I was working in the engineering section of the East African Meteorological Department in Nairobi, Kenya. A large part of the work involved the extensive telecoms network that gathered data from remote stations and presented it to the meteorologists. Once processed into charts and synoptic forecasts, the data had to be distributed worldwide by HF RTTY and Mufax to other regions, airports, etc.
For many years the message handling was done by a "torn tape switching center" with dozens of teleprinters, tape punches, and tape readers managed by a team of operators who would read the holes on the incoming tapes, tear off the individual messages, and then put them on the relevant tape reader for retransmission or local printing. We were in the process of replacing this with a more modern electronic system. Normally the torn-tape system worked pretty well and so we were all quite happy to take a few days off.
When we returned to work, we found the switching center in chaos and completely out of action. Over the holiday, all the motors in the teleprinters, tape readers, and tape punches had overheated and most had burned out. Following standing orders, the operators had kept replacing machines from the spares store until there were no more left. Then they just sat around doing nothing. No one had thought to call for help from the engineering staff. We first checked the mains voltage, which was within tolerance as much as it ever was. So with the teleprinter mechanics working flat out to repair the dozens of damaged machines, we had to try to figure out what had happened.
We reviewed all the work that had been done in the few days leading up to the holiday weekend and found that a subcontractor had been working right up to the last minute trying to finish some work on the new standby generator installation. We summoned the supervisor and asked him to show us the work. Standing beside a large new shiny switchboard, he suddenly went pale, unlocked a cover, and discovered a neutral link lying in the bottom of the cabinet. In a rush to finish before the holiday, his workers had re-fitted the main incoming phase fuses but not the neutral link.
This didn't matter too much while the whole site was in use as the overall load was fairly well balanced, but over the long weekend, all the other offices and workshops were unoccupied. That meant the loads on the three phases had become unbalanced and this caused the voltage fed to the equipment in the switching center hut to rise. With everyone back at work, the balance was more or less restored. The sub-contractor's insurance doubtless paid dearly for the mistake.
There were two lessons to learn. First, the need to supervise subcontractors especially at completion of jobs, and second, the need for better informed operators and better standing orders. If the alarm had been raised after the second or third failure in similar circumstances then we could have diagnosed the excessive mains voltage and fixed the problem before it escalated to near disaster.
As always, it's easy to be wise after the event. One could also argue that the mains distribution system was far from ideal, but the extensive headquarters site also comprised a number of buildings and huts that had grown over a period of 10 years. New circuits and feeders, both single-phase and three-phase, had been installed around the site with little thought of maintaining perfect load balance between the three phases.
This entry was submitted by Rod Hine and edited by Jennifer Campbell.
Rod Hine graduated from Churchill College in Cambridge, England. He worked in satellite communications, meteorological telecoms, and then general automation, machine tools, and industrial control systems. He has also lectured in electronic engineering and cybernetics.
Tell us your experience in solving a knotty engineering problem. Send stories to Jennifer Campbell for Sherlock Ohms.
Good lessons indeed! It is always a good idea to review a subcontractors work and I am thinking that probably would have happened if it wasn't so close to a holiday. For some reason it seems that every time we near a holiday - typically competent people that follow procedure and pay attention to detail tend to lose their usual focus in their eagerness to enjoy their time off, which is simply human nature. Ill timing for that particular job to come up right next to a holiday and this story is a good reminder that a job needs to be seen to completion including a final check that it was done properly before leaving it for an extended period of time.
The second lesson of better informed operators and standing orders surprises me. I wonder if that is a product of their corporate culture - I can't think of anywhere I have worked where someone wouldn't have called for engineering assistance rather than to continually burn up all of the spare parts in stock...
I'd believe it, Nancy--the pattern you've seen near holidays. People already drive poorly and shop crazily; it would make sense that they'd do things carelessly at work, too.
People definitely get distracted, Ann. We always had company parties on site and everyone would be in a huge rush to finish up so that they could get to the party - it's very easy to overlook something that way. The parties were a lot of fun and great for employee morale though!
We have a rule where I work: No New Work On "Fridays." We'll do paperwork, fix up things that aren't working, clean up the shop, etc. The quotes around the Friday are because we're talking about any day before a vacation or long weekend --whatever.
This also applies to contractors. We will hold them on site until we get our paperwork and documentation. We will inspect their work thoroughly, and they'll know this ahead of time.
What we're trying to avoid is exactly the kind of shoddy work that we're all lamenting. I've seen enough of it for many lifetimes and I am indeed thankful that nobody has ever been hurt on jobs where I've been involved. Sometimes, it is only dumb luck that has saved me.
That's why I was wondering if it was cultural, Charles. In some cultures, thinking "outside the box" (such as calling engineering rather than following the replacement procedure which obviously wasn't working) is discouraged. For example, while two Americans may find two different approaches for solving a math problem and are congratulated on their initiative, in some cultures following the prescribed method without deviation is what is valued and they would have been chastized for using a different formula from the one being taught. Value systems and worldview affect us on levels we aren't even aware of and in ways that people from other cultures often find very puzzling.
When our factory was moved to a new location the assemblers were given torque specifications for every threaded fastener because judgment calls were to be avoided in their culture. I would have product shipped to me to sample production runs and one unit caught my attention because something was rattling inside the case. When I opened it up I found that a potentiometer was loose. The nut had been tightened properly to torque, but it was cross-threaded. Certainly the assembler and inspector knew the pot was loose, but questioning authority was taboo, after all, the pot was tightened to spec.
Nancy, you have certainly described the deffect in a few cultures. Of course there are thoise that will defend them as "just diufferent, not deffective", but demanding that nobody think is what that culture is all about. Sort of a different kind of slavery, the slavery to ignorance, instead of some other kind. JUst as bad as the slavery that we know about, but a bit different.
The typical beurocrat is not willing to think, but only to follow a script. That is a terrible fault, capable of destroying a whole nation if it is allowed to go unheeded and uncorrected.
This story has touched on some deep matters, Nancy. You are correct that there were cultural and even political attitudes at work. At the time it was just seven years since Kenya had gained independence and I was one of a younger generation of engineers working with and training the "locals", backed by British aid. We got along fine with most of the younger well educated trainee engineers but some of the older operators had experienced decades of colonial government and the scars of the struggle for independence were still raw. You must also realise that many of the local staff might work with modern technology during the day but would go back home to a single room shack with an oil lamp for lighting and a charcoal stove for cooking. So when things went wrong some of them tended to adopt a sullen attitude and assume that we, the wazungu (white men), would blame them or ridicule them anyway, so why bother to think at all. It wasn't all bad and I enjoyed the work, even switching to teaching and staying on in Kenya for several more years, but you needed to be aware of the cultural differences and work very tactfully to cultivate good work attitudes. The old colonial method of abusing and shouting loudly at the wananchi (locals) just fuelled the resentment. Similar attitudes were explored very powerfully in the 1967 film "In the Heat of the Night". Hopefully we have ALL moved on since those days.
Thank you for the additional insights, akili. It seems much was at work below the surface insofar as how problem-solving was approached. I think we often make unfair assumptions when interacting with other cultures or even within our own - I admire how you sought to look beyond the surface and tried to understand where these attitudes came from. You just can't expect folks to want to have initiative and go the extra mile when they are struggling to survive and have been treated poorly...I think one thing is universal and you hit it right on the head. No one wants to be physically or verbally abused - kindness goes a long way. When I worked at a major semiconductor company, I would often have some type of assembly task that we would give to the ladies that worked on the line. Whenever I asked one of the ladies to do some work, I would first inquire as to how she and her family were doing. I would then explain why we needed this particular job done (engineers typically never explained why, just what) and I acknowledged how busy she must be and how much I appreciated her work. My work typically got done very quickly and correctly...a little kindness goes a long way.
If I can just add one more thought - the one cultural attitude I found hard to accept was the tendency for some of the more ambitious Kenyans to work hard until they had an office and a secretary. Suddenly they would begin treating their own staff far worse than any colonial official ever did and they would never be willing to get stuck in to real work any more. All they wanted to do was tell other people what to do and go for long lunch breaks... But it was all a long time ago and Kenya has moved on, though the recent electoral upsets and violence don't bode well for the future.
It maybe cultural, but it maybe governmental. Isn't this a government department? Or at least overseen by the government? How many times, even in American culture, that government workers tend to follow the beuracracies unfettered by thought or common sense?
And before you government workers bombard me with, "I do not do that!" I am only telling my experience. You may actually be smart and use common sense.
I've worked for a government organization. It's full of managers writing requirements telling how things should be done, with no option for initiative. Two thirds of the time it works, the rest of the time either the instructions are insufficient or common sense provides the better solution. The more open minded question authority, the rest are "pot-plants" and follow the rules.
Double checking sub-contractors is good advice. I recently worked on a job that required wiring low voltage communication and high voltage control voltage from valve sets to a main control panel. The bid job clearly stated that the control voltage and comm lines were to be seperate conduit to avoid interference between the lines. The contractor used the same conduir forboth to save time. Fortunately, we caught the error before signing off the project.
@ Tim: Very true. You need to check the work and what sort of a quality level has been matched. They always try to finish stuff early as possible since they can take advantage of that and do someone else's work as well plus they also know that they do not get paid for time but for the work.
It doesn't even have to be an electrical contractor. One of my customers had the parking lot repaved and the PAVING contractor broke the ground connection for the electrical system. On a 480 volt system they were blowing uip items left and right.
I wish only subcontractors made these errors. About a month ago Verizon crew cut all the coper wires in the back of my house. When asked why the cut my phone, fax, DSL, etc... hey responded hat in a month or so we will get wired for FIOS.
GREAT SCHEDULING !!!!!
I'm sill fighing with Verizon to restore my phone and fax.
Oh could I tell tales of construction foulups. I live in a California county where building contractors and construction workers form the main industry--or did before the economic collapse. They still form a major industry, but at least many of the worst crummy ones have left the business and the county, because of stiff competition after the downturn. Before that, though, I went through 5 or 6 different idiots working on my house until I found a contractor that was honest, thorough, fair, competent and even highly creative. Then he moved back home to the Midwest. He fixed many of the problems caused by the other guys. But the one that takes the cake he couldn't fix without a major rebuild: one of the dummies cut a doorway about 6 inches too short. I discovered this when it came time to buy a new door. After that, I started checking their work more often, although that doesn't save me from highly specialized potential mistakes I can't see and/or am not specialized enough to supervise. Isn't that the point, anyway, of hiring specialists? To hire someone who either knows what you do but saves you time, or knows what you don't?
This reminds me of a time I visited my sister in California. She lived in an older house. She asked about her kitchen light changing brightness. Looking into it I noticed that when the refrigitor turned on the light got 'brighter'. I asked to see here breaker panel. I found it warm and upon removing the cover, the incoming neutral connection was fried to a crisp. It was quite a job to replace that bar and connection. To top it off, the panel was located inside the master bedroom closet!
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