The Seventh Flow

Those of you who are familiar with Shingijutsu’s materials and teaching (or at least familiar with Nakao-san’s version of things) have heard of “The Seven Flows.” As a brief overview for everyone else, the original version, and my interpretations are:

  1. The flow of people.
  2. The flow of information.
  3. The flow of raw materials (incoming materials).
  4. The flow of sub-assemblies (work-in-process).
  5. The flow of finished goods (outgoing materials).
  6. The flow of machines.
  7. The flow of engineering. (The subject of this post.)

A common explanation of “the flow of engineering” is “the footprints of the engineer on the shop floor.” I suppose that is nice-sounding at a philosophical level, but it doesn’t do anything for me because I still didn’t get what it looks like (unless we make engineers walk through wet paint before going to the work area).

Common interpretations are to point to all of the great gadgets, gizmos and devices that it does take an engineer (or at least someone with an engineer’s mindset, if not the formal training) to design and produce.

I think that misses the point.

All of those gizmos and gadgets should be there as countermeasures to real, actual problems that have either been encountered or were anticipated and prevented. But that is not a “flow.” It is a result.

My “put” here is that “The Flow Of Engineering” is better expressed as “The Flow of Problem Solving.”

When a problem is encountered in the work flow, what is the process to:

  • Detect that there even is a problem. (“A deviation from the standard”)
  • Stop trying to continue to blindly execute the same process as though there was no problem.
  • Fix or correct the problem to restore (at a minimum) safety and protect downstream from any quality issues.
  • Determine why it happened in the first place, and apply an effective countermeasure against the root cause.

If you do not see plain, clear, and convincing evidence that this is happening as you walk through or observe your work areas, then frankly, it probably isn’t happening.

Other evidence that it isn’t happening:

At the cultural and human-interaction level:

  • Leaders saying things like “Don’t just bring me the problem, bring a solution!” or belittling people for bring up “small problems” instead of just handling them.
  • People who bring up problems being branded as “complainers.”
  • A system where any line stop results in overtime.
  • No simple, on/off signal to call for assistance. No immediate response.
    • If initially getting help requires knowing who to phone, and making a long explanation before anyone else shows up, that ain’t it.
  • “Escalation” as something the customer (or customer process) does when the supplying organization doesn’t respond. Escalation must be automatic and based on elapsed-time-without-resolution.

Go look. How is your “Flow of Problem Solving?

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?”

“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. 🙂

Hidden Negative Consequences

“Stop the line if there is a problem” is a common mantra of lean manufacturing. But it is harder than first imagined to actually implement.

The management mindset that “production must continue, no matter what” is usually the first obstacle. But even when that is overcome, I have seen two independent cases where peer social pressure between the workers discouraged anyone from signaling a problem. The result was that only problems that could not be ignored would come to anyone’s attention – exactly the opposite of the intention.

Both of these operations had calculated takt time using every available minute in the day. (Shift Length – Breaks etc.) Further, they had a fairly primitive implementation of andon and escalation: The line stop time would usually be tacked onto the end of the shift as overtime. (The alternative, in these instances, is to fall behind on production, and it has to be made up sometime.)

So why were people reluctant to call for help? Peer pressure. Anyone engaging the system was forcing overtime for everyone else.


On an automobile line, the initial help call does not stop the line immediately. The Team Leader has a limited time to clear the problem and keep the line from stopping. If the problem is not cleared in time, the problem stops the line, not the person who called attention to it. This is subtle, but important. And it gives everyone an incentive to work fast to understand and clear the problem – especially if they know it takes longer to clear the problem if it escapes down-line and more parts get added on top.

There are a number of ways to organize your problem escalation process, but try to remember that the primary issue is human psychology, not technology.

Hoopla – Another Quality Story

As I said in a previous post, I am spending the majority of my time in China right now.

As part of his preparation for attending a corporate class, one of my kaizen specialists was reviewing some of the training materials. From the other side of the cubicle wall he asks “What is ‘hoopla?” Although his English is very good, he is Chinese, and “hoopla” just isn’t a word that they teach in the universities.

Now I know for sure he is not the first non-native English speaker to read that material, and I also strongly suspect many before him did not know what “hoopla” means. But the others just made a guess from the context and kept reading.

Derrick, though, applied the first two steps of jidoka – he Detected a problem – something wasn’t right, didn’t meet the standard, or seemed to be in the way. Then he Stopped the process, and called for assistance. Instead of guessing what to do, the Team Member pulled the andon (got his Team Leader’s attention) and pointed out the problem.

The standard in this case is that the person reading the material can understand it, or at least understand the words that are not specifically being explained by the material. In this case, that didn’t happen. “Hoopla” was not understood, so the andon was pulled.

The third step is Fix or correct the problem, restore the standard (without compromising safety or customer quality in any way) and re-start the process. I explained what “hoopla” means, and Derrick could keep reading.

The fourth step is Investigate the Root Cause, Apply a Countermeasure. I sent an email to our training developer and mentioned what has now become “the hoopla incident.” The ensuing discussion among the training developers has resulted in a set of standards and guidelines for writing materials. Among other things, it calls out the need to avoid idioms and slang that might not be understood by non-native speakers. It also addresses other issues which will both make the materials easier for non-native speakers to read and make it easier for translators working to port the material to German, French, Spanish or… Mandarin.

W e should have some hoopla! The process worked – all because someone called out something he didn’t understand instead of just dealing with it on his own.

A Quality Story

On a cloudy morning a few years ago I started my truck, turned on the headlights and noticed one of them was not working. While changing a headlight isn’t that big a deal, I needed a state safety inspection anyway, and I really didn’t want to mess around under the hood.

So I called the auto repair and tire place up the road, and arranged to come in.

When I got there, I explained that the right headlight was out. Since I knew from experience that the left one would probably fail in a few weeks, I said “Go ahead and change the left one too, and I need the state safety inspection.”

Unfortunately they only had one headlight in stock, so they couldn’t change both, I said OK and got a soda to wait.

A while later, everything was good-to-go, I drove back to work and went home that evening. The next day was sunny.

The following day, however, was cloudy again. I turned on the headlights in the garage, and the right headlight was still out. Hmmm. I took a quick look and noticed that the LEFT headlight was new. They had changed the wrong one.

When I got back to work, I called the shop, explained the issue, and they said come over and they would make it right. (Meaning they would replace the RIGHT headlight at no charge.) After handing the keys back in, the mechanic who did the work came out and tried to convince me that he had simply followed the instructions, and it wasn’t his fault.

OK — let’s break down this situation from the perspective of quality and delivery.

Starting from the end of the story, why did the mechanic feel obligated to try to convince me that I had responsibility for a mistake that the owner had already agreed to correct? What could possibly be gained by trying to make the customer feel wrong here?

Now let’s go back to the beginning.
Customer reports a headlight is out. What is the very first thing you would do? How would you confirm the problem?

Turn on the headlights and check. This takes about 10 seconds. If there was a confusing communication about the problem, this is the time to discover it.

Once the repair has been completed, how would you confirm that it worked?
Turn on the headlights and check. This would verify that the results were as intended. (What does the customer need here? Two headlights that work.)

The other item that was on the instruction was a state safety inspection. Now I am not an expert on the New York State safety inspection, but I am willing to bet at least a can of soda that it includes the headlights. So as part of that inspection, the mechanic should turn on the headlights and check.

Even if the problem had gone undetected up to this point, it should have been caught here. Obviously the “inspection” was just a paperwork drill in this case.

Of course, as the customer, I also failed to turn on the headlights and check when I picked up the vehicle. Silly me.

What is the point of all of this?

The first step of solving any problem is to understand or verify the current condition and compare it with your expectations or standard. (More about standards and expectations later.)

Once a countermeasure had been developed and put into place, the situation must be re-checked to ensure that the countermeasure worked as intended and the process or system is back to the standard condition.

Any process has some kind of intended result. In this case, the headlight repair process should result in two headlights that work. Yet the results were not verified, and the incorrect product was delivered to the customer.

So what did all of this cost?

It cost me my time.
It cost the repair place

  • Double the mechanic time.
  • A headlight +the time to go get one during business hours (because they had not replaced the one they installed on the left two days earlier).
  • Good will. (Later, when they failed to tighten the filter after an oil change, I stopped doing business there altogether. One mistake I was willing to overlook, but I was starting to see a trend developing. I also later had some extensive maintenance and repairs done on the truck, but I didn’t have them done there because I could not trust them to change a headlight or change the oil.)

By the way, I still have the truck. It is coming up on 200,000 miles and runs great.

The Essence of Jidoka

SME: The Essence of Jidoka – dead link

You can download it here.

This link is to an article I wrote for the SME online “Lean Directions” site back in 2002. I am including it on this site for the sake of completeness. I noticed that the Wikipedia article on the same subject is largely derived from this, which I simply consider flattery.