Attack on Ambiguity

When real effort is spent getting to the cause of problems (vs. a reflex to find someone to blame), ambiguity often enters into the picture.

Problem solving is a process of asking questions and clarification.

Is a “defect-free” outcome of the process specified? Does the Team Member know what “success” is?
Is there a way for the Team Member to actually verify the result?
Does that check give the Team Member a clear Yes/No; Met/Not Met; Pass/Fail response? Or is there interpretation and judgment involved?

If there is good specification for “defect-free” – is there a specification for how to achieve it? Do you know what must be done to assure the result that you want? Does the Team Member know? Is the Team Member guided through the process? Are there verifications (poka-yoke, etc) at critical points?

If all of the above is in place, do you know what conditions must be in place for success? What is the minimum pressure for your air tools? Is there a pressure gage? Does it cut off the tool if the pressure is too low? Is there some visual check that all of the required parts, pieces, tools are there before work starts? Thank about the things you assume are there when the Team Member gets started.

For ALL OF THE ABOVE, if something isn’t right, is there a clear, unambiguous way to alert the Team Member immediately?
Is there a clear way for the Team Member to alert the chain-of-support that something isn’t right?

If there is a defined result, a defined process to achieve it, and all of the conditions required for success are present –
Is the Team Member alerted if he deviates from the specified process, or if a critical intermediate result is not right?
More poka-yoke.

Now you have the very basics for consistent execution.

Is the process carried out as you expect?
Is the result what you expected?

If not, then the process may be clear, but it clearly does not work. Stop, investigate. Fix it.

All of this is about getting more and more about what is SUPPOSED to happen and compare it to what is REALLY happening… continuously. I say continuously because “continuous improvement” does not happen unless there is continuous checking and continuous correction and problem solving. If you want “continuous improvement” you cannot rely on special “events” to get it. It has to be embedded into the work that is done every day.

Ask “Why?” – but How?

Get to the root cause by “Asking Why?” five times.
We have all heard it, read it. Our sensei’s have pounded it into us. It is a cliché, obviously, since getting to the root cause of a problem is (most of the time) a touch more complicated than just repeatedly asking “Why?”

Isn’t it?

Maybe not. Maybe it is a matter of skill.

Some people are really good at it. They seem to instinctively get to the core issue, and they are usually right. Others take the “Problem Solving” class and still seem to struggle. So what is it that the “naturals” do unconsciously?

Let me introduce another piece of data here. “Problem Solving” is taught to be an application of the scientific method. The scientific method, in turn, is hypothesis testing. How does that relate to “ask why? five times” ?

Each iteration of asking “why?” is an iteration of hypothesis testing.

How do you “ask why?”

Observe and gather information.
Formulate possible hypotheses.
For each reasonable possibility, determine what information would confirm or refute it. (Devise experiments, which really means “Decide what questions to ask next and figure out a way to answer them.”)
Observe, gather information, experiment. Get answers to those questions.
Confirm or refute possible causes.

At each level, a confirmed cause is the result of “observe and gather information” so the process iterates back to the top.

Eventually, though, a point is reached where going further either obviously makes no sense, or is of no additional help. If you are now looking at something you can fix, you are at the “root cause” for the purpose of the exercise. Yes, you can probably keep going, but part of this is knowing how far is far enough.

Is this something I can fix easily?
Does it make sense to go further?

Otherwise, iterate again.

Now: Devise a countermeasure.

A countermeasure, itself, is a hypothesis. You are saying “If I take this action, I should get this result” i.e. the problem goes away.

Put the countermeasure into place. Does it work? That is yet another experiment only now you are (hopefully) confirming or refuting your fix on every production cycle. The andon will tell you if you are right.

We tell people “Ask why five times” but we really don’t teach them how to “ask why.”

The book examples usually show this neat chain of cause/effect/cause/effect, but the real world isn’t that tidy. When the problem is first being investigated, each level often has many possibilities. Once the chain is built then the chain can be used as a check.

But that isn’t how you GET there.

Why don’t the books do a good job teaching this?

“They” say that critical thinking is difficult to teach. I disagree. If the people who do it unconsciously can step back and become consciously competent, and know how they do it, then it breaks down into a skill, and a skill can be taught.

A Real World Example
My computer works, but it’s network connection to the outside world doesn’t.
OK. What could be wrong?
It could be software in the computer.
It could be a problem with the hardware.

Look at where the cable plugs into the back of the computer. Are the little lights flashing? No? Then there is no data going through that connection.

How could that be?

Well.. the it could be a problem in the computer or operating system.
It could be a problem with the hardware in the computer.
It could be a bad cable.
It could be a problem behind the network jack on the wall.

The QUICKEST thing to do is unplug the cable and plug my co-worker’s cable into the computer. (Please make sure he isn’t busy with email before you do this!). Do the lights come on? Yes? Does your network stuff work now? Yes? Then it isn’t anything in the computer. You have just done a hypothesis test – conducted an experiment.

Take his KNOWN GOOD cable out of the wall and plug it into your jack. Does your network work now? Yes? You have a bad cable. No? It is a problem behind the jack.. call I.T. and tell them. (unless you are at home, then head to the little blue box in the basement and start looking at flashing lights down there. But same process.. as you systematically eliminate internal causes, you are left with an external one.)

This is a natural flow, but most people wouldn’t describe it as “asking why?” or “hypothesis testing” – and the big words scare them off.

Still – when you (the lean guru) are teaching others, it is important for them to understand HOW TO ASK WHY is just a process of learning by systematic elimination of the impossible. (Whatever remains, however unlikely, must be the truth – Author Conan Doyle through Sherlock Holmes)

How The Sensei Sees

Steven Spear told an interesting story in our session with him.

A Toyota sensei, very senior, was looking at a process unlike anything in his previous experience base. The researchers watching expected him to do “analysis by analogy” – to take what he observed, find a matching analogy in his deep experience, and then draw conclusions about the current situation.

This model, by the way, is a commonly accepted one for how “experts” work with new situations.

But that isn’t what happened. The insights were very fundamental, and quite specific to the process he was seeing for the first time.

The way he worked was revealed in the way he described the issues.

“Ideally,” he would say, “it should be ___________ . But the problem is __________ .”

In describing the “problem” he would describe the departure from the ideal situation. In so doing he was seeing problems, not as “seeing waste” but as seeing “departure from the ideal.”

This was, at least for me, a fairly significant ah-ha. I realized two things immediately.

  1. If I may be so bold, I got some insight into what I did in the same situation. At the risk of over-stating myself, I have found I am fairly good at getting to the core issues when looking at a process. Becoming a little more concious about it will, first, let me be better at it and, more importantly it will allow me to be much better at teaching others to do it.
  2. Tying back to #1, we teach this wrong. We teach people to look for “waste.” We teach them to look for ways to “make the process better.” We are always measuring “what could be” from a baseline of “what is.” This is totally backwards.

What we should be doing is measuring “what is” from a baseline of “what is perfect?”

What is the difference? I think it is important on a couple of levels. First is simple engagement of the workforce.

Ask someone “How can we make your work better than it is?” And the question carries all kinds of baggage. It says “Obviously you don’t do it as well as you could.” Whether or not it is meant this way is irrelevant. That is how it, all too often, comes across. The common symptom of this thinking is when you hear “This is as good as we can make it.”

Ask, instead, “Where is this process imperfect?” or “What gets in your way of doing this perfectly?” and you disarm the above objection. Anyone who works in the midst of complexity encounters dozens or hundreds of things every day that must be worked around or somehow coped with. All of those things take time, effort, energy, and each decision about how to handle something unforseen brings in the possibility of getting it wrong – making a mistake.

Think about it – how many mistakes result from someone just trying to figure out what should be done to correct some kind of anomaly, and making the wrong judgment?

Over the next few posts I am going to continue to beat these concepts to death from different angles. Forgive me in advance – it is my way of exploring it in my mind, and I am using you, the reader, as a sounding board. Writing things down forces me to think about them in more detail.

Shingijutsu Kaizen Seminar – Day 1

As I mentioned in the last post, this is the third time I have been through one of these events. The first time was in 1998, then again in late 2000, now in 2008 – so it has been a while. As you may or may not know, the company that was Shingijutsu back in 2000 had an internal factional split a few years ago, so now there are two of them. This seminar is being conducted by what I would call the “Nakao faction.” It was a credit to Nakao-sensei that he recognized me, as did his son and daughter who are also working for the company. They are all very good people, as usual.

The first day of these seminars is lecture.

I will be the first to tell you that the Japanese style of teaching, especially when filtered through an interpreter, can be difficult for a Westerner to follow. Nevertheless, it was good to re-grounded on some of the very basics.

Take-away quotes:

“I have them see what I am seeing.”

– Nakao-sensei describing taking a senior manager to the shop floor and questioning what she saw until she saw “it.” My early postings about “the chalk circle” reflect my own experience with the same thing. My note to myself was:

“Teaching through directed observation is a core concept.”

This is very consistent with the experience recounted in Steven Spear’s article “Learning to Lead at Toyota.”

The other key point (at least for me) was the end of a story told about the response to recommending more frequent deliveries from suppliers:

“That would be expensive.”
Response: “Why?”
And thus, the muda is revealed when implementing better flow merely as a thought experiment.
Many years ago Hirano published the same advice: Force single-piece-flow, at least temporarily, into the process to reveal what waste you need to work on. Then work on it.

Tomorrow we go to the shop floor. I found out that I am the “team leader” for this group of people, about half from my company, so it should be an interesting experience. There is a very diverse spread in the level of knowledge and understanding. I asked this afternoon who had not had experience with time studies before. Those are the people I will put on the point for gathering the current condition as this is a learning exercise. Too often people get obsessed with the targets, or with proving they “already know this” – that’s not the point, and not what our companies are paying us to do here. We are supposed to be learning.

Good night, it is an early morning.

Getting Leaders Involved

“How do I get the leaders involved?” How often have we all heard, or even asked, that question? Of course the actual answer is “you can’t.” At least you can’t force them to. But there are things that might help the leader decide to get involved.

I think the biggest mistake people make is to assume that in the face of adequate logical argument, a right-thinking leader will see the benefits and jump right in. This thinking ignores one simple truth: Leaders are human. Humans, in spite of our desire to believe otherwise, make decisions at an emotional level, and then construct a logical argument to support the decision. Actually we construct illogical arguments, carefully shaping, amplifying, demoting, excluding evidence to rationalize what we want to do. We humans would all like to believe (or would like other humans to believe) that our decisions are logical and rational. Sorry, just ’tain’t so. Advertisers and marketers know this, as do good politicians.

Another big mistake is to think it is possible to use measures to “make” them engage. “If only,” it is thought, “we used the right metrics.” Again, sorry. You can’t measure people into behaving a certain way. An even worse approach is to try to measure “lean implementation” as if you can quantify it by looking at what tools are in use. That, at best, drives the wrong behavior with shallow understanding. At worst, it poisons the entire implementation. Counting kaizen events falls into this category, as does demanding central reporting on them.

True leaders do what they believe are the right things, metrics be damned. And the ones who focus all of their decisions on making the metrics look good are not the people you want to have that kind of responsibility.

So what does work?

Let’s go back and think through what we want here.

Consider this: We emphasize full involvement and participation from the people who carry out the production processes, but we don’t demand the same level of participation from the people who carry out the management process.

So what do we do to get the production people fully participating? I can’t speak for anyone else, but what I have found that works is to give them the opportunity to step back and just watch the process and understand what is actually happening.

Remember, there are no guarantees. Nothing is a sure bet. But if you buy the argument that a purely logical argument probably isn’t going to do it, then you need to look at how to make an emotional impact.

I think the key is to help them see one important thing: Most of the things which disrupt people’s work are small. They are small problems, and each one has a small impact. It is the cumulative impact of these issues which overwhelm the traditional response system.

But those small things are also wonderful because almost anyone with a little time, a little smarts, and a little leadership support can come up with countermeasures that make those problems go away. Since “smarts” is pretty much randomly distributed in the organization (meaning no one has a monopoly on it by virtue of position), it is the other two ingredients which leadership must provide.

The classic “kaizen event” is a wonderful way to teach just what this is about. In fact, that was the original intention of the classic “kaizen event.” I have already talked about that. But you don’t need a formal kaizen event to do this, you just need you and a leader willing to humor you.

Take your leader down to the work area. Stand with him “in the chalk circle” and give him a running commentary of what you see. Call out everything that isn’t value-add, and get him thinking why that activity is necessary. Then go fix something. The two of you, together. Go get the cardboard, the bins. Go propose a couple of solutions to the affected worker(s). Going to them with something concrete to bounce from is a more effective way (in the beginning) to get their input than asking them a totally open-ended “What do you want here?” question.

Try a few things, make an improvement.

Then make another. Then another.

Work at this for as long as you can get away with it.

Then ask your leader to do the same thing you just did with him, only do it with his direct report(s). At that point, try to shift your role to that of a facilitator and adviser.

If you succeed, you leader catches kaizen fever.


I guess four months into this, it kind of makes sense to talk about waste. But rather than repeat what everyone else says, maybe I can contribute to the dialog and toss out some things to think about.

Identifying / Seeing Waste.

Taiichi Ohno had 7 wastes, a few publications say 7+1. I have always disliked trying to put “types of waste” into buckets. I have seen long discussions, some of them fairly heated, about which list of wastes is “correct” and whether this waste or that waste should be included, or whether it is included in another one. None of this passes the “So What?” test. (A related military acronym is DILLIGAS, but I’ll leave it as an exercise for the reader to work out what it means.)

The problem, as I see it, with lists of categories isn’t the categories themselves. It is that we teach people using the categories. We make people memorize the categories. We create clever mnemonics like TIMWOOD and CLOSEDMITT. We send them on waste safari with cameras to collect “examples” of various types of waste. Well.. you can’t take a photo of overproduction because it is a verb. You can only photograph the result – excess inventory. So which is it? People end up in theological discussions that serve no purpose.

Like I mentioned in an earlier post, teach it by inverting the problem. The thing people need to understand is this: Anything that is not adding value is waste. If you understand what value is, then waste is easy to see. It is anything else. What category of waste is that? Who cares. That only matters when you are working on a countermeasure.

What about “necessary waste?” Even Ohno concedes there is some of that. OK – ask “does this work directly enable a task that does add value?” Then it is probably necessary – for now.

Let’s take a real-world example from my little corner of the world – welding. Welding is pretty easy. If there is an arc, it is very likely value is being added. Not always, but it is a good place to start. Now – watch a welder. What does he do when he is not “burning wire?” (the phrase “and producing a quality weld” has to be tacked onto the end of this because I can burn wire, but it doesn’t mean I am welding.)

What stops the welder from welding? When, and why, does he have to put down the gun and do something else? For that matter, what makes him let go of the trigger and stop the arc? Is he loading parts into the jig? Does he have to jiggle those parts into place? Does he have to adjust the jig?

Special Types of Waste

In spite of what I said above, there are two types of waste that merit special attention. Most everyone who can spell “J-I-T” knows that overproduction is one of them. I won’t go into it here – anyone who is reading this probably already gets that at some level. If I am wrong about that, leave a comment and I’ll expand.

The other is the “waste of waiting.” Of all of the categories, overproduction is clearly the worst, but the waste of waiting is the best. Why?

It is the only type of waste that can be translated directly into productivity. It is the waste you are creating as you are using kaizen to remove the others. That is because all of your kaizen is focused on saving time and time savings, in the short term, turn busy people into idle people.

Let me cite some examples:

  • The Team Member is overproducing. You put in a control mechanism to stop it. Now the team member must wait for the signal or work cycle to start again before resuming work.
  • You remove excess conveyance by moving operations closer together. The person doing the conveyance now has less to do. He is idle part of the time where he was busy.
  • Defects and rework – eliminate those and there is less to do. More idle people.
  • Overprocessing – eliminate that, less to do.
  • Materials – somebody has to bring those excess materials. Somebody has to count them, transport them, weigh them. Somebody has to dispose of the scrap.
  • Inconsistent work or disruptions: Eliminate those and people are done early more often than they were. More idle time.

If you look at a load chart, these are all things which push the cycle times down. You have converted the other wastes to the waste of waiting.

Now your challenge is how to convert that wait time to productivity. What you do depends on your circumstance. You can drop the takt time and increase output with the same people. Or you can to a major re-balance and free up people – do the same with fewer, and divert those resources to something productive elsewhere.

Does something stop you from doing that? Do you have two half-high bars that you can’t combine onto one person? Start asking “Why?” and you have your next kaizen project. Maybe you have to move those processes closer together, or untie a worker from a machine.


  • Don’t worry too much about teaching categories of waste. Teach people to see what is truly value-adding, and to realize everything else is waste – something to streamline or eliminate.
  • In most cases your kaizen activity will result in more waste of waiting. This is good because wait-time is the only waste that converts directly to increased productivity.

Do Your People Solve the Problem or Work The System?

This article by Anita Tucker and Amy Edmondson at Harvard highlights a problem that is as common on the manufacturing floor as it is in the hospitals they studied:

When people encounter a problem that stops their work, they work the system, get what they need, and continue their work.

A lot of people call this initiative, and most organizations reward this behavior. Many of those organizations have actual or implied negative consequences for bringing up an issue that “you could have solved yourself.” Unfortunately this behavior only accomplishes one thing: It guarantees that the problem will occur again.

What is the big deal? Simple. Small problems accumulate. They do not go away, and more come into play every day. Eventually the Team Members are overwhelmed by “too much to do.” Supervisors press for “more people,” the organization grows in size, and the cycle continues. In health care all you have to do is spend an hour talking to harried nurse to know all of the things that keep them from providing patient care.

Go stand in the chalk circle on your own shop floor. What things keep your Team Members from doing their jobs?

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.