Far too often, there is a big problem with our team’s problem solving. This problem not only results in ineffective countermeasures and re-occurrence of the problem, but can also break the trust between the leaders and the team or operators.
When problem solving or reviewing a root cause analysis with your team, if the root cause is determined to be the operator(s) not following standard work, your “spidey senses” should be going off! Seldom is not following standard work the root cause, but rather it should be the starting point of an in-depth analysis. Unfortunately, it is far too common for leaders to determine that the root cause of a safety, quality or productivity issue is a result of not following standard work and they place “blame” upon the operator(s) for not doing so. It is common, that when a process has been in control and then suddenly there is an issue, it is likely a standardized work issue, but even if so, that is not the root cause. Of course, any one of the 6Ms; Man, Method, Material, Machine, Mother Nature, or Measure could also be an issue. However, if it is a standard work violation, it is super critical to determine the root cause as to why the operator did not follow the standard work. If they are fully trained operators and/or are aware of the standard work, there will be a reason why they missed or stopped following it. Our job as leaders is to find out why. When we do, what we find is usually a golden nugget!
I fundamentally believe that operators do not wake up in the morning thinking of how they will not follow standard work that day. They just do not! Therefore, if they do not follow standard work, there is a VERY good reason for it! They either cannot follow the standard work due to an issue with one of the other 5Ms, think they have determined a more efficient way of performing their task, or were distracted or interrupted, to name a few. In any case, we need to determine why they did not follow the standard work so that we can address the root cause. Often when the root cause is determined to be the operator not following standard work, the counter measures are poor and obviously will not solve the problem, and improvements, if made at all, are not sustainable. The number one countermeasure I have seen in these cases are to “re-train” the operators or issue a communication to “remind them of the importance to follow standard work”. These type of counter measures rarely, if ever, address the root cause, upset the operators and break trust because they know the leaders are not listening or investigating deeply enough, and actions are not sustainable. The issue will pop up its ugly head again; it is just a matter of time. Sometimes, the cause of not following the standard work can even be a hidden cultural issue within your organization.
Over the years, I have experienced many times where my team has determined the root cause of an issue as a standard work violation. After some coaching and a request to start the root cause analysis at why the operator was not following standard work, the teams made some amazing findings. Sometimes they found there were parts and materials out of specification within a specific lot, stacking of tolerance issues, and interruptions in their standard work by other processes, line downtime, periodic work, etc. In all cases though, there was a very good explanation as to why the operator missed or did not follow the standard work. Sometimes, to determine the root cause, a great deal of digging was required, and that root cause found was not pretty!
One of the most memorable experiences and examples for me was when we had a significant quality issue on a customer’s car on their initial drive home from the dealership. The process of concern had automated equipment with multiple pokeyokes designed to prevent process completion unless critical to quality aspects and been performed and verified. Trials conducted on the equipment confirming functionality that the equipment was working as designed and expected were completed. The initial conclusion as to root cause was that the operators were not following standard work and on occasion when the equipment faulted, would by-pass the automation and pokeyokes. Engineers made improvements in fault detection, tractability, and installed additional pokeyokes on the equipment to remove all potential of manually over-riding the process. We retrained Operators and reminded them about the importance to follow standard work. Then there was a second occurrence after the implementation of all the described countermeasures! How was that possible!!! To make a long story short, line leaders, not operators, were determined to be by-passing the process altogether and had implemented an off-line uncontrolled process in the event that the main line went down. They were doing this because they wanted to keep the line going to prevent downtime and loss of productivity. Although they had the best of intentions, this was the wrong thing to do. However, it was not their fault. I, and the senior leaders, had given these line leaders the perception that productivity was more important than quality. The culture that we had allowed to become ingrained defied everything that we had attempted to create and thought we had created. We had a significant cultural issue; this was not a standard work issue at all. Not following standard work was an issue, but it was just a symptom of an altogether much different and bigger issue.
Another example of where a team felt that root cause was operators not following known standards was because the operators were relatively new and inexperienced in their process. The corrective actions were to retrain and to conduct periodic audits to catch the operators not following standard work and then to remind them to do so. Your spider senses should be going crazy! We requested the team to dig deeper and coached them on the importance of starting with why the operators were not following standard work. What they found was enlightening! Important dimensions of key materials used in the process had changed over time; however, adjustments to the equipment used in the process to accommodate the changes in the materials were not completed. In addition, they identified an impactful non-standard layout issue by talking with the operators through seeking to understand why they were not following the standard work.
So develop and hone your “spidey senses” to be on alert to standard work violations identified as the root cause of an issue. Coach your teams to start there and dig deep to understand why an operator would not follow the standard work. An obvious, but also often overlooked step, ask the operator why they missed or did not follow standard work. Do not accept the “I don’t know” or “I forgot” answers. Worse, do not assume they negligently chose not to follow the standard work. I guarantee there is more to it. If you get these types of answers, it is imperative to coach the operator on the importance of understanding what is preventing or resulting in them not following standard work, as it is key to addressing a problem they are clearly experiencing.
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