How many times do you make a mistake, then compound it with another while trying to fix the first? When you try to explain your way out, someone may say, "Two wrongs don't make it right." Most of us have heard that. Making a mistake and then compounding it with another happens regularly in manufacturing plants today. Despite good intentions, the original problem still isn't resolved.

How a temporary repair became a permanent problem

While working in a manufacturing plant, I conducted a line-level failure mode and effects analysis (FMEA). Reviewing the line's CMMS bad actor report, a cartoner appeared repeatedly. I pulled up the work order history and found that an unplanned failure occurred two years earlier. Maintenance implemented a temporary repair to get production running again. After speaking with a technician, I learned the repair was intended to last at most a few weeks. Two years later, it was still there.

That was the first wrong.

That same technician disagreed with the repair approach, noting that it introduced mounting and alignment issues. The repair also required production to operate the cartoner below its rated design speed. At the time, this wasn't a significant concern because production rates were below that speed, and the line still met the production target.

But like most plants, production demands increased over time, and the cartoner eventually became the bottleneck. Using Reliability-Centered Mainteance 2 (RCM2) terminology, the operating context for the cartoner had changed. What was once tolerable was no longer acceptable. Restoring the cartoner to its original design speed would enable the line to meet those requirements without additional modifications elsewhere.

That's the second wrong.

And here is where it gets interesting.

Work order management gaps let corrective actions disappear

In the original reactive repair work order comments, the technician noted that follow-on work was required to restore the item to its original state. However, the technician never created that follow-up work order. The maintenance supervisor did not review the completed work order, so no one saw the missing follow-on work order. 

As a result, the needed work fell into the black hole of maintenance. The work order was closed, but the defect remained.

Time seems to erase memories, especially in reactive environments. At first, maintenance and production leadership knew the repair was temporary. But the cartoner was running, and other issues took priority. Days turned into weeks, weeks into months, and eventually, two years had elapsed. 

The temporary repair became the new normal. People may forget, but that's why we have a work order system with defined processes.

We often find that sites have written business processes that depend on people. But we can't rely on someone's memory. The process should require technicians to initiate follow-up corrective activities. In some systems, that's as simple as a checkbox. In others, it requires the technician to actually create the work order. The supervisor or lead reviews completed work orders and ensures the process is followed. None of this is complicated, but it requires the discipline to keep defects from disappearing into the daily demands of keeping a plant running.

Equipment bad-actor reports require corrective action

The breakdown in the work management process was only a part of the problem. Maintenance and production leadership periodically reviewed the equipment bad-actor report. The cartoner repeatedly appeared, yet they took no actions, just acknowledgment. The failure to act becomes a historical record of our willingness to tolerate repetitive failures. 

Rather than focusing on critical equipment, identify where the plant is experiencing the greatest losses. Equipment criticality matters, but it shouldn't be the only factor to determine where we focus improvement efforts. Losses may come from downtime events, reduced production rates, quality issues or high maintenance costs.

Use tools such as Critical Event Reporting or Failure Reporting, Analysis, and Corrective Action System (FRACAS) identify recurring failure patterns and triggers. Solutions are sometimes straightforward, and others require a more comprehensive root cause approach.

Regardless of the approach, analysis without the corrective actions fails to deliver business results. Assign owners, set completion dates and follow up to verify effectiveness. Otherwise, we're simply documenting the same failures repeatedly.This is just one asset on one line. Consider what happens when you have an entire plant with thousands of assets in many lines.

Maintenance reliability depends on management discipline

The plant had multiple opportunities to prevent the problem. 

The technician recognized the need to follow up with a better fix. Had the supervisor followed the process, they could have caught the missing corrective actions. Leadership repeatedly saw the cartoner issues. The plant lacked the management discipline to turn that information into results.

Reliability depends on more than having the right people, tools, and technology. It depends on systems that enable those resources to produce the right outcomes.

Two wrongs don't make it right. They just make the problem more expensive to live deal with in the long run.