Respect, Standards and Jidoka

Many years ago I wrote an article for SME called The Essence of Jidoka. In that article I described a four step process designed to improve productivity and drive continuous improvement. Since then these four steps have been picked up and incorporated into the training materials of many consultants, used to write the Wikipedia article on jidoka (which I most assuredly did not author), and even found their way into some academic papers. Sometimes with attribution back to my article, may times without.

In that article, “jidoka” was described as a four step process:

  1. Detect a problem.
  2. Stop.
  3. Fix or correct the problem.
  4. Find the root cause and implement a permanent countermeasure.

But I would like to take a hard look at the first step: Detect the problem. This is where, I believe, most organizations actually fall down. And in doing so, they also fall down on respect for people.

The key question is: “What do you consider a problem?”

Most organizations do not see a problem until the symptoms are bad enough that they are compelled to do something about it. This means people have been struggling with issues for some time already. The machine isn’t reliably producing good parts. Or someone is having to rework material. Or the supplies cabinet is always short, and the nurses have to launch a safari to find what they need.

Contrast this with a company like Toyota. Every Toyota-trained leader I have ever dealt with is very consistent. A problem is any deviation from the standard. More importantly, a deviation from the standard (1) forces people to improvise and (2) is an opportunity to learn.

This definition, of course, leads to a question: “What is a standard?”

Probably the best explanation to date is in the research done by Steven Spear at Harvard. His work was summarized in the landmark article Decoding the DNA of the Toyota Production System.

Spear’s research concluded there were four tacit rules for how activities, information connections, flow paths, and improvements were designed and executed in Toyota operations. Each of those rules describes:

Any deviation from the standard triggers some kind of alert that gets someone’s attention. And whose attention is explicitly defined – That is a standard as well.

As I look at a work area, I often see a lot of 5S type of activity. Things and their intended locations are marked and labeled. These are standards. They establish what should be where. But the question to ask is “What happens if something is out of place?”

That is a deviation from the standard. It is a problem.


Fix or Correct (put it back – restore the standard condition)

Investigate the root cause

“What’s going on with the air wrench today?”

“Actually it is an extra one.”

“Really? Where did it come from?”

“I borrowed it from the Team Member in work zone 3.”

“Ah, OK. Why did you need his?”

“The regular one isn’t working.”

“Hey – thanks for letting me know. I’ll get it to maintenance.”


“Did you tell anyone about the problem before now?”

“No, I just borrowed the wrench. I just needed to get this job done, then forgot. It’s no big deal, it’s easier to just borrow Scott’s wrench.”

And in that exchange, what have you discovered about your daily management system by simply being curious about a trivial deviation from a 5S standard?

Is this the Team Member’s fault?

Probably not. What is your standard? What is he supposed to do if the wrench stops working? Is there an escalation process and a response for this kind of small stoppage? Or are your Team Members just expected to find a way to work through the issue? Which of those responses is more respectful of the Team Member who spends her time trying to create value for you?

Often times there is no standard.

But without a standard you have no way to tell if there is a problem (other than a feeling that something isn’t right). And if you are sure there is a problem, without a standard you can’t really define what “fixed” is.

So start with defining the standard. First, go back to Decoding the DNA of the Toyota Production System. You can get an idea of the kinds of things you should standardize.

As you think of standards, consider a standard for your standard:

  • Express it from the viewpoint of the process customer.
  • Define it in a way that can be verified as “met” or “not met.” No gray zones. You can quantify the magnitude of a problem, but not whether you have one.
  • There is a visual or other control tells the appropriate person, right away, if there is a deviation from your standard?
  • Is there a standard that triggers a response to clear the problem?

5S is nothing more than the first step of setting standards. Many people say to start there, but don’t say why. The point is to practice setting standards and holding them. Taiichi Ohno is quoted as saying:

“If there is no standard, there can be no kaizen.”

Any deviation from the standard is a problem.

Your choice, as a leader, is how to handle that problem.

More About Mistake-Proofing

After yesterday’s post about trucks crashing into the famous 11foot8 bridge and mistake proofing, I got the feeling I should drive home my key point that the problem isn’t with the driver, it is with the environment.

As of this writing,  Jürgen has recorded 154 crashes of overheight vehicles into the bridge.

And I’ll put even money that if all of the data were known, this process would pass any test for statistical control and we are getting what we should expect from a stable system. It might not be what we want, but it is what we should expect. (All images are copyright  Jürgen Henn,

So addressing the individual incidents probably isn’t a solution. In any case, it is unlikely that any driver will repeat the mistake.* For the TWI folks – this isn’t really a Job Relations type of problem. It might feel like it is, but it isn’t.

In the Factory

I was working with a company with a similar problem. Their inspectors kept missing defects. The response was often to say “I don’t see how she could have missed that!” and even write them up for failure to do something that wasn’t particularly well specified.

But the fact on the ground was, like the bridge, the misses weren’t confined to any particular individuals, any particular shift, any particular anything. People missed things all of the time because the expectations greatly exceeded the limitations of what humans can do for 12 hours (or even one hour). It isn’t an inspection problem. (The reliance on inspection vs. upstream controls is another topic for another day.)

People Work Within a System

It is all too easy to fall into the “bad apple” fallacy and seek out someone who was negligent. It feels good, like we did something about the problem. But the problem will happen again, with someone else. Then I hear frustrated managers start to make disparaging comments about their entire workforce that “doesn’t care” about quality.

I challenged a quality manager to do that inspection job for two hours – not even a complete shift – under the watchful eye of the inspector whose job he was trying to do. Funny – he was a lot slower to assign blame after that experience. He couldn’t keep up.

Deming was pretty clear about the ineffectiveness of exhortation as a way to get better performance. “Be more careful!” might well work for one individual for a short time. “Making an example of someone” might well work for a group for a short time. But there are norms, and the system will return to those norms very quickly. There are simple limits to what humans can focus on and for how long.

The Bridge is a Metaphor

To be clear, the bridge represents a working system, but it is different than what we would find in a company. This is public infrastructure, and the truck drivers that get featured on the videos are not part of a single organization.

This means that you have more control than the city engineers in Durham do. You can establish procedures, ask questions, train people, have them practice, alert them to the Gregson Street Bridge on their route. You can make sure your navigation system routes your trucks around the low bridges. You can support your people so they are less likely to even end up in the situation. All of these are system changes – and that is what it will take to change the outcome.

Change the System: Raising the Bridge

In late 2019 the city of Durham, in coordination with the railroad who owns the bridge, did actually raise the bridge by 8 inches. It is now 11 feet 16 inches (3.76m).

And that is a legitimate approach. Rather than trying to create infallible humans, what can we do to make the system less vulnerable to fallible humans.

While that likely reduced the number of trucks that hit the bridge…

*Caveat: There is one video where a truck seems to avoid the bridge, then circle back around and hit it. And another video where a truck that hit this bridge then proceeded to run into another low bridge with the damaged truck.

Mistake Proofing – Getting People’s Attention

Besides being a great source of schadenfreude, Jürgen Henn’s website, 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:

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:

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: 🙂

There is a follow-up to this post here:

KataCon4 Keynote: The Meta-Patterns of Innovation

Yes – the title isn’t a typo. This goes back to KataCon 4 in Atlanta. Though I had attended all of them, this was the first time I actually spoke at one. My task was to follow Rich Sheridan and share why I thought his message was a powerful one for an audience of Kata Geeks even if he wasn’t specifically talking about Toyota Kata in his company.

As an experiment, I took the sound recording from my talk and synchronized it with the slide deck. (That is harder that it sounds, by the way.) As another experiment I am sharing it via hosting on WordPress (the back-end of this site) rather than YouTube or a similar host. It is a little over 13 minutes long, and there is another experiment below it.

Simon Sinek – Remote Teaming Tips

How Remote Teams Can Connect Meaningfully – Simon Sinek – March 20, 2020

We are all being pushed into the zone beyond our knowledge base right now – having to rapidly adapt and adjust to different ways of working together.

This morning Craig Stritar forwarded a cool little video to me from Simon Sinek’s YouTube channel. In it Steve Shedletzky, a member of Simon’s team, introduces their weekly huddle – a way that this team, which has been working remotely for years, maintains their connection to one another.

One of the keys here is that this meeting is not a conversation about the business at hand. There are other meetings for that. This one is intended to strengthen the social bonds of the group.

They dedicate 75 minutes a week to this task. The video is a condensed version to give us a taste of their structure.

And it is structure that makes it work. It is structure that makes sure no individual dominates the conversation, and structure that keeps it from becoming the kind of wide-ranging conversation that happens over beer and pizza.

It is structure that gives them the freedom to hear and be heard.

With that – here is the video.

For those who can’t see the embedded video, here is the YouTube link:

Thoughts and Notes from KataCon 2020

This is the first in series of posts I am drafting about what I saw, heard, learned at KataCon6 in Austin.

I was originally writing this up in huge chunks, maybe two posts. But when I bounced the “Part 1” draft off Craig Stritar, I got some good advice – there are a lot of topics here, and it might be more useful to break these up into smaller pieces, so that is what I am doing.

My intent is to generate discussion – so I would like to explicitly invite comments, questions and especially take-aways from others. In other words – let’s continue the great conversations that were taking place in Austin.

Day -1 and Day 0

Lean Frontiers traditionally runs the TWI Summit and KataCon back-to-back in the same week, alternating which comes first. This year the TWI Summit was Monday and Tuesday, and KataCon was officially Thursday and Friday.

Both conferences, though, have semi-formal activities and get-togethers prior to the first official day. Since there are things going on Wednesday, some people begin to arrive Tuesday evening. And because I was already on site from the TWI Summit, Tuesday evening is really when things got started for me.

Something I have observed in the past is that each KataCon seems to take on an informal theme of its own – a common thread or feeling that is established more by the participants than the presenters. Where the first KataCon was the excited buzz of a community coming together for the first time, this one seemed to me to be like a reunion. To be clear – it was a welcoming reunion. Unlike other conferences I have attended, there is nothing “clique-ish” about this one.

With that reunion theme, I want to give a shout out to Beth Carrington. She is a vital member in the fabric of this community and this is the first KataCon she has missed. I think I can speak for all of the regulars when I say “we missed you.” Those who do not know you still felt your presence and influence through your impact on the rest of us.

The other thing (for me) that was cool was just how much of the conversation took place after hours in the hotel lobby bar. There were long-time regulars catching up, and there were first-timers and newbies getting rich tutorials and insights from the veterans. That is why I titled this section starting with day “-1.” Those conversations were happening on Tuesday afternoon and evening as people started to arrive.

This is a community of sharing. Many of us are consultants and nominally competitors in an increasingly crowded market. Yet nothing was held back. We build on each other’s stuff, and pretty much everyone shares what they are thinking with everyone else. That’s pretty cool in my estimation.

The Kata Geek Meetup

Kata Geek Button from KataCon 1

The Kata Geek Meetup started at the first KataCon. At the time it was an informal mailing list invitation to attend a get-together before the conference started. Everyone got a “Kata Geek” button to wear with the idea that the other conference participants could identify those with a bit more experience under their belt if they wanted to ask questions, etc. The event wasn’t publicized on the conference agenda.

Over the years this has morphed into a mini-preconference that is open to all who can attend. People share brief presentations – maybe something they want to try out for an audience, maybe a rhetorical question, maybe a “what we are learning.” The pacing is much more flexible than the actual conference, and there is time for lively discussion and Q&A. Sometimes tough, challenging questions get asked – though always in the spirit of curiosity rather than trying to one-up anyone.

As I get into the actual content, I want to clarify my purpose in writing what I do. When I listen to presentations, I am more likely to take down notes of what thoughts or insights I take away than the actual content. These things are often a fusion of key points the presenter is making, or the way they are saying something, and my own paradigms and listening framework. That is what I am writing about here. I am not making any attempt to “cover” the presentations as a reporter or reviewer would or be complete in mentioning everything that was said.

PLEASE contribute in comments if something I didn’t mention resonated with you, or something written here sparked another thought for you.

Dorsey Sherman made a simple point: All coaching is not the same. It depends on your intention (as a coach).

Thinking about it a bit, the classic TWI Job Relations is coaching – usually (in its original form) to fix or change behavior in some way. TWI Job Instruction is coaching – in this case to teach / coach for skill. At a deeper level, the classes themselves are designed to give novice coaches a structure they can practice.

The Improvement Kata framework itself is a pretty universal structure that I can pour a lot of different intentions into and test ideas that I think will move me in a particular direction. I think all coaching is a process of exploring and experimentation simply for the fact that we are dealing with other people. We may begin with assumptions about what they think, know, feel but if we don’t take deliberate steps to test those assumptions we are just guessing in the dark.

Hugh Alley

Hugh is a friend from neighboring beautiful British Columbia. I recall telling an audience in British Columbia that Canada represents that nice couple living quietly in an apartment over a rowdy biker bar. 😉

A couple of take-aways I noted down as Hugh was speaking:

  • The storyboard represents a picture of the learner’s mindset – it is like an MRI.
  • Correction: Hugh informs me (see his comment below) that the MRI analogy came from Panos Eftsa.

I loved that analogy. When I look at the storyboard I am really seeing how organized the learner’s thinking is, how detailed, and whether or not they are connecting the dots of cause and effect from the levels of their target conditions to their metrics down to their experiments and predictions.

I thought of an image like this:

Public Domain: From Wikimedia Commons

Hugh was asking the audience about his situation of a client company that started up 13 storyboards at once. Some of the thoughts that came out:

  • Um… OK, you have already done that. *smile*
  • Establish a specific area of work for each board, each coach. Don’t try to bring them along all at once.
  • Work through each phase of the Coaching Kata, anchor success and mastery one-by-one rather than trying to batch everything through at once.

What was good about his client’s approach, though, is they are establishing a routine of people talking about why the work is the way it is – and that is awesome.

Toyota Kata Level-Set

At this point I am letting go of trying to write in the sequence of the agenda. There are topics I want to go deeper into, others I may combine.

Oscar Roche

The Toyota Kata Summit attracts people across a wide spectrum of knowledge and experience with “Toyota Kata” itself. Balancing the conference can present a real challenge. There are people who have been practicing this in the trenches for a decade and are pushing the boundaries. There are people who might have read the book and are curious about learning more.

One of the countermeasures is a “level set” presentation at the beginning of the formal conference. This is a brief overview of the fundamental principles of Toyota Kata and I think it is a good grounding for the veterans as well – it is always good to pull us back to the basics now and again.

Traditionally Mike Rother has done the “level set” presentation. This year, though, was a change and Oscar Roche stepped up. Oscar’s title slide drove home a critical point that we often miss:

  • “Kata is the a thing that helps you develop the a way”

His next slide answers the implied question:

Scientific thinking is a mental framework of continuous comparison between what we predict will happen next, and what actually happens, then adjusting our understanding based on the difference.
My thoughts – and a digression

A lot of practitioners get hung up on the idea that the way they know best is the best way, sometimes to the point of believing it is the only way. This is true for Toyota Kata practitioners, general “lean” practitioners, Six Sigmites, Theory of Constraints, TQM, you name it.

Sometimes I hear people make sweeping statements that dismiss an entire community, perhaps focusing in on one thing they perceive as flawed. “Lean addresses waste but not quality (or not variation).” “TOC doesn’t address flow.” “Six Sigma is only about big projects.” “Toyota Kata is only about the storyboard.” All of these statements are demonstrably false, but it is hard to have an open minded discussion that begins with an absolute.

All (credible) continuous improvement has a foundation of scientific thinking. Any approach you take has some basic “first moves” to get you started thinking that way. Toyota Kata is more explicit about that than most, but the underlying principles are the same across the board.

Oscar’s opening slide emphasized this point: Toyota Kata is a way, not the way. We can all learn to adapt vs. continuing to hammer on a nail that has hit a knot and is bending over.

Steven Kane

  • A teacher provides insight.
  • A coach pulls insight from the learner.
  • You may go back and forth between these two roles. Be crystal clear which role you are in at the moment.

I’ll probably write more about this in the future in a separate post. What I liked about this thought is that it is appropriate for the coach to provide direction or insight at times. My own presentation at KataCon kind of hinted at this – someone has to bring in the paradigm of what “really good” looks like.

Nevertheless, it is critical for the coach to drop into the “teacher” role only when necessary (which I think is a lot less often than we like to think it is), and then get back into true “coach” mode as quickly as possible. Why? Because unless I am in “curious” mode with my learner, I really have no way to know if my brilliant insights got any traction. 😉

Paraphrasing from Steven’s presentation, the question “What did you learn?” is there to see if there has been a moment of discovery.

  • The Power of Nothing

The most powerful follow-on question to “What did you learn?” is silence. If initial response is fluffy or vague, or you think there is more, just wait. Don’t try to say anything. The learner will instinctively fill in the awkward silence.

  • Target Condition vs. a Result

This came up a lot during the conference. Billy Taylor talked about the difference between “Key Activities” (KA) vs. “Key Indicators” (KI or KPI). What are the things that people have to do that will give us the result we are striving for? Leaders, all too often, push only on the outcome, and don’t ask whether the key activities are actually being carried out – or worse, don’t think about what activities are required (or the time and resources that will be required). I’m going dedicate a post on that topic.

And finally (and I am making this one bold so I remember it!) –

  • Don’t rob the leaner of their opportunity to make discoveries.

How often do we do that?

Michael Lombard

Michael had a brief presentation on “What we are learning” focused specifically into the health care field. His thoughts on medical students actually apply universally with anyone who perceives themselves as successful.

  • We need to de-stigmatize struggle. Productive struggle is part of deep learning. Medical students should not feel shame when they struggle to learn a new skill.

Why do they? Michael pointed out that the people who manage to get admitted to medical school are high-achievers. Things may well have come easily for them in high school and their undergraduate studies. Now they are in a group with other high-achievers, they don’t stand out from the crowd, and the concepts can be difficult to master.

We see the same things in other environments – a lot of people in senior positions of authority got there the same way. Many are ultra-competitive. Now we are asking them to master a skill that runs entirely counter to their paradigm of intuitive decision making. Note that that intuitive decision making has worked well for them in the past. But maybe they are at the limit of what they can do themselves, and have to find ways to engage others. I don’t know… there could be lots of scenarios that put them into completely unfamiliar territory.

Our challenge is how we de-stigmatize struggle.

Michael’s other key point touched one of the Wicked Problems in health care. I’m going to go into some more depth when I get to Tyson Ortiz’s presentation, but want to acknowledge the Great Question posed here:

  • “99% of activity needed to maintain wellness never involves a health system. Can we increase the striving capabilities and mental resilience of our patients, families, & communities so they can own their health journey?”

Amy Mervack

Amy tied our practice to the concept of “mindfulness.” One of her key points was learning to see that the pattern we are trying to teach may well be there in some form other than the explicit Improvement Kata.

She wrapped up with some guided practice of “being mindful” for the audience – which she said stretched her a bit as she had never done it with a group that large.

As a change agent, a mindfulness approach is critical. We have to learn to find everything about the way things are being done that we can leverage and extend. This means paying attention vs. the mindless approach of dismissing them out of hand with a single statement. Making people feel wrong may get attention focused on you, but it rarely helps make progress.


The afternoon was “Experientials” – four hour breakout sessions that went deep into a particular topic. As Craig Stritar and I were hosting one, I didn’t attend any of the others. Always a downside of being up-front – I see more of my own stuff than the awesome things others bring.

As I mentioned above, I am going to be digging into some of the topics in more depth, and I want to keep those individual posts focused vs. trying to cover a rich diversity of discussions all at once. Hmmm… one-by-one vs. batching. That might be a concept. 😉

The Cancer of Fear

File:Nandu River Iron Bridge corrosion - 03.jpg

I am sitting in on a daily production status meeting. The site has been in trouble meeting its schedule, and the division president is on the call.

The fact that a shipment of material hadn’t been loaded onto the truck to an outside process is brought up. The actual consequence was a small delay, with no impact on production.

The problem was brought up because bringing up process misses is how we learn what we need to work on.

The division president, taking the problem out of context, snaps and questions the competence of the entire organization. The room goes quiet, a few words are spoken in an attempt to just smooth over the current awkwardness. The call ends.

The conversation among those managers for the rest of that day, and the next, was more around how to carefully phrase what they say in the meeting, and less about how do we surface and solve problems.

This is understandable. The division president clearly didn’t want to hear about problems, failures, or the like. He expected perfect execution, and likely believed that by making that expectation loud and clear that he would get perfect execution.

That approach, in turn, now has an effect on every decision as the managers concern themselves with how things will look to the division president.

Problems are being discussed in hallways, in side conversations, but not written down. All of this is a unconscious but focused effort to present the illusion that things are progressing according to plan.

Asking for help? An admission of failure or incompetence.

This, of course, gets reflected in the conversations throughout the organization. At lower levels, problems are worked around, things are improvised, and things accumulate and fester until they cannot be ignored.

They the bubble up to the next level, and another layer of paint is plastered over the corrosion.

Until something breaks. And everyone is surprised – why didn’t you say anything? Because you didn’t want us to!

In a completely different organization, there were pre-meetings before the meeting with the chief of engineering. The purpose of these pre-meetings was to control what things would be brought up, and how they would be brought up.

The staff was concealing information from the boss because snap reaction decisions were derailing the effort to advance the project.

And in yet another organization they are getting long lists of “initiatives” from multiple senior people at the overseas corporate level. Time is being spent debating about whether a particular improvement should be credited to this-or-that scope. It this a “value improvement,” is it a “quality improvement,” is it a “continuous improvement” project?

Why? Because these senior level executives are competing with one another for how much “savings” they can show.

Result at the working level? People are so overwhelmed that they get much less done… and the site leader is accused of “not being committed” to this-or-that program because he is trying to juggle his list of 204 mandated improvement projects and manage the work of the half-a-dozen site people who are on the hook to get it all done.

And one final case study – an organization where the site leader berates people, directly calls them incompetent, diminishes their value… “I don’t know what you do all day”, one-ups any hint of expert opinion with some version of “I already know all of that better than you possibly could.”

In response? Well, I think it actually is fostering the staff to unite as a tight team, but perhaps not for the reasons he expects. They are working to support each other emotionally as well as running the plant as they know it should be run in spite of this behavior.

He is getting the response he expects – people are not offering thoughts (other than his) for improvements, though they are experimenting in stealth mode in a sort of continuous improvement underground.

And people are sending out resumes and talking to recruiters.

This is all the metastasized result of the cancer of fear.

Five Characteristics of Fear Based Leaders

Back in 2015 Liz Ryan wrote a piece in Forbes online called The Five Characteristics of Fear Based Leaders.

In her intro, Liz Ryan sets out her working hypothesis:

I don’t believe there’s a manager anywhere who would say “I manage my team through fear.”

They have no idea that they are fear-based managers — and no one around them will tell them the truth!

And I think, for the most part, this is true. If I type “how to lead with fear” into Google I get, not surprisingly, no hits that describe the importance of intimidation for a good leader – though there are clearly leaders (as my example above) who overtly say that intimidation is something they do.)

My interpretation of her baseline would be summarized:

People who use fear and intimidation from a position of authority are often tying their own self-esteem to their position within that bureaucratic structure. Their behavior extends from their need to reinforce their externally granted power, as they have very little power that comes from within them.

They are, themselves, afraid of being revealed as unqualified, or making mistakes, or uncertain, or needing help or advice.

I have probably extended a bit of my own feelings into this, but it is my take-away.

She then goes on to outline five characteristic behaviors she sees in these “leaders.” I’ll let you read the article and see if anything resonates.

Liz Ryan’s article is, I think, about how to spot these leaders and avoid taking jobs working for them.

This post is about how the organization responds to fear based leadership.

The Breakdown of Trust

A long time ago, I wrote a post about :The 3 Elements of “Safety First”. Today I would probably do a better and more nuanced job expressing myself, but here is my key point:

If a team member does not feel safe from emotional or professional repercussions, it means they do not trust you.

Fear based leadership systematically breaks down trust, which chokes off the truth from every conversation.

Here is my question: Do you want people to hide the truth?

If the answer is “No,” then the next question is “What forces in your organization encourage them to do so?” because:

Your organization is PERFECTLY designed to produce the BEHAVIORS you are currently experiencing.

– VitalSmarts via Rich Sheridan

Lessons from Driving a Forklift

The spring and summer of 2000 were a long time ago, but I learned some lessons during those months that have stayed with me. In fact, the learning from that experience is still happening as I continue to connect it to things I see today.

I was a member of a team working hard to stand up a new production line of a new product. The rate pressures were very high, the production, production control, and quality processes were immature.

At a high level, the parts flow was supposed to work like this:

Steel parts are fabricated and welded, based on the production schedule for various configurations.

Unit sets of parts were sent to outside paint. (We didn’t have our own paint system yet.) In reality, unit sets would be broken up as some parts went to sister plants, others went to outside vendors, each with their own lead times and flow times.

Parts return from outside paint. Because of the different vendors and lead times, different parts arrive on different days.

On assembly day, kits are built for the parts required at each entry point on the assembly line. Those kits are delivered based on a pull. The assembly line had a number of entry points and feeders, so for each takt time cycle, though only one “unit’s worth” of parts were actually delivered, those parts were for different units, as feeders had different lead times into the main line.


The innocuous challenge was to develop the kitting process (in red) that broke down the parts into  kits and got them delivered to the line.

I got pulled in on Thursday of a “kaizen event” that was supposed to develop this process. What had actually happened, though, was analysis paralysis, a lot of theoretical discussions, a lot of drawings on a white board, but nothing had actually been tested or tried. My assignment was simple: Organize this and get it going on Monday.

I had four people working for me, though they were not officially direct reports. They were an eclectic mix of personalities and styles.

A few things became apparent very quickly:

The process of scheduling which parts needed to be fabricated and welded to be sent through painting on any particular day was broken. Result: What was needed wasn’t necessarily what got sent to paint.

The processes of keeping parts organized during the various outside paint operations was broken. Result: Unit sets got mixed together, parts went missing.

As a result this is what my days looked like:

I came in before a hint of dawn at 4:45am to prepare for the assembly line starting at 5:40. I would go out into the parts yard with the day’s production schedule and a flashlight. My goal was to answer a simple question:

What units on this list can I build with the parts that are here?

I would re-sequence the production schedule to front-load the units that looked like we had everything we needed. (This caused all kinds of problems with serial number sequences and engineering change control, but that is a different story.)

We would start pulling in those parts, and breaking them down into the kits. We set up FIFO lanes for each entry point on the assembly line, and worked as fast as we could to build up about a three hour backlog. Why? Because it took about three hours to expedite a missing part through paint. Once we had that queue built up, as we discovered shortages (or parts painted the wrong color!), we had a chance to get the situation corrected and have a shot at not creating a shortage on the line.

We were working 10 hour shifts, I was typically there for 12-14 hours. Even though I was a “lean guy” my daily work was orchestrating all of this chaos, expediting and delivering parts, and I spent at least six of those hours every day driving a forklift. I got really good at forktruck operation that summer.

At the end of the day, I might sit and chill for a little while, then would get in my truck, go home, and do it all again tomorrow. One of those days as I went to back out of the parking space, I hit the turn signal to put my stick-shift truck into reverse – because that’s how the forklift controls worked.

What I Learned

I actually continue to learn. But here are a few things that have stood out for me.

Shop Floor Production Supervisor is a really hard job. I wasn’t a supervisor, but I was doing many of the things that we asked supervisors to do. Making my people take their breaks. Slow down on the pallet jack. Listening to a frustrated guy who was ready to quit – understanding his paradigm, and helping him re-frame his experience. Constant radio calls to places in whatever building I wasn’t in at the time. Operating within a system that functions only with continuous intervention.

I totally knew how to set up a workable, stable process. I knew how to get all of these processes linked together to pull everything through. I knew how to build in effective quality checks.

What I was able to do was spend a few minutes at the end of my day, or during my lunch breaks (instead of eating) trying to implement some kind of simple visual control that mitigated against repeating a mistake we had just made. We attached a tag with a production sequence number (000 through 999, repeating) to each kit. That let us, and the people on the line, see if we had delivered something out of sequence.

Then, after I had delivered a yellow painted kit to go onto an otherwise blue painted unit (oops) we made a board with the production sequence numbers and the associated colors for the major components.

Then… after I had delivered (note the theme here) the wrong size of a major component to the line, we added that information to the board AND tagged those components so we could quickly distinguish one from the other.

But I was never able to address the upstream issues that were delivering short kits to us in the first place. All I could do was add steps, add time, add inventory to protect myself from those things and do my best to fix it before the main line got stopped.

We had a saying in the Army: “When you are up to your a$$ in alligators, it is hard to work on finding the best way to drain the swamp.”


It is unreasonable to expect systems improvements when everyone is scrambling to make the system function at all. It isn’t that they don’t want to make improvements. It isn’t that they don’t know what to do. It is that there is barely time to breathe before the next problem needs to be stamped down.

And finally: A five person job requires five people. I had four people working for me. That wasn’t enough. Guess who had to fill in the rest of it? I tried my best to handle the problems so they could get into some kind of cadence on the stuff that wasn’t a problem. But (Routine+Problems) = (or greater than) 5 people in this case, and it took all of us just to navigate the rapids without dumping everyone out of the boat. If everything was running smoothly, it was probably a three person job. If we could have set up a sequenced pull from assembly all the way back through weld, it would have been a two or even one person job.


That forklift key is still on the keyring in my pocket as a reminder of that time. What follows are some of the bigger-picture things that come to mind as I continue to construct, tear down and reconstruct my own thinking.

Attribution Error

There is a strong tendency among us humans to attribute our own failures to a poor environment, but to attribute other’s failings to individual character or capability. Yet in many cases, simply changing the venue or circumstances can allow a previously low-performer to blossom. We see this (and the opposite) all of the time in professional athletics.

Making this error is easy when we are talking about “they.”  If only they… Why don’t they… They don’t get it… “They” are people who are likely doing the very best they can within the context of the system they are in. And, as I pointed out above, changing the system from the inside is hard.

Actually that isn’t quite accurate. Changing the system is hard work.

The Pace of Change

The organization I was describing above was experiencing circumstances at the time that outpaced their ability to experiment, reflect, and adapt. Every organization has a rate at which they are able to change.

Just to make things more complicated, it is possible to learn what must be done much faster than those things can be put into place. This frustrates a lot of change agents. They see the technical changes that must take place, but often struggle against cultural barriers and obstacles. These things take much longer, and it is pretty much impossible to put them on a fixed timeline or project plan. Thus, we frame them as “resistance to change.” We know what must be done, but “they” don’t do it.

Organizations Under Stress

When an organization is under stress, there is fear of complete breakdown. People become very conservative and avoid the uncertain and unfamiliar. If they become overwhelmed just trying to get their task done, they are going to shut out any information that isn’t relevant right now. Horizontal communications break down, and the feeling of isolation increases.

At this point, all coordination has to funnel upward and then downward through the vertical linkages, as cross-functional coordination largely isn’t happening.

Now the higher leader gets overwhelmed, feeling she has to micro-manage every detail- because she does. “Why don’t they talk to each other?” Well, the structures for that were probably very informal, and now have broken down.

This Isn’t About “Them”

As I mentioned above, it is really easy to attribute the perception of dysfunction to individuals. And as people become isolated within their own task-worlds, avoiding a mistake becomes the dominate motivation. This happens even in organizations with the most benign intentions.

If you are a leader, pay attention to the emotions. If people are snippy, are pushing back on ideas as “just more work” then that saturation point may well have been reached. Pushing harder isn’t going to make things go faster, it is going to slow them down.


Creating Resistance As You Go (Don’t)

The role of “change agent” is actually a role of leadership.

Leading change is difficult work that involves changes in the norms, routines, working relationships, behavior within and between groups. It is required when a simple technical change either isn’t going to get the job done, or requires the above changes to work at all. Most (if not all!) of the “lean tools”* fall into the later: The process changes are straight forward, but making them work requires altering the habitual patterns of how people work together.

Before I dive into what works, I want to spend a little time on what doesn’t work.

The Bulldozer: Creating Resistance

Bulldozer climbing a mound of dirt.

A team had a challenge – the result they were striving to achieve – of getting a 2-3 week administrative workflow (that sometimes went longer) down to a consistent three days. Their target condition was a pretty good work flow that, by all accounts so far, could avoid a lot of delays (on the order of days and weeks).

The changes they proposed would eliminate a number of transfers from one department to another (which always means another queue). However it also calls for eliminating some long-standing work-arounds that involve filling out forms and passing them along by email. But now they have a new ERP system, and the intent has been that this work is done within that system.

Those forms are in another department’s process, and involve people who haven’t been involved (so far) with the work to date. (There are valid reasons for this, and yes, some of this could have been avoided by involving everyone from the beginning, but that isn’t the point of the story.)

A functional department manager set off a flurry of pushback through a series of emails that essentially said “This is the future” and exhorting people to get on board with the new process vs. defending the old one.

One of the tenants of an effective change agent is “Don’t work uphill” with the corollary of “Don’t create hills in front of you.” I call the opposite of this the bulldozer approach. Unfortunately, like the picture above, just trying to push things through tends to build up a mound of resistance in front of you.

What did we learn?

Rather than trying to engage the new idea as an experiment – “Let’s try this and see what we learn,” the change agent tried to use position power to push the idea through. He took an action, and had an (implied) expected result – that people would see the light and adopt the new process.. The actual result, though, was quite different than what was expected – they doubled down on their resistance.**

A scientific-thinking change agent (a.k.a “a leader”) is going to step back and assess. Why did I get the reaction I did? What triggered it? What are the values of this constituency that are being challenged? Most pushback comes from a perceived threat to something that is regarded as valuable.

Perhaps the current workflow solves a very real problem. Perhaps it is otherwise very useful for something I am not aware of. Or maybe there is some emotional stake attached to the status quo. There is likely a combination of all three, or other factors I haven’t mentioned.

When proposing a new idea there is an opportunity to become curious about what previously hidden (to us at least) obstacles have just been uncovered, step back and work on the next one.

Leadership is a series of experiments. Not everything will work. But everything is an opportunity for learning and adjusting or adapting the next step appropriately.

People who expect their position-power to carry them through often tend to assign blame to individuals as “resisting the change.” But if we carry a different assumption – that everyone is doing the best they can to do the best job they can – then we can reframe and possibly reinterpret the reaction we are getting.

What other interpretations could we assign to this pushback other than “They don’t want to?” How many of those interpretations can we think of?

What is your next step or experiment?

Each of those possible interpretations is a testable assumption. Now I can frame my next action, conversation, or intervention to test one or more of those assumptions. This requires me to go into curiosity mode, because I really don’t know if they are true or not.

Now I have a different conversation because I am seeking first to understand. I can test assumptions without threatening anyone. Listen. Don’t defend. Paraphrase back until you hear “That’s right” signaling agreement that you heard what they were saying. That doesn’t mean you agree, but that you heard. Until someone feels heard they aren’t going to be soaking in what you are trying to tell them, they are going to be setting up the next defense of their position.

There is VERY rarely a need to directly confront someone over a different interpretation of the facts.

Don’t be a bulldozer – it doesn’t work.


*And Six Sigma tools, and Theory of Constraints tools, and TQM Tools, and the tools associated with pretty much any other “program” that falls under the umbrella of continuous improvement.

**Though, Dr. Phil’s coaching would probably be something along the lines of “What did you THINK would happen??” (Semi-apology to my non-US readers who may not have context for this attempt at cultural humor.)

The Ecosystem of Culture


An organization’s culture and mindset evolve over time. When confronted with a problem or challenge, the organization (or more accurately, the people in the organization) view it through a filter of their experiences. Ideas that they believe have worked for them under past similar conditions are more likely to be applied again. Ideas that have seemed less successful, or more difficult, in the past are less likely to be applied again.

Over time, this collective experience determines how they respond to the day to day rough spots as well as more serious challenges. Those unconscious biases drive the responses, and in turn, shape how their processes are structured.

Different Cultures = Different Ecosystems

The process mechanics in a company like Toyota evolved over decades in a very specific organizational culture ecosystem, with specific values and beliefs shaped by their historic experiences.

When we are looking at the current processes in a different company, we are seeing the process mechanics that evolved in their management culture. Those process mechanics are optimized by the pressures that are exerted by the way THAT company is managed. Since Toyota is managed differently, its processes are optimized by different pressures, so will look different.

If we take Toyota’s process mechanics and shift them into a different ecosystem, they will have the different pressures exerted upon them. Different default decisions will be made. These alien process mechanics will likely begin to resemble the legacy processes rather quickly, if they survive at all.

This is why the promise of a rapid and dramatic change in operational results is frequently unfulfilled. The process mechanics are imported from a tropical rain forest, and installed in an alpine meadow. As beautiful as it looks in one environment, it won’t stand for long in the other.


Adjusting the Culture vs. Adjusting the Process Mechanics

If we want this transplant to work, we have to pay careful attention to those evolutionary pressures. In practical terms, this means we try the new mechanics, we must watch carefully to learn what problems they reveal. We also need to observe the decisions that are made when these problems come up.

What adjustments need to be made in the way people interact, and to the immediate response to problems or surprises if this new process is to thrive?

Having a formal structure for this deliberate self-reflection is critical.

The Improvement Kata is engineered to specifically drive this kind of reflection by making changes as experiments, then deliberately reflecting with the question “What have we learned?”

For this to work, of course, we must be honest with ourselves and not just issue a flip answer like “It doesn’t work.”

Because we are asking people to adjust their responses, we are asking them to do things which are unfamiliar and may well run opposite from what they have experienced as successful for them in the past. If we try to move too fast, we are asking them to trust an alien process which is, in their experience, unproven in their environment. We might be asking them to reveal their own limits of knowledge – which is very scary for most of us.

That, in turn, asks for reflection on why “I don’t know…” is so scary to admit in the organization’s culture.

We have sold “lean” as a deceptively simple set of common-sense process mechanics with the idea that if we just implement them, we’ll get incredibly great results. As true as that is, “just implement them” is a lot harder than most of the “rapid improvement” models imply.

There is a lot going on behind what appears to be well understood and simple on the surface.