Silver Laze

Fil is the winner of Name this Blogpost with "Silver Laze"! Definitely the most original and thought provoking title, if you followed the comments section of this post. Fil, contact me via email and I'll send you a copy of the Job Instruction Participant's Manual! Thanks for your contribution to the TWI Blog!

Here is what happened today...I think it is shaping up to be a good genba lesson for me...

My manufacturing manager came to me late in the day and informed me of a mistake that was made. It was a pretty expensive mistake, but not the end of the world. The short story is that the person who made the mistake knows how to repair the problem and bring it back to standard, but not without a little self-inflicted pain to the budget and schedule. On the other hand, the long story begins with the question: "How can this problem be prevented from reoccurring?" The reason for the mistake is known by the person who did it. I asked him the question..."What happened?"

He replied, "I've done this a hundred times, it shouldn't have even happened." He was feeling pretty bad at this point.

I tried to encouraged him, "Look, I get that, you are good at your job. But these things happen to the best of us. Based on what you demonstrated, this was bound to happen at some point. Don't beat yourself up, its in the past. Let's focus on what can be done now. Can you show me the mold and we will take a look at how things happened?"

This seemed to bring him around and open to discussing mistake-proofing ideas, but I could see that he was still dwelling on the mistake that he felt he shouldn't have even done this to begin with. Part of me did wonder if he thought I was barking up the wrong tree. After all, he was the one that had been doing this for 30 years, not me. What did I know about this anyway? Persistent and maybe even naive, I offered up an idea, careful to not steal his monkey and let him off the hook to think about the problem a bit more: "What if a protective device were installed to prevent damage to the mold? I'm not sure how it could be done and the device would have to be designed a certain way to do the job, but what do you think?"

We discussed this for a few minutes, to the point where he was starting to carefully weigh design ideas. He had concerns about creating a shield, but it would prevent damage from reoccurring. He would give it some thought. He then pulled out the tools used in the incident again and wondered aloud how those could be modified, or replaced, to prevent the damage. We were interrupted by others looking for me to attend a meeting, so I thanked him for fixing the mistake and taking the time to talk with me. I will need to follow up with him in a day or so to see what is next for a permanent solution against recurrence.

In the meantime, I'm really not sure what the lesson(s) are here, but the following things come to mind:

1) The result of the mistake is large, somewhat complex and disruptive in nature.
2) The root cause of this problem is relatively simple.
3) An experienced person didn't foresee this problem occurring.
4) A two minute demonstration of the mistake made it obvious that this has always been a potential problem.
5) If left untouched, this problem will occur again.
6) Are people thinking about potential problems as they do their work?
7) Are my shop floor leaders helping people see problems and supporting them in kaizen solutions?
8) Simple questions can lead to ideas.
9) Would we have come up with credible ideas if we didn't go to genba and directly observe the job?
10) More simple questions led to complicated obstacles in the way of the simple idea.
11) Anything else...?

I have a feeling that this is going to lead to more work... :)

In writing this post tonight, my intent was to share a lesson, but how to summarize this lesson in a simple blog post title? I'll leave that to you. Please email or post your suggestion in the comments below. The winning title will receive one free copy of the Job Instruction Training Manual!