How a misdiagnosed bearing exposed gaps in maintenance culture and reliability practices
Key takeaways
- Misdiagnosed equipment issues can lead to major downtime—use condition-based tools to avoid preventable failures.
- Maintenance errors often reflect system and culture flaws, not just technician performance.
- Turning failure into a coaching moment builds technician accountability and long-term reliability.
- A proactive maintenance culture starts with leaders who prioritize training, tools, and continuous learning.
Earlier this year I received an email from a very upset maintenance manager (let’s call him John). A maintenance technician’s misdiagnosis led to a significant equipment failure event at the plant.
The case involved a bearing failure on a conveyor that was diagnosed as “it’s the chain, not the bearing.” This misdiagnosis resulted in a snapped shaft, eight hours of unplanned downtime, and a lot of angry people. John was getting yelled at by both the plant manager and production manager. The entire maintenance organization had a black eye.
John was embarrassed. He was considering issuing discipline to the technician for poor job performance, and reached out to me for my thoughts on how to react to the event.
While the damage was limited to time and material, the bigger story lies in how such events are managed, and more importantly, how organizations learn and grow from them. I see this as a textbook example of the difference between reactive and proactive leadership in the world of reliability and maintenance.
Root cause of equipment failure: Misdiagnosed bearing leads to catastrophic downtime
At face value, the failure was simple: A bearing was misdiagnosed as functional when it was, in fact, failing. The incorrect diagnosis by two technicians led to a catastrophic shaft failure. In hindsight, the bearing was likely emitting clear signals: audible noise(s), a temperature increase, an ultrasonic anomaly, and/or increased vibration – all indicating impending failure. These were either missed, dismissed, or never measured.
This event should prompt an immediate technical debrief. What was seen, heard, felt, and smelled? Has this failure happened before? Were condition-based maintenance tools available, such as infrared thermography (IR), ultrasound, or vibration analysis? If so, were they used? If not, why? Was it a lack of access, training, or initiative? Were the technicians in a rush or under other pressures?
These are the fundamental reliability questions that determine whether the failure was due to system flaws or personnel performance. It is easy to cast blame in the wake of failure, but blame is a poor substitute for root cause analysis. The true failure here was not the bearing alone; it was a failure of culture.
How maintenance culture and technician training impact asset reliability
The incident exposed a deeper issue: the prevailing maintenance culture. The technician’s comment, “It’s the chain, not the bearing,” was not just a technical misstep; it was a cultural symptom. Was this diagnosis the result of guesswork, convenience, or a real analysis? Was there a structured troubleshooting protocol? Was the technician given time to do troubleshooting? Were there pressures to rush the assessment? Had this technician ever been held accountable or trained to validate such assumptions with data? Was this just the way things have always been done?
This leads to a critical leadership question: Is the organization truly committed to a reliability culture, or is it stuck in a reactive, run-to-failure mode? If the latter, then expecting precision and accountability from technicians without investing in the right systems and training is both unfair and unsustainable.
Technicians are only as good as the system they work within. If their job has been reduced to keeping things moving and “getting by,” then errors like this are inevitable. If they are expected to be professionals – diagnosing and solving root causes – they need the tools, training, time, and support to do so.
From reaction to strategy: Leading through maintenance failures with coaching and accountability
John’s gut response was “I want to tear them a new one,” and it’s an understandable reaction. Downtime is expensive. Failure is frustrating and embarrassing. But emotional responses often make poor long-term strategies. The objective should not be to punish, but to correct and improve. The real challenge is to convert a failure event into a coaching opportunity. Coaching that will make us better tomorrow than today.
Before jumping to conclusions, every leader should ask, “Are these employees worth saving?” Are they good people who made a bad call, or are they warm bodies filling a schedule? If they are salvageable, and especially if they have potential, the best course of action is to develop them.
Here is a structured process to approach this situation:
- Debrief with purpose – Gather the involved technicians and walk through the failure. Ask open-ended questions about their decision-making process. Use 5-Whys to dive deep into their thought process.
- Require reflection – Ask each technician to send an email outlining what they learned and what they would do differently next time. This encourages personal accountability and growth without public shame.
- Turn failure into ownership – Consider making the involved technicians the site’s new “rotating equipment” champions. Have them research bearing failure modes and present new practices to prevent failures and propose predictive tools to find problems very early. Use the event to build expertise, not destroy morale.
- Coach up or coach out – If a technician is not coachable, does not care, or continually underperforms, then it is time for a hard decision. But coaching should always be the first step.
Institutionalize the Learning – Update your maintenance procedures or inspection protocols. If this happened once, it can happen again. Make it a team learning moment, not just an individual one.
Building a proactive maintenance culture through leadership and system design
Reliability is not simply achieved by installing better equipment and parts. It’s most often achieved by installing better culture: across teams, across departments, and across leadership. Equipment fails. But when people fail to learn, grow and change from those failures, that is a leadership failure.
This event is a mirror showing the weaknesses of your team and your maintenance culture. I told John on Monday to get the maintenance leadership team together to ask these hard questions:
- Do we have a proactive maintenance culture or a reactive one?
- Do our technicians have the tools and training they need?
- Are we holding people accountable in a way that also helps them grow?
Are we using failures as opportunities to build a stronger team and culture of reliability?
Investing in people over replacement: Long-term gains in maintenance reliability
In today’s labor market, good craftsmen are hard to find and even harder to keep. If your technicians are basically good people who got it wrong (assume this is the case), you are better off developing them than replacing them. The return on investment for coaching is almost always higher than hiring anew, especially if the root cause lies more in culture and process than individual incompetence.
Leadership in maintenance and reliability is not about who yells the loudest after a failure. It is about who builds the system that makes the next failure less likely. If we want proactive, data-driven technicians, we need proactive, data-driven leaders. I call this a culture of reliability.
In the end, the broken shaft is just steel. The real value is in how you respond and whether your team and culture are stronger or weaker because of it.
