One of my favorite book genres are “whodunits”. There are many to choose from and they have been popular for decades. Great crime solvers such as Hercule Poirot, Sherlock Holmes or Nero Wolfe were always willing to pull apart fact from fiction to get to the truth.
Television has given us many additional detectives like James Rockford, Columbo, Jessica Fletcher, Quincy or more recently Monk. Each detective sets out to gain an understanding of the situation, gathers the evidence and finds out “who did it and why.”
In the same vein, I think “manufacturing spills” are like “whodunits”. Something happened that wasn’t intended to happen. There is investigating, questioning and more importantly listening, tediously poring over data, and brilliant insight. Like Abby on NCIS – data is gathered and a picture of what happened falls into place.
My husband’s fishbone on why his NCAA brackets performed poorly.
One tool that helps unravel the complexity of all the inputs is a fish bone diagram. It is a simple tool – you don’t need a fancy software package, or an expensive piece of measuring equipment. All you need is a piece of paper and a pencil. Heck, write it on the whiteboard, just don’t use a permanent marker.
First identify the main categories that could fail. In manufacturing the “usual suspects” are: man, machine, method, material. These become the main “bones” of your diagram.
Next – based on your investigation (i.e., going to the floor and having conversations with people, uncovering the extant data), you begin identifying what could possible fail for each category. These become the tributaries of the main bones. Then, using your “5 whys”, establish why these failures happen.
Using this data, each path can then be addressed:
- How likely is it?
- Who is a player, who is not?
- What is worth further investigation?
- Is a solution established?
Some of the paths may just be “innocent bystanders” pretending to be the real issue but are not. However until you lay it all out, the complexity of the moment can become an emotionally charged powder keg. Certainly you could yell at each other but who’d win? Nobody. So don’t do that.
Instead, like Columbo, Bones or Jethro Gibbs, gather the clues, pull them apart piece by piece, strip out the emotion and you can get to a focused, causal solution everyone can agree on. Then take action!
The deductive route is not easy and can be painstaking. But the changes are lasting.
Have you ever been around a young child who starts what I call the “why game”? They ask a simple question and follow every answer you provide with “why?” until the adult says in frustration, “Cause I said so!” I read somewhere that children do this in all countries and languages because they have found that it keeps adults talking – so they learn about something and learn the language.
One of the tools in “corrective actions” is answering the “5-whys”. It is a wonderful tool to really understand the path that caused the failure.
Here are FIVE ideas that can make this tool even more successful for you…
1. It doesn’t have to be 5. It could be 4, or it could be 10. The number is not the important thing.
2. You ask why until you get to what can be actionable such that the problem is fixed – sustainably
3. If you start with the wrong first why, you will never get to the answer. Sometimes, you have to do the why-path a couple of times to get to a best answer
4. Don’t answer based on your opinion. Rather go ask some questions of the team. Their input will put you on the right path.
5. You should be able to read the whys in order, saying why in-between. If you read them out loud, you can tell easily if they flow correctly.
When you do 5-Whys, do not, EVER decide what your corrective action is and then work backwards. You could be cheating yourself and your team out of the real answer by focusing on a correlated, not causal, action. And WHY would you do that?
Learning from history is not a new concept, nor is it specific to manufacturing. Learning from past mistakes, ours or others, ensures progress. So why is the exercise of “corrective actions” so annoying? Partly the time it takes, partly because of people’s attitudes involved, partly because we suspect the process is flawed, or partly because we erroneously think our manufacturing floor is too complex for 5 Whys. Sadly, many view “corrective actions” as punishment and the tools in the bucket the execution of the punishment.
Fundamentally, corrective actions and the tools to help are based on tried and true ways to “fix” stuff. They offer strong platforms to ensure you get to the causal, not the correlated, issue. However, they take time and persistence.
Over the next few weeks, I want to explore some of the building blocks of corrective actions, things like 5 whys, PDCAs, 8Ds, fish bone, 4Ms.
If these are not part of your vocabulary, tools you pull out daily, I would argue you aren’t really focused on corrective actions.
I believe discipline makes us better – it comes in all forms and it always improves us.