WHY Must This Happen?

This is irritating.

From the Safety Files at online mag, Machine Design.com, we learn how poor maintenance resulted in an on the job injury.

Bottom line: a poorly maintained dock leveler crushed a person’s hand. We can imagine how a five why session may play out in this situation. If you prefer to, please go to the article link above and follow along with the full story and pictures.

Q - WHY did the person’s hand get crushed?
A - The lip on the ramp hit the truck, building up tension and then jumped loose, pinching his hand.

Q - WHY did the truck hit the ramp?
A - Well, it wasn’t the truck that hit the ramp. It’s really the other way around. Normally the ramp clears the truck bed and then in full extension the lifter it swings the lip to extend from vertical to horizontal. This time it didn’t. So the lip just got caught on the truck.

Q - O.k. WHY didn’t the lifter clear the truck bed?
A - Well it did, but it just didn’t get to its full extension which is what swings out the lip and bridge the gap between the dock and truck bed.

Q - O.k., so WHY didn’t the lifter reach full extension?
A - I’m not sure. But we do know it doesn’t work the way it should. I have to manually lift that lip each time. I’ve asked to have somebody take a look at it but nothing has been done.

Q - HOW do you lift that safely then?
A - Well, I use a hook to pull the chain that engages lift mechanism. That allows me to manually lift the lip edge from inside the truck while the dock lowers.

Q - Is that hook provided by the manufacturer?
A - Nope. I made it so I could get the job done. Drivers are waiting for me you know and we have ontime shipments to make!

Q - Well, HOW does the manufacturer recommend to you the operation of that lift?
A - Normally the chain is pulled through a hole on the other side of the ramp. But because it doesn’t work, I have to be on that side of the ramp, inside the truck, to make it work correctly. The hook allows me to pull the chain from inside the truck.

Q - Let's ask a mechanic why that lift mechanism isn't working properly...

By now you should be getting the point, of which there are many.

#1 - A questioning attitude in the genba is the only way to see and understand these types of problems. Hosin Kanri workshops for five days and four glorious nights at an offsite conference center in San Diego will not solve this problem. Only a genba approach will do. (My apologies to Hoshin Kanri consultants in San Diego who may offer pricey workshops for five days - it just seemed like a nice place to go when you are in Vermont and WINTER WON'T GO AWAY!)

#2 - NEVER stop questioning until you get to root cause and can verify your line of questioning through cause and effect. 5Y doesn't really mean ONLY to ask WHY? five times. (tangential- random-thought-taking-over: The next time I see a 5Y worksheet with only five questions on it...well, that's what us lean consultants have marketed it as, eh? We only have ourselves to blame.)

#3 - Our problems do not exist on their own - they live on and become parasitic because we allow them to. The system is a direct reflection of the architects and keepers of that system - namely MANAGEMENT. Leaders make management better.

#4 - There is a saying in lean: "to find the waste, look for the piles of inventory." The same is true with makeshift devices. The makeshift hook is a clue for shopfloor leaders that something is wrong.

#5 - The MOST troubling point out of all of this is that the drivers "had repeatedly complained about the dock leveler problems" - yet NOTHING was done. Scratch that - management allowed something to be done: they permitted the driver to craft a hook so he could operate defective equipment that put his family's livelihood, the business itself, other truck drivers and the leveler manufacturer at risk. This scenario represents the eighth waste in manufacturing - waste of intellect and at the very least it demonstrates ZERO respect for people and in this case the lack of respect went WAY beyond just the employee.

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