The 3 Elements of “Safety First”

When we talk about safety, most people consider the context of accidents and injuries. But if we are to achieve a true continuous improvement environment, where everyone fully participates, we have to consider more.

A good way to sum it up is with three elements that all start with ‘P.’

1) Physical Safety

This is what most people think of when we say “safety is the most important thing.” But, aside from the moral, legal and financial imperatives, what are some other reasons why physical safety is important?

Simple. We want our Team Members 100% engaged in performing their work and improving it. We do not want any of their precious mental bandwidth consumed by worrying about whether or not they will get hurt.

This is a far cry from the “blame the victim” approach I have seen. Root Cause of Accident: Team Member failed to pay attention. Countermeasure: Team Member given written warning.”

A few years ago I was painting my house. I will tell you right now that I am not fond of ladders. (Go figure, I spent three years in the 82nd Airborne, you’d think I would be over it.) There I was up near the top of an extension ladder painting the eaves of the roof. I can tell you that I was paying a lot more attention to staying on the ladder than to where the paint was going. The quality of the job suffered, for sure.

The truth is that a physically safe environment is more, not less, productive. Ergonomically bad motions take more time than good ones. Well designed fail-safe’s and guards prevent quality issues and rework. An even, sustainable pace of work reduces disruptions upstream and downstream. Good lighting lets people catch quality issues and mistakes sooner. Reduced noise levels foster communication. High noise isolates people in invisible bubbles.

2) Psychological Safety

Can your Team Members freely share problems and ideas free of concern for ridicule or rejection by their co-workers? Or is it safer for them to keep to themselves? Do you know who the natural leaders are? Do you know who the influencers are? Do you know who the bullies are? Do you know which line leaders people are afraid of? Which co-workers? Don’t kid yourself, it is only the truly exceptional team that does not have these issues. And most teams that move past these issues become truly exceptional. It is something called “trust” but that is just another way of saying “feeling safe being vulnerable.”

3) Professional Safety

This is a deceptively simple concept. The Team Member is not put in fear (real or implied) of losing his job for doing what is expected of him. That sounds so simple. The really obvious example is the Team Member being asked to contribute to saving cycle time (and therefore, labor) when he knows unnecessary people lose their jobs. But it goes further.

How often do we expect, by implication, people to short-cut The Rules in order to get something done more quickly? Sidney Dekker has authored a number of books and publications focusing on human error as the cause of accidents. One of his key points is that within any organization there are The Rules, and a slightly (sometimes greatly) lower standard of the norms – the way people routinely do things. The norms are established by the day-to-day interactions and the real and implied expectations placed on people to get the job done.

Well meaning Team Members, just trying to meet the real or perceived pressures of everyday work take shortcuts. They do it because they feel they must in order to avoid some kind of negative consequence.

At this point you can hopefully see that these three elements blur together. The work environment and culture play as much a part in a safe work place as the machine guards and safety glasses.

All of these things, together, set the tone for the other things you say are “important” such as following the quality checks (when there is no time built in to the work cycle to do so), and calling out problems (when halting the line means everybody has to work overtime).

One more point – everything that applies to safety also applies to quality. The causes of problems in both are the same, as are the preventions and countermeasures. Do you use the same problem solving approach in both contexts? More about simplifying your standards sometime in the future.

Is Your Lean Implementation Sticky or Slick?

My posts about “Made to Stick” and visual controls created some interesting responses on Jon Miller’s Gemba Panta Rei blog, so I want to continue the great dialog. Jon asks the great question “Is your lean deployment made to stick?” and extends the context from just visual controls to the entire concept.

Of course this level of thinking is the author’s intent in the book. I’d like to ask you, the reader and change agent, some questions that might help you see if you are obscuring your own message.

What is core message of your implementation?

The words “vision” and “mission” are so worn out today that people are cynical. And with good reason. By the time the board rooms are done with wordsmithing, there is no content left.

When I was growing up, current events in the USA were dominated by two stories:

  • The war in Vietnam.
  • Sending people to the moon.

Both were major undertakings and consumed a lot of talent and resources. Consider the core message for each.

Vietnam: Bad things will happen if we leave.

The Moon: “…achieving the goal, before this decade is out, of landing a man on the Moon, and returning him safely to the Earth.”

Which is those is “sticky?” Which one captures the essence of True North so that everyone just knows not only what we are trying to do, but how they can contribute?

Take JFK’s commitment and put it in the language of a typical corporate mission statement: “We will be a world leader in space exploration.” Yawn. How will we know when we get there? Exactly. It is a very safe goal since it allows redefining success at any point.

Kennedy’s commitment is simple, concrete, credible, emotionally appealing, and made a hell of a story. How does yours stand up?

But we so-called “lean professionals” are by no means off the hook.

What is the core message of the TPS?

That is a little tougher to get to. Why? My theory is that we “professionals” are all cursed with what Heath and Heath call “the curse of knowledge.” We understand the nuances and details of how all of the pieces fit together. The question is: How much of that wealth of knowledge passes the “So What?” test. What is the lead story?

When you start talking about takt time, work sequences, cycle times, kanban loops, andon signals, painting lines on the floor, all of the so-called “tools” of the TPS, do people’s eyes glaze over? What ties it all together? What is the central theme, the core message?

I’ve re-written this paragraph about a dozen times. How can we get it down to Herb Kelleher’s “Southwest is the low-fare airline” (p 29 in the book) and not lose anything?

I think, at its fundamental core, the Toyota Production System is “A structured work environment which captures people’s creativity and focuses it solving problems every day.”

The next line in the story: “All of the tools, techniques, principles that people associate with the Toyota Production System are simply the best currently known mechanisms to surface problems, or they are the best currently known countermeasures to common problems.”

Nope, that is still to complicated.

The Toyota Production System structures the organization and the work so that people can solve problems to save time.

That comes closer. I think a test question: “Does that save time?” (without compromising safety, quality or the customer in any way) would usually discriminate between a good idea and a bad one.

Readers – there is no way on Earth (or the moon) that I have got this right, or even close, sitting here in a Beijing apartment at 11pm on a muggy Saturday night. My challenge is: in one sentence, as direct as “The low-fare airline,” capture the core message of the TPS in a way that guides decisions toward True North.

Next – your training.

Most of us use some kind of training materials. Question: Does each topic have a lead? Does it build the story? Does it tie to the top story? As you go into more depth, are the interconnections more and more apparent? Do you tie everything back to the TPS Lead Story? Failure to do these things decomposes the system. It gives people the impression they can pick and choose the tools vs. understanding that they all are doing the same thing in different contexts. It implies there is some kind of set-piece sequence of implementation.

Are your examples concrete? Are they things people can go do?

Do you build a shared experience base by telling stories? Or do you deliver abstract, cold, analytical bullet lists of “the three elements of standard work?” Who cares? Obviously they are important, but how well do you communicate exactly why balance to the takt time contributes to the effort of surfacing and solving problems?

OK – it is late, and I am rambling. I hope I have provoked a little thought.

I originally titled this piece “Is Your Lean Implementation Velcro or Teflon?” But Velcro Industries has enough challenges protecting their trademark without me making it worse.

“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.

Made To Stick

Why Some Ideas Survive and Others Die
In Made to Stick, Chip and Dan Heath have addressed head-on one of the biggest problems with implementing change in people’s thinking and behavior — crafting the concept in a way that makes it compelling.. “sticky” in their words.

The book is an extension of the concept described in Gladwell’s The Tipping Point which outlines “stickiness” as one of the things required for an idea to catch on and spread.

Read this book, then take a look at your presentations and training materials, and compare the messages with the examples in the book. Make an honest assessment:

Is your message:

Simple? Is the core concept immediately apparent?

Unexpected? Does it come across in a way that compels retention?

Concrete? Do analogies and examples make the concept something people can see, touch, feel in their minds (or even better, physically)?

Credible? Does it just make sense?

Emotional? Does it appeal to people’s feelings, or is it “just the facts” with cold analytical presentation.

Have stories? Does the presentation include experiences people can visualize?

Other books on organizational transformation, like John Kotter’s Leading Change talk about the critical importance of creating a sense of urgency, creating a vision, communicating that vision, but Made to Stick goes further and gives you tools to actually make sure your message gets across in a way that compels people to act differently.

Trust, Then Verify

This article NPR : Mattel Recalls More China-Made Toys highlights one of the problems with doing business with an unproven supply chain.

In this case, the OEM in China had specified the correct paint to their supplier – who was a friend of the owner – but the paint supplier had given them less expensive lead based paint. (Some friend, huh?)

As the story reports, the owner of the OEM company took the coward’s way out and hanged himself.

So – Mattel probably trusted that their OEM supplier in China would deliver what they specified (and would continue to do so after first article inspections). The OEM, in turn, trusted their paint supplier would deliver as specified. Now Mattel’s reputation is in recovery mode and China itself is internationally embarrassed. (Believe me, they do not like it when that happens. On second thought, maybe suicide wasn’t a bad strategy after all.)

The awful truth is that the world out there has people in it who either do not understand that a particular specification is important (which is pretty common here), or worse, are out to make more money (less common, but it happens).

Lean Thinking Question:
What would you learn from this if YOU were Mattel?

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. 🙂

Think From The Customer’s Perspective

I was browsing my web email, and I saw an ad for web hosting. The ad was actually set out pretty well because I remember the two pieces of key information: Web hosting for $9.95 a month (free domain, etc.) and the prominent text on the ad: “Superpages.com”

Well, I suppose the ad authors can be forgiven if I didn’t click through the ad. Instead, I typed “superpages.com” into my browser.

The page so prominently called out in the ad carried not even a hint that superpages.com offers web hosting. And by now the ad was no longer displayed.

I typed “superpages” and “web hosting” into the search engine, and found a news article that repeated a 2005 press release. About 2/3 of the way down, it mentioned “my.superpages.com” so I tried that.

There is a mention on that page of web hosting, but it took two more clicks to finally get a page that mentions any details. I stopped at that point.

A couple of things come to mind here.

First – take the perspective of your customer, or better, find someone who doesn’t know the details or designer’s intent of your system and have them navigate it in unexpected ways. Just how many obstacles do you throw in front of the customer who wants to buy your product? How much digging must the prospective customer do in order to get basic information?

Second – and this is much harder – take the perspective of your competitor’s customer. Go buy their product. Experience what their customers experience. Don’t rely on market surveys, go and see for yourself. (“genchi genbutsu”)

What if:

Airline executives bought tickets through their own web site, rode in coach, and checked in just like everyone else – every time, not just as an experiment. They need to be a “frequent flyer” just like the very customers they are trying to retain. What if those same airline executives had to do 50% of their travel on competitor’s airlines? In coach, waiting in the same lines as everyone else.

Do you think it would be interesting for an executive of a prominent red-tailed airline to know that the “elite” line for check-in is much slower than the regular one? Or that they mix re-booking for a canceled flight in with first-class check-in and slow the process to a crawl? What would be that airline executive’s experience if he were to wait in line and just listen to his customers talk to each other? (He would hear the complaints nobody bothers to make because they think nobody cares.)

What would that airline executive’s experience be if he sat in the seat across from the flight attendant who lets all of the customers know what a terrible place his airline is to work. (I have had this experience twice, with the same flight attendant, but I fly a lot.)

What if Ford executives were directed to buy and drive….. Toyotas, and get them serviced at their local dealer just like everyone else. Would they learn anything? Not that Toyota is perfect, certainly their U.S. dealer network is pretty much just like everyone else’s. But that Ford executive might just find a weakness to exploit. What kind of car does Alan Mullally drive? What if auto executives had to buy their cars from heavy-handed closers just like everyone else?

But all of us frequent flyers can laugh about the airlines. What about your company? Do you really know what your customers experience?

Market surveys just don’t do this. They aggregate, consolidate, take averages, and generally dull the senses to what is really happening.

Go and see for yourself.

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.

Countermeasure?

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.

Be Sure: What Are You Trying To Accomplish?

And how will you know you have accomplished it?

This article on Tech Republic is about defense against a hacker strategy called “Social Engineering” wherein the hacker uses a ruse to gain someone’s trust. The goal (for the hacker) is to leverage human nature and get information or access.

So what does this have to do with lean thinking?

It emphasizes the nature of policies with unintended consequences. I have seen all kinds of environments where a Team Member would suffer negative consequences for doing the very thing required to assure safety, quality, delivery or reduce costs. Never happens in your company, right? The examples in the article are mainly in items (2), (3), and (4).

I especially like (4) where the hacker poses as a person in power and simply intimidates the Team Member into giving him the information he wants. What is the countermeasure?

Strict policies and procedures created to discourage this kind of bullying. If it’s allowed from management, someone engaging in social engineering will be able to employ it.

Think about it. If someone abusing his authority is normal behavior, then your Team Member will not be able to detect this condition something out of the ordinary.

In another context, if a Team Member is routinely told “We’ll fix it in inspection” or to otherwise ignore a defect and allow it to pass on, then he will quickly stop reporting them.

Think through the behavior you want people to exhibit. Then, study (stand in the chalk circle again) and see for yourself what the actual behavior is. If it is different than what you expect or what you want, start asking the 5 Why’s. What people do every day is the norm of your organization. It is the path of least resistance. If you want people to do something different, then you must make the right way the easiest way.

This accomplished by a combination of mistake-proofing, policies and procedures that support people who do the right thing, and continuous two-level checking by leaders to reinforce and encourage.

In Item (2) in the article, the author talks about the “I don’t want to get in trouble” excuse. In his example, there is a negative consequence for reporting a lost or misplaced ID badge, so everyone works to avoid reporting the problem. Perhaps the intent was to have people pay more attention. As Deming said, you must drive out fear, and this isn’t the way to do it.

Remember: The right process will produce the right results. Think:

What results are you trying to accomplish? How will you know you have accomplished them? (How will you check or verify your results?)

The more clear you are on the target condition, the better equipped you are to think through how you will achieve it. When dealing with people, it is easier than you think to build negative consequences for the very thing you want them to do.

Lean Dilemma: System Principles vs. Management Accounting Controls

Today I came across an article called Lean Dilemma:Choose System Principles or Management Accounting Controls, Not Both by H. Thomas Johnson.

It is, or it should be a thought-provoking read, especially for a CEO or other senior manager.

The author also wrote “Profit Beyond Measure” which I have not read, but based on this article, I will.

My personal challenge question is: What is the ROI on an environment where people work so well together that no detail is overlooked? It is, of course, impossible to calculate. Nevertheless, no one would argue that such a company would be a formidable competitor in any market.

Perhaps what you measure is what you get.
More likely, what you measure is all you get. What you don’t (or can’t) measure is lost.

Today the mantra of “Sarbanes-Oxley” is being used as justification to plant, fertilize and cultivate a garden of chokeweed that will embrace and strangle any attempt to streamline processes. I have run into the same “regulations won’t allow it” excuse in the aerospace industry (“the FAA won’t allow that”), in health care products (“the FDA requires this”), and, believe it or not, in ISO-9000 registrations. (“That violates ISO”) Of course, in every case, it was a smoke screen.

Once the assumptions are challenged, and the actual requirements are studied and understood, there is always a way to comply with the letter and spirit of the requirements with minimal (or no) waste. The problem comes in when people confuse the requirements themselves with the policies of the company to implement them. Those policies can be changed with the stroke of a pen, sometimes followed by convincing an auditor that the new way is better.

But I digress. Toyota operates in the USA and is subject to exactly the same regulations and financial securities laws as everyone else – yet, somehow, they manage to operate without these things as justifications for the status quo.

Read the article – tell me what you think.

Edit – 9 August – Someone pointed out to me that there are people who are turned off by Johnson’s environmental stewardship message toward the end of the article. My view is that intelligent people should be able to read the article and agree or disagree with that message, while still “getting” the core message: Traditional management accounting controls damage shareholder value.