What are you doing about iatrogenic failures?

Did you know there the term for failures that are caused by the technician? They are called iatrogenic failures.

The term comes from the medical industry where iatrogenic – meaning caused –illness is a huge concern.

All types of maintenance are subject to iatrogenic failures.

Engine Shutdown

This is the story of one iatrogenic failure. Soon after departing Miami airport, Eastern Flight 855 had one engine shut down due to a low oil warning.

As the L1011 aircraft turned back to the airport, the low oil lights for the other two engines started blinking. Shortly thereafter, the second engine failed, followed by the failure of the remaining engine.

The jet descended without power from 13,000 to 4,000 feet when the crew managed to get one of the engines restarted. The jet landed safely in Miami with no injuries to the 172 passengers.

The FAA found that the same technicians who replaced the oil in all three engines failed to replace all the oil sealing rings in each engine.

In the pilot’s own words: “We were met at the gate by Captain Bert Beech, the Miami assistant chief pilot and a foreman for line maintenance. The foreman made the statement to us that he knew exactly what happened. That was the first time the word O-rings was used.

“We were led straight to a convened NTSB hearing. It was concluded that two mechanics had installed the master chip detectors on all three engines without O-ring seals, thereby putting the lives of 172 people in grave danger.”

The Likelihood

Right now, your fleet is subject to possible iatrogenic failures.

Have your drivers ever made the complaints: “When they’re done with the PM, the unit never is right the first time,” or “When maintenance gets their hands on my unit they always return it with something else broken?”

The fact is there is the probability of causing a problem whenever anyone touches a machine, no matter how casually.

I remember adding oil to my car’s engine and forgetting to put the oil cap back on. The cap must have fallen off the engine as I merrily drove away since I never saw it again.

It didn’t take long for the oil to come out and spray on the exhaust manifold, and all the while dirt was getting into the oil.

Failure Avoidance

The question is, what can be done to avoid iatrogenic failures?

For the answer to that we should look at the medicine and aviation industries where iatrogenic failure is recognized, studied and mitigated. Some of the solutions are just good, plain old, common sense.

For example, mixing up patients in hospitals used to be pretty common and occasionally deadly.

If you go into a hospital for an operation now, be prepared to be asked your name and birth date dozens of times. Everyone who treats you or gives you a medicine or does a test will typically verify your identity.

If we go back to the aviation O-ring mistake, the problem was caused by the same crew that replaced the oil on all three engines.

Some airlines do not allow all the engines on an aircraft to be serviced at the same time. This reduces the probability that all the engines would be taken out by the same mistake.

Steps to Take

By far, the best thing you can about iatrogenic failures is to recognize that they do occur. Occasionally, bring the matter up at your toolbox or safety meetings.

One single lapse of attention can cause a problem.

With some consciousness applied, you, too, can have systems in place to catch the worst of iatrogenic failures before they become late deliveries or accidents.

Joel Levitt has trained more than 6,000 maintenance leaders from more than 3,000 organizations. Since 1980, he has been the president of Springfield Resources, a management consulting firm that services a variety of clients on a wide range of maintenance issues. www.maintenancetraining.com.

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