Digging and stepping on thunder

Zheng Yun was created on 2015/2/6 and last updated on 2015/7/8

Key words: digging pits, burying mines, stepping on mines, RCA, question set

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This document is intended for: technical personnel

Introduction

Before talking about digging, let's quote a true story told by Taiwanese writer Hou Wenyong.

 

It is said that in the 1990s, in order to meet the business opportunities of the cross-strait three links, Taiwan established a lot of small airlines. Pay attention to a few key words, hurry up and get on the market, just like how we build a technical system, the building starts up.

In this context, there are so many bizarre things about the crash of a small civil aviation plane.

First, without warning, the pilot had just notified the plane of a stall and then crashed.

Second, the body was severely deformed, but the plane did not explode.

Third, a warning light responsible for monitoring the combustion condition of the engine, the tungsten wire is severely burned out and deformed, so it may be lit in the event of an accident.

 

So the investigation team asked experts to carry out forensic work on the engine, but could not find the cause that might have caused the engine to burn abnormally.

Just then, the chemical forensics officer called.

 

Is there any problem with the jet fuel you provide, he said, it's not gasoline at all, it's water .

The fuel in the fuel tank of the crashed plane was re-sampled, and they were asked to check again. The report came back and it was still 100% pure water.   

 

Check the refueling records, check the gasoline in the oil sump (note: gasoline for piston engines), everything is up to standard.

It was incomprehensible.

 

I told the story here at the new employee training meeting, and made a point: If you know how to die, you generally don't die. The problem is that you often don't know where.

 

It is said that one day the protagonist was eating at home, and the wife cooked a pork rib soup, looked at the oil floating on the soup surface, looked at it, and suddenly, the protagonist was so blessed, so he ran to the scene again. The airline has two large self-made oil storage tanks. The one that used to refuel the crashed plane has run out of gasoline, and the other large tank has nearly half of it left.

Since it is a small civil aviation company, there are not many flights, and it took about four months for the last barrel of gasoline.

So far, the answer is clear.

 

The protagonist asked someone to find a pipe, stretched it to the bottom of the oil tank, and used the principle of a siphon to pump out the gasoline at the bottom. Sure enough, a lot of clear, odorless liquid came out of the tube. No need to test to know it's 100% pure water. No wonder the plane didn't explode.   

 

Why is this happening?

At the new employee training meeting, some people guessed whether the owner deliberately added water with shoddy charging. In mainland China, news has been breaking out over the years, and a large number of vehicles will lie down after refueling, suspecting that the gasoline has been mixed with water.

 

Please note that Taiwan is an island country with relatively high humidity. For the past four months, the air in the tank condensed into water droplets when the temperature increased during the day, and continuously slipped into the gasoline along the inner wall. Since the specific gravity of water is greater than that of oil, all this water sinks to the bottom.  

The protagonist finds out the design of the foreign oil storage tank and finds that everyone can exclude or avoid the use of the bottom liquid. The small civil aviation company made an oil storage tank in a hurry in order to lock the position. Although the appearance is similar, its actual function is just a container.  

 

So, the tragedy happened. The unlucky plane had multiple fuel tanks, one was the remaining gasoline, and the other was filled with water from the bottom of the tank. After the first fuel tank was exhausted, it suddenly stalled and fell down. , a stomach of water will naturally not explode.

 

Many people are like this. It seems that they have worked in large companies, or their team has launched a well-known system. In fact, all they may see are "results" or "final execution instructions". As for why various designs and decisions are In this way, he may not have experienced these speculations about which changes he has experienced in the middle, why each change is, which ones are right and which ones are wrong. In other words, he never dug a hole and stepped on a thunder. Then what happens when he goes to another new team and new company that is in a hurry?

 

I haven't stepped on thunder, I haven't concluded, I haven't passed it on, I will continue to dig holes

We have also been in a hurry, building high-rise buildings on the ground, doing many things right, and doing more wrong.

This is also why I have to implement the RCA (Root Cause Analysis) system, keep publishing RCA reports and quarterly reviews, and organize the "question set". I don't know the history, so how can there be a future?

Feng Lun said that we should regard the history of others as our own future, so that we can know what others were doing in the past and what we should do now .

Therefore, newcomers should consciously understand how to do it right, why it is right, what the preconditions are, what is wrong, and where it is wrong. Look at what has been wrong and right over the past few years. Of course, if your supervisor can sum it all up and tell you, that's the best.

 

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