Archive | March 2016

Root cause analysis Rule #3


This week I’ve seen a problem that happens (sadly) all the time.

Imagine a company / department / team that has a problem (e. g. equipment failure that could impact the product quality). People who work at the work center and their immediate supervision meet at the gemba and agree how to investigate the problem. Some ask their managers if it is ok if they investigate, management says “of course, we believe in people, you are the experts, we trust you”. The team thinks, develops ideas, tests, learns together (e.g. “what are the equipment failure modes?”, “how could we detect them?”, “how can we know is this error has happened?”, “how can we prove our hypothesis right or wrong?”, “how can we evaluate if the product is still good?”). They discover the root cause of the problem and develop an action plan to avoid it in the future.

They call a meeting to share their learning with the site directors and then….. shit happened. I’ll list the sad list of problems:

  • Directors came to the meeting with their own root cause analysis (of course, none of them had been at the work center or had spoken with any of the workers). It was a nice PowerPoint Ishikawa.
  • Directors developed their own action plan. It was a wonderful MS Project file.
  • The first time a team member talked at the meeting was 15 minutes after the meeting had started.
  • The team’s improvement ideas were ignored. No director asked about their analysis or improvement action plan. The team had spent more than 20 hours in 2 days doing their investigation.
  • Most of the meeting time was used by management to show why their ideas were great. 2 team members tried to talk and make a point about their ideas, but they were ignored. The team stayed in silence the rest of the meeting.
  • One director finished the meeting asking: “But, what do you think about this?” Another one said she was very happy to see the team working together. Nobody else said a word.
  • When leaving the meeting, one worker said “I’ve learned something. Never think by yourself.”

Meeting minutes:

always right 2

Director actions were implemented and the problem happened again 3 days afterwards.

This story is an example of one of the most important questions about problem solving: “what is the role of management in problem solving?” The tricky part is to see the difference between “supporting” and “doing somebody else’s job”. Remember rule #3: Problems must be solved by those who do the job. How can we do this? Let’s listen to the experts:

Management must move from “telling what to do” to “asking questions that provoke the right thinking”. Telling people what to do takes away responsibility from the person. Management main goals are a) find and frame problems by observing (at the gemba) front line learning and b) challenge, enable and remove obstacles for front line while they are solving problems.

Daniel T. Jones, Lean Conference 2014

The most important question from the management side is “What are your problems?” Management work is not to solve problems by themselves, but to develop problem solvers. Otherwise, you’ll become a manager like this:


Lean principle #5: Seek perfection


Lean looks for the perfect process: perfect value with no waste. That’s why “seek perfection” is one of the lean principles defined by the Lean Enterprise Institute (learn more here). Perfection means providing customers with a safe product (Health), of high value (Quality), on time and in the right quantity (Delivery) and affordable (Cost). Additionally, the process must develop problem solvers who improve the product and increase value (People) and take care of the community and the environment (Morale)

Some might say that aiming for perfection but thinking that improvement is a never-ending journey is a contradiction. Is it possible to believe in the Lean Principle #4: Improvement is a cycle (the “PDCA” principle) and pursuing perfection at the same time? Yes!

There are 2 reasons why perfection and trial-and-error philosophies are compatible:

  1. Perfection is a never ending journey: The perfect use of resources is theoretically impossible (link). We can get better and better but reducing waste to zero would need an immense amount of resources (which is waste itself). Using math terms, improvement tends asymptotically to perfection.
  2. Customer needs change over time: In other words, customers raise the bar constantly and request new features and products. Even if the perfect process was possible, we need to change direction and adapt constantly to the new definition of good.

In summary, Lean is about adapting processes to customer needs, all the time, no matter how quick they change. The better one company adapts to customers and the environment, the more successful it will be.

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