“A3” is an Obligation for the Coach

In Western business it is pretty typical for someone to be assigned to come up with a proposed solution to a problem, and then seek approval for that solution. In some companies that consider themselves more forward thinking, they might even say something like “bring me an A3.”

As a result I have seen a number of organizations that produce some kind of guideline for “how to fill out and A3.” They teach “problem solving” courses so people can learn to do this properly. I have developed, and delivered, a couple of those back when I was working in internal continuous improvement offices. We had case studies, exercises, all in an effort to teach people to be better problem solvers.

Similarly, a (very) long time ago, I recall an exchange on an online “lean” forum where someone had asked about Toyota’s “problem solving class.” The thought was that because Toyota has good problem solvers, that their course must be really good.

My response was that I have a copy of Toyota teaching materials for a problem solving course. It is good, but nothing magical. Because that isn’t how Toyota develops good problem solvers.

They do it with coaching.

What makes the “A3” process work isn’t the A3, or even the structure. It isn’t the instructions, guidelines, or the quality of the problem solving classes.

It is the almost continuous interaction between the problem solver and the coach.

The problem solver’s thinking is challenged. “What evidence do you have?” “Have you tested that assumption?” “How is that happening?” “Why do you think that is the problem?” “What are you planning for your next step?” “What do you expect to learn?”

And it is the coach’s stubborn refusal to give the problem solver the answer. Rather, they insist on following the rigor of the problem solving process using scientific thinking.*

The process is an application of the principle of “Challenge” followed by support to enable the problem solver / learner to meet the challenge. They have to bring perseverance to to the table, but the coach is there to make sure they actually learn to be better problem solvers in the process.

Likely (if you are reading this) you already know that. We knew that when we worked so hard to make those A3 guidelines and problem solving courses. But we did those things anyway.

Why? Because it is easier to develop and deliver those general class materials than it is to develop managers into coaches and leaders.

But the fact remains:

If you want to develop better problem solvers, what you need are better coaches.

The implications here are really profound for most organizations.

If you assign someone to solve a problem, to “do an A3” (or whatever structure you use), you are obligating yourself to coach them through the process.

This is far more than getting status updates. And it is far more work. Because you are teaching, not just supervising. If they fail, it’s on you, not them. “If the student hasn’t learned, the teacher hasn’t taught.”

In Toyota Kata world we have reduced those questions down to the critical few in the Coaching Kata. That, of course, is a start. Your job as a leader is to practice until the flow of the logic is second nature to you, until you can go beyond the script. Until your first-nature, reflexive response to anyone proposing to do something is “What problem are you trying to solve?” or “What are you trying to learn?” and then carefully listening to their logic and pushing them to the edge of their ability with the next step.

When you can take your own coaching training wheels off, you can then (and only then) ask someone else to ride a bicycle for you, because you will know how to teach them to ride – and that involves more than sending them to a PowerPoint lecture on “Riding a Bicycle.”

“Because knowledge is not understanding” – Destin Sandlin.


*Some years ago I worked briefly with a manager who had been one of the key players in Toyota’s initial startup of their plant in Kentucky (TMMK). He told me an interesting story. In the beginning, he noted, the U.S. managers would go to their coordinators (Japanese Toyota senior leaders there to advise the new team) and ask for advice.

Then one week all of the U.S. team went through the problem solving / A3 course. The following Monday, he went to his coordinator with a question, and the response was “Doug-san, where is your A3?” After that day, the coordinators would not engage unless there was an A3 that outlined, in writing, what the manager already understood about the problem, what he was seeking to learn, and how he proposed to go about learning it.

Think about that story vs. sending people to “problem solving class” or even a “Toyota Kata” class. When they return, do you insist that they apply what they have learned whenever it is appropriate from that day forward? If you don’t then you are wasting their time and your money sending them to that class. They will never develop the skill without practice, and it is always easier not to practice something we are not comfortable doing.

Mistake Proofing – Getting People’s Attention

Besides being a great source of schadenfreude, Jürgen Henn’s website, 11foot8.com offers some great insight in the difficulty of effective mistake-proofing.


The clearance between the road and the railroad bridge at 201 Gregson Street in Durham, North Carolina is officially 11 feet 8 inches (3.55 meters).

A typical rental box truck is about 12 feet high (3.65 meters).

The result:

Penske rental truck smashed under low bridge.

The more astute of you may have noticed the “OVERHEIGHT MUST TURN” sign just above the smashed truck.

Well before the truck approaches the intersection, it passes under a height sensor. If the vehicle is overheight, the OVERHEIGHT MUST TURN sign comes on and starts to flash, and the traffic lights turn red.

While this effort did mitigate the problem, obviously there are drivers who simply do not notice. Lots of them. Jürgen has cameras trained on the intersection and captures over a dozen crashes in a typical year. As a result, his website has attracted international attention. See the short documentary here: http://11foot8.com/about/the-documentary/

Familiar Tasks = “In the Zone”

The human brain is an amazing thing. It also works by deceiving us. It creates the illusion of complete awareness of the things around us when, in reality, we are simply aware of a model our brains have constructed of what we perceive to be there.

It is also an amazing engine at engaging actions based on pattern matching. For example –

In sessions I facilitate, I routinely ask people if they can recall a time when they arrived home after work but realized they didn’t remember driving the route. Nearly every hand in the room goes up. That is pretty amazing because driving is an incredibly complex task. But, assuming you get a license in your mid-teens, by the time you are in your early 20s, most people don’t give it much thought. (There is a reason your insurance rates drop when you turn 25.)

It has become a hard-wired neural pattern, a series of habits, a programmed set of responses that are operating below below the conscious and deliberate thinking part of the brain. This is really good because this process is much faster and more responsive than the alternative. Think about how it felt to be driving when you were just learning – or how it feels to be doing anything new when you are just learning.

The downside to this amazing programming is that things that don’t jar us into consciousness often go unnoticed.

And the more familiar, the more expert, we are with the task at hand, the more likely this will happen.

Levels of Mistake Proofing

I like to talk about three levels of mistake-proofing. Four actually, if you count Zero as a level.

  • Level 0 – the task must be performed correctly from memory.
  • Level 1 – there is a discrete task of checking build into the job.
  • Level 2 – there is an active indication when a mistake is about to be made (or has just been made and there is still time to correct without consequences).
  • Level 3 – there is active prevention that gets in the way of making the mistake.

The OVERHEIGHT MUST TURN sign is a Level 2. The driver has already passed signs informing him of the bridge clearance about 100m before the bridge.

The height sensors are on the poles just past the speed limit signs.

Low clearance signs about 100m before the bridge. (Google Street View)

Then in the next block, there is another sign telling the driver to turn:

Approaching the last intersection (Google Street View)

And finally the light changes and the OVERHEIGHT MUST TURN sign illuminates.

And still they miss it.

(Direct YouTube link for the email readers: https://youtu.be/I0BJmC6u7MU)

To be clear, the vast majority of truck drivers don’t hit the bridge. But over a dozen a year do. (There were more before the flashing sign was put in.)

“Pay Attention!” = Fundamental Attribution Error

As we watch Jürgen’s videos it is easy to assign character attributes to the drivers who hit the bridge. If only they were better drivers. (The vast majority people who are asked to rate their driving skill will say they are “above average” by the way. Think about that.)

But it is human nature to get lulled into a bit of complacency when engaging a routine task- and driving is a routine task in spite of the complexity.

Now – think about the people in your organization. How many opportunities to they have to make a mistake every day… every hour… in the course of their work? How many of those possible mistakes have serious or expensive consequences?

They are experts at what they do. And they don’t make many mistakes. And they usually catch themselves before there is a problem. But the Law of Large Numbers says “Given enough opportunities, the unlikely is inevitable.”

Can anyone reading this honestly say they have never inadvertently run a stop sign? Yet accidents rarely occur. Now and then there is some panic braking, and rarely there is a collision.

Yet it is really easy to single out the person who:

Performs the work the same way, in the same conditions as everyone else.

Makes the same mistakes, just as often, as everyone else.

Just like everyone else, usually they are caught in time, or other conditions aren’t present for a bad outcome.

But this time everything lined up and BANG – the defective product got missed, or the leak wasn’t noticed before the sump went dry.

Then that person gets singled out for “not following procedure” when nobody follows procedure.

Job Instruction “Key Points” = Opportunity

In a Job Breakdown for TWI Job Instruction we assign a “Key Point” as something the learner must remember specifically because it:

  • Might result in a hazard – injure the worker or someone else.
  • “Make or break the job” – if something isn’t done a specific way, the task fails.
  • Is a “knack” or technique that makes it easier to do.

Those first two are red flags. You are asking your team member to memorize critical to safety and critical to quality tasks. My challenge: How many of those key points can you “mistake proof” out of the job breakdown?

Finally – rather than the sensors and flashing lit signs, there is this approach from “somewhere on the Internet.”

Warning Sign: If you hit this sign, you will hit that bridge.

That is awesome because even if the driver doesn’t see the sign, the BANG! may get his attention in time for it to register and stop. In the Durham, NC example above, apparently this wouldn’t work because there are legitimate reasons for trucks to come down the street up to the intersection just before the bridge. After that, it is really too late unless the driver is already aware that he has to turn.

Oh – and by the way – you can get souvenirs from the Gregson Street Bridge at  Jürgen’s store here:  https://squareup.com/store/11foot8-dot-com/ 🙂

There is a follow-up to this post here: http://theleanthinker.com/2020/05/28/more-about-mistake-proofing/

Troubleshooting by Defining Standards

Sometimes I see people chasing their tails when trying to troubleshoot a process. This usually (though not always) follows a complaint or rejection of some kind.

A few years ago I posted Organize, Standardize, Stabilize, Optimize and talked in general terms about the sequence of thinking that gives reliable outcomes.

This is a series of questions that, if asked and addressed in sequence, can help you troubleshoot a process. The idea is that you have to have a very clear “YES” to every question above before proceeding to the next.

Question 1: Is there a clear standard for the outcome?

Why? Because if you don’t have a clear expectation of what “good” looks like then your definition of “not good” is subjective and varies depending on who, what, when things are being looked at.

If no, then define:

  • What are you trying to accomplish from the customer’s perspective? What does “good” look like? How do you know?
  • How does the team member performing the work know (and verify) that this expectation has been “met” or “not met” – each time.
  • This includes not only the physical quality expectations but the required timing.
  • What do you want the team member to do if she finds a problem? What is your process for escalation / response?

Question 2: Is there a clear standard for the method that will achieve the standard results?

Why? Because if you (as an organization) don’t know how to reliably achieve the standard you are relying on luck.

If no, then define:

  • What steps must be performed, in what order, to get the outcome you expect?
  • Content, Sequence, Timing to give the desired Outcome.
  • How will the team member doing the work know (and verify to themselves) that the method was either “applied” or “not applied” according to your standard – each time?
  • What do you want the team member to do is he can’t or didn’t carry out the process as defined? What is your process for escalation / response?

Question 3: Are the conditions required for success present?

Why? Because if the team member does not have the time, tools, materials, environment that are required to execute the process as designed they have to improvise and compromise.

If no, then define:

  • What conditions must exist for your standard method to work?
  • What conditions must exist to enable the team member to consistently execute to the standard with no work-arounds?
  • How will you assure that the conditions exist prior to process execution each time?
  • What stops the process from proceeding if the required conditions do not exist?

Question 4: Is there consistent execution of the standard method?

Why? If you have defined the method, and assured that the conditions required for success exist, then you must examine what other factors are causing process variation.


  • CONFIRM the standard conditions exist. Correct or restore. Check for process stability.
  • CHECK FOR other conditions which affect execution. Establish new standard conditions. Check for process stability.
  • CONFIRM clear understanding of the standard method. This would be a good time to engage TWI Job Instruction. Check for process stability.
  • For all of the above – verify all suspect process output vs. the standard for outcome and results.
  • If you discover an alternative work method that is clearly superior to the standard then Confirm, capture, verify. DEFINE a process for process improvement – how to alternatives get confirmed and incorporated vs. random mutations?
  • Define your mistake-proofing / poka-yoke at the point where process execution varied to increase stability.

Question 5: Was a standard method followed and the results were as expected or predicted?

Why? After we have verified process stability, then we can ask “Does the process that we specified actually work as we predicted?

  • REEXAMINE your standard method and conditions.
  • Identify process failure points and sources of variation.
  • Adjust the process to address those failure points and sources of variation.
  • Repeat until your process is capable and consistently performs to the standard.

Question 6: Does everything work OK, but you want or need to do better?

Only a stable baseline can tell you how well you are performing today. Then you can assess if you need changes. If so, then reset your standard for expectations. Return to the top.

The Improvement Kata: Next Step and Expected Result

In the Improvement Kata sometimes it helps to think about the outcome desired and then the step required to accomplish it.

A couple of months ago, I gave a tip I’ve learned for helping a coach vet an obstacle.

Another issue I come across frequently is a weak link between the “Next Step” and the “Expected Outcome.”

In the “Five Questions” of the Coaching Kata we have:

What is your next step or experiment?” Here we expect the learner / improver to describe something he is going to do. I’m looking for a coherent statement that includes a subject, verb, object here.

Then we ask “What do you expect?” meaning “What do you expect to happen?” or “What do you expect to learn?” from taking that step?

I want to see that the “Expected Result” is a clear and direct consequence of taking the “Next Step.”

Often, though, the learner struggles a bit with being clear about the expected outcome, or just re-states the next step in the past tense.

While this is the order we ask the questions, sometimes it helps to think about them in reverse.

Reverse the Order

Have the learner first, think about (and then describe) what she is trying to accomplish with this step. Look at the obstacle being addressed, and what was learned from the last step.

Based on those things, ask “what do you want to accomplish with your next step?”

The goal here is to get the learner to think about the desired result. Don’t be surprised if that is still stated as something to do, because we are all conditioned to think in terms of action items, not outcomes.

“What do you need to learn?” sometimes helps.

“I need to learn if ______ will eliminate the problem.” might be a reply.

Even a proposed change to the process usually has “to learn if” as an expected outcome, because we generally don’t know for certain what the outcome will be until we try it.

Have the learner fill in the “Expected Outcome” block.

NOW ask “OK, what do you have to do to ______ (read what is in the expected outcome)?”

PDCA Outcome-Activity

That should get your learner thinking about the actions that will lead to that outcome.

A Verbal Test

A verbal test can be to say “In order to ______ (read the expected outcome), I intend to _____ (read the next step.”

If that makes sense grammatically and logically, it is probably well thought out.

An irrational post today.

Posted 3.14.15 9:26 am

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Oh No! Toyota is “Cutting the andon cord!”


I’ve had three or four people forward various links to a story from Automotive News titled “Toyota Cutting the Fabled Andon Cord, Symbol of Toyota Way.”

Most of those people didn’t read past the headline.

I’ll quote from one paragraph into the article:

“In its place are yellow call buttons perched waist-high within easy reach along the line for workers to hit when a problem pops up requiring help or the line to be stopped.

Toyota switched to the buttons last year at its flagship Tsutsumi assembly plant in Toyota City, during a factory renovation. In Japan, the buttons were first used by a vehicle-assembling subsidiary, Toyota Motor East Japan Inc., at a Miyagi plant.”

The implication?

They got tired of the overhead rope getting in the way of flexibility in how they arranged the line, material, work flows. They improved their system. It is easier for a worker to initiate a help call (which leads to a line stop if the issue isn’t resolved quickly).

They first saw an obstacle (rope in the way) to another improvement (flexibility). They ran an experiment (at the Miyagi plant), wrung out the details, then put it into place in Tsutsumi for a larger scale trial.

What is totally consistent here is the approach to improvement.

We, once again, have confused the artifacts (overhead ropes, work documented a certain way, a method for distributing parts, an approach to tracking quality issues) with the purpose: Making gaps between “what should be” and “what actual is” every more clear so the can work on getting to the next level.

I suppose a headline that read “Toyota Replaces Overhead Rope With Buttons for Improved Flexibility” wouldn’t garner the same number of hits, nor would it trigger blog posts across the lean community, so I guess that headline worked for its intended purpose.

Here is what the andon is all about:

If anyone is looking for evidence that Toyota is somehow abandoning the principle of “Stop the line before passing along bad quality… this isn’t it.”

Move along…

Discussing Challenge and Direction

A manager and his direct report were discussing the challenge and direction for the next round of improvement. The conversation was going around in circles.

The manager was concerned about the excessive overtime, and wanted to establish a challenge to reduce it significantly.

The improver was skipping directly to talking about the things he would have to change in the process – mainly trying to level his demand signal somehow… long before “current condition” had been established… this conversation was just about context.

The manager was frustrated because he knows people habitually jump to solutions instead of first digging into the problem, and he was getting that right now.

The manager was repeating his question “But how can we reduce the overtime.”

Each time the manager asked about the process performance, the improver was offering improvement solutions.

Then I realized… The manager was asking for an improvement solution.

“How can we reduce the overtime?”

I asked him to just ask what he wanted the process to achieve. He still reiterated the same question.

Finally I said “Don’t say ‘how can we.’

Start with “I want…”

“I want the overtime to be 10% or less.”

The tone of the conversation changed immediately, because we really didn’t know what factors were driving the overtime. NOW it is time for the improver to go grasp the current condition (with help from his coach) and establish the next target condition (with help from his coach).

Then he can come back with:

“To keep overtime under 10% , we will need the process to operate like this.”

“Today, it is working like this, and we are running overtime as high as 30% in the worst weeks.”

“As my first step, I intend to…”

And how we’re moving in the right direction.

When the manager was asking “How can we…?” he was asking for a proposed solution right now, even if he didn’t mean to. The answer to a “how can we?” question is “Well, we could…” and we are immediately grasping at possible changes.

Listen to the words you use.

Be clear about what you are actually asking people to do, because that is what you are going to get.

…And we’re back

Some of you likely noticed the site was down for about 12 hours over Jan 2/3.

I had been the target of a “brute force” attack to attempt to login to the site administration, presumably to install malicious scripts, etc.

The attack was not successful, however it did consume all of the CPU cycles of my host’s server, so they shut off access to the site.

I have installed countermeasures, none of which are visible to readers.

It’s the wild west out there.

5S and Workflow

This company launched their focus on continuous improvement with a 5S campaign. Teams were set up, had the basic 5S training, and met with their management sponsors weekly.

One team was having problems getting past the initial “sort” phase of clearing out unused stuff. They struggled with setting up any kind of visual controls, for example.

A couple of months ago, we focused on their workflow for introducing the PDCA improvement cycle (“kata”) to the area supervisor.

We were using a combination of observation of the actual work, running tabletop simulations to develop things to try out, and live experiments in the work area as we ran rapid PDCA cycles throughout the days. We were after concentrated reps so they could practice.

They still struggled until we finally got the tabletop simulation to flow. The supervisor “got it.” She said “Oh…. I can see the big picture now.” She had been bogged down in the details, and hadn’t been seeing that they could improve their productivity dramatically by slowing down to the planned cycle time.

Once they had a target work cycle, they then tackled obstacles that were in the way of making real life work like what they had simulated, working them one by one.

Along the way, they saw a need to make “what to do” visual, and build it into the work area itself vs. just “telling then” or (probably worse) writing some kind of procedure.

Suddenly 5S had purpose. It was to help communicate what to do next, and to help see if “what is happening” is different from “what should be happening.”

The key learning is that this is really difficult if you haven’t thought through “what should be happening” first.

This team is now has the highest 5S score in the company… because 5S has a purpose.

I came across this old fable again recently.

So much of it applies to the improvement culture – especially if you run your equipment all the time to “maximize your output”

Once upon a time, a very strong woodcutter asked for a job in a timber merchant and he got it. The pay was really good and so was the work condition. For those reasons, the woodcutter was determined to do his best.

His boss gave him an axe and showed him the area where he supposed to work.

The first day, the woodcutter brought 18 trees.

“Congratulations,” the boss said. “Go on that way!”

Very motivated by the boss words, the woodcutter tried harder the next day, but he could only bring 15 trees. The third day he tried even harder, but he could only bring 10 trees. Day after day he was bringing less and less trees.

“I must be losing my strength”, the woodcutter thought. He went to the boss and apologized, saying that he could not understand what was going on.

“When was the last time you sharpened your axe?” the boss asked.

“Sharpen? I had no time to sharpen my axe. I have been very busy trying to cut trees…”

In the real world, this kind of decline happens much more slowly.

And it happens well beyond the context of equipment and maintenance.

If you don’t work to continuously improve your processes, they are degrading. You can’t just “standardize” your way to stability.