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Title: Engineering 1000 Chapter 3: Problem Formulation


1
Engineering 1000Chapter 3 Problem Formulation
2
Outline
  • Teams and personalities
  • Mental models
  • Herrmann Brain Dominance Model
  • Whole Brain Model
  • Knowledge Creation Model
  • Metaphors for creative problem solving
  • personalities
  • Mental blocks to creative thinking
  • lessons from exercises
  • Heuristics for problem formulation
  • statement re-statement
  • present-state desired-state
  • Kepner-Tregoe analysis

3
Camels
Somewhere in the Middle East, a man owned 17
camels his entire wealth. He had three children
who helped him in his transportation business.
While on one of their trips, the father fell ill
at an oasis. He called his children to his side
and told them his last will the oldest child was
to have half of the camels, the middle child one
third of the camels, and the youngest child one
ninth of the camels (which represented a fair
share of the time each had helped the father in
his business). Then the man died. After the
burial, the children were faced with the problem
of how to divide the camels according to their
fathers wishes. The discussion soon centred,
rather heatedly on how to kill and cut up some of
the camels to come up with the specified
shares. At this moment an old man arrived at
camp, hungry and thirsty, and with a camel in the
same condition. The old man listened to the
argument for a while and then offered to solve
the dilemma by giving them his camel, if they
would provide shelter and food for him for the
night. The children agreed. During the night, the
oldest child decided he better leave with his
share of the camels before the old man or his
siblings had a change of heart. Later, the
middle child awoke, noticed nine camels gone, and
hastened to depart with six. In the morning, the
youngest child, noting that the others had helped
themselves to their inheritance, took the allowed
two camels, and bid farewell to the old man with
thanks. The old man then resumed his journey with
his well-fed and rested camel.
Creative Problem Solving and Engineering Design,
Lumsdaine et al., McGraw Hill 1999
  • What is the real problem here?
  • How do we identify and formulate problems?

4
Problems, Teams, and Personalities
  • Much of engineering (and other business) is now
    performed in teams
  • so it is not surprising that a lot of research
    has been performed into what makes teams
    successful
  • including the development and management of the
    team, the roles and skills of the members, the
    personalities of the members, conflict resolution
  • Along with the team management is a personal
    emphasis
  • how do I learn to be a better team member?
  • and hence to do well at my job
  • To do this, we need to understand basic aspects
    of our personality
  • so simple and reliable have been developed to
    indicate basic personality types
  • the most famous is the Meyers Briggs test
  • e.g. http//www.humanmetrics.com/cgi-win/JTypes1.h
    tm

5
Advantages and Disadvantages of Teams
  • Advantages
  • wider knowledge and experience is available
  • interaction of people leads to synergy
  • better chance of finding optimal solution
  • team members accept the solution and work better
    to implement it
  • team members learn from each other
  • encourages development of leadership skills
  • Disadvantages
  • more time and personnel needed to build team
  • team process has low efficiency lots of ideas
    but few practical ones
  • team conflict
  • group think

6
A Good Creative Team
  • What makes a good creative team?

7
Mental Models
  • Mental models are tools for aiding problem
    solving
  • and for understanding why individuals tackle
    problems in different ways
  • We will look briefly at three concepts
  • the Herrmann brain dominance model
  • knowledge creation
  • creative problem solving

8
Herrmann Brain Dominance Model
  • Loosely based on the anatomy of the brain, this
    technique uses a questionnaire to determine a
    persons relative strengths in four quadrants

http//www.hbdi.com/
9
  • The profile for engineers is typically
  • very strong in quadrant A
  • less strong in B and D
  • weak in C
  • None of the categories is bad
  • the idea is to identify your natural strengths
    and to concentrate on developing your less strong
    areas
  • with the aim of being equally strong in all
    areas, i.e. multi-dominant or whole brain
  • Engineers with strengths in each category are
    important
  • e.g. for a bridge construction

A technical specs, financing, project logistics
B low-risk, efficient work flow, how to build it
C connecting people, effect on communities and environment, politics
D traffic projections, different possibilities, aesthetics
10
Whole-Brain
Creative Problem Solving and Engineering Design
Lumsdaine et al. McGraw Hill 1999
11
In Which Quadrant Are You?
  • Based on the data from the previous page give
    yourself a score out of 10 for each quadrant
  • note this is not how the real test is done!
  • When in a team, do you find yourself behaving
    according to your dominant quadrant?
  • do you see others displaying other quadrants?
  • do you see their contributions as valuable to the
    team?

12
Knowledge Creation Model
  • How can the whole-brain model be extended to give
    an understanding of the innovation process?
  • in Creative Problem Solving and Engineering
    Design Lumsdaine et al. combine the whole-brain
    approach with lessons for innovation drawn from
    Japanese companies
  • The idea is that knowledge is created as we move
    from one quadrant of the Herrmann diagram to the
    next
  • It is important here to identify two types of
    knowledge
  • Explicit knowledge
  • hard knowledge that can be expressed in
    formulae, descriptions, instructions, diagrams
  • it can be transmitted readily by manuals,
    documents etc.
  • Tacit knowledge
  • know-how, experience, intuition, craft, skill
  • tacit knowledge must be transmitted by
    interaction and personal instruction

13
  • The combined knowledge creation diagram
    identifies four stages
  • socialization shared vision, corporate culture
  • externalization discussions and brainstorming
  • combination analysis and evaluation of concepts
  • internalization learning and integrating the new
    knowledge

Creative Problem Solving and Engineering Design
Lumsdaine et al. McGraw Hill 1999
14
  • You can see similarities/connections with
  • the design process itself
  • the levels of failure from Ch.2

15
Example Oakland Bay Bridge
Early History Soc. Public discussion and increasing traffic needs after WW1.
Extern. 38 proposals and design concepts by 1928.
Comb. Board of 3 distinguished engineers recommends analysis of preferred site for more detailed design and cost estimates. benefits of bridge versus tunnel.
Intern. Focus on bridge failures with large cantilever designs.
Bridge Authority Soc. Political efforts underway
Extern. Creating a publicly-owned facility
Comb. Financing, appointment of state highway engineer, boring and analysis of potential sites
Intern. Detailed traffic studies, best route, California Toll Bridge Authority
Bridge Design Soc. Many engineers and consultants work together, port expansion wishes accommodated
Extern. Intensive design work on many designs, scenic beauty a factor
Comb. Engineering experience and judgement play key roles in narrowing down design possibilities. Switch from cantilever to suspension bridge on San Francisco section for economic, safety and aesthetic reasons.
Intern. Model testing carried out because multiple-span suspension bridge was a new concept
  • Completed in 1936 ahead of schedule and within
    budget

16
http//www.lib.berkeley.edu/Exhibits/Bridge/bb_ce0
06.html
17
Metaphors for Creative Problem Solving
  • So far, we have considered the thought processes
    and dynamics of knowledge creation
  • now we consider the mind-sets required at each
    stage of the process
  • These mind-sets can be conveniently though of in
    terms of fictitious personalities
  • these are the roles required during the different
    phases of the knowledge creation process
  • Explorer
  • is needed to seek out new ideas and to see the
    opportunities presented by the big picture
  • Detective
  • performs a more detailed analysis of the
    situation
  • problem formulation typically ends after these
    two roles
  • Artist
  • generates creative and imaginative ideas
  • but may not analyse them critically

18
  • Engineer
  • shapes the creative ideas into something more
    practical, examine the technical issues,
    optimisation
  • Judge
  • identifies flaws in the solutions proposed and
    works with the artist and engineer to
    overcome them
  • Producer
  • puts it all together to come out with a good
    product, i.e. solves the problems of
    implementation
  • may be the project sponsor higher up in the
    organisation
  • Without any one of these personalities, a
    critical element of the problem-solving team is
    absent
  • These personalities fit with the Herrmann diagram
    and the knowledge creation cycle as shown on the
    next page

19
Creative Problem Solving and Engineering Design
Lumsdaine et al. McGraw Hill 1999
20
Mental Blocks to Creative Thinking
  • There are three common barriers to creative
    thinking
  • false assumptions
  • habitual thinking
  • attitude barriers
  • From the following list, choose who you think is
    the most creative group of people
  • NASA engineers, high school teachers, homemakers,
    college students, first graders, journalists,
    movie producers, abstract painters, auto mechanics

21
  • An intelligent mind is a good thinker ?
  • Not necessarily untrained intelligent people may
    be poor thinkers for a number of reasons
  • they can create a good justification for any
    point of view and do not see the need to explore
    alternatives
  • they confuse verbal fluency for good thinking
  • their mental quickness leads them to jump to
    conclusions
  • they think that quick thinking is good
    understanding
  • they use intelligence to criticise rather than
    construct
  • Other valuable attributes
  • play
  • humour
  • what if ?

22
Exercises
  • 1a. Which of these figures is different from the
    rest? Why?
  • Reason
  • 1b. An army must move some soldiers to a
    different location. If a maximum of 39 soldiers
    and their gear fit into a bus, how many buses are
    needed to move 1261 soldiers?
  • (a) 31 (b) 32 (c) 32.33 (d) 33 (e) 34
  • Answer
  • 2. How many squares are there?

23
  • 3a. Join all the dots with 4 straight lines with
    no more than one line through any dot
  • 3b. Sketch a path from A to B

24
  • 4. What do you see below?

25
  • 5a. What do you see?
  • 5b. Can you find all 9 people?

http//www.grand-illusions.com/
26
Bad Habits
  • Exercise 1a 1b
  • it is possible to make a good case for any shape
    being the odd one out
  • hence the question is too vague
  • Block 1there is more than one correct answer
  • Corollary to exercise 1
  • in order to know the best answer of those we
    have, we must look at the context
  • Block 2 do not look at the problem in isolation
  • Exercise 2
  • the simple answer is that there are 17 squares
  • but this is limited thinking, e.g. it assumes
    that the picture is 2-D what happens if this is
    looking at the top of a column of blocks?
  • Exercises 3a 3b
  • thinking outside the box
  • Block 3 following the rules

27
  • Exercise 4 to check progress
  • chances are you answered a black dot
  • possibly a rectangle containing a black dot
  • in fact 95 of the rectangle is white space!
  • Exercise 5a 5b
  • shows ambiguous images can you see both images
    interchangeably?
  • Block 4 discomfort with ambiguity
  • very little in life is 100 clear including
    ENG1000 assignments
  • Attitudinal blocks
  • Block 5 risk avoidance/fear of failure
  • if you never fail, youre not reaching far
    enough
  • Block 6 negative thinking
  • itll never work

28
Problem Formulation
  • Following our knowledge creation cycle, the
    explorer and then the detective personalities
    are appropriate for problem formulation
  • Problem formulation (or problem definition) is
    needed to
  • ensure everyone realises that there is a problem
  • and to specify the real problem
  • On the following page, we see how the two
    personalities approach the same issues

29
Creative Problem Solving and Engineering Design
Lumsdaine et al. McGraw Hill 1999
30
The Explorer
  • The explorer personality is used for divergent
    thinking
  • quadrant D thinking
  • taking the far view
  • spotting trends
  • predicting the future
  • How you become a trend spotter?
  • be selective about information you take in
  • read articles that contain ideas
  • talk to people
  • have broad-ranging interests
  • synthesise ideas (i.e. think!)
  • observe what is around you
  • ask questions
  • identify how things change over time
  • find opportunities

http//www.angelfire.com/me/jakub/indy/
31
The Detective
  • In contrast to the explorer, the detective
    specialises in convergent thinking
  • quadrant B personality
  • looks for root causes
  • accumulates information, surveys, data
  • who, what, when, where, why, how much?
  • Kepner-Tregoe approach (see later)
  • explicit and tacit knowledge
  • persistent

http//www.sherlock-holmes.org.uk
32
Heuristics
  • A heuristic technique is essentially a trial and
    error approach
  • a number of options are generated and the best is
    selected
  • a try-it-and-see experimental approach
  • a rule of thumb
  • We will look at several heuristic approaches to
    problem definition
  • statement re-statement
  • source and cause
  • revision method
  • present state and desired state
  • Kepner-Tregoe situation analysis
  • Remember that these (and the methods we have
    already discussed) are merely aids for thinking
  • not guaranteed to produce good results

33
Statement Re-statement Technique
  • This approach aims to promote a better
    understanding of a problem by stating and
    re-stating the problem in different ways
  • hence focusing in on the problem
  • The statement re-statement technique consists of
    four parts
  • for which we assume there is a problem statement
    of some sort already in existence
  • 1. Determine the real problem
  • this can be done by rewriting the problem
    statement to see what solutions are triggered
  • see next page
  • 2. Determine actual constraints and boundaries
  • sometimes the perceived constraints are tougher
    than the real ones
  • in the problem statement, relax the constraints
    to see if it has changed in a significant way if
    not the original constraints were too tough
  • e.g. car gt500km/h replaced by car gt 200km/h
  • e.g. lowest price replaced by affordable

34
Restatement Description Increase the number of commuters who use the TTC
Vary the emphasis Has the focus of the problem itself changed? How? Is it a better statement? Increase decrease fares? Make more convenient Commuters advertise benefits of TTC to commuters TTC bus lanes, subway to York
Substitute explicit definitions Is the problem statement clearer and more precise? In what way? Why? Commuter ? people travelling to work each day encourage employers to reward TTC users. TTC ? trains/buses make working easier on trains/buses
Change positives to negatives and vice versa Reverse the statement. Instead of how to make the car faster, ask what slows the car down. Reduce the number of commuterswhy dont more people use TTC? Fix reasons.
Replace persuasive and/or implied words Where obviously or clearly occur, examine the reasoning. If reasoning is flawed, what effect will this have? Underlying reasoning is that by increasing TTC ridership, we reduce number of private cars, pollution etc. i.e. number of commuters is constant. Promote telecommuting instead.
35
  • 3. Prioritise goals
  • as we saw in Ch.2, not all objectives are equally
    important
  • satisficing
  • 4. Link outputs to inputs
  • determine what transforms inputs (raw materials,
    people, money) into outputs (the desired benefits
    of the design)
  • are any stages of the transformation process
    missing?
  • are any stages unpredictable? What would you do
    about them?
  • re-state problem statement to reflect what is
    known, unknown, desired, and unpredictable

36
Present State and Desired State
  • An alternative heuristic approach to problem
    definition is to focus on the present and desired
    states
  • by manipulating statements of the present state
    (PS) and the desired state (DS) we aim to make a
    clear correlation between the two

PS too many commuters use private cars DS less
traffic PS too many commuters use private cars
because there is no viable alternative DS less
traffic PS too many people use private cars
because they must commute and they dont take
public transport DS we need to reduce commuting
by private car PS too many people use private
cars because they must commute and they dont
take public transport DS people should be
encouraged to reduce their commute or take public
transport PS too many people use private cars
because they must commute and they dont take
public transport DS people allowed to work
closer to/at home or public transport should be
made attractive
37
  • How would this sequence have been different if
    the DS had been reduced pollution?
  • The PS/DS approach can be expressed
    diagrammatically
  • in the so-called Duncker diagram

Engineering by Design G. Voland, Addison
Wesley, 1999
38
  • This is very similar to the objectives and
    functions trees we saw in Ch.2
  • except that the aim is to start from the PS and
    DS and work from both ends
  • it enables both more complex and multiple
    statements to be included simultaneously

39
KepnerTregoe Analysis
  • In their 1981 book The New Rational Manager
    Kepner and Tregoe developed a four-step problem
    solving approach
  • Situation Analysis (SA) critical aspects first
  • Problem Analysis (PA) what past event may have
    caused problem?
  • Decision Analysis (DA) what actions are needed
    to correct problem?
  • Potential Problem Analysis (PPA) how to prevent
    further problems?
  • SA and PA are relevant here
  • DA and PPA are used later in the design process
  • Kepner-Tregoe is now a large management
    consulting and strategy company
  • http//www.kepner-tregoe.com
  • This analysis is primarily intended for
    engineering problems in progress
  • but can aid in structuring the search for the
    real problem in any design process

40
Situation Analysis (SA)
  • The current situation is analysed according to
    three criteria
  • timing which is the most urgent problem?
  • trend is the problem getting better or worse?
    how quickly?
  • impact what are the consequences of the problem
    being left unsolved?
  • For each problem and sub-problem, each criterion
    is given a high, medium, or low ranking of
    importance
  • see example from p.90 of Engineering by Design
    (reproduced here for convenience)

41
Example The Water Tank Disaster
  • The following news story is based on the Nassau
    edition of Newsday, the Long Island, N.Y.,
    newspaper (April 24, 1981 ) and OPLOW, American
    Water Works Association, vol.7, no.6,June 1981,
    p.3.
  • Inadequate safety precautions and an accident
    inside an empty water tank caused the deaths of
    two workmen in New Jersey on April 23. At 4 P.M.,
    a scaffold inside the tank collapsed and caused
    the two men painting the tank to fall to the
    bottom. Stranded there, they were overcome by
    paint fumes and eventually lost consciousness.
    John Bakalopoulos, 34, of Brooklyn, N.Y., and
    Leslie Salomon, 31, also of Brooklyn, were not
    wearing oxygen masks. The Suffolk County Water
    Authority's contract for the painting job
    specified that workmen wear "air hoods," masks
    connected to air compressors. The masks were
    available, but Bakalopoulos and Salomon had
    decided not to wear them because they were
    unwieldy. Instead, Bakalopoulos wore a thin gauze
    mask designed 4to filter out dust and paint
    particles. Salomon wore no mask.
  • Peter Koustas, the safety man who was handling
    the compressor and paint feed outside the tank,
    asked a nearby resident to call firemen sic as
    soon as he realized the scaffold had collapsed.
    Then he rushed into the tank with no oxygen mask,
    and he, too, was overcome by the fumes and lost
    consciousness. The men lay unconscious for hours
    as rescue efforts of more than 100 policemen,
    firemen, and volunteers were hampered by bad
    weather. Intense fog, rain, and high winds made
    climbing the tank difficult and restricted the
    use of machinery. Several men collapsed from
    fatigue.

42
  • Inside the tank, conditions were worse. Because
    of the heavy fumes, rescuers used only hand-held,
    battery-powered lights, fearing that sparks from
    electric lights might cause an explosion. Lt.
    Larry Viverito, 38, a Centereach, N.Y,. volunteer
    fireman, was overcome by fumes 65 ft (20 m) above
    the floor of the tank. Fellow rescuers had to
    pull him out.
  • Rescuer John Flynn, a veteran mountain climber,
    said he hoped he would never have to go through
    anything like that night again. For five hours he
    set up block-and-tackle pulleys, tied knots,
    adjusted straps on stretchers, and attached
    safety lines and double safety lines. The
    interior of the tank was as blindingly white as
    an Alpine blizzardcompletely and nauseatingly
    disorienting. Fans that had been set up to pull
    fresh air into the tank caused deafening noise.
  • When Flynn first reached the tank floor, he
    stepped into the wet paint and began to slide
    toward the uncovered 4-ft (1.2 m) opening to the
    feeder pipe in the center of the floor. Flynn was
    able to stop sliding, but John Bakalopoulos
    wasn't as fortunate.
  • As rescuers watched helplessly, Bakalopoulos,
    still out of reach, stirred, rolled over, and in
    the slippery paint slid into the feeder pipe. He
    plunged 1 10 ft (34 m) to the bottom.
  • Bakalopoulos was dead on arrival at the
    University Hospital in Stony Brook, N.Y., Peter
    Koustas, rescued at 145 A.M. and suffering from
    hypothermia, died the following morning when his
    heart failed and he could not be revived. Only
    Leslie Salomon survived.

43
  • Although there may be additional concerns that
    could be identified (such as rescue expenses and
    the subsequent use of the water tank), let us
    assume that Table 3.2 includes the major elements
    of the problem. A review of the priorities given
    to each subconcern indicates that "paint fumes"
    received high levels of concern in all three
    categories (timing, trend, and impact) for both
    paint crew members and their rescuers. Therefore,
    we should initially focus on this most urgent
    aspect of the situation.
  • This first step in Kepner-Tregoe analysis further
    requires that we classify each aspect of a
    situation into one of three categories,
    corresponding to the next step (problem analysis,
    decision analysis, or potential problem analysis)
    to be performed in resolving the problem. In the
    case of the water tank problem, since we already
    know the cause of the paint fumes (the paint
    itself), Kepner-Tregoe problem analysis is
    unnecessary we would move directly to decision
    analysis (see Chapter 10 of text) and strive to
    eliminate the need for painting the tank.

From Engineering by Design G. Voland, Addison
Wesley, 1999
44
Problem Analysis (PA)
  • SA aids our determination of which problem(s) to
    tackle first
  • problem analysis assist our thinking for a
    specific sub-problem
  • PA asks the following questions
  • what is the problem? and what is not?
  • when did the problem occur and when did it not?
  • where did the problem occur? and where did it
    not?
  • what is the extent of the problem?
  • much of this seems like common sense, but it
    helps to have a structure to follow in instances
    of duress like drilling soldiers
  • These key considerations are summarized as
  • identity, location, timing, magnitude
  • The aim is to determine why there is a difference
    between is and is not, between positive and
    megative

45
Engineering by Design G. Voland, Addison
Wesley, 1999
46
Example - Electronics Manufacture
An electronics manufacturing company is involved
in the demanding task of producing miniaturized
printed circuitry. One day, the production
quality fell off sharply and the number of
rejected circuits skyrocketed. "Why?" demanded
the boss. "Why?" echoed his subordinates.
"Temperature in the leaching bath is too high,"
said one technician. So temperatures were
lowered. A week later, when rejects climbed
still higher, temperatures were raised, then
lowered again, then systematically varied up and
down for days. Rejects remained astronomical.
"Cleanliness is not what it should be. That's
what's causing the trouble," someone offered. So
everything was scrubbed, polished, filtered, and
wiped. The rejects dropped, then rose again. Acid
concentration was the next idea. Same results.
Water purity was checked out on Wednesday,
Thursday, and Friday. The possibility of oil
transferred from the operator's fingertips
received full scrutiny on the following Monday
and Tuesday. Rejects still were high. They might
have remained high had not one supervisor begun
to ask systematic questions. "What is wrong with
the rejected pieces?" This produced the
information that the acid leaching step of the
printed circuit pattern was occurring unevenly as
if some waterborne contaminant in the leaching
solution was inhibiting the action. "When does
it occur?" A check of the records showed that
rejects were at their highest on Monday mornings,
lower on Monday afternoons, and gone by noon on
Tuesday.
47
  • This cast a different light on everything. Now
    nobody was asking "Why?" about the cause of a
    general, ill-defined deviation. Instead they
    focused on what was distinctive about Monday
    mornings compared with the rest of the week. They
    focused on what might have been changed that bore
    a relationship to this timing. An immediate
    distinction was recognized "Monday morning is
    the first work period following the non-work
    period of the weekend." And what changed on
    Monday morning? On each Monday, as soon as the
    tap was turned, water that had stood in the lines
    over the weekend came into the printed circuit
    leaching laboratories.
  • The water used in the process had to go through
    intensive purification, since purity standards of
    a few parts per-billion are required. A quick
    search turned up the fact that some valves had
    been changed several months before. These valves
    used a silicone packing material. As water stood
    in the lines over the weekend, enough of this
    silicone packing material had begun to diffuse
    into the water and degrade the leaching process.
    The result? Many rejections on Monday morning,
    fewer in the afternoon, and none after Tuesday
    noon. By then the contaminated water had been
    purged from the system.
  • From The New Rational manager, C. Kepner and B.
    Tregoe, Princeton Research Press, 1981.

48
Summary
  • A good problem definition is necessary for a good
    design or solution
  • Understanding of thinking preferences and
    elimination of poor thinking techniques assists
    the process
  • Using metaphors can help to adopt the necessary
    approaches to the problem
  • Certain techniques (heuristics) can assist in the
    process of formulating the problem

49
Homework
  • Read and understand Chapter 3 of the text book
  • Read the case studies
  • Do problem 3.7

50
Exercise Leaking Oil
  • Apply Kepner-Tregoe analysis (SA and PA) to
    determine the priorities and possible causes of
    the following problem
  • Our client is a major food processor. One of the
    company plants produces oil from corn and
    soybeans. The five units that filter the oil are
    located in one building. On the day the problem
    was first observed, a foreman rushed into his
    supervisor's office "Number One Filter is
    leaking. There's oil all over the floor of the
    filter house."
  • The foreman guessed that the leak was caused by
    valves loosening up from vibration. This had
    happened once before. "Number One sits right next
    to the main feedwater pump and gets shaken up
    more than the other four filters." A mechanic
    tried to find the leak but couldn't tell much
    because the oil had already been cleaned up. The
    lid fastener looked all right. After examining
    pipes, valves, and the walls of the filter
    chamber, the mechanic concluded that the oil had
    spilled from another source.
  • The next day there was more oil. Another
    mechanic traced the leak to the cleanout hatch
    but that didn't help much. Why should the
    cleanout hatch leak? It looked perfectly all
    right. Just to be on the safe side, he replaced
    the gasket even though it looked new. The hatch
    continued to leak. "Maintenance people just
    aren't closing it tight enough after they clean
    it out," someone volunteered. "There are a couple
    of new guys on maintenance here since the shifts
    were changed around last month. I wonder if
    they're using a torque wrench like they're
    supposed to. This happened to us once before
    because somebody didn't use a torque wrench." No
    one could say for sure.

51
The next day an operator slipped on the oil-slick
floor and hurt his back. The cleanup task was
becoming more than irksome, according to some
outspoken comments overheard by the foreman. A
few people began grumbling about promises made at
the last safety meeting about improving
conditions in the filter house. Two days later
the plant manager got wind of the situation,
called in the supervisor and the foreman, and
made it clear that he expected a solution to the
oil mess problem within the day. From The New
Rational manager, C. Kepner and B. Tregoe,
Princeton Research Press, 1981.
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