What Nukes?

Cruise Missiles

Warning to Reader: This piece has a lot of free-association flow to it!

Oops. A few weeks ago a story emerged in the press that a B-52 had flown from North Dakota to Louisiana with half-a-dozen nuclear armed missiles under its wing. The aircrew thought they were transporting disarmed missiles. This is a rather major oh-oh for the USAF, as in general, they are supposed to keep track of nuclear warheads. (Yeah, I am understating this. I, by the way, can speak from a small amount of experience as I once held a certification to deal with these things, so I have some idea how rigorous the procedures are.)

Normally the military deals with nuclear weapons issues with a simple “We do not confirm or deny…” but in this case they have released an unprecedented amount of information, including a confirmation that nukes were on a particular plane in a particular location at a particular time.

The news story of the report summarized a culture of casual disregard for the procedures – the standard work – for handling nukes. I quote the gist of it here:

A main reason for the error was that crews had decided not to follow a complex schedule under which the status of the missiles is tracked while they are disarmed, loaded, moved and so on, one official said on condition of anonymity because he was not authorized to speak on the record.

The airmen replaced the schedule with their own “informal” system, he said, though he didn’t say why they did that nor how long they had been doing it their own way.

“This was an unacceptable mistake and a clear deviation from our exacting standards,” Air Force Secretary Michael W. Wynne said at a Pentagon press conference with Newton. “We hold ourselves accountable to the American people and want to ensure proper corrective action has been taken.”

So what’s the point, and what has this got to do with lean manufacturing?

The right process produces the right result.

As true as this is, it isn’t the point. The point is that the Airmen didn’t follow the procedures. And now the Air Force will apply the “Bad Apple” theory, weed out the people who are to blame, re-emphasize the correct procedures everywhere else, and call it good.

How often do you do this when there is a quality problem, an accident or a near miss? How often to you cite “Human Error” or “not following procedures” or “didn’t follow standard work” as a so-called root cause?

You need to keep asking “why” some more, probably three or four more times.


Field Guide to Understanding Human ErrorTo this end, I believe Sydney Dekker’s book “Field Guide To Understanding Human Error” should be mandatory reading for all safety and quality processionals.

Dekker has done most of his research in the aviation industry, and mostly around accidents and incidents, but his work applies anywhere that people’s mistakes can result in problems.

In the USAF case cited above, there was (according to the reports in the open press) a culture of casual disregard for the established procedures. This probably worked for months or years because there wasn’t a problem. The “norms” of the organization differed from “the rules” and I would speculate there was considerable peer pressure, and possibly even supervisory pressure, to stick with the “norms” as they seemed to be adequate.

Admittedly, in this case, things went further than they normally do, but let’s take it away from nuclear weapons and into an industrial work environment.

Look at your fork truck drivers. Assuming they got the same training I did, they were taught a set of “rules” regarding always fastening seat belts, managing the weight of the load, keeping speed down and under control, checking what is behind and to the sides before starting a turn (as the rear-end swings out.. the opposite of a car). All of these things are necessary to ensure safe operation.

Now go to the shop floor. Things are late. The place is crowded. The drivers are under time pressure, real or perceived. They have to continuously mount and dismount. The seatbelt is a pain. They get to work, have the meeting, then are expected to be driving, so there is no real time for the “required” mechanical checks. They start taking little shortcuts in order to get the job done the way they believe they are expected to do it. The “rules” become supplemented by “the norms.” This works because The Rules apply an extra margin of safety that is well above the other random things that just happen around us every day. The Norms – the way things are actually done erode that safety margin a little bit, but normally nothing happens.

Murphy’s Law is wrong. Things that could go wrong usually don’t.

The “Bad Apple” theory suggest that accidents (and defects) are the fault of a few people who refuse to follow the correct procedures. “If only ‘they’ followed ‘the rules’ then this would not have happened.” But that does not ask why they didn’t do it that way.

Recall another couple of catastrophes: We have lost two Space Shuttle crews to the same problem. In both the Challenger and Columbia accident reports, the investigators cite a culture where a problem which could have caused an airframe loss happened frequently. Eventually concern about it became routine. Then, one time, other factors come into play and what usually happens didn’t happen and we are wringing our hands about what happened this time. Truth is it nearly happened every time. But we don’t see that because we assume that every bad incident is an exception, the result of something different this time. In reality, it is usually just bad luck in a system which eroded to the point where luck was relied upon to ensure a safe, quality outcome. In this case they didn’t single out “bad apples” because the investigations were actually done pretty well. Unfortunately the culture at NASA didn’t adjust accordingly. (Plus Space Flight involves the management of unimaginable amounts of energy, and sometimes that energy goes where we don’t want it to.)

So – those quality checks in your standard work. Do you have explicit time built in to the work cycle to do them? Are your team members under pressure real or perceived to go faster?

What happens if there is an accident or a defect? Does the single team member who, today, was doing the same thing that everyone does every day get called out and blamed? Just look at your accident reports to find out. If the countermeasure is “Team Member trained” or “Team Member told to pay more attention” or just about anything else that calls out action on a single Team Member then… guilty.

What about everybody else? Following an incident or accident, the organization emphasizes following The Rules. They put up banners, have all-hands meetings, maybe even tape signs up in the work place as reminders and call them “visual controls.” And everything goes great for a few weeks, but then the inevitable pressure returns and The Norms are re-asserted.

Another example: Steve and I were watching an inspection process. The product was small and composed of layers of material assembled by machine. Sometimes the machine screwed up and left one out. More rarely, it screwed up and doubled something up. As a countermeasure, the Team Member was to take each item and place it on a precise scale, note the weight, and compare the weight to a chart of the normal ranges for the various products.

There were a couple of problems with this. First, the human factors were terrible. The scale had a digital readout. The chart was printed and taped to the table. The Team Member had to know what product it was, reference the correct line on the chart, and compare a displayed number with a set of displayed numbers which were expressed to two decimal places. So the scale might say “5.42” and she had to verify whether that was in or out of the range of “5.38 – 5.45”

Human nature, when reading numbers, is that you will see what you expect to see. You might recall that it was different after five or six more reads. So telling the Team Member to “pay more attention” if she made a mistake was unreasonable. Remember, she is doing this for a 12 hour shift. There is no way anyone could pay attention continuously in this kind of work. If a defective item got through, though, there would be a root cause of “Team Member didn’t pay attention.” She is set up to fail.

But wait, there’s more!

She was weighing the items two at a time. Then she was mentally dividing the weight by two, and then looking it up. Even if she was very good at the mental math and had the acceptable range memorized, that isn’t going to work. Plus, and this is the key point, in the unlikely but possible scenario where the machine left out a layer in one item, then doubled up the next, the net weight of the two defective items together would be just fine.

“Why do you weight two at a time?” Answer: “It’s faster.” This is true, but:

  • It doesn’t work.
  • She doesn’t need to go faster.

Her cycle time for weighing single items was well within the required work pace. But the supervisor was under pressure for more output because of problems elsewhere, and had translated that pressure to the Team Member in a vague “work faster if you can” way. It was the norm in that area, which was different from the rules.

Where is all of this going?

The Air Force has ruined 70 careers as a result of the cruise missile incident. They may have been right to do so, I wasn’t there, and this was a pretty serious case. But the fact that it got to this point is a process and system breakdown, and it goes way beyond the base involved.

Go to your own shop floor. Stand in the chalk circle. Watch, in detail, what is actually happening. Compare it with what you believe should be happening. Then start asking “Why?” and include:

“Why do people believe they have to take this shortcut?”

Getting A Plant Tour

A couple of days ago I wrote about how to host a tour. Here are some thoughts on how to get one. As always, I’d love to hear your comments and experiences.

Don’t expect your hosts to change your “cement heads.” I have had requests from groups who wanted to send their “resistant managers” to our factory so we can show them things that will change their minds. Doesn’t work. Sorry, that is your job. My experience is that people who don’t want to see the benefits will always find all of the things that are “unique” about their circumstance, and special case reasons why the other place is doing so much better.

Go to learn, not to look. In my last post I made reference to “industrial tourists.” Those are groups that are more interested in the layout and clever gizmos than in the thinking behind them. They are, at best, looking for ideas and technical solutions to their problems. Copying others’ solutions is not thinking.

Going to learn is a different attitude. When you look at a layout, or other technical solution, ask yourself this: “What problem does that solve?” How does it save time? How does it remove variation from the process? What did the operation look like before they did that? Force yourself to think in four dimensions. Not just what you see now, but what it would have looked like in the past. WHY did they do this?

Although many people think lean manufacturing is counter-intuitive, I think that with this line of thinking you will find it actually is just common-sense solutions to the problems that everyone has, every day.

Nobody is perfect. Even a Toyota plant has obvious issues. If you end up fault-finding, you will miss the good stuff. I was touring a Toyota plant with a group a couple of years ago and it had obviously slipped. This is old news, and one of the reasons for their internal back-to-basics approach. But two things came to light: The rich visual controls made it easy for total strangers on the 1 hour tour to SEE the difference between “what should be” and “what is.” Wow. Try that in YOUR factory. And, reading the news stories, it was a problem they were taking very seriously and doing something about it vs. not noticing the deterioration and just letting things go.

Every plant has issues. Some have great material flow and pull systems, but only average problem solving. Others have a great technical base for home-grown tools, fixtures and machines. A few have great problem solving (They seem to be doing better than others.) Take in what is working, and what is holding them back. What would be the next problem they are working on?

Pay attention to the people. People are the system. How do they interact with the physical artifacts (layout, machines, etc.) An operation that has their stuff together will have people who are obviously comfortable with the pace of work. It will be obvious they get support when there are problems.

Don’t ask too many questions. What? Aren’t you there to learn? Yes. But try to learn with your eyes first. Even if you are moving, “stand in the chalk circle” and see the problems and the solutions. Sharpen your observation skills before you take the tour. Practice in your own plant. When I am hosting visitors and we have the time, my response to a question is to show them where to look for their answer, then ask them what they saw.

If allowed, make sketches. Most operations will have a prohibition against photographs. Even if they allow photos, however, you will capture much more if you stand and sketch what you see. You don’t have to produce a work of art. The purpose is to force your eye to pay attention to the small details. You will see much more through the eyes of the artist than you will through a camera.

Remember they are in the business of production, not consulting.
“Be a good guest” and remember that everybody there has a real job.

Edit 5 Sept: And Jon Miller correctly pointed out something I missed:

Give Back. You will bring “fresh eyes” to their environment and see things they do not. Everyone suffers from a degree of blindness to the familiar. If you are really going to see and learn, you will gain insights that can help your hosts in their own improvements. Ask them the questions that will help them see what you see.

“Sticky” Visual Controls

The textbook purpose of visual controls is “to make abnormal conditions obvious to anyone.” But do your visual controls pass the Sticky test, and compel action?

Simple: Does your control convey a single, simple message? Or does it “bury the lead story” in an overwhelming display of interesting, but irrelevant, information. According to Spear and Bowen (“Decoding the DNA of the Toyota Production System”) information connecting one process to another is “binary and direct.” The signal is either “On” – something is required of “Off” – nothing is required. There is no ambiguity.

Take a look at some of your visual controls. Do they pass the test? Do they clearly convey that something needs attention, or is that fact subject to interpretation?

Unexpected: Why would a visual control need to be “unexpected?” Consider the opposite. Who pays attention to car alarms these days? Yes, they are annoying, but because they so often mean nothing, nobody pays attention to them. We expect car alarms to be false alarms. If your visual control is to mean something, you must respond each time it tells you to. If it is a false alarm, you have detected a problem. Congratulations, your system is working. But it will only continue to work if you follow-through: STOP your routine; FIX or correct the condition; INVESTIGATE the root cause and apply a countermeasure. All of this jargon really means you must adjust your system to prevent the false alarm. Failure to do so will render the real alarm meaningless. It will “Cry Wolf” and no one will take it seriously.

Concreteness: Is it very clear? Do people relate to what your visual control is telling them? Does the Team Leader know that the worker in zone 4 needs help, and that the line will stop in a few minutes if he doesn’t get it?

Credibility: If the condition is worsening, does your visual control show it? Does it warn of increased risk? A typical example would be an inventory control rack with a yellow and red control point on it. Yellow means “Do something” Red means “You better start expediting or making alternate plans because you are going to run out.” Setting the red limit too far up, though, sends out false alarms (see unexpected), and eventually everyone “knows” the process can eat a little into the red with no problem. Why have yellow? What visual control can you put at the yellow line that tells you someone has seen it and is responding to the problem? (Left as an exercise for the reader.)

Emotions: How does your visual control compel action? Does it penetrate consciousness? A few words of warning on an obscure LCD panel aren’t going to mean very much unless someone reads them. How do you get the attention of the person who is supposed to respond? “He should have paid more attention” is the totally wrong way to approach missed information.

Stories: I really connected with this one. Stories are a great way to teach. Simulations are interactive stories. When teaching the andon / escalation process in a couple of different plants we divided the group into small teams, gave them a real-life defect or problem scenario and had them construct a stick-figure comic book that told the story of what would happen. That has proven a great way to reinforce and personalize the theoretical learning.

I will admit that these analogies can be a bit of a stretch, but the real issue is there. Visual controls are critical to your operation because they highlight things that must compel a response.

Your system is not static, or even really stable. It is either improving continuously through your continuous intervention, correction and improvement based on the problems you discover; or it is continuously deteriorating because those little problems are slowly eroding the process with more and more work-arounds and accommodations.

Go to your work area and watch. What happens when there is a problem or break in the standard? What do people do? Can they tell right away that something is out of the ordinary? How can they tell? For that matter, how can you tell by watching? If you are not sure, then first work to clarify the situation and put in more visuals. That will force you to consider what your standard expectations are, and think about responding when things are different than your standard.

5S – Learning To Ask “Why?”

ShadowboardThis photo could have been taken anywhere, in any factory I have ever seen. The fact that I do not have to describe what is out of place is a credit to the visual control. It is obvious. But one of my Japanese sensei’s once said “A visual control that does not trigger action is just a decoration.”

What action should be triggered? What would the lean thinker do?

The easy thing is to put the tape where it belongs.
But there is some more thinking to do here. Ask “Why?”

Why is the tape out of place? Is this part of the normal process? It the tape even necessary? If the Team Member feels the need to have the tape, what is it used for? If the Team Member needs the tape there has the process changed? Or did we just design a poor shadow board?

That last question is important because when you first get started, it is usually the case. We make great looking shadow boards, but the tools and hardware end up somewhere else when they are actually being used.

Why? Where is the natural flow of the process?

Before locking down “point of use” for things, you need to really understand the POINT where things are actually USED. If the location for things like this does not support the actual flow of the normal process, then you will have no way to tell “the way things are” from “the way they should be.”

The purpose of 5S is not to clean up the shop. The purpose is to make it easier to stand in your chalk circle and see what is really happening. The purpose is to begin to ask “Why?”

By the way – if you see an office chair or a trash can being used as an assembly bench, you need to spend a little more time in your chalk circle. 🙂

5 Seconds Matter

I was with the factory’s kaizen leader, and we were watching an operation toward the end of the assembly line.The takt time of this particular line was on the order of 400 minutes, about one unit a day. The exact takt really doesn’t matter, it was long compared to most.

One of the Team Members needed to pump some grease into a fitting on the vehicle he was building. But his grease bucket was broken. We watched as he wandered up the line until he found a good grease bucket, retrieved it, went back to his own position and continued his work. The entire delay was much less than a minute. No big deal when you compare it to 400+ minutes, right?

Let’s do some math.

There are six positions on this particular line. Each one has two workers, a few have three, for a total of 14.

What if, every day, each worker finds three improvements that each save about 5 seconds. That is a total of 15 seconds per worker, per day. Getting a working grease bucket would certainly be one (maybe two) of those improvements. (Consider that the worker he took it from now doesn’t have to come and get it back!)

That is 14 workers x 15 seconds = 210 seconds a day.
210 seconds x 200 days / year = 42,000 seconds / year.
42,000 seconds / 60 = 700 minutes
700 minutes / the 400 minute takt time = we are close to having a line that works with 12 instead of 14 workers.

What is that grease bucket really worth?

Of course your mileage may vary.

But how often do you pay attention to 5 second delays?

Of course getting the grease bucket is really just simple 5S — making sure the Team Member has the things he needs, where and when he needs them.

So how would 5S apply in this case?
Mainly a good visual control would alert the Team Leader, or any other alert leader, to the fact that the grease bucket is out of place. A good leader will see that and ask a simple question:

Why?

And from that simple question comes the whole story, and an improvement opportunity.
But in order to ask “Why?” there must first be recognition that something isn’t right. And this is the power of a standard.

The Chalk Circle – Continued

Yesterday I wrote a little about my own experience with Taiichi Ohno’s “chalk circle” as well as some stories I have gathered from others during the years.

Although the insights I got from Iwata-sensei changed my perspective, it was some years later that a few other things got solidified.

My colleagues and I had been hired as a team of “experts” to help a major household-name company implement “lean manufacturing” into their production and logistics processes.

A couple of years into the effort, it was still a struggle.

Although there were a lot of kaizen events happening, it was a continual battle to sustain the results. We were quickly reaching the point where 100% of our effort would be expended simply re-implementing areas where we had already been. That is the danger point when forward progress stops and the program stalls.

Of course we were busy lamenting about the “lack of management commitment” to support and sustain the great work these teams were doing.

The next week we were around the table trying to figure out a countermeasure.

First we had to understand the problem.

As we talked and shared, we discovered that each of us had one area, a single operation, that was showing better results than the others. Operationally, these areas were actually quite diverse. What did they have in common?

Each of them was the area under our respective responsibility that had the weakest or no internal infrastructure for kaizen events. In fact the most successful implementations were happening in the operations that held the least number of week-long kaizen events.

Needless to say, that realization was interesting. So what else did they have in common?

Because we did not have our internally trained people leading kaizen in those areas, we were coordinating and leading the effort personally. One of us, not someone we had trained, was guiding those areas through their implementation.

Why were our results different than the people we trained? What did we do differently?

As we talked, we found that we all would take the line leaders, the managers, the people responsible, to their shop floors, and teach them how to spot problems and what to do about it.

We would stand with them, observe something happening, and ask “What do you see?” We would continue to ask questions until they saw the things that we did. Then we would begin asking about causes. “Why does this happen?” Our objective was to teach the leaders to be intensely curious about what was going on, to compare what they saw against a picture in their mind of an ideal state, and further be curious about why there was a difference.

We paid attention to progress, focused their attention into areas that needed work, and always, constantly, asked questions.

  • “What is supposed to be happening here?”
  • “What is really happening?”
  • “Is that really what you want?”
  • “Why is there a difference? What is in the way?”
  • “Does the Team Member know what to do? How do you know? How does he learn?”
  • “Is this process on track? How can you tell?”
  • “How many are supposed to be here? Why are there extras?”
  • “Why is no one working here? Where did they go?”

Not because we wanted answers, but we were teaching them the questions.

These are the same questions that Iwata-sensei was asking me years earlier.
It was an insightful and team-building moment when we realized that, in spite of our diverse backgrounds (we had not met prior to working here), we all approached things pretty much the same way. The second insight was that, in spite of our diverse backgrounds, we had all learned pretty much from the same teachers, and those teachers had been taught directly by Ohno.

If a line leader “got” what we were trying to get across, they wouldn’t ever see their operation the same way. They would be constantly comparing what they saw (what is actually happening) against some kind of expectation or standard — explicit or implicit — or against an ideal state (what should be happening).

They would see any gap between what should be happening and what was actually happening as a problem to be addressed and at the minimum, corrected.

They would begin to ask different questions of their people, and manage activities toward identifying these gaps and closing them.

Our question to ourselves was: If this worked so well, what did we have everyone else doing?

When we asked this, Dave stands up and starts through his certification program to teach his kaizen leaders how to

  • Present the various training modules
  • Prepare the various forms and reports
  • Organize kaizen events

Then someone, I don’t remember who, asked “Who is teaching the leaders how to manage the new system?”

A long pause followed.

Then Dave said, “oh shit.”

Maybe Dave said it, but we all thought it.

We had started happily blaming the leaders. Then we realized no one was teaching the leaders. THAT was our fault. We weren’t teaching anyone to teach the leaders. Now the question was “What do we do about it?”

Now we understood the current condition and the gap we needed to close.

The Chalk Circle

In “The Toyota Way ” and “The Toyota Way Fieldbook” Jeffry Liker describes “standing in the chalk circle.”

This, of course, is a reference to a legendary exercise where Taiichi Ohno would stand a manager in a chalk circle drawn on the shop floor. His direction would be simple: “Watch.”

Several hours later, Ohno would return and ask “What do you see?”

Usually Ohno had spotted something earlier, and wanted the manager to learn to see it. So if the reply to “What do you see?” was something other than what Ohno had already seen, his response would be “Watch some more.”

This would continue until the manager saw the same problem Ohno had seen.

Over the years I have talked to a number of ex-Toyota managers who worked for Ohno, and they all relate this story from personal experience, sometimes standing in the circle for a complete shift or even longer. I also heard from another Toyota manager, an American who was involved in the start-up in Georgetown, Kentucky. He told me what occurred when he decided, after 90 minutes, he had seen everything, and left the circle. His coordinator was not happy. But I digress.

My own story is a little different.

I was a new kaizen workshop leader and was involved in an event at a major supplier. Late deliveries from this supplier had shut down production several times. We were looking to reduce the changeover times on their (old!) milling machines so we could keep parts moving through the process.

The current state of the changeover was that it could easily take three or four shifts. We were going through the classic SMED sequence, and starting to study exactly what happened during a changeover.

My pager went off. (Yes, this was a long time ago, remember those little things that only displayed a phone number?)

To cut to the point, on Wednesday I would be joined by the Division Vice President; Mr. Iwata, the Chairman of Shingijutsu; and an entourage to “help” with my workshop.

Iwata-sensei was an imposing character. During the next two days he and I would stand and just watch the Team Member going through the changeover. Iwata would constantly fire questions:

  • “Why is he doing that?”
  • “What is that for?”
  • “Where is he going?”
  • “What is he doing now?”
  • “Why?”
  • “What is that tool for?”
  • “What is he waiting on?”

Of course, we would work hard to get him the answers.

And each time he would listen to the answer and, with a dramatic wave of his arm and a hiss through his teeth, we would be dismissed.

Yet the questions continued.

At the end of this week, I never saw a factory the same way. I would get a feeling, almost a gut instinct, of what was happening, where the problems were, what to watch to verify. This skill has proven very useful over the years. Yet it was really not until nearly a year after Iwata’s death that I finally got it and understood what he was teaching.

He didn’t care about the answers. He was teaching me the questions.

I believe I was hearing a stream of consciousness of the questions he was asking himself as he watched. He was giving me a great gift of how to “stand in the chalk circle.” He was passing on some small bit of his decades of experience.

A great teacher continues to teach even after his death.