Wednesday, December 10, 2008

Another Missed Opportunity

During our kaizen event last week, I was walking up and down the assembly line, practicing my observation skills when I noticed a small hesitation in work by one of our hardware bar assemblers. It appears that he stopped for a couple of seconds to examine an end bar with decals and rub his thumb over one of the decals. No sooner did this catch my attention, when he jumped right back into his assembly groove and fastened the side bar to the casket.

By no means is this examination of parts completely foreign to our associates. After all, we do specify as part of everyone’s standard work to check the quality of our products throughout the process. Quality is number, don’t you know.

However, from my vantage point at about 20 feet away, I could clearly see what caught his eye. The label had a small scratch resulting in a small torn hole. A defect that would most certainly disappoint our customer and clearly not pass our quality standards.

At this point, my thoughts zoomed in on this single unit and my curiosity kicked into high gear. Would he stop the line to signal a problem? Where was our team leader? Would the unit be fixed on the spot or sent down the line? Would the defect be tagged? What was our lean thinking on the line and what behaviors will I see in response to this defect?

Well, I didn’t have to wait long for my answer with our short takt time. After completing the assembly, the associate rushed to the next unit in line. This casket with a small torn label kept moving down the paced assembly line. No andon lights flashing, no buzzers blaring, no quick support help running to our aid, no red tags, nothing. If you didn’t see it just happen, it was like it never happened. Not even a little tick mark on a data sheet to record the problem.

How utterly disappointing it was to see this happen from one perspective and extremely exciting from another perspective. Realizing we have this problem is our opportunity for improvement. It is a chance for us to learn and kaizen.

With my new found understanding of our process behavior, I followed this casket down the line with added curiosity. Would someone else notice the defect? Anyone? How far down the process will this casket go before this defect is seen? Would it get all the way through to final inspection without detection? Would it even be caught by our inspector?

This casket moved along the conveyor matched to takt time, station by station, without a single associate taking notice to the small scratch with a small, torn hole on the bar label. Finally, the unit arrives at final inspection. I figure we have an 80% chance that this defect would be noticed in our human inspection process. The small scratch goes unnoticed and the units is passed, ready to be packed for delivery. I guess this unit fell on the 20% side of the equation.

Before the unit had a chance to continue on to our customer, I pointed out the defect to our inspector. It was subsequently tagged and repaired, a simple repair was all that was required.

Does things like this happen in your operation? If you were part of the leadership at this site, what lessons would you learn from this? What is the true problem or problems? Can you see all the missed opportunities?


Anonymous said...


I would say that even though your organization has espoused a lean culture and nurtured it for quite some time, that this is one instance where fear came into play. The operator either feared retribution for the defect either interms of a reprimand or he/she did't want to stop the line (fear of ridicule from co-workers). It's also disturbing that so many other operators took no action, which may imply that this operator's feelings are shared with many others. Not a good sign.
Or, maybe operators didn't notice the defect because they're not being rotated enough. I would investigate maybe with a little fishbone diagram with a few of the more candid team members - maybe try some 5 whys - to get to the root cause - but do so with a spirit of a "free pass" - no fear, so they could speak their minds. This defect seemed too obvious to make it through the line the way it did.

Mike Wroblewski said...

Anonymous-No matter how good we think we are, they is always room for improvement which holds very true at Batesville. Of course I have used this example internally as a teaching story to help us see better. The spacing between units down the line helps hide this particular problem and our main fear is having a loss cycle (stopping the line) which is a cost driven behavior. We are making this problem visible so we can fix it.