By Kevin Meyer
Most people and organizations abhor and outright fear failure. Why? Failure can create an impetus for improvement like no other event.
Last Thursday was one of those days that every organization needs every once in a while. By 8:15am I was being bombarded with visits and emails from members of my team updating me on an increasingly complex situation created by a cascading set of failures. By 8:30am I was taking a walk to cool off, wondering how this could have happened.
Luckily in the grand scheme it wasn't too serious – no one had been hurt, the expense incurred was rather minimal, and nothing had reached a customer – in fact it was purely internal. But a lot of people were involved at three different facilities across the country, including several members of my senior leadership team. Very busy people were spending a tremendous amount of time picking up the pieces.
Believe it or not it all started with the best of intentions – an off-hand remark to an internal customer suggesting an alternative solution to a capacity and lead time issue. That bounced to an informal phone conversation with a production employee at another facility who, with an admirable attitude of satisfying the customer (even internal) decided to dive right in and help. That employee's supervisor was coincidentally offsite at lean training (again, believe it or not) and not available to ensure that the correct internal order entry procedure was still used in this urgent internal situation. Since the procedure was not used, the material was run without the benefits of required traceability. That was caught and flagged by robust processes, which is what then brought the situation to the attention of the QA and Customer Care leadership team members. This all happened within the span of a couple hours – by 8:15am at our headquarters thanks to the facilities being in different time zones.
In a traditional organization the next step would have been the assignment of blame and the public flogging of the guilty. Not in ours – instead we had people lined up volunteering to take full responsibility, but each not completely understanding just how complex the overall situation was. Quite honestly that was a proud moment. Ownership of problems was desired, not feared.
But it was still wrong. It's not about blame, even if voluntarily accepted. The vast majority of problems, including this one, are not due to the failures of people. They are due to the failures of processes. That's what must be improved.
So what went wrong? How did an informal suggestion create a situation that circumvented systems, procedures, methods, and authority? How do we improve the processes so it won't happen again? That's what we're working on now. Root cause, investigation, going to the gemba and talking directly with those involved, brainstorming and implementing changes.
We'll be better when we're done. Processes will be improved and the leadership team will have demonstrated that processes failed, not people, and that will be noticed by the entire organization.
What started off as a bad day ended as one of my favorite days because a very complex failure became such an opportunity for improvement and for teaching.
Embrace the opportunity of failure!