An extremely important instrument in WWII was the B17 Bomber. Unfortunately, there was an issue with them. The planes were “crashing”. Well, specifically, the landing gear was being retracted after landing, while the planes were on the ground. The propeller would hit the ground, destroying the engine, and rendering the plane useless.
After many destroyed planes, it was finally diagnosed as a pilot error. As it turned out, the B17 was the first plane to have hydraulics to power both the flaps and the landing gear. When coming in for landing, pilots would lower the flaps and then lower the landing gear. After they landed, they would raise the flaps. However, sometimes pilots would accidentally raise the landing gear instead of the flaps. Commanders were furious! They tried everything, checklists, training, and finally discipline and pilot dismissal. Let’s pause here for a second and think about the financial and resource loss to the military associated with pilot dismissal.
Finally, 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 and it attached it to the landing gear control. Low and behold, the problem NEVER happened again.
The problem of making people the problem
Making people into problems is first-order thinking that goes like this: identify the person who made the error, discipline or get rid of that person, problem solved. Unfortunately, the world is substantially more complex than that. John Willis, 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 like Endsight can learn from Lean principles. One of the first principles is that in the “lean” mode, culture is king. None of the tools will work without a cultural foundation to build on. In that vein, lean companies must change their language and attitude from “Who caused the problem?” to “What caused the problem?”
I can already hear the skeptics! “…but sometimes someone actually did cause a problem, right? What about accountability! Doesn’t this give individuals permission for lazy thinking or thoughtless action?”
Another story – Toyota’s brake suppliers bring production to a grinding halt
Another story: At some point in the 80s, one of Toyota’s brake suppliers had a serious issue that stopped production of brakes. 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. 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) were going to 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:
- “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 **** together.”
What if professional services had an Andon Cord?
Let’s also introduce the idea of the Andon Cord. The Andon Cord was a physical cord that ran through the entire assembly line. Pulling the cord stopped the entire line. Assembly line workers were praised every time they pulled the cord. The culture was such that each pull (in essence a quality failure) was considered a learning opportunity, thus more pulls was considered better! More pulls meant that learning was occurring faster. When the number of cord pulls was too low, managers would increase tolerances to make sure the line was constantly improving. At Toyota, quality issues were considered learning opportunities. They were never buried and always shared amongst all workers (without shame) to increase the system learning.
In the lean model you never…ever…knowingly pass defects to downstream work centers. When a defect hits a downstream work center, the Andon Cord is pulled and production stops dead in its tracks. The mission becomes about learning (while production is paused). Problems get addressed and quality improves with every mistake.
Back to the skeptics, you can’t take things out of context. When all workers are completely bought into the idea of never passing quality defects to downstream work centers, then (in that model) all workers approach the defect in blameless fashion. “What (not who) caused this problem?”
As you can imagine, most errors are in fact human errors, but even in those cases, 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 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 really easy to see. It’s a big pile of parts that can’t ship due to defects. It’s wasted raw materials in a pile somewhere. Our commodity of “time” is elusive and intangible. However, we need to be relentless about reducing waste of this most precious resource. For example, in software, you can see waste in a feature of the software that isn’t used or that clients aren’t willing to pay for. That’s wasted code, which equates to wasted time.
Nine ways toward greater quality and reduced waste
Below I’ve listed some items that any company has to address in order to move toward greater quality and reducing waste:
- Foster a “blameless” culture necessary to engage frontline staff. For example, an organization must have employees who are 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 our problems.
- View organizational problems as system problems, not department problems. Like the 1000 engineers in 100 companies in the Toyota supply chain, work on the most pressing problem of the company even, no especially, when it has nothing to do with our department or individual responsibility. Work in a value stream. No “supplier” in the value stream wins unless the whole car ships. Think, “We are all in it together.”
- Don’t just simply point out a problem and let “them” fix it. Get involved, offer solutions, and truly see what you can do to help.
- Never value your own work center above the entire work system (or value stream). Sometimes it’s compelling to let work pass to a downstream work center with a quality issue because it saves your work center valuable time. Think about how damaging this is to the system. Not only does it cost the system more time, it also erodes trust.
- Time can never be a reason to pass quality issues to a downstream work center. If your work center is a bottleneck, there are tools (like Kanban boards) to deal with it, but passing quality issues down destroys the output and efficiency of the value stream.
- Pull the Andon Cord. Don’t cover up problems in the value stream! We must see problems as they occur! 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, eliminate low-value work, etc. 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 maintain 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 - 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 passed from reviewers to engineers, and errors in fulfillment that go from engineer to the 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. Learning can be multiplied and mistakes don’t have to happen multiple times with multiple people. If lean principles are adopted, this process could be so dialed in that it would be the crown jewel of the company.
Accepting mistakes is the key to lasting growth
A process is not made to stand still. Each mistake offers us an opportunity to make the process more efficient and less prone to errors. Leadership needs to cultivate their organization toward a culture and a mindset around mistakes. The more Andon pulls the better. This is what defines a learning organization that can learn at a faster pace than market competitors who cover mistakes or force a seasoned employee to pay for it. A culture that accepts mistakes and moves through them in a healthy way can perform at high levels. This is one way Endsight aims to raise the quality of everything we touch.
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