Category: Root Cause Analysis

Learning From Mistakes

always make new mistakes
Always make new mistakes (Photo credit: elycefeliz)

An event occurred this afternoon that required an immediate resolution. When asked whether we were going to pursue the root cause, I could only respond with this question:

What’s the point of making mistakes if we’re not going to learn from them?

This is likely the shortest post I ever published here, however, I think the simplicity of the message makes the point very clear.

If you do wish to delve deeper into the topic of mistakes, I encourage you to read some of the related articles featured below.

Until Next Time – STAY lean

Vergence Analytics

The Invisible Gorilla

Just when you thought everything was under control, someone asks you about something that isn’t even on your radar.  Our perceptions can be deceiving and are not always as accurate or reliable as we think.  This is nicely documented and demonstrated in this article and video that we found on Yahoo today:  The Invisible Gorilla.

If the above link doesn’t work, cut and paste the following link into your browser:

What does this mean to the lean practitioner?  Waste and other factors that can influence the performance of our operations are not always where we expect to find them.  Similarly, too much focus on one area can cause us to miss out on many other opportunities as well.

Often times a fresh eyes approach can reveal simple opportunities that are easily overlooked as the complex solution is being sought after.  We highly recommend using video as an integral part of the process review and assessment.  It is so much easier to play it back and review than attempt to recall our perception of the events of interest.

What we perceive may deceive if we aren’t careful with our analysis and the conclusions we are looking to draw.  Yes you may find what you were looking for but … what did you miss in the process?

Until Next Time – STAY lean!

Vergence Analytics

Solutions by Definition

3973 Problem solving
Image by godzillante|photochopper via Flickr

The recent British Petroleum (BP) oil dilemma brings yet another problem solving opportunity to the forefront.  Fortunately, few of us have to deal with problems of this scope and magnitude.

Problem solving is a daily challenge for many of us and, like the BP oil dilemma, rarely are they presented in clear and concise terms. Our ability to define and describe the problem is typically compromised by our innate desire to solve the problem before we truly understand what the problem is – all in the interest of “saving time”.

Our experience suggests that the following problem solving anecdote is worthy of serious consideration to improve your problem solving initiatives.

The formulation of a problem is often more essential than its solution, which may be merely a matter of mathematical or experimental skill.

… Albert Einstein

Until Next Time – STAY lean!

Vergence Analytics

The High-Velocity Edge Is Here!

Update:  Steven J. Spear has been awarded the Philip Crosby Medal for his book “The High-Velocity Edge: How Market Leaders Leverage Operational Excellence to Beat the Competition” according to a Press release from ASQ—the world’s largest network of quality resources and experts (Milwaukee, WI March 2, 2011).

We have raved about the book “Chasing the Rabbit” written by Steven J. Spear and have just learned that the book has been re-released under a new a title, The High-Velocity Edge: How Market Leaders Leverage Operational Excellence to Beat the Competition.  Recognizing that your time is a valuable commodity, we aim to provide information that is relevant to our readers and visitors.  This book provides much more information on certain topics than one could ever hope to achieve through a website or blog – hence our recommendation.

This is perhaps an unprecedented marketing strategy for what was an already very successful book.  In one respect this reflects the wisdom of Peter Drucker who suggested that there is a time to abandon the old (even if it is considered an award winning success) in lieu of the fresh and new.  The following are excerpts from the e-mail we received from Steve that explain the reasons for this change:

Dear Friends and Colleagues,

The High Velocity Edge shows the particular skills and capabilities that lead to broad-based, high-speed, non-stop improvement and innovation.  Master these and you achieve exceptional, rival-beating performance, even if facing intense competition. If you don’t, you watch as someone else wins

The book (and the website supporting it) are replete with examples of how these capabilities are developed and deployed in high tech and heavy industry, in design and production, in services like health care and in manufacturing.

There is Pratt and Whitney’s compression in time and cost of jet engine design, the Navy’s creation of nuclear propulsion  with breath taking speed, Alcoa’s achieving near perfect workplace safety, and the exceptional improvement of care in medical institutions.

Toyota features prominently as an example, both in showing how  successfully cultivating the capabilities introduced and illustrated in The High Velocity Edgeare the source of  tremendous competitive strength and also in showing how the capacity to develop such capabilities can be overburdened.

With the release of The High Velocity Edge, I’m testing new media approaches, being released on its website, to bring the book’s ideas into broader practice more quickly than traditional means alone allow.

Here’s a closer look at what is new.

New Title and Cover: Why a  new name and cover after three awards, versions in four languages, and flattering reviews?  Well, people do judge a book by its cover, and those who didn’t read the reviews or learn of the awards were too often left  wondering what was inside.  Not so with the new.

New material:  You’ll find a new preface and epilogue, drawing lessons about leadership, innovation, and operational excellence from  Toyota’s recent  struggles.

New media: I’m testing ways to  help  people master more quickly and reliably the skills that allow individuals and organizations to achieve broad-based, high-speed improvement and innovation.

On the way are an interactive web-based case study, an ‘open school’ course for those in health care professions, and a series of short tutorials to help people review what they’ve read and to help them teach what they’ve learned to their own students and colleagues. The results will be introduced on the book’s website.

Of course, there will still be postings, applying the principles of leadership, innovation, and operational excellence to current topics.

I certainly hope you find the new look, content, and format useful in pursuing perfection.

Please share your feedback, and let’s talk about how I can help you put these ideas  to use in your own organization.


Steve Spear

A high velocity organization is, in our opinion, a step above and beyond the traditional lean principles that are typical of most text books and seminars on this topic.  The High-Velocity Edge: How Market Leaders Leverage Operational Excellence to Beat the Competition will prove to be a worthwhile read and we highly recommend this to any company seriously seeking to take their organization to the next level.  We have also added this book to our recommended reading list.

Until Next Time – STAY lean!

Vergence Business Analytics

Foundations of Failure

The problem with many of the problems we find ourselves having to contend with at any given time is that we learn of their existence after the fact (when the damage is done) or after discovering that the results we were looking for simply didn’t materialize.  As we learned from Michael A. Roberto’s book, “Know What You Don’t Know“, there are a number of reasons why problems don’t surface until after the fact.  I highly recommend reading “Know What You Don’t Know” as well Steven J. Spear’s “Chasing the Rabbit” as both books present numerous examples and extensive research that span across a wide variety manufacturing and service industries.

In many cases, the pathology of a given problem reveals that much of the information surrounding a given failure, or series of failures, is “common” knowledge.  In isolation, many of the contributing factors appear to be insignificant or irrelevant.  However, when we review all of the “insignificant” bits and pieces of evidence as part of the whole, we discover that it is these “pieces” that make the puzzle complete.  This was certainly the case with 9-11, Three Mile Island, The Challenger, and perhaps even the most recent economic collapse.

The expression, “If it ain’t broke, don’t fix it”, comes to mind as I think of problem solving in the general sense.  Even today, we find this philosophy is embedded deep within the culture of many corporations.  In some cases, the designs are so fragile, that any deviation from normal or intended use may result in failure.  Broken plates and glasses remind us that they are not intended to be dropped – either intentionally or by accident.  We are also painfully aware that the absence of past failures does not automatically exclude or make the process or product immune from future failure.  There are too many examples of failure where past successes are suddenly shattered by a catastrophic failure.

Of course, many products are subject to numerous hours of testing in varying degrees of severity and exposure limits.  Yet somehow, these tests still do not capture all of the possible failure modes that are observed in practice.  Too many product recalls are evidence of our inability to anticipate the vast array of problems that continue to haunt manufacturer’s around the globe.  Just maybe the the “If it ain’t broke” expression needs a little rework itself.  If it ain’t broke please break it – or at least try!  Computer hackers around the world having been giving Microsoft and other major corporations their fair share of problems as they continually find and develop “new” ways to break into very sophisticated and high tech systems.

Our Foundations of Failure model is based on the premise that every failure has a known and identifiable root cause.  The challenge for today’s companies is to learn how to identify problems before the product makes it to market or the process is released to manufacturing for production.  The objective is to instill an innate ability to constructively critique your concepts and designs to identify and anticipate the “What if …” scenarios that your product or service may be subject to.

Perhaps an even greater skill to be learned is to identify and anticipate how the product or process may be used or abused – with or without intent or malice.  From this perspective, lean manufacturing principles and standardized work can certainly help us to map our road to success.  Technically, if the ideal process and it’s inherent steps are performed as specified, then any deviations from the prescribed process or design are subject to a system breakdown or product failure.  As discussed in “Chasing the Rabbit“, this was (and is) certainly the case for the US Nuclear Submarines.

Are your system, process, and product specifications documented to the extent that deviations from their intended purpose or function can be, or are, readily identified?  Is it even possible to forecast or anticipate every possible failure mode?  Is it fair to suggest that prescribing a solution to a problem suggests that the original scope of the problem was or is fully understood?

As we have learned from the numerous failures in our financial markets and the collapse of many high profile businesses and companies around the globe, common symptoms and effects of failure may be the result of radically different root causes:  ignorance, negligence, willful misconduct, and even fraud.  We need to implement systems and processes that are robust and assure our future successes are built on solid fundamental business practices.  When the foundation is faulty, the entire business enterprise is at risk.

In summary, the first step is the most critical step.  The first few steps of any new initiative, process, product, or service, form the foundation of all decisions that follow.  Just as a building requires a solid foundation, so do our future successes.  I recall a little sign that was posted in a retail store that read as follows:

Lovely to look at,
Lovely to Hold,
But if you drop it …
Consider it Sold!

Until Next Time – STAY lean!

Toyota: Managing Nightmares

The Nightmare

Toyota continues to be plagued by recalls.  The current acceleration issues (either floor mats or “sticky” accelerators), braking issues on the Prius Hybrid, and now reports in the USA of steering problems with 2009 and 2010 Corollas.  While the majority of the news reports focus on the next steps to repair faulty vehicles, the real nightmare is the human tragedy that was and may still be pending until these issues are resolved.

What is also surprising is the scope of the recalls as they extend to include 2004 model year vehicles.  This is a lot for one company to absorb over such a short period.  It is clear that a flawed design can bring a company to it’s knees overnight.  In the wake of this nightmare, it is also disappointing that Toyota has been less than forthcoming with their communication strategy.

Toyota Lessons Learned

A crucial lesson for Toyota and other companies is to learn to recognize when a problem is really a problem.  Rather than dismissing a fault or failure as a remote possibility or “highly unlikely event”, the key to solving any problem is acknowledging that one exists.  This may have been the greatest error of all in this case.

As consumers we may be too naïve to think that companies are operating with our best interests in mind and not necessarily putting the interests of their stakeholders first.  To be more specific, there is a very fine line between managing solutions, managing risk, and managing a profitable business.  Problems without resolutions or preventable measures are subject to risk management strategy and the price of many products on the market today include a company’s costs to manage risks and potential liabilities.

Responsiveness versus Excuses

Is it the investment or the lives that were lost that call for varying degrees of “investigation”, problem solving, and government intervention?  The timeline of events leading to the recall for accelerator issues spans months and perhaps even years when the problem was first reported.  What does it take before a company finally decides that an event has statistical significance?

The lesson that all companies can learn from this is that the value of human life cannot be measured or dismissed by a risk assessment or  an extremely remote chance of recurrence.  There is little comfort in statistics if you happen to be that one person in a million that has the problem.  We are not suggesting that Toyota dismissed prior reports of problems; we are simply asking “out loud” if they could have had cause to act sooner.

Some media reports have suggested that Toyota grew too fast over the past few years.  How would that have any impact on the design of the vehicle?  Toyota design changes are typically perceived as enhancements and improvements over time.  Yes, Toyota gained significant increases in market share as interest in hybrid vehicles grew with ever increasing gas prices.  Yes, increased volumes place an unprecedented strain on resources throughout the supply chain and perhaps even more so for those suppliers that have been surviving on reduced staff and personnel.  None of these are excuses for a failed design.  This was not a manufacturing defect as we understand it.

Toyota Trust

Unfortunately for Toyota, this recall is not a nightmare they can just wake up from – it is a bitter reality.  Although Toyota vows to improve quality, this needs to be demonstrated.  These same words were uttered by Toyota President Katsuaki Watanabe in 2006 as investigations were pending for the recall of over a million vehicles for a faulty steering component that was initially discovered in 2004.  Akio Toyoda now finds himself making similar commitments again in 2010.

When we consider the number of vehicles produced, we also have to consider the effectiveness of the solution seemingly contrived over recent weeks or, for the benefit of the doubt, months.

How do we really know the proposed solution is effective?  The reality is that we don’t.  As with the discovery of the original defect, only time will tell.  Despite all the testing performed to simulate “the real world”, it is crucial to understand that tests are only simulations – they are not real life.  Even though a failure is predictable, it is not always preventable and just because it didn’t happen doesn’t mean it can’t happen.

Restoring consumer confidence and trust will take some time and Toyota’s crisis management skills will certainly be challenged.  The communication strategy to date has been less than admirable by some accounts, while others continue to praise Toyota’s product line and have re-affirmed their confidence in the company.

Owing to their own lean principles, we are hopeful that Toyota will continue to embrace problems as opportunities to learn and to strengthen the company  and its products.  Toyota is the last company we would expect to see with this number of problems on their hands at any one time.

Our disappointment with Toyota is the lapse between discovery and fix, and subsequently the lapse in communication as the recalls are officially made public.  To this end, Toyota’s reputation may be waning.

Until Next Time – STAY lean!

Agility Through Problem Solving: a Model for Training and Thinking

We tend to use analogies when we are discussing certain topics, introducing new concepts, or simply presenting an abstract idea.  Analogies are intended to serve as a model that people understand, can relate to or identify with, and, more importantly, remember.  Our challenge is to identify a simple model that can be used to teach people to identify and solve problems – a core competency requirement for lean.

We have learned that teaching people to see problems is just as important as teaching them to solve problems.  Our education system taught us how to use the scientific method to solve problems that were already conveniently packaged in the form of a question or modeled in a case study.  Using case studies for teaching is typically more effective than traditional “information only” or “just the facts” methods.  (The government of Ontario is presently considering a complete overhaul of the education system using case studies as a core instruction method.)

The effectiveness of any training people receive is compromised by time – the retention span.  Our school systems are challenged by this at the start of every school year.  Teachers must re-engage students with materials covered in the last semester or topics covered prior to the break.  In business we may be too eager to provide training at a time when current business activities are not aligned for the new skills to be practiced or exercised.  A commitment to training also requires  a commitment to develop and routinely exercise these skills to stay sharp.

One of the fundamental rules of engagement for lean is to eliminate waste, where value added activities are optimized and non-value added activities are reduced or eliminated.  Although it may appear that we have identified the problem to be solved, in reality we have only framed the objective to be achieved.  We understand that the real solution to achieving this objective is by solving many other smaller problems.

The Sudoku Analogy – A Model for Finding and Solving Problems

A favourite past time is solving Sudoku puzzles, the seemingly simple 9 x 9 matrix of numbers just waiting for someone to enter the solution.  The reasons for selecting and recommending Sudoku as an introductory model for training are as follows:

  1. Familiarity:  Sudoku puzzles are published in all daily newspapers and numerous magazines and they have become as popular as cross-word puzzles.  Most people have either attempted to solve a puzzle or know someone who has.
  2. Rules of Engagement:  the rules of the game are simple.  Each standard Sudoku puzzle has 9 rows and 9 columns that form a grid of 81 squares.  This grid is further divided into nine 3 x 3 sub-sections.  The challenge is to enter the digits 1 through 9 into the blank spaces on the grid.  Every row, column, and 3 x 3 sub-section of the grid must contain one and only one of each digit.  We refer to these as “rules of engagement” as opposed to “framing the problem”.
  3. Degrees of Difficulty:   Sudoku puzzles are typically published in sets of 3 puzzles each having varying degrees or levels of difficulty.  Each level typically requires more time to complete and requires the player to use more complex reasoning or logic skills.  The claim is that all puzzles can be solved.
  4. Incremental or Progressive Solutions:  Sudoku solutions are achieved incrementally by solving instances of smaller problems.  In other words, the solution builds as correctly deduced numbers are added to the grid.  New “problems” are discovered as part of the search for the final solution.
  5. Variety:  every Sudoku game is different.  While some of the search and solve techniques may be similar, the problems and challenges presented by each game are uniquely different.  Although the rules of engagement are constant, the player must search for and find the first problem to be solved.
  6. Single Solution:  a multiple number of solutions may appear to satisfy the rules of the game, however, only one solution exists.  Learning to solve Sudoku puzzles may be a challenge for some players, however, even seasoned Sudoku players can be stumped by some of the more advanced level puzzles.  To this end, they are ever and always challenging.
  7. Skill Level:  Sudoku puzzles do not require any math skills.  Numbers are naturally easier to remember and universal.  Letters are language dependent and the game would lose international appeal.
  8. Logical:  deductive reasoning is used to determine potential solutions for each empty square in the grid.  As the game is played, a player may identify a number of potential solutions for a single square.  These final solution will eventually be resolved as the game is played.

In practice

We recommend introducing the team to Sudoku using an example to demonstrate how the game is played.  It is best to discuss some of the strategies that can be used to find solutions that eventually lead to solving the complete puzzle.  The Sudoku model will allow you to demonstrate the following ten objectives:

  1. Look for Options:  The solution for the problem to be solved may consist many other smaller problems of varying degrees of difficulty.
  2. Break down the problem:  There may be more than one problem that needs to be solved.  Every Sudoku puzzle represents many different problem instances that need to be resolved before arriving at the final solution.  Each incremental solution to a problem instance is used to discover new problems to solve that also become part of the overall solution.  This may also be termed as progressive problem solving.
  3. Multiple solutions – One Ideal:  There may be times where more than one solution seems possible.  Continue to solve other problems on the grid that will eventually reveal the ideal single solution.
  4. Prioritizing:  more than one problem instance may be solvable at the same time, however, you can only focus on one at a time.
  5. Focus:  Problem solving involves varying states of focus:
    • Divergence:  Expand the focus and perform a top-level search for a problem from the many to be solved
    • Convergence:  Narrow the focus on the specific problem instance and determine the specific solution.
  6. Test and Validate:  Every problem instance that is solved is immediately verified or validated against the other squares on the grid.  In other words the solution must comply with the rules of engagement.
  7. Incubation:  some puzzles can be quite difficult to solve.  Sometimes you need to take a break and return later with a fresh eyes approach.
  8. Action:  There is no defined or “correct” starting point.  The first problem instance to be resolved will be as unique as the number of players participating.  No matter where you start, the finished solution will be exactly the same.
  9. Tangents:  when entering a solution into a square, you may notice other potential problems or solutions that suddenly seemed to appear.  It is very easy to digress from the original problem / solution.  This is also true in the real world where “side projects” somehow appear to be the main focus.
  10. Method:  There is no pre-defined method or approach to determine what problem to solve first.  The only guiding principles for discovering the problem instance to be solved are the rules of engagement.

Lean companies train their teams to see problems and break them down into smaller problems with solvable steps.  Sudoku demonstrates the process of incremental or progressive problem solving.  Even with this technique it is possible to enjoy major break through events.  There are times when even seasoned Sudoku players will recognize the “break through point” when solving a puzzle.

Solve time is another element of the Sudoku puzzle that may be used to add another level of complexity to the problem solving process.  Our objective was not to create a competitive environment or to single out any individual skill levels whether good or bad.  Lean is a TEAM sport.

In Summary:

Sudoku solvers are able to hone their skills every day.  Perhaps Sudoku Masters even exist.  Imagine someone coming to work with the same simple focus to eliminate waste every day.  Although there is no preset solution, we are able to identify and consider any number of potential problems and solve them as quickly as we can.  The smaller problems solved are a critical part of the overall solution to achieve the goal.

Most professional athletes and musicians understand that skills are developed through consistent practice and exercise.  Repetition develops technique and speed.  Imagine a culture where discovering new opportunities or problems and implementing solutions  is just a normal part of the average working day.  This is one of the defining traits that characterize high velocity companies around the world.

Truly agile companies are experts at seeing and solving problems quickly.  They discover new opportunities in every day events that in turn become opportunities to exercise their problem seeing and solving skills.  Crisis situations are circumvented early and disruptions are managed with relative ease – all in a days work. 

The next time you see a Sudoku puzzle you may:

  • be inclined to pick up a pencil and play or
  • be reminded of the time you were inspired by the game to solve problems and reach new goals or
  • simply reflect on this post and ponder your next break through.

Until Next Time – STAY Lean!