Scenario: an engineer is called to a job. 2 repairs required. 1 cannot be done as parts not available. The other repair is carried out - but unknowingly the engineer uses the wrong type of material. He signs the job off INCOMPLETE as there is still work to be done.
Next person comes along, wants to use equipment, decides to sign job off as COMPLETE.
Next person tests the equipment, using water. Leak occurs but due to lack of staff does not relate problems (leak).
Next person runs the equipment with substances. Leak occurs. Due to lack of staff - delay in shutting equipment down to stop leak.
Who is to blame for this incident?