Building 18 - It Could Happen Anywhere - So Don't Let It Happen
To You by Maj. Ricky
Smith, US Army
As a result of negative media attention last February, Secretary
Defense Robert Gates formed an investigative team to examine
problems at the Walter Reed Army Medical Center. I was proud to
serve on a team of professionals that included former Military
Surgeons General, lawmakers, and military officers tasked to
identify the root problems and the root causes within 30 days.
While newspapers and other media outlets went on to focus on
other issues with the transition of ill and injured Warriors,
our team’s task was clear: get to the bottom of the problems
now! What our investigation found was that Building 18 was in
ill repair due to sporadic ongoing maintenance and there was a
clear need for a structured, supervised preventive maintenance
plan moving forward.
It’s important to note that the problems we found and identified
were confined to non-medical facilities (called Garrison
facilities), and involved the buildings, such as Building 18, in
which out-patients at the facility are housed.
The facility maintenance management system that the US Army
developed for its preventive maintenance program was not used
properly in the Garrison Facilities at Walter Reed Army Medical
Center. Consequently, senior leadership was left blind to the
looming maintenance problems.
If you are a senior leader or maintenance manager you need to
ask yourself these three questions:
1. What metrics tell me how effective my Preventive Maintenance
(PM) program is?
2. Are my assets ranked based on risks to the business?
3. Is that ranking used to determine on which assets I must
execute PM, on schedule, 100% of the time?
Knowing the answers to these questions will help keep your
preventive maintenance program pointed in the right direction.
Be sure to keep in mind that, when manpower is short, you cannot
accept the risk of ignoring PM in your high risk assets.
For leaders outside the world of preventive maintenance and
reliability engineering, these tasks may not seem very dynamic,
and could easily be overlooked. It is not unusual for leadership
to have a lack of understanding, or a lack of passion, for
However, if leadership does not give it the right priority, they
can expect to discover in their organization what I saw at the
Walter Reed Garrison early last spring.
It was not the first time I have seen such major maintenance
issues, and it won’t be the last. I have visited hundreds of
industrial plants and facilities in situations similar to the
Walter Reed Garrison, so I would say to civilian leaders “Be
careful! This could happen to you.”
In our report to the Secretary of Defense, the Director of
Public Works at Walter Reed stated that, because the rooms in
Building 18 were occupied, the maintenance staff did not inspect
the rooms routinely and, therefore, Standard Preventive
Maintenance checks were not completed. He stated the department
did provide maintenance personnel on a 24 hour, 7 day a week
schedule to “respond to problems”.
All facilities managers should track PM Labor Hours and
Emergency Labor Hours, and monitor the trend. If PM Labor Hours
are low and Emergency Labor Hours are high, either your
Preventive Maintenance is not effective or you are not
performing PM (see Figure 1). It’s possible that your people may
be going through the actions but not performing them to an
Next, you need to identify the assets that are taking the most
emergency labor hours and make those assets maintainable. You
then need to protect them with a sustainable PM program, using
what I call the 10% Rule of Preventive Maintenance.
The 10% Rule simply states that a PM regimen is completed within
10% of the regularly scheduled intervals. An example is a PM
scheduled to be executed every 30 days must be completed within
three days or it is out of compliance.
Two other items must follow this rule.
1) A detailed procedure with specifications must be followed on
any PM procedure
2) All PMs do not need to follow the 10%
Rule, only high risk assets, and these must meet 100% PM
Compliance (PM Compliance is the percent of incidents during
which a PM is accomplished on time). One problem you will
probably find right away is inaccuracy. People may record
activities on work orders or service orders without actually
having performed those activities. Discipline should be a
requirement, not an option.
What has the US Army done since February 2007?
It may have taken national headlines to get attention focused
where it needed to be, but most of the people I talk to in the
military agree that the attention was invaluable. With the
Army’s leadership focused on the issue, changes began
immediately. In fact, a number of changes came about within the
Our military has great leaders who are not ashamed to admit when
problems occur. However, they will not accept repeat occurrence.
The Walter Reed Building 18 revelations set in motion a series
of events which have changed the US Army forever. Let’s explore
those events from the Facilities Management and Engineering
perspective, by examining some significant findings our
facilities investigation disclosed.
Basically, the Walter Reed Garrison had a collapse of structured
processes, leadership visibility, and, in my opinion, common
Processes That Failed
Preventive Maintenance (PM) – The PM program the US Army
developed for facilities is based on known failure modes of an
The program addresses how and why an asset fails, and mandates
preventive maintenance accordingly. This Reliability-Centered
Maintenance protocol has withstood the test of time in many Army
facilities. The inspection typically is a time-based program,
executed on priority ranking, and looks for the first detection
of failure. Inspections examine predictive, detective, or
condition based maintenance, and require strictly disciplined
attention, as well as performance, if they are to be
No evidence appeared to demonstrate an effective prioritization
process had been established for the Garrison facilities.
Potential problems must come to leaders’ attention, as a key to
success in any organization. This did not happen in the Building
18 event. Leaders need to have a clear view of how their
organizations conduct maintenance.
If the Captain of the Titanic had seen the iceberg in time, he
could have steered around it to avoid disaster. Instead, he
didn’t know, because he couldn’t see it. Leaders need to know
if the maintenance process in place actually controls how the
facilities are maintained. Therefore, leading metrics, such as
PM Compliance, Schedule Compliance, Mean Time Between Failure,
etc. should be captured, recorded and trended. Leading metrics
help you identify your “bad actors.” These are your worst
performing assets, facilities or equipment, as shown in your
periodic and spot assessments. Identifying your “bad actors”
allows resources to be allocated to the right asset at the right
times excuses for maintenance failures can be the reason the
failures don’t get repaired properly. And many times these
excuses just don’t make sense. Below are some excuses I have
heard, and perhaps your organization uses them as well.
No time for Preventive Maintenance – High frequencies of
emergency repair seem to take your available labor time away
from preventive maintenance. To get out of that spiral, you must
identify high priority assets first, and restore them to a
manageable maintenance routine. Next, apply PM Procedures on a
disciplined schedule. You will never overcome emergency
maintenance burdens until you get preventive maintenance under
Emergency repair frequencies keep going up for no known
reason – When you have so many problems that you can’t get a
handle on them, you must step back and develop a good plan to
get them under control. The first step is to track all failures
by using a metric called Mean Time between Failure (MTBF). This
metric allows you to focus on the asset which is failing the
most. You derive the metric by dividing units of time by the
number of emergency repair sequences occurring during that time.
For example, performing three emergency repair sequences in 24
hours gives you a MTBF of eight.
Not enough money to hire an expert – I once visited a
facility where the roof had failed numerous times over several
years. During this time, the organization repaired or replaced
the ceiling, flooring and walls repeatedly.
The maintenance manager explained that the roof was not repaired
properly because the maintenance person was not formally trained
in roofing, but was the best on staff, and the manager could not
afford to hire a roofing company. This statement seemed to ask
more questions than it answered, since the cost of repeated
ceiling repair and room damage must have far exceeded the cost
of hiring a professional to fix the roof right in the first
Not enough maintenance staff – You never will have enough
maintenance staff if you do not reduce your emergency repair
requirements for failing assets. You will also never control the
failures if you don’t develop and manage a true PM program.
Skimping on maintenance is OK because this building/equipment is
scheduled for retirement – Are the demands or expectations on a
piece of equipment, or a facility, being reduced? If not, they
must be maintained to full capability and functionality. One of
the main requirements of Reliability Centered Maintenance is for
the functional capability of an asset to meet the needs of the
user. If the assets or facility do not meet user needs, they
have failed functionally.
Assets or facilities must be maintained to full functionality
until shutting down permanently. Do any of these sound familiar?
Could a breakdown in any of your processes, leadership, or
managers’ application of common sense create a failure in your
maintenance program? One of the best solutions is to educate
your leaders in the value of maintenance and reliability.
What did the US Army do to correct the Garrison Facility Issue?
US Army Medical Command acted swiftly, while awaiting reports
from outside agencies. They took immediate corrective action.
Here’s a short list.
• Conducted an immediate Facility Condition Assessment of all
Garrison facilities at the Walter Reed Army Medical Center
Complex. This was contracted to the US Army Corps of Engineers.
• Established a clear line of command and control, and
responsibility regarding maintenance of the non-medical
• Assigned an experienced facilities engineer to oversee
Garrison maintenance requirements.
• Established a rapid response team to ensure maintenance issues
in housing areas were resolved quickly, no matter what the time
• Examined maintenance and construction funding, re-prioritizing
where necessary, to ensure wounded, ill and injured soldiers,
and their families, would be accommodated according to their
• Facility deficiencies at Walter Reed Garrison received
corrective action to repair or replace broken, insufficient, or
substandard components, such as walls, ceilings, plumbing or
• Wounded, ill and injured soldiers received priority
consideration to occupy available housing.
• Garrison housing managers assigned wounded, ill and injured
soldiers, and families, to the best available housing units on
the military installation, with the closest proximity to the
medical treatment facility.
• Standardized PM checklist to ensure checklist meets the
requirements of maintaining the facilities to standard.
• Leadership instructed to inspect their facilities weekly and
report their status weekly to their higher chain of command.
Ongoing Steps for Continuous Improvement
• Perform maintenance and reliability process assessments at six
US Army Medical Treatment Facilities to ensure these facilities
use the best practices to maintain their facilities to the
• Design a new maintenance and reliability process which meets
the future facility needs of the US Army Medical Command, where
assessment identifies a gap.
• Develop viable leading and lagging metrics, and dashboards, to
be used by all levels of military leadership, to measure and
monitor maintenance, and reliability issues at facilities.
• Implement a training and certification program for maintenance
leaders at all Army Medical Treatment Facilities. This training
and certification will become the standard for contractors and
US Army personnel.
• Develop a system to collect and analyze feedback from wounded,
ill and injured soldiers, their families, physicians, nurses and
other key staff, as part of the preventive maintenance program.
• Ensure new facilities are designed and constructed to meet the
needs of the Army’s wounded, ill and injured soldiers, and their
• Launch a new software package to help support facilities
management, including tracking the type of out-patient assigned
to a specific type of room (American Disabilities Act), if
Preventive Maintenance was performed on time, outstanding work
orders on rooms, etc.
• Implement new maintenance and reliability processes throughout
US Army Medical Command World Wide, if, during the assessment,
any gaps are found in the current maintenance and reliability
Summary of Recommendations
matter how large it is or how strong its leadership, no
organization is immune to serious maintenance problems, which
have the potential to create controversy or major financial
loss. In other words, what happened at the Walter Reed Garrison
facilities could happen to any organization. To ensure this does
not happen to your organization, follow some of the simple
recommendations detailed in this article.
1. Ensure metrics are in place to verify your organization’s
Preventive Maintenance Program is working. Just a few
a. Track PM Labor compared to Emergency Labor Hours
b. Track Mean Time between Failure
c. Walk through your facility or plant, make sure what your
metrics show is what you see with your eyes.
2. Inspect your Preventive Maintenance Procedures and ensure
they have specifications, steps, procedures, and time standards
clearly delineated. Use checklists. If a maintenance person
tells you they don’t need checklists, they are telling you they
have an unlimited and an infallible memory, which is not
3. Rank your assets and/or facilities based on risk to your
business or organization. Ensure your high-risk assets have 100%
PM Compliance using the 10% Rule of Preventive Maintenance.
4. Attend training on asset reliability, which discusses both
preventive maintenance, and reliability-centered maintenance, in
the same program. Reliability Centered Maintenance methodology
is where all true preventive maintenance programs are developed,
focusing on failure modes and risk associated with them.
MAJ Ricky Smith has spent most of his life as a US Army
Reservist, a maintenance professional in maintenance management,
and as a reliability consultant in private industry where his
skills and knowledge from each area have served him well. He
developed his skills and experience while serving as a
maintenance company commander in support of Operation Iraqi
Freedom in Iraq and Kuwait and consulting with large
corporations in their reliability initiatives to save jobs and
lives. He is a noted Author of such books as Lean Maintenance,
Rules of Thumb in Maintenance and Reliability Engineering, and
Industrial Repair – Best Maintenance Practices.
Ricky can be contacted at Richard.firstname.lastname@example.org