440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700

July 5, 2000

02 05 02 61 00070501

Mr. Charles R. Mori
S & C Ford
450 Rhode Island Street
San Francisco, CA 94107-2320

Subject:   Claim of $900


  1. S&C Rental Invoice #54232 dated April 13, 2000
  2. S&C invoice for Emergency Repairs on April 14, 2000
  3. S&C invoice for Service on March 24, 2000
  4. S&C Invoice #338040 dated June 30, 2000

Dear Charles,

S&C performed service on June 30, and generally did a good job, relative to service performed by other organizations. Several pending matters require follow up by S&C management. Previously, Larry Smith coordinated completion of service issues. On June 30 we learned that Larry has retired. Since you have been helpful expediting prior matters, this letter is sent to you.

The letter is submitted in conventional printed form, and, also, via email for access on the web. Accordingly, there is no need to print this off the email. As I mentioned in our telecon, you are encouraged to go read this on the web, rather than use the printed material. Review is greatly expedited using the web, via email, since S&C's invoices and related activity can be accessed instantly at relevant places, saving time of assembling and handling a lot of documents, and trying to find specific information. Previously, Larry Smith was able to use this method to expedite review. If you need assistance, please call.

  1. The next service sticker was prepared incorrectly, probably because of the high volume of work S&C is doing with a booming economy. The sticker on the windshield shows the date of June 24, 2000, and 85K miles, which is the date of the recent service. Normally it should show a date approximately 3 months hence, and 3K miles of use. I recall watching Ryan prepare a new service sticker while we talked about the Work Order on Friday morning. Evidently, there was not enough time to replace the prior notice with the new one. Therefore, please submit a sticker showing the correct date and mileage for the next service.

  2. S&C's invoice #338040 on June 30, 2000 seems to show that an oil/fluid leak S&C discovered during work on March 24, 2000 under your invoice #332357, which sets out in the Quality Care report that the matter needed Immediate Attention, may have been fixed by emergency service S&C performed on April 14, 2000 under your invoice #333498.

    This record presents several issues...

    1. Is it correct that the leaks reported on March 24, where those that led to emergency service on April 13 and April 14?

      If so, why didn't S&C notify the customer on March 24, 2000 that "immediate attention" was needed to fix a problem, as noted on the Quality Care report, and has been done in the past by S&C and other vendors? Wouldn't this have reduced the time, cost and inconvenience of emergency repairs? For example, on May 7, 1999 S&C issued an initial estimate of $160. Then, using Quality Care, S&C gave various notices through the day that increased the estimate to over $2,000. This shows pattern and practice for S&C's Service Advisor to expedite same-day service of issues discovered during preventive maintenance. The record is replete with similar examples over the past 5 years or so. Same-day notice helps avoid emergency repairs, which otherwise cause congestion that escalate costs, and further cause additional mistakes from distractions of new and untimely information and tasks forced into communication and work streams, to the detriment of S&C, the work force and customers?

    2. Since S&C failed to give timely notice on March 24, 2000 so that the leak could be fixed without incurring car rental expense, and additional customer time, should S&C refund the car rental expense charged by your invoice #54232, also dated April 14, 2000 in the amount of $43.01, plus reasonable compensation for the customer's time to assist S&C in remedying the error on March 24, 2000? Would $500 be reasonable compensation for customer inconvenience and loss of income on April 13 and 14, to recover from S&C's mistake?

    3. If the leak identified by S&C on March 24, 2000 was different from the leak that required emergency service on April 14, 2000, then please point out where in the record this leak has been repaired.

      A problem that needs "immediate attention" cannot simply disappear.

      If it has not been fixed, then it must now be worse, and, therefore, poses an even greater risk than on March 24, 2000 when "immediate attention" was needed. If so, where is the notice in the invoice on June 30 to fix the leak discovered on March 24?

  3. Multi-point service in S&C invoice #332357 on March 24, 2000 gives no indication of what is actually accomplished. There is a separate entry in the same invoice for servicing latches, hinges, etc, and a charge of $8.40, because the Service Advisor reported that S&C's policy is to charge separately for this latter scope.

    Multi-Point service in S&C invoice #338040 on June 30, 2000 lists the following work performed...


    There is no charge for this scope of service.

    This record presents several issues...

    1. What is the scope of Multi-point service?

      We could take the trouble to list in this letter all of the prior invoices that show the same tasks listed under different headings on different service visits, with the result that the actual work performed is not established by S&C's record. These conflicts are more than mere paperwork.

      If it covers lubing latches, door hinges, etc., as shown on June 30, then the charge of $8.40 on the March 24, 2000 invoice is a duplication, and should be credited.

    2. On March 24, 2000 there is no record in invoice #332357 that fluids were topped off, as there is in prior invoices under Multi-Point service. There is an indication this was done in the Quality Care report, but that report has a history of conflicts, as seen from the record of service on May 7, 1999.

      One conclusion is that fluids were not topped off on March 24, 2000 and this caused the vehicle to overheat when it was used by the customer in the days following service, and thereafter either increased or compounded inconsequential seepage into harmful leaks in the cooling system, culminating in emergency service on April 13 and 14, 2000.

      A possible scenario may have occurred where a hurried mechanic reported a leak requiring "immediate attention," which cannot however, be substantiated by independent inspection, as occurred on May 7, 1999. The mechanic thereafter expected this to result in a change to the Work Order to fix the alleged leak, after which, fluid would have been added. The mechanic checked the box in the Quality Care report showing "fluid was topped off," even though it wasn't, because it is standard industry practice not to release a vehicle to the customer that requires immediate attention to a critical operating system. Limited time and a high work load created a complex dynamic that caused the leak, real or imaginary, not to be fixed. Any number of circumstances could have caused this, including getting mixed up in filling out Quality Care reports for different vehicles by different people at different times, and no review by management.

      As a result, S&C's invoice #33498 in the amount of $404.06 for work on April 14, 2000 should be credited as an expense caused by S&C's failure to perform.

    3. On April 14, 2000 several trips to S&C were required due to lack of notice about payment and scope of work. Please suggest improvements in communication that can benefit S&C and customer partnership.

  4. S&C failed to give notice that a rear brake light needs to be repaired, discovered in the Multi-Point inspection on June 30, 2000.

    This seems like a safety issue, perhaps subject to regulation, statute or industry standard. S&C's Quality Care, also, mentions the need for repairing the rear brake light under Comments.

    S&C should now give prompt notice about whether this matter needs immediate repair, or can wait until the next service on or about the date established under paragraph one (1), above.

    If immediate attention is justified, how much should the customer be compensated for assisting S&C in recovering from this mistake?

  5. S&C's invoice #338040 on June 30, 2000 shows a charge of $12.95 for rotating tires, which conflicts with terms of sale by S&C on May 5, 1999, and should therefore be credited. When the car was received on Friday afternoon, S&C's service advisor, Antone, maintained that S&C has a policy of charging for rotating tires. He argued S&C's policy supersedes terms of sale. Antone consulted a colleague, Jasvir, who affirmed Antone's understanding that S&C has a policy of always charging for rotating tires, and has never included this work with the cost of selling tires. Neither Antone nor Jasvir produced a policy statement to support their memory. Antone placed a call for Wendell to double check S&C's policy; but, Wendell did not answer. Additionally, on November 19, 1999 S&C rotated the tires at no charge in conformance the terms of sale, as shown in S&C's invoice #325875. Jasvir was the Service Advisor for that work, and given the passage of time, understandably may not have recalled this transaction he supervised on November 19, 1999, in the discussion with Antone on June 30, 2000.

    Regardless of what people remember, or what S&C policy may be about rotating tires, the best course is to follow the terms of sale.

  6. The Work Order called for balancing the tires on June 30, 2000. This work was not performed. Antone advised this failure occurred due to a communication mistake by S&C.

    Balancing tires was written in ink, as an additional scope, because the Service Advisor did not include it in the printed Work Order. This is a relatively minor matter, except the tire warranty requires the customer to rotate and balance the tires regularly. Since S&C is the tire vendor, we hold S&C responsible in the event of any subsequent issue of improper wear that might require tire replacement, as occurred, for example, on May 7, 1999.

    The Quality Care report on June 30, 2000 shows no comments on tire wear, but that may reflect inadequate reporting due to limited time from a heavy schedule that causes lack of attention by a mechanic.

  7. S&C's Quality Care report on June 30, 2000 shows the brakes were inspected, which was also entered as an additional request on the Work Order, similar to balancing the wheels. The invoice ( #338040 does not show this work, which is highly unusual, since it is normally a $50 or $60 charge.

    Accordingly, we ask that S&C confirm that a brake inspection was actually performed. Of additional concern is that the valuations are all 5 MM. It seems unusual that front and back brakes would have the same readings. Our records seem to indicate that past measurements were in 32nds of an inch. On October 1, 1999 NASA reported that a change in units of measure caused the loss of a $125M vehicle that crashed on Mars due to the compounding effect over time of errors. S&C should make a reasonable effort to establish that similar fate is not at risk from this change in reporting standards. A possible concern is that on November 19, 1999, S&C reported the rear brakes were at 10/32nds; after 7 months and approximately 4K miles, the reading is now 5 MM. This is 3 months less time for a prior comparable change in lining on the rear brakes.

Credits total approximately $970 and the additional charge for a brake inspection, if performed, is typically in the range of $60, leaving a balance owed to the customer of about $900. S&C should, also, correct the Next Service sticker problem, and comment on the rear brake light issue.

On September 24, 1999 analysis showed the high cost of medical mistakes, which official estimates place at three (3) times the rate of automobile and airplane accidents combined, was put at several $billion dollars annually. This cost is attributed to small mistakes in communication that are overlooked in a complex, high pressure environment, that compound over time into crisis.

A national initiative was announced on December 7, 1999 to improve medical practice. While the problem in engineering has not yet become a national crisis, the record today may suggest ideas for improvement, provided there is time to think. Many managers today are making too much money and having too much fun in a booming economy to worry about improving work practice. It is easier to buy off mistakes with sunshine profits, and ignore notice of growing problems, as the machinations of disruptive customers. The only way to sound the alert is to show that poor management costs money, and that better management saves time, money, conflict and stress.

Currently, many research and commercial organizations, notably SRI, Intel, Los Alamos National Lab, Microsoft and IBM, are trying to develop a Knowledge Management capability. The announced purpose is to solve world problems like ending war, hunger, poverty, fixing the environment. These efforts are foundering on lack of focus. Nobody seems to know how to explain the meaning of "knowledge" in a way that tools can make an impact. On January 20, 2000 the SRI team was notified to begin their project by first making meetings, calls and correspondence productive under the theory that the biggest risk in enterprise is communication, as occurs in handling daily working information. At a meeting of the SRI project team on May 18, 2000 professor Mary Keeler offered an explanation of knowledge that shows an effective development path. My sense working with S&C, Kaiser, and other top organizations, is that a lot of the answer can be found in mundane, daily working information, like S&C invoices.

Most people, however, have difficulty recognizing this opportunity. They see a $125M crash on Mars, a 9 month delay in releasing a new chip set, or a 2 year delay in completing harbor improvements, and feel these were caused by a big mistake in engineering or management, rather than a mere communication error that occurs every day in the form of continual bumbling. The solution proposed for medical practice on September 24, 1999 was to introduce a metric that strengthens alignment between communication and objectives, commitments and requirements. This is commonly called "traceability to original sources," also an "audit trail," so that daily work is less susceptible to the fragility of human memory. Better memory might help the instant situtation, as well.

In any event, to keep the focus on improving the work, we are pleased to withdraw all claims of monetary recovery in this letter, which thereafter may serve as a useful case study, or what seems to be called in Knowledge Management "Use Case" analysis.

We would like to get that sticker though, if at all possible.



Rod Welch