SEE, DECIDE, ACT

Why did the machine stop? There was an overload and the fuse blew.

?Why was there an overload? The bearing was not sufficiently lubricated

?Why was it not lubricated sufficiently? The lubricating pump was not pumping sufficiently

?Why was it not pumping sufficiently? The shaft of the pump was worn and rattling

?Why was the shaft worn out? There was no strainer attached and metal scrap got in

?Recognize this? This is the classic 5 why example from Taiichi Ohno’s book on the Toyota Production System. Interestingly, very few other examples can be found in the lean literature. Why is five why so hard? Because you have to know what you’re looking inside out before you attempt to ask why five times. Insight is born from connecting two apparently unconnected facts, which requires to know the facts beforehand. To conduct the preceding analysis, you have to know that:

• Overloads blow fuses and stop the machine
• ?Unlubricated bearings create friction and overload the circuit
• ?Lubricating pumps can lubricate insufficiently
• Worn shafts of pumps slow their efficiency
• Metal scrap getting to the shaft will wear it down

In order to recognize what you’re seeing you need to have a strong functional mental model of the machine – or your five why will take you in any silly directions.

?I had that experience with a therapeutic pool not working in a hospital for trauma patients:

?Why is the pool not available? Because the pump is not working

?Why is the pump not working? Because the fuse blew

?Why did the fuse blow? Because the pump was over strained

?Why was the pump overstrained? Because the water filters were clogged with lime

?Why were the filters clogged? Local water was very hard and filters not changed often enough

?It looks straightforward but we flayed around for hours until the maintenance specialist showed up and went straight to the filters: it was simple for him – he knew where to look.

?There are two bottlenecks to mindful action. First attention: knowing where to look. Second, decision: choosing what to do. Which leads to third, action: knowing how to do.

SEE —> DECIDE —> ACT

?Attention is the first real bottleneck here. Although we can know a quasi-infinite number of things, our minds can largely focus on only one thing at a time, which is why talking on the speaker phone while driving is so dangerous. This is intuitive to anyone. The second bottleneck is harder to see. Recognizing things we already know in our context is natural and feels great, particularly if they seem new. It feels like we learn things. The harder part is mobilizing existing knowledge in situations. We often think of a better way to do things after the fact. We knew it already but couldn’t access it. Familiarity makes an enormous difference.

?In order to truly learn, we need to backtrack the process, which feels profoundly unfamiliar and often almost painful:

?Review actions —> Challenge decisions —> look at the situation differently

?In Ohno’s example, learning occurs when we learn to look at where scrap metal goes in as opposed to the fuse. In my pool example, it means looking at the filters rather than at the pump. Learning occurs when we change what we look at.

?Visual management, which is unique to lean, is a way to take advantage of this cognitive process. By highlighting visually what to look at, it speeds up the attentional process. But it also spurs the motivational need for action. As psychologists have found out, it’s very hard to motivate anyone to change their own behavior. Behavior is sticky and trying to convince someone of changing rarely works. However, a different context often does. The key to lasting motivation is to create a context in which people motivate themselves, which is what visualization does. Painting a spot as a resting place for a machine creates a spontaneous motivation to put it back in its place.

Setting up an andon board that lits up when people flag an abnormality creates a spontaneous motivation to go and see what is going on and help if we can. Stopping the line until the problem is solved creates additional urgency – it’s self-motivating.

Learning of new facts is easy, but often an illusion. We naturally enjoy confirming what we already know with further instances. True learning is hard because it starts with the discovery of looking at something else – something that didn’t seem so important to start with. Like stepping on a scale when you feel overweight. The controlling your behavior by looking at it every day and adapting as you go. This is essentially what Kanban does for a production process: by showing where finished parts overflow from the shop stock, we can look at the queue of incoming Kanban instruction and figure out what is going wrong. More importantly, we’re motivated to do so.

?From that perspective, the history of the Toyota Production System, the lean system outside of Toyota, is a history of building new visual control points and adapting planning and production processes accordingly. And it indeed starts with asking why? Again and again. But to ask why effectively, we have to know what we’re looking at. The first step to learning is learning to see.

?

?

?