Perspective and what we focus on influences our outcomes. As a technician, when a clock doesn’t work, we take it apart and look for that thing, the bad piece, the “bad apple” in the bunch. We pride ourselves on quickly finding the problem and fixing the clock. The greater picture, however, might be much more complex than is immediately apparent, much the way the formation of a cloud is many dynamic forces coming together, which ultimately create rain in the sky or a life-changing hurricane. How we approach our work, looking for that one “bad apple” thing (clocks) or analyzing the big picture forces in a dynamic environment (clouds) will dictate our outcomes.
The "bad apple shortcut" can be described as a bias. We hunt for the bad apple by default in any system that is not operating correctly. When we find a thing that’s not right, we label it, replace it, and check the system to see if it’s operating correctly. A bad apple bias is dangerous because it stops us from looking at the bigger picture – it stops our learning from the complexity of the situation.
OK, let's wrap our hands around this. That engine is in the shop again. An unscheduled, out-of-service failure, again. EGR. How is it that three little letters can evoke so much heated stress… Quickly the technician identifies the EGR cooler, that was installed not too long ago, has failed again. Bad apple. Fortunately, we now stock one on the shelf and the technician is getting really good at installing them. Engine repaired, back in service.
I sense a cloud forming. No, it’s not forming over my head because I’m fuming over these new engines hammering my budgets. It’s a sinking feeling there are greater forces at work here that I really need to figure out. EGR coolers are not apples. Really take this one apart and realize it is only certain vehicles that have these pattern failures. Now do a failure analysis of the cooler and identify thermal shock is tearing up the coolers. Research the engine manufacturers guidelines on how to avoid thermal shock: idle. All engine manufacturers recommend an idle downtime to allow the insanely hot cooler to thermally stabilize.
With the addition of EGR coolers to our diesel engines, we now must train our drivers to always idle down the diesel engine before turning it off. Not intending to create mayhem here but one major difference between the much-loved Ford 7.3L and the dreaded 6.0L is the EGR cooler. So how many have you replaced? Did anyone ever tell the drivers to idle down the engine before they turn it off? Have you ever heard the rig return to the station with the engine snap, crackle, and popping like an overheated brake rotor or drum creating heat check?
OK, bad apple eradication day. ABS computers are not bad apples. If you don’t allow the solenoids to cycle before you hit the starter motor, you will brown out the ECU in its boot-up and it will die just outside of warranty. Leave your headlights on and fire off the starter immediately after ignition on and you can brown-out even a stout transmission ECU eventually.
Become the Master EVT your fire department needs and manage your emergency fleet. No more bad apples, and while you’re at it, give a polite little shout-out to your training division about reopening the operator manuals on the vehicles with new technology. It wouldn’t hurt to let them know there are no bad apples on their crews, but there might be a station that could use some close driver re-training soon.
I would like to recognize Travis Dotson and Brit Rosso of the Wildland Fire Lessons Learned Center for exposing me to the Bad Apple Theory and the “Clocks & Clouds Theory.” For more on the Bad Apples Theory, search for Sydney Decker and the Field Guide to Human Error. Karl Popper is the philosopher credited with “Of Clouds and Clocks”.