And this is why procedures and check lists are just as valuable to pros as they are to novices: they stop your perceived probability from overlooking the obvious or worse, leading you to incorrect conclusions. The more experience you have, the more likely it is perceived probability will get in the way - especially if you're not conscious of it.
I guess we in the hydraulics biz are fortunate in as much as, unlike doctors, we don't 'bury' our troubleshooting mistakes; ours are not life or death decisions. Nevertheless, I have of course been addressing this issue all along. In Insider Secrets to Hydraulics and in greater detail in my Hydraulic Breakdown Prevention Blueprint I spell out the importance and value of check lists and procedures. And, regularly here; I push for their development and use.
A troubleshooting procedure or check list should always begin with checking the obvious things first. What the 'obvious' is depends on the circumstances. In the medical emergency described above, the obvious was: recent abdominal surgery; check for bleeding into the abdomen.
NEVER let smarts or experience get in the way of checking the obvious.
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The hydraulic fluid's best friend|
Regardless of whether the hydraulic oil you use is a synthetic, a high viscosity index maximum-efficiency hydraulic fluid (MEHF), ashless, zinc-free, multigrade or monograde - or any other of the myriad of options available today, to do its job well, it needs a little help from its friends.
To get the full story, read my column in the January 2010 Issue of Machinery Lubrication
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