I had a gas leak last night.
I live in a house that is about 50 years old, and I was contacted about 18 months ago by our gas infrastructure owner to replace and update my gas meter. After many stupid and ignorant effforts by them to make someone be in my house by just arranging dates and telling me about 4 months in advance, and then it falling through, by accident someone was in to receive the ministrations of a gas fitter.
My gas meter is under the stairs, like the vast majority of all meters.
Since then we have assiduously stuck to the guidelines left by the man who changed the meter, leave the cupboard door open and there will be an initial smell of gas which will disipate eventually.
Turns out he was wrong. The smell won’t disapear of its own volition because he didn’t bother tightening the bolt that connects the gas meter to the pipe that carries the mains supply. It is like not bothering to turn off the tap in your bathroom sink, except you would notice not closing off a water tap. It is like that, in the sense of it being obvious and essential.
In my house the distinctive and unpleasantly Alan Partridgey smell of gas increased gradually until tonight when the alarm was raised. It stank.
Tonight we realised it was dangerously stinky of gas. Luckily there is an in-house gas fitter (CORGI registered) who kindly came out with an array of gas weapons including my favourite below.
This long necked beast smells gas. It clicks like a boring old Geiger counter, but detects gas instead of the more long range killers. This giraffe was stuck into the cupbaord, it clicked like a mini-Chernobyl was under my stairs, then the cuplrit was found, the loose bolt.
The bolt was hand tight. i.e. Very loose. It seems a basic thing, like wiping your feet when you come in the house to get rid of THE DOG SHIT ON YOUR SHOES. Sorry, I’m still annoyed.
Here is the systems thinking lesson.
The systems thinking lesson
The visible failure was the engineer who didn’t tighten the bolt on the pipe. A command and control thinker would stop here and blame the fool they can see, rather than the fools they can’t
What about the failures I cannot see that also caused this? I don’t know the thinking, or system conditions, that have caused this performance (in every sense of the word), but here are some guesses that are typical of large command and control organisations that cause poor service.
- I can’t see the performance management system and targets that allocate time and jobs to the engineer to cause him to be too speedy in his work
- I can’t see the bonus system that distorts his purpose
- I can’t see the work system that allocates jobs according to some arbitary and inaccurate time system
- I can’t see the senior managers who bid for the contract to replace the gas meters based on cost not quality
- I can’t see the planners who have recruited staff based on inaccurate and overly optimistic plans that are not based on knowledge but on guessology
- I can’t see the leaders who fail to learn from the errors (such as not correctly fitting my gas meter) as they have no system set up to learn
- I can’t see the call centre managers who, if I rang up to complain about the dangerously fitted equipment, haven’t set up a system to listen to the demand coming into their system, and would probably treat the issue as a “complaint” rather than failure demand.
- I can’t see the manager of the department who deals with “complaints” (really failure demand) who would treat the issue as a training problem, and not tackle the system.
I can’t see these things. They are hidden. The only failure I can see is the failure of the engineer. He is unlucky, his failures are in full view, but the much bigger systemic failures of leaders and managers are hidden, and often rewarded too.