Archive for April, 2011

Guest Post: Sleeping Air Traffic Controllers. Mistake-Proofing Anyone?

Recent headlines have screamed about third shift air traffic controllers who have fallen asleep on the job, causing some inconvenience to inbound aircraft. I use the word inconvenience because there are procedures to follow when landing aircraft lose communication.  The pilots do the actual flying, not the air traffic controllers.

There are a lot of reasons why an air traffic controller may fall asleep on the job, particularly if he/she is the sole person on duty.  Late night air traffic control can be very boring.  Perhaps they haven’t had enough rest prior to their shift (another matter, indeed). In certain locations, there may be very few flight arrivals over several hours.  Tower cabs and radar rooms have subdued lighting and playing radios or other electronic devices are not allowed.

So, you have several red flag conditions contributing to an environment that make it easy for a controller to fall asleep. So the reaction from the FAA administration?

  • Suspend/fire the offenders.
  • Hire a second controller for each facility.

So with the additional personnel, you are now going to have an already light work load divided between two workers, making the non-value added situation even worse.

Let’s look at it from a mistake-proofing point of view.  What is the source error?  While there are several contributing factors, the source error is the controller falling asleep because there is not enough activity to keep him awake.

Once you have determined the source error to any defect, finding a mistake-proofing device is relatively easy.  We simply need some kind of automatic control to keep the controllers attention. Let’s brainstorm for a solution.

  • Take the controllers chairs away, so they must stand.
  • I once heard that in Australia there is a railroad track that runs absolutely straight for hundreds of miles, and because of poor track, the train can only travel at 30 mph.  To keep the engineers from falling asleep, every 3 minutes or so he has to push a button.  If the button is not pushed, the train slows to a stop.  Interlocks are in place to prevent the engineer from bypassing the intent of the button.  Perhaps we could devise a similar device for our sleepy controllers.

Here are a few suggestions taken from readers on a blog at AvWeb:

  • If there is so little traffic the controllers can’t stay awake, then I say close the tower during those hours. Spokane/GEG has airlines landing at night with the tower closed. Why double your costs when you can eliminate them? In this time of budget cuts is no time to increase costs unnecessarily. As pilots, we all know that night ops can be safely flown at night with no tower. (Note:  many smaller air traffic control towers in the USA close at night.  After hours, the pilots simply broadcast their intentions on the tower frequency.  We’ve been doing it that way since day one. Air Traffic Controllers don’t land the plane, pilots do.)
  • Anyone suggest a $200 CCTV camera run to the nearest night shift security guard? Too simple to be elegant?
  • What if the feds considered staffing the midnight shift with one controller, and one student in an ATC program. Perhaps offering college credit, a guaranteed interview, and perhaps even meager pay to the college kid would be enough to entice them, and it would be much better experience than they’ll get in the classroom. If nothing else, the night shift guys would have someone to play cards with in the off time!

Can you think of some more?

The whole point is, throwing an additional person at an under-tasked job is making a wasteful condition even worse and many companies do it.  Mistake-proof it instead.  Look at your source error, then devise a low cost/no cost method to keep it from happening. Don’t just throw more people a the problem.

How do you think we could keep a lone air traffic controller awake? Send in your comments and let’s hear your ideas.

This post was written by Sam Hoskins, CSSBB, MS, president of MistakeProofing.Net. Sam is an experienced hands-on mistake-proofing trainer and facilitator, who has conducted dozens of events for a diverse range of industries such as explosives manufacturing, processed food companies, welding and fabricating shops, and healthcare.  He learned lean and mistake-proofing while at the Ensign-Bickford Company and authored the mistake-proofing portion of their successful application for the 2001 Shingo Prize.  In addition to mistake-proofing, he is currently conducting Lean 101 training for a variety of companies through Parkland College in central Illinois. You may reach Sam at

Related Post: Guest Post: Preventing Mistakes – Not Just Chump Change


Guest Post – Minarai: apprentice, beginner; learn by observing

As I ready myself for a new mentoring relationship in a few weeks, I’ve been pondering roles and approaches. What will I do the same, what will I change as I help facilitate a new lean transformation?

My job, as teacher and coach, is to assist the organization make change. Their chosen strategy is to implement lean and six sigma. The knowledge transfer approach I prefer is see one, do one, teach one.

At first the apprentice just watches me do my thing – plan the calendar, roles, objectives; do the training, explain the principles, and run the events; check the metrics and take everyone’s pulse; act on what I see. Usually I don’t explain what I’m doing; I just run the kaizen event; form subs teams, hand out assignments, train-and-do.

After a time, the student is called upon to perform some of the routine activities, give some of the lessons,  and apply some of the tougher tools. Then comes the day when the roles start to reverse; the student tries to run a kaizen and the teacher observes, intervening off-line, giving feedback quietly, and asking questions, checking comprehension. As confidence and experience grow the student becomes the teacher.

Asked the other day, “What’s the difference in your approach and Shingijutsu?”  I was reminded of something James Womack once wrote. It’s a lengthy, but insightful quote,

We’re now trying to write down all of the techniques you need to actually become lean. The Toyota teaching method is what we would call sensei-deshi, with the sensei being the great teacher and the deshi, the student. Basically, here’s how it works at Toyota: The kids get out of the university and join the company. Then they’re told, ‘Okay, you know how to do math, and you know how to read. Forget all the rest of the crap. We hope you had a lot of party time because now you’re going to be working long hours for the next 40 years, and we will teach you what you need to know. We’ll start by having you stay right here and look around for waste—muda in Japanese— and we’ll be back in a few hours.’ When the teacher comes back, he’ll ask the employee to tell him all about the waste he sees. It’s an empirical teaching method in which the sensei simply asks questions: ‘What do you think about this operation?’ ‘Why aren’t you looking over here?’ ‘Over there?’ ‘Why is something happening this way?’ They start with applications, and let you figure out the principles. Generally, the way we teach in the West is to start with principles, and then let the pupil to work out applications.

Which way is better?

This post was authored by Larry Loucka, a lean six sigma coach and Certified Supply Chain Professional. He has extensive industry experience in supplier development, global sourcing, logistics, outsourcing, warehousing, integrating MRP and Kanban, logistics network optimization and modeling, demand management, visual workplace, kaizen, quick changeover, operational analysis, supply chain strategy, and accelerated change management. Larry is the founder of, and principal contributor to, Lean Sigma Supply Chain Blog and is the principal of Resource Systems Group, LLC.

Related Posts: Two Cents on Lean Certifications…and a Cow Named “Fuku”, Lean Leadership – Lessons from My Dog Obedience Sensei


Guest Post: Staying Power

We all have clients or know of companies that are losing their struggle to sustain Lean. Just yesterday, I was contemplating one such company as I strolled through downtown. As I walked, looking at everything and nothing in particular, a bright flash of color caught the corner of my eye from a slight downhill distance. Turning my head to get a better look I thought, “Wow, that’s beautiful,” only then realizing it was the side of an old building entirely plastered with graffiti.

As I frowned and contemplated what it must cost to clean that stuff off, I noticed what looked like a conventional signature in the lower corner of the wall. This I had to see. When I got closer I was able to read the following (from Da Vinci),

“All our knowledge has its origins in our perceptions.”

Toward the middle of the wall, a less dismissible version of that thought came as an accusation –

“Stay Dum!”

And my first unfiltered expert thought was…You talkin’ to me?

Later that day, still ruminating on that same client’s sustainability issues, I came upon someone’s recent description of a “lean learning formula” and how to apply it as an “effective teaching method.” Eager for a clue to my own question, I read on though suspiciously.

I’m a bit uncomfortable whenever a set of deliberately adaptive principles or practices accruing over many years are pinned to the wallboard, so to speak, and labeled Veritatis Rei (specimen). Alas, it’s in our nature to try and pin down unwieldy phenomena with words. How else to clarify, analyze, promote, handle, reassemble, and…teach? Littera scripta manet, as the Latin goes – the written word survives. Pretty convenient.

That convenience, however, can be costly. Codifying – in words – the amorphous experience of teaching and learning is problematic, and over the ages has left just as many chewing their pencils as tasting the truth.

The formula in question went something like this:

1.      Make a commitment to learn.

2.      Assess performance gaps.

3.      Acquire new knowledge.

4.      Build competency through practice.

5.      Integrate the newly gained skill into daily practice.

Despite great intentions to apply the new knowledge, the author continues, we fall short when it comes to conscious practice and integration. “This is where the learning process falls apart.”

Hmm, something just doesn’t seem right about both the simple formula and the throwaway conclusion. What do you think?

The success (or, more accurately, failure) of such standard “teaching methods” is a perennial source of debate. Rightly so. This approach to teaching/coaching is still the so-called standard in spite of the fact that – as many of us know firsthand – it consistently fails to produce lasting, sustainable changes in behavior.

Notice that I didn’t say the teaching method fails to produce new knowledge. It often does. However, the ultimate goal in personal (and corporate) transformation is a change in self-governed behavior, not merely understanding. As our daily lives demonstrate constantly, new knowledge alone rarely causes us to change persistent habits of thought or action with which we have become comfortable. This is especially true when the habit is the result of a stressful emotional, psychological, or perceptual issue as opposed to a factual misunderstanding. These types of behavior, personal and institutional, are coping mechanisms and they persist stubbornly even when tangible rewards for change are offered.

For example, I know that I should not bite my fingernails. It has been explained to me many times over the years by well-meaning folks of every sort: parents, teachers, doctors, spouses, friends, children, and counselors. I trust and respect the knowledge and opinions of these people. I know that biting my nails makes me feel bad (self-conscious, low confidence, pain and potential infection, etc.) The benefits are clear too (improved self-image, new-found confidence, better health, etc.) What’s more, I really want to change.

But although I succeed temporarily in “practice,” I fail when it comes to the full and permanent integration into daily life. The improvement isn’t sustained. Why?

The entangled reasons for this failure in private behavior change are many, and the reasons are just as numerous and profound when institutionalized behavior (change at work) in public is the goal. And this is my point: admonitions to “be disciplined, practice daily, and do better” – though logical and necessary – are insufficient on their own. Nor do they undermine the foundational paradigm or worldview of which the negative behavior is just one small expression.

But the individual/company is “on-board.” Their brain/boardroom is thinking and actively engaged. Commitment to the overt steps toward change are being sincerely embraced. Permission and encouragement from stakeholders is plentiful. And yet change is short-lived; the preexisting – though ineffective- equilibrium returns. Pessimism creeps in.

So what gives here?

Before we start to argue about why this is so and how to achieve better results, it is paramount to first acknowledge that – yes – what’s been described above is in fact what results from most training and coaching in our industry.

Let me be the first. Personally, as a “lean champion” with my reputation on the line, I profess this unfortunate state of affairs is true. Furthermore, I would add that most individual and corporate patrons of coaching/training also know this is true but are ashamed to admit it. They’ve been paying dearly for this guidance from an experienced expert after all. Their head office has mandated Lean Training. Also, in a sinister twist, clients are often taught implicitly that they are primarily responsibility for any failures in reaching the stated goals. “These are proven methods,” we remind them dutifully. “Look at Toyota.”

Sounds like a full-blown case of The Emperor’s New Clothes Syndrome, doesn’t it?

But if that’s not our goal as coaches and mentors, and that’s not the goal of our students and clients, then it’s time we reevaluated the typical “lean learning formula” as it is currently practiced here in the US.

Specifically, what dimension(s) is missing from the Lean Journeys we claim to lead?

It seems appropriate here to use the The 5 Whys approach (I don’t think it’s broken) as our tool to examine the primary symptom confronting us: individuals and companies are not sustaining the beneficial changes we have worked with them to accomplish. It’s axiomatic: If, in spite of clients’ best efforts and properly established conditions, they do not succeed, then we have also failed somewhere.

As a way of putting us in the right “12-year-old” mindset for this inquiry, I’ll repeat a conundrum described by Dr. Jeff Liker, author of The Toyota Way and 8 time recipient of the Shingo Prize, in an interview with Mike Wall on RadioLean ( Liker says that upon realizing our Lean accomplishments are being lost, we panic and resort to pushing even harder on the technical, quantifiable components in the system namely, processes. Our perceptions narrow and we lose sight of the people. “When that happens,” Liker continues, “you start asking questions like ‘What are the tools for sustaining lean?’ [At that point] this is really a meaningless question.”

This post was written by Zane Ferry, president of ADP Services. Zane has 20 years of experience with the Toyota Production System beginning in Japan where he worked for 10 years. He helps companies in many industries improve by adopting TPS principles and methods that transform how people improve processes for people. In addition to this work, he is also a Japanese-English interpreter for Shingijutsu, a pioneering consultancy founded by members of Taiichi Ohno’s Toyota Production System implementation team. Zane lives in the Seattle area and can be contacted at

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Does Your Cycle Time Have a Weight Problem?

Understanding a process’ cycle time is extremely important, especially in the context of takt time. In a mixed model environment, cycle time can be a bit less straight-forward. That’s where weighted averages may make sense.

Weighted average cycle time, also known as “average weighted cycle time,” provides a representative average cycle time. Varied models or services in a given cell, line or work area often have varied work contents due to different steps, duration of steps, sequence of steps, etc. Accordingly, the cycle times vary.

Weighted average cycle times can be calculated for operator cycle times, machine cycle times and effective machine cycle times. Often weighted average cycle times are presumed to be operator related, but this is not always the case.

As we endeavor to maintain a cycle time that is less than or, at most, equal to takt time, mixed models and their varying work content will likely have cycle times for some products or services that are below takt time, while others exceed takt time. The weighted average cycle time serves as an average proxy for cycle time and is often the same as the planned cycle time.

Clearly, change in product or service mix will change the weighted average cycle time. As the demand mix shifts to one with a greater proportion of cycle time(s) that exceed the average, then the weighted average cycle time will approach and may exceed takt time. The lean practitioner must be aware of these dynamics and should proactively address the situation through reducing work content, optimizing balance between operators, adding additional operator(s) or lines, strategically applying/sizing FIFO lanes, etc.

See below for the weighted average cycle time formula and an example (click to enlarge).

Related post: Musings About FIFO Lane Sizing “Math”