Carefully Aim Before Firing In Toyota’s internal Toyota Way 2001 document they describe problem solving under the broad category genchi genbutsu—the actual part, the actual place. The discipline of carefully observing actual processes directly without preconcep- tion—with a blank mind—starts the process of truly understanding the problem. This leads to a thorough explanation of what is happening and its effect on the area, the team, the customer, or the company and reveals why the problem deserves attention. The first requirement of problem solving is to determine the merit of solving the problem. At this stage, all problems can be weighed side by side, and the most important are tackled first. Lesser problems may be assigned to small teams, such as Quality Circles, or even to individuals. There’s a saying that mocks both American and Japanese styles of problem solving. The Americans say, “Ready, fire, aim,” while the Japanese say, “Ready, aim, aim, aim, fire.” There is an element of truth in both of these approaches, and an element of both strength and weakness in each. Many companies in the United States are so focused and driven by short-term (quarterly) results that improvement activities are initiated before the situation is clearly understood. These actions are completed, and a new (90-day) plan is Develop a Thorough Understanding of the Situation and Define the Problem Chapter 14 Copyright © 2006 by The McGraw-Hill Companies, Inc. Click here for terms of use. developed each quarter. This short-term “fire first and set the target later” approach leads to a “shotgun” effect, resulting in bits of improvement here and there. Often these random improvements are made to issues unrelated to the situation being addressed. Activities are completed, but the desired condition is not achieved, and because there was no defined reason for these activities, a long-term sustainment of “results” is virtually guaranteed to fail. In contrast, the Japanese (and Toyota) can be painstakingly meticulous in the initial phase of understanding the situation, which frustrates Americans who are ready to “get started.” This apparently belabored process is vital to a successful problem-solving activity for two reasons. 1. Careful consideration must be given to understanding the characteristics of the problem—by weighing the impact of the problem on customers, employees, and the company, and finally by deciding if the problem is important enough to dedicate valuable time and attention to solving. The inventor Charles Kettering said, “A problem well stated is a problem half solved.” Put another way, a large proportion of the problem-solving activity should be devoted to thoroughly understanding the problem sit- uation, which leads to focusing on the problem rather than its symptoms. 2. Focusing energy and leveraging resources is critical to achieving a higher level of success with minimal effort. This starts with reaching agreement with all affected parties on the need to pursue the issue. Within Toyota, the question, “Why did you pick up this problem?” is often used. It means, “How did you determine that this problem deserves your time and attention?” And also, “Why did you choose this problem over the many other possible issues?” In addition, there is an implied request: “Please explain your reasoning so I can understand the situation, ensure that you’ve done ade- quate reflection, assure that we are in agreement and alignment on the issue— and so I can provide necessary support and guidelines for your process.” There are many things packed into that one simple question, issues that must be examined in order to develop a thorough understanding of the situation. THE TOYOTA WAY FIELDBOOK324 TRAP Avoid the mistake of putting too much effort and expense into solving insignificant problems. Carefully consider the importance and value of solving the problem prior to beginning activity. Do not exert one dollar’s worth of effort to solve a five-cent problem. If the problem is relatively minor in comparison to other prob- lems, it can be addressed by the individual or team most affected by it, rather than by a large team or member of management. This rigorous questioning often leads to frustration for Americans, who tend to feel that it questions their ability to handle the situation on their own (an American characteristic), or that their evaluation was not complete. Within Toyota, many people meticulously review the process of understanding the sit- uation, and feedback is always given. Often, after initial rounds of questions, additional rounds of questioning ensue. This is the “aim, aim, aim” phase. Valuable insights can be gained by this repetition, perhaps bringing new things to light through various reviewers, and in the long run much time can be saved by not chasing errant issues of lesser importance. If your organization hasn’t had an effective process for making improvement, there will probably be numerous issues in the backlog. When the word “problem” is mentioned or people know that you want to improve processes and are inter- ested in knowing what the problems are, two things will probably happen: 1. You’ll be deluged with many problems, ranging from broken water foun- tains and fans (which should be corrected without the need for long-term problem solving) to issues that occurred years ago. 2. As soon as any “problem” is mentioned, solutions will be proposed. Since the existence of a problem has not been confirmed, any proposal of solu- tions is premature and a waste of time (not focused or leveraged). Initiating this process may be like opening Pandora’s box. After looking inside, you may wish you had kept the lid closed! It’s easy to be overwhelmed by the magnitude of opportunity for improvement available (and necessary) and the sheer numbers of problems that will surface. Chapter 14. Develop a Thorough Understanding 325 TIP You must be prepared to help people differentiate between issues that can and should be corrected in the short term without in-depth analysis and long-term endemic issues that affect the performance of the person, group, or company. TRAP One of the signs of a “Ready, fire, aim” culture is the tendency to “jump” immediately from the “problem” to the “solution.” In many cases the problem may be mentioned casually and much time spent proposing various “solutions” before the “problem” has been clearly defined. At this stage in the process it is likely that a symptom has been observed rather than a true problem. The following is a typical conversation that might occur, indicating the trap of jumping to solutions prematurely: Manager: We have been having trouble with defects lately. (Note the vague “definition” of a “problem”.) Employee 1: A lot of the damage is coming from handling. (Note the “root cause analysis”.) Employee 2: Why don’t we get new carts? (Note the jump to a solution.) Employee 1: Yeah, Joe had a design for one a while back. (Now the conver- sation gets way off track!) Employee 3: Do you know what happened to it? Employee 1: No, but I know he had one. Employee 2: I saw it too, but I’m not sure what happened to it. I think he told the engineer, but nothing was ever done. Manager: Would you ask Joe to find out about his design and see if he still has it? (Now valuable time will be wasted chasing a “solution” to an unde- fined problem.) Employee: Yes, I should know something by next week’s meeting. Problem solved! Or was it? What was the problem? “Defects” is a fairly broad issue. Why did the employee jump to the conclusion that “defects” were caused by handling? That may be his personal experience regarding “defects,” but it’s only one possibility. Do you see how the process was so easily side- tracked? The conversation went from a general statement about defects (not a well-defined problem), to a cause (handling), to a solution (Joe’s carts), to an action (follow up with Joe) in a matter of seconds. What will happen next? There will be follow-up with Joe, additional meetings when time is spent (wast- ed) debating why Joe’s solution was never used in the first place, and then debate about whether it was actually a good design and a different design is needed. Finally, a decision may be reached to build new carts, and they will be put in place. Do you think the “defect” problem will be resolved? The sad part THE TOYOTA WAY FIELDBOOK326 TIP To avoid premature discussion of solutions and to keep the process on track, record ideas for solutions with a statement such as: “Okay, that may be a possible solution and I don’t want to lose your idea, so I’ll write it down and we can discuss it later, when we’re investigating possible solutions. However, right now we want to stay focused on identifying the problem.” is that this group is under the illusion that they’re actually getting “results,” and in fact they may somewhat improve the results. But it’s a case of focusing on the nickels (small causes) while the dollars (major causes) fly overhead. Find the True Problem to Get the Most Significant Results When beginning the process of identifying the true problem, it’s a challenge to find the issue at the most significant level. Often a problem is perceived based on personal experience, but this may only be “a problem” rather than “the prob- lem.” If we ask, “What is your main problem?” the answer is likely to be an issue that is most present and frequently experienced by the person being asked. For example, an operator who experiences a persistent problem every day will likely perceive it to be “the problem.” In addition, a person’s role in the organization tends to skew the importance of an issue for him or her. Those in the accounting department, for example, tend to see cost issues as the most important. Those in purchasing often believe that vendors are the primary concern, and engineers tend to focus on equipment-related issues. Toyota refers to the Five-why process (explained later) as a “causal chain,” because the problems and their causes are linked together in a series of single and branched chains. In an attempt to identify “the problem,” people often enter the causal chain at the problem perception point, or the “point of recognition,” rather than at the level of the true problem. They have identified what they believe the problem to be, but they may be further down the causal chain rather than at the top, where the true problem resides. Finding the true problem is based on understanding its effect at the highest level, where the full impact of the issue is experienced. When identifying any problem, Toyota views it in the context of the primary performance measures, which are safety, quality, productivity, and cost (Figure 14-1). These measures are inherently linked to one another, and it’s not possible to negatively impact one of the measures without also negatively influencing another. For example, if a defect affects quality performance, it may also affect Chapter 14. Develop a Thorough Understanding 327 TRAP It’s easy to confuse activity with results. A poorly defined problem and a rush to solution and action lead to activity without achiev- ing the desired results. If you desire to maximize your return, a focused effort on a clearly defined problem followed by a thor- ough analysis will lead to significant results. the ability to produce the desired quantity of product, thus causing customer service levels to suffer. To avoid affecting the customer, appropriate countermea- sures such as increased inspection or production time may be employed to protect the customer. These extra measures will increase the cost. An operator who detects the defect may conclude that the defect is “the problem,” when in fact the true problem is the affect on customer service, and ultimately on the total cost. The placement of the measures in this model does not imply importance. In other words, cost is not the most important measure. Customer satisfaction is the most important measure. We want to achieve the highest level of customer satisfaction while maintaining the lowest possible cost. Delivering a quality product to the customer is always understood to be the number one goal. A tenet of the Toyota Way is that a defect should never knowingly be passed on to the next process. The effort to ensure the correction, containment, or control of the quality problem will have a negative impact on productivity and cost. Notice the lack of “customer delivery” or “safety.” Within Toyota, all processes are closely linked to each other, and the “cus- tomer” is actually the next process. Given these tight connections and the fact that all processes in the plant and throughout the entire supply chain are inher- ently linked, if you fail to meet the customer demand (the next process), the entire operation will begin to stop, one process at a time (like dominos). For this reason, the satisfaction of the customer is implicitly understood and does not need to be measured separately. If a process is unable to meet the demand, it is a productivity issue. In addition, safety is an implicit expectation for everyone, and as such, may be “omitted” from the discussion of measures. Safety as the number one priority is a given. THE TOYOTA WAY FIELDBOOK328 COST CUSTOMER SERVICE QUALITY PRODUCTIVITY Figure 14-1. Relationship of primary performance measures It may helpful to think of these relationships in terms of the problem, symp- toms of the problem, and the causes of the problem. Using a medical condition as an analogy: Suppose you visit the doctor and complain of aches and fever. These are not the problem. They are symptoms of the problem. The problem is that you don’t feel well (and as a result may miss work or other activities). The doctor will take information and perform tests and gather facts (vital signs) that are part of the analysis, to find the cause of the aches and fever. Visually, the process looks like Figure 14-2. Symptoms are presented to the side of the problem, as in “I have this problem, and as a result I have these symptoms.” To get to the cause(s), the information is analyzed to evaluate all possibilities. The symptoms are an important piece in the overall understanding of the problem. They provide supporting evidence that a problem exists. They also provide quantifiable data showing the magnitude of the problem. In this case, a fever of 104 degrees is more significant than a fever of 100, thus increasing the need to treat the problem. The relationship of the three primary measures will follow the same model of Problems, Symptoms, and Causes, as shown in Figure 14-3. In this case, low productivity would be the problem, poor quality a cause, and high cost a symptom or result. Using this model is important because it forces con- sideration of the bigger picture. We may believe that a repetitive quality problem Chapter 14. Develop a Thorough Understanding 329 PROBLEM (Don't feel well) AS A RESULT OF THE PROBLEM THESE SYMPTOMS EXIST (Aches and Fever) ROOT CAUSES ANALYSIS LEADS TO Figure 14-2. Illness symptoms versus root causes is the true problem, but if we look further, we find there is an issue having a greater impact (this is assuming that the rule to never knowingly pass a defect to the next process is followed). Quality is a causal factor for poor productivity. This thought process is depicted in Figure 14-4. The problem is perceived at the point of recognition (where the problem is “found”). To consider this “problem” in a larger context, we would use a statement such as; “We have this problem, there- fore, this happens.” For example, suppose that the perceived problem is a machine malfunction resulting in scrap parts. The statement would be, “The machine mal- functions, therefore the part is scrap.” Continuing this line of thinking we state, “The part is scrap, therefore we are losing production capacity and increasing cost. Therefore, we are not able to meet the production requirement,” or, “Therefore our cost it too high.” At this point we begin to understand the greater significance of the true problem. If we do not consider the situation in a larger context, we may limit the pos- sible solutions as well and the total impact of solving a larger problem. Thinking in this way allows us to identify the true problem and thus provides three distinct advantages: 1. Ensuring that the most significant opportunity has been captured maxi- mizes results with minimal effort. THE TOYOTA WAY FIELDBOOK330 PROBLEM (Reduced Productivity) AS A RESULT OF THE PROBLEM SYMPTOMS: Increased Cost, Poor Customer Service Quality (Scrap and Rework) Quality Issue Causes Figure 14-3. Problem symptoms versus root causes 2. Taking a larger view opens the possibility of solving the true problem by correcting causes in addition to the ones initially identified. 3. The lower-level cause identified may be very difficult to correct (which is why it is perceived as the biggest problem), and focusing only on this dif- ficult condition will preclude consideration of larger and easier causes, which lead to greater opportunity. The following was an actual conversation between a Toyota sensei (teacher) and a process engineer at an automotive parts plant. It examines the challenge of shifting focus from the perceived problem to the true problem. Sensei: What is the problem in your area? Engineer: The welding robot keeps breaking down. (The perception of the “problem” is based on personal experience and the person’s role.) Sensei: Are you sure that is your problem? Engineer: Yes. It breaks down all the time. We’ve tried various things to correct it but have had only limited success. We need to get a new robot. (Notice the jump to a solution.) Sensei: I am not sure that is your real problem. Engineer: Yes it is. It has been the problem for a long time. We have data to show how much it breaks down. Chapter 14. Develop a Thorough Understanding 331 True Problem Point of Recognition Point of Cause (Where the problem physically occurs) Exploration of the perceived problem may lead to discovery of a Larger Problem Solving a Larger Problem may yield different opportunities for solution Therefore…. Moving towards understanding the True Problem (The "perceived problem") 5 Whys? Moving toward solutions Root Causes (Solving will correct the True Problem) Figure 14-4. The problem-solving continuum Sensei: I am sure it breaks down, but I am still not sure it is the real problem. Engineer (a little angrily): It is the problem. I’ve been working on this for almost four years and I can tell you it is a problem. (Is it the problem or a problem?) Sensei: Yes, I know you’ve been working hard on the robot; however, let me explain why it is not the real problem. When the robot breaks down, what happens? Engineer: There is a fault at Loading Zone 3 because the weld nut does not feed. We’ve been working with the vendor to improve the feeder. Sensei: Okay, what I mean is, what happens to the line when the robot breaks down? Engineer: It stops, of course. Sensei: When the line stops, what happens? Engineer: Everyone stands around, and they call me to fix the robot. Sensei: I mean, what happens to the flow of product? Engineer: It stops. Sensei: When the product flow stops, what happens? Engineer: Everyone stands around. Sensei: I mean, what happens to our ability to make parts? Engineer: Of course we can’t make parts with the line stopped! Sensei: So we are not able to satisfy our customer with the required number of parts? Engineer: We can’t meet the demand without working overtime. Sensei: So the real problem is that we are unable to meet customer demand without working overtime? Engineer: No. The problem is the robot. Sensei: Well, let’s go to the line and look. As the sensei and engineer proceed to the line, the engineer wants to take the sensei to the robot to show him the “problem.” The sensei knows that line stoppage for any reason will ultimately affect the ability to meet production demand and that the robot is only one possibility. Therefore, it is further down the causal chain and not the high-level problem he’s looking for. The sensei takes the engineer to the end of the line to observe flow. In a few minutes he notices that the flow stops. Sensei: Why did the line stop? Engineer: The employees are rotating positions. Sensei: How often do they rotate? THE TOYOTA WAY FIELDBOOK332 [...]... continue to state “therefore” proceeding upward until the true problem is identified Therefore: The process can’t meet demand without overtime This is the true problem Therefore: Process doesn’t make parts Therefore: The product flow stops 334 THE TOYOTA WAY FIELDBOOK Therefore: The line stops The robot breaks down Start with the perceived problem and work up to find the true problem Once the true problem... the only solution considered The young engineer explains that the documentation supports the conclusion that this is a good solution “But could there not be even better solutions?” the mentor asks So it’s back to the drawing board to identify other potential solutions The mentor may in fact think it is a perfectly good solution What he or she is trying to teach is a way of thinking The Toyota Way documented... to keep the focus narrow by answering the direct question Look for the broad categories under which the detailed answers will fall Remember to use the “Therefore” method if you find yourself answering further down the chain If the answer “Setup time is too long” arises, state “Therefore” and find the answer In this situation it would be: “Therefore the machine is not running for a long time.” The following... Making the Transition to Lean," in J.K Liker (ed.), Becoming Lean, Productivity Press, 1997 346 THE TOYOTA WAY FIELDBOOK Continuing with the causal analysis (Five-Why) process in this example revealed the chain in Figure 15-4 Follow the bold text chain to the root cause in the outlined box Toyota uses this process of continually narrowing, isolating (using the 80 /20 rule), and focusing efforts on the. .. Machine 352 THE TOYOTA WAY FIELDBOOK Putting It All Together: The A3 One-Page Report The analysis phase is typically where most of the problem-solving time is spent The primary purpose of the analysis is to understand the causal relationships and to find enough causes that, when corrected, will yield an improvement sufficient to solve the problem It is important to convey the basic findings in a way that... understanding the many potential causes of the problem From those potential causes, it’s necessary to narrow the field and focus on the most significant ones Much of Toyota s great success stems from the ability to fully analyze a situation and understand the many Copyright © 2006 by The McGraw-Hill Companies, Inc Click here for terms of use 342 THE TOYOTA WAY FIELDBOOK causes of the problem beyond the most... actually resolve the problem Chapter 16 Consider Alternative Solutions While Building Consensus J UST AS THERE ARE many potential causes and root causes for any problem, there is always more than one way to solve any problem! The creativity of the problem solver is an important aspect of the Toyota Way of thinking, so there are few absolutes regarding the best approach; however, there are some key... would challenge the boss’s request? But none of these answers support the effort to resolve the problem! They’re a dead end They presume lack of ability and responsibility for improvement The answer to the question “Why?” must be related to the goal of capturing lost time opportunities and must be solvable Think about the issue in terms of the goal of reducing the time required for cleaning The current... through the causal chain to the original problem, we’re looking only for those activities that take time away from the value-adding task In other words, if the operator is performing a non-value-adding task but the machine is adding value while the operator does the task, improving this item will not lead to reducing the problem, and thus is not a beneficial improvement The first priority is to address the. .. Statement Quantity 80 340 THE TOYOTA WAY FIELDBOOK Reflect and Learn from the Process Identify and select a problem you want to solve and use to reflect upon in Chapters 14 through 18 The problem should be significant, but not one of the most difficult problems you have We suggest learning the problem-solving process on simpler issues before tackling more difficult ones 1 Gather facts related to the problem . are long. Each of these answers may be “true,” as in the conversation between the engineer and the lean sensei described in chapter 14, but they are further down THE TOYOTA WAY FIELDBOOK3 42 . identify the problem,” people often enter the causal chain at the problem perception point, or the “point of recognition,” rather than at the level of the true problem. They have identified what they believe. they believe the problem to be, but they may be further down the causal chain rather than at the top, where the true problem resides. Finding the true problem is based on understanding its effect at the