Lack of a Formal System almost always leads to Complacency

It’s the end of summer as I write this.  Yes I know summer doesn’t officially end until the end of September but for all intents and purposes the last weekend of August has always signified summer’s demise.  When I was young the last weekend of August was the turning point.  I went from playing endless games of stick ball pretending to be one of the greatest baseball players of all time to thinking about the teachers and the subjects to be mastered in the coming school year.  As a teenager, the last weekend of August meant a steep decline in disposable income as summer employment became history and coursework replaced earning power.  In later years, especially when I worked with many Europeans, the end of August meant the beginning of very early teleconferences as those who had taken most of August as holiday returned to the tasks at hand.  So it is today with me as I sit at my computer terminal a gently warm breeze blowing into the office.   I am torn between thinking  about how it was that just yesterday I returned from an absolutely wonderful week at the beach and deciding what to write for this post.  As I take in the warm breeze inspiration hits me, I shall write about this summer’s safety problem.

Those who are readers of this blog know that I frequently talk about working on the edge, meaning taking needless chances that don’t have to be taken in pursuit of doing a job.  This summer showed us that people can be “on the edge” while going about their normal day to day routines in what they consider a safe manner.  I am thinking about this summer’s outbreak of Legionnaire’s disease in New York City.   This outbreak was the worse in the city’s history with 12 people dying and over 100 becoming seriously ill.  What were these people doing?  They were going about their normal everyday business in the borough of the Bronx in NYC.  They were walking on the street, shopping, or as I am doing now, sitting by their window experiencing a gentle early summer breeze.  Yes, many of them probably just took a deep breath enjoying the advent of a New York summer.  Their problem was what they were breathing wasn’t just a breath of fresh air but  a mixture of air and some microscopic water droplets that contained Legionella pneumophila.

Legionella is a bacteria that is transmitted through the inhalation of contaminated aerosols.  So how does the bacteria get into the air?  This type of bacteria is a natural inhabitant of fresh water systems that have a warm environment.  If the water in these systems can lay stagnate or turnover slowly and there is a high concentration of algae, slime or other bacteria along with degraded plumbing materials that are decomposing or rusting then you have the perfect petrie dish to grow Legionella.  What types of equipment can supply these conditions that support growth?   The most common place for Legionella to grow is in air conditioning cooling towers, those big pieces of equipment that always seem to spewing mist from their perch on rooftops of large buildings.  But there are also other places that can be conducive to bacteria growth.  These are evaporative condensers, hot water systems, spas, humidifiers, foggers and water misting systems, shower heads and decorative fountains, almost anywhere that warm water is present and there are nutrients for the bacteria to munch on.

The symptoms of Legionella are fever, accompanied with chills, aching muscles, a dry cough, severe headaches and shortness of breath.  Essentially the famous “flu-like” symptomology.    The incubation period for legionnaires disease is usually two to ten days.  Diagnosis is made by means of blood tests or identifying the organism in respiratory secretions.  Thus, it is probable that many more people come down with Legionnaires’ than are reported.  This disease usually first strikes people who have other problems that lower their immune systems.  People who suffer from diseases such as chronic lung disease, asthma, or suffer from heart disease or diabetes are particularly susceptible to contracting Legionnaires’ disease.  Thus, in the Bronx where many residents are known to have such complicating health issues, was unfortunately the worst place for a water system to contain the bacteria.

So how did it happen here?  A hotel that was specifically located in the Bronx to help this economically challenged neighborhood by bringing jobs and visitors to the area was found to be ground zero for the spread of the disease.  The hotel that has on its roof a cooling tower that is only two years old and reportedly equipped with the most modern technology  was found to be source of the bacteria.  So as people who lived or worked nearby walked on the street below the hotel they unknowingly were on the edge with each and every breathe they took.  According to an article in the New York Times on August 21, 2015, hotel officials said that the tower in question was cleaned by an in-house engineering department on a regular basis, following industry guidelines.

Since the outbreak the New York City government  has issued new regulations and guidelines that will try to assure that something like this will never happen again.  The regulations require that building owners conduct quarterly inspections of all cooling towers and take steps to thoroughly clean and disinfect any that are found to be contaminated.  As has been explained in the “living on the edge” theory this is the typical and expected governmental response .  Something bad happens and in order to try to minimize future events we put in place laws, regulations and guidelines that demand certain actions be taken.  Wouldn’t it be so much better if we were proactive about these things and didn’t let a situation develop into one that requires governmental action?

I don’t know what actions were actually taken at the hotel in question.  The newspaper reported that hotel management stated that they had a maintenance plan in place.  I have spent the last twenty five years of my professional life being a proponent of the formal management system.  One reason why is that I have seen many a plan that was well written and thought out. They were issued, not implemented, and soon became what I call SHELF PLANS.  Again, I am not specifically calling out the hotel in this instance.  I have no direct knowledge as to what did or did not get followed in their particular instance, but I can say that if a formal management system was being followed there would be an implemented plan with a feedback loop that would have assured that preventative maintenance and inspections had taken place, that test results were reviewed and corrective actions taken.  All of which would be recorded and held for subsequent audit and trend analysis.

Most managers when they hear the term “formal management system” roll their eyes and say that there just is no time for that kind of thing.  They then state that they trust their people to do the right thing and that there is no need for more than letting their people do what they think is right.  Most often these managers are probably right, but unfortunately there are many instances where this laissez-faire attitude just isn’t enough.  It isn’t that people don’t want to do the right thing. It is, I believe, that  people need structure in their lives.  Our brains work by recognizing patterns and a formal management system is the best way to develop a pattern in the working environment.  As a hypothetical, we might extend this logic to the case we are reviewing today,  maybe the maintenance plan was in place and being followed at the beginning.  Maybe the first several bacterial readings were nil.  Maybe the maintenance supervisor or the technician deduced that they could save the hotel time and money if they just performed a visual inspection instead of going through the whole procedure.  After all nothing ever gets found anyway.  As I say I don’t know if anything like that happened, but I can relay many many stories of similar such situations where things went awry with the best intentions in place.

Formal management systems very often get associated with international standards such as ISO 9000 and ISO 14001 among others.   Having built several business-wide management systems to

these standards I can attest to the benefits.  I can also say that there are those who have built and “certified” their systems to standards such as these with the only outcome being a certificate hanging on the wall.   If one seriously wants to  put a formal management system in place, one that meets the requirements of the business not just the intent of the standard, then there is some initiation energy that must be expended.  Nothing good happens without working at it.  But like everything else that is worthwhile in life, once in place and shown to be important by the whole management line, then it becomes the way business is done.  The results will be the lack of problems, the avoidance of penalties and no need for those onerous regulations industry loves to rail against.

Now for me it is off to buy batteries for my smoke and carbon monoxide detectors.  This task happens to be a requirement of my household formal management system.  It is on the calendar each year to  install new batteries each and every Labor Day.  We don’t cross out the action until it has been accomplished.  This is a simple but effective way to assure things get done, especially when you get to my age where memory doesn’t always serve me as well as it used to.  Oops, there is one other thing, I am as of today starting an inspection and bleach-based cleaning of all shower heads and infrequently used sinks at my house.  Pardon me while I update my calendar and my management system.