The B17 Bomber became legendary during WWII. But it didn’t start that way: The planes were crashing because the landing gear was being retracted after landing while the planes were on the ground. This meant the propeller would hit the ground, destroying the engine, and rendering the plane useless.
After many planes were destroyed, it was finally diagnosed as a pilot error. Pilots would lower the flaps and then lower the landing gear when coming in for a landing. After they landed, they would raise the flaps. However, sometimes, pilots accidentally raise the landing gear instead of the flaps.
Commanders were furious! They tried everything – checklists, training, discipline, and pilot dismissal. Think about the financial and resource loss to the military associated with pilot dismissal!
Fortunately, a mechanical engineer took a different approach to the problem. He noticed that the controls were identical and very close to each other. He decided to try a novel countermeasure. He made a little flap and attached it to the flap control and a little wheel to the landing gear control. The problem NEVER happened again.
The problem with making people the problem
Making people into problems is first-order thinking: identify the person who made the error, discipline or get rid of that person, and the problem is solved. Unfortunately, the world is substantially more complex.
John Willis, IT manager and the author of the “Phoenix Project,” says, “By making the person the problem, we deprive ourselves of being able to learn from error and to create effective preventive measures for the next person."
One of the most well-known and understood Total Quality Management (TQM) systems is called “Lean” and was originally developed at Toyota. Over the years, Lean has been adapted for service organizations, and there are many things that companies can learn from Lean principles.
One of the first principles of Lean methodology is that culture is king. None of the tools will work without the right cultural foundation. Lean companies must change their language and attitude from who caused the problem to what caused it.
Toyota’s brake suppliers bring production to a grinding halt
Here’s a great example.
At some point in the 1980s, one of Toyota’s brake suppliers had a serious issue that stopped production. The story goes that over 1000 different engineers from over 100 different supply chain companies stepped in to help solve the problem on behalf of the brake supplier and production was restored.
On the surface, this type of action from the supply chain is obvious. You can’t sell a car without brakes, no matter how well-built the engine, tires, exhaust, etc. Given that no cars (and no supply chain parts) would ship without brakes, nothing was more important to any of the businesses in the value stream than the brake supplier’s current outage.
Still, think about the obvious and usual reactions you would probably expect from Toyota and the rest of the supply chain:
- “Unacceptable”
- “They need to be held accountable!”
- “We’re doing our job. They need to do theirs!”
- “We’ll keep improving our business, while they get their act together.”
What if professional services had an Andon Cord?
The Andon Cord is a physical cord that runs through the entire Toyota assembly line. Pulling the cord stops the entire line. Assembly line workers are praised every time they pull the cord. The culture is such that each pull (a quality failure) is considered a learning opportunity. Thus, more pulls are considered better.
More pulls meant that learning was happening faster. Managers will increase tolerances when the number of cord pulls is too low to ensure the line is constantly improving. Learning opportunities are never buried and always shared amongst all workers (without shame) to increase systemic learning.
In Lean methodology, you never…ever…knowingly pass defects to downstream work centers. When a defect hits downstream, the Andon Cord is pulled, and production stops dead. The mission becomes about learning while production is paused, problems get addressed, and quality improves with every mistake.
I can already hear the skeptics! “…but sometimes someone did cause a problem, right? What about accountability? Doesn’t this give individuals permission for lazy thinking or thoughtless action?”
Well, you can’t take things out of context. When all workers embrace the idea of never passing quality defects to downstream work centers, then all workers approach the defect in a blameless fashion. “What (not who) caused this problem?”
As you can imagine, most errors are human, but lean companies look for solutions like the mechanical engineer with the B17 bomber. Pilots are too costly to develop and train and too important to the mission to dismiss, just like IT workers at IT service firms. Pilots and/or IT workers will likely be unmotivated by discipline.
What’s a more effective countermeasure: telling pilots to “be more careful” or attaching wings and wheels to the controls? Humans make mistakes, but by taking a blameless approach to defects, we surface facts quickly and encourage innovative, creative ways to prevent other humans from making those same mistakes.
Lean is about reducing waste
The Lean model is all about reducing waste. In manufacturing, waste is easy to see. It’s a big pile of parts that can’t ship due to defects. It’s wasted raw materials in a corner somewhere. The commodity of time is elusive and intangible. However, we need to be relentless about reducing the waste of this most precious resource. For example, in software, you can see waste in a feature that isn’t used or that clients aren’t willing to pay for. That’s wasted code, which equates to wasted time.
9 essentials for better quality and reduced waste
There are some items that any company must address to move toward better quality and reduced waste:
- Foster the “blameless” culture necessary to engage frontline staff. Organizations must have employees willing to surface errors, even if those errors paint them in a bad light, without concern that their individual reputation or professional status will be in jeopardy. Imagine how many B17 bombers could have been saved if pilots weren’t trying to cover their butts and instead explained the problem simply and quickly without fear of how commanders would react.
- Require a “what” versus “who” mentality when thinking about problems.
- View organizational problems as systemic problems not limited by department. Like the 1000 engineers in 100 companies in the Toyota supply chain, they work on the company's most pressing problem, even if it has nothing to do with a particular department or individual responsibility. Work in a value stream. No stakeholder in the value stream wins unless the whole product ships. The thinking should be, “We are all in it together.”
- Don’t just point out a problem and expect them to fix it. Get involved, offer solutions, and see how you can help.
- Never value your work center above the entire work system or value stream. Sometimes, letting work pass to a downstream department with a quality issue is compelling because it saves your department valuable time. Think about how damaging this is to the system. Not only does it cost the system more time, but it also erodes trust.
- Time can never be a reason to pass quality issues downstream. If your department is a bottleneck, there are productivity and project management tools to deal with it. Passing quality issues down destroys the output and efficiency of the entire value stream.
- Pull the Andon Cord. Don’t cover up problems in the value stream. We must see problems as they occur, and when we see a work quality issue, we must be willing to stop production and start learning.
- Be relentless about eliminating waste and wasted time. Reuse work, automate work, and eliminate low-value work. Your guiding principle should be that if your time doesn’t create value that meets or exceeds your professional rates, then question whether it makes sense to do it at all. If it does, find more efficient ways to do it.
- Fully commit your organization to maintaining a learning culture that multiplies learning. If one employee makes a mistake, all employees learn from it. Each of your pilots doesn’t need to crash a B17 bomber before you install a countermeasure.
A common professional services conflict – the tension between scope and fulfillment
I’ve heard about tensions between writers of project work scopes, reviewers of those scopes, and engineers who fulfill the scopes. Errors pass from writers to reviewers, errors pass from reviewers to engineers, and fulfillment errors go from engineer to client. In such cases, it’s easy to blame people and point fingers – who versus what.
The Andon Cord is never pulled, and thus, each mistake remains just that, a mistake. But when the Andon Cord is pulled, you can turn the mistake into an opportunity for the entire organization to improve. If lean principles are adopted, this process can be so dialed in that it would be the company's crown jewel.
Accepting mistakes is the key to lasting growth
A process is not made to stand still. Each mistake allows us to make the process more efficient and error-prone. Leadership must embody and cultivate a culture and a productive, learning mindset around mistakes.
The more Andon pulls, the better. This creates an organization that can learn faster than market competitors who cover mistakes or force a seasoned employee to pay. A culture that accepts mistakes and healthily moves through them can perform at high levels. This is one-way Endsight aims to raise the quality of everything we touch.
As we say, “standards emerge from years and years of trial and error.” Learn more about the Endsight way.
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