What, exactly, do you mean when you say that I have to SLOW DOWN!
The 4-hour discussion was prompted by two Root Cause Analyses that were presented by their Principal Investigators (PI's) to a group of 30 people who had just gone through 4 days of Root Cause Analysis training. Amongst the trainees were operators, maintenance people, technical resources, and managers. The recently-trained people were surprised at what was presented by the trained PI's, and especially at their answers to some of their questions.
Why didn't you follow the approach suggested in the training? Why did you take so many shortcuts? Why did you leave-out the most important ingredients of a successful investigation (keeping the 3 vectors of evidence separate, and requiring the stakeholders to come to their own conclusions).
As the PI's listened to the criticism, they became a bit emotional. After being more-or-less attacked by the recently-trained group, one of the PI's stood up and said:
You have no idea of how difficult it is to do the things we've been taught in the classroom. The methods are easy, and the concepts are sound. But getting the required resources and time is almost impossible.
The impassioned plea from the PI's lasted about 30 minutes. The essence of their argument was that management is not interested in truly understanding why things go wrong. They're too focused on goals and objectives. They're going fast, and they want to go faster. After they finished their rebuttal, about 25 of the attendees loudly applauded!!!!
As I said, managers were in attendance. They had been part of the 4-day training. One of them was a Plant Manager. Sitting in silence, listening first to the attacks and then to the PI's as they defended themselves, and finally after hearing the applause, the Plant Manager asked a pointed question:
What, exactly, do you mean when you say that I have to SLOW DOWN! Can you tell me what you'd like me to do? What would you like me to change? How would you like me to act?
The group's response was interesting. One fellow tried to explain WHY it was important to slow down. Another person said "you shouldn't have to ask that question because you've taken the same training as us!" Another suggested that "slowing down is a matter of attitude, more than it is action."
As I listened to the Plant Manager's question, and then the attendees answers I tried to put myself in her shoes. I immediately understood. What DO we mean when we ask each other to slow down? Why do we always expect the OTHER person to do the "slowing down" instead of asking ourselves the same question?
What, exactly, do we mean when we say we ought to slow down?
Any ideas?
(please post them)
1 comment:
To me I would discribe "slowing down" as an attitude - be willing to take the time to be sure we really understand and have the evidence to support our conclusions. During any investigation it is easy to find something wrong that likely contributed to an event - but are we sure this is what happened and do we take the time to more thoroughly investigate and explain everything?
A willingness to jump to a conclusion and make recommendations - without full understanding or solid evidence - is the opposite of "slowing down". I recall one experience where a pump had a bearing failure, and one possible explanation could be dirty installation conditions in the machine shop. We found some dirty conditions in the bearing room and implemented a clean-up effort. The pump bearings continued to fail, and until we did more thorough examination and engineering analysis we did not recognize a small design change by the bearing manufacturer that had led to an instability problem with the bearing in operation. After a change to a better bearing design the problem for that pump was solved. Additional reviews and discussions with our procurement staff and suppliers of bearings and other parts were helpful to be sure we are properly informed of these types of changes in the future. If we had slowed down a bit and really understood the first failure we could have prevented two more successive failures and improved our parts supply processes many months sooner than we did. By "moving fast" it took much longer to correctly understand and solve that problem.
By the way - the team was rewarded with lunch tickets after we identified and "solved" the dirty bearing room problem, even though it did not make any difference toward preventing the second bearing failure a couple of weeks later. The point is that we get rewarded for working fast and coming to answers and solutions very quickly. There does not seem to be the same recognition or rewards for good "slow" work that actually identifies true causes and effective solutions...
Post a Comment