This is what $1 billion (and $25 million a year) gets you.

by Dan Markovitz

The New York subway system has invested nearly $1 billion investment since the early 1990s -- and $25 million per year in maintenance cost -- in equipping stations with elevators and escalators. The results have been less-than stellar.

According to a recent article in the New York Times,

One of every six elevators and escalators in the subway system was out of service for more than a month last year.

The 169 escalators in the subway averaged 68 breakdowns or repair calls each last year, with the worst machines logging more than double that number. And some of the least reliable escalators in the system are also some of the newest.

Two-thirds of the subway elevators — many of which travel all of 15 feet — had at least one breakdown last year in which passengers were trapped inside.

Now, keeping the NYC subway system running is in many ways a Herculean task. The system serves five million riders per day, and runs 24 hours a day. It's also incredibly far-flung, which slows maintenance responses to breakdowns. And there's all kinds of, um, ancillary abuse:

Elevators become makeshift bathrooms, and escalator steps are pounded by heavily loaded hand trucks.

Notwithstanding those challenges, however, New York City Transit has sown the seeds of its own difficulties by violating key lean principles. Take investment in people:

In private industry, many workers go through a rigorous four-year training and apprenticeship to become elevator and escalator mechanics.

At New York City Transit, newly hired mechanics, many of whom have no experience in the field, are given a four-week introductory course in elevator and escalator maintenance. They are then issued a bag of tools and sent to work, paired up initially with a more experienced mechanic.

There is no requirement for refresher training.

It's not just a private sector/public sector difference, either: the Washington Metropolitan Area Transit Authority created its own training program that includes a four-year apprenticeship with 1300 hours of classroom training.

More significantly, the agency has a culture of trying to solve problems without trying to understand the root causes of the breakdowns.

In many cases, riders were trapped in elevators where a mechanical problem occurred again and again. Some times, mechanics may have lacked the ability to solve the problem. At other times, transit officials said, supervisors failed to see patterns of breakdowns or felt pressured to put the machines back into operation in a hurry even though they needed additional work.

In one particular case, an elevator had broken down five times in the eight days leading up to a serious (40 minute) breakdown. Each time, mechanics came, made minor adjustments and put the machine back in service — only to have it break down again. You'd think that an "Ohno Circle," or at the very least a "Five Whys"/root cause analysis, would have been not only useful, but ultimately more time efficient and cost-effective.

The transit agency is making important changes. Contractors are now supervised by experienced employees when they install equipment. And there's now a special group of mechanics to conduct tests at key stages of construction.

But there's still an attitude that the mechanics just "have to do better." After three out of six escalators were found with improperly installed bolts (which caused steps to literally fall out of the machine), Joseph Joyce, the transit agency’s general superintendent of elevators and escalators said that he was trying to

[foster] a culture of accountability among his mechanics and managers. “I’m trying to get these guys to think that, you know what, that could be your mom that’s walking with a cane and needs that escalator."

And after the drive chain on another escalator snapped, Joyce said

“They’re good mechanics, but they missed something that day. I think they had a bad day that day."

But as Mark has pointed out many times, this kind of thinking just doesn't work. For one thing, the implicit assumption is that the workers don't care enough to want to do a good job -- an assumption that flies in the face of lean thinking. More importantly, no matter how often doctors -- or mechanics -- are told to be careful, they're guaranteed to make mistakes if they don't have enough training, or sufficient authority to shut down a machine and conduct a root cause analyses, or proper standard work procedures to ensure they don't miss critical steps.

Human beings will always make mistakes. It's management's job to create a process that prevents those errors from occurring. The New York City Transit Authority is moving in the right direction, but at the top level they still need to change the way they think about the problems -- and their employees. At $25 million a year, the riders and taxpayers of New York deserve nothing less.

Subscribe via RSS | Lean Blog Main Page | Podcast | Message Board

Bad Systems in the News: Not the Worst "Oops" Possible with Nukes

The Lean Thinker » What Nukes?

I had been mulling over trying to do a post on this story since the original story broke in August that some nuclear-armed cruise missiles were "accidentally" or "mistakenly" moved from one base in North Dakota to another in Louisiana.

I've read a number of stories, and there doesn't seem to be a clear story about what happened. The most recent stories are more about punishment and blame. I'm more interested in "root causes." There are different theories:

1. A mistake occurred. Procedures got lax, airmen weren't following procedures and leaders didn't notice or didn't take action. The system didn't have enough controls or oversight.
   
2. A mistake like this couldn't possibly have happened. The systems are too air tight and there are too many controls in place.

So which is it? I'm not sure. If you read too far into possibility #2, Google search results quickly get you to conspiracy theories worthy of the show "24." The systems are too tight for this to have happened unless someone was trying to send a message to a foreign country or somebody was trying to steal a nuke. I'm not endorsing those theories and I quit reading when I realized I was getting close to the lunatic paranoid fringe.

There are some really interesting underlying issues here, related to Lean concepts of standardized work, error proofing, and the role of leadership. Heck, if Air Force personnel were really coming up with their own unauthorized process, there's a horribly astray attempt at "kaizen," perhaps.

I've linked to a lengthy post from the new "Lean Thinker" blog. Check it out. Who has some insight into this? This story makes my head spin.

"An Organizational Accident"

'Chicago Way' is no way to run mass-transit system

It's something I've written about before, about how the media and the public tend to blame individuals, or at least we want a scapegoat. Who screwed up? Whose fault? This has been the case in airport near misses and in hospitals. The Lean mindset (going back to the Deming philosophy) teaches us to look for systemic causes of problems rather than just pointing the finger of blame. As Deming always taught, management is responsible for the system -- they have the means and the authority to actually help fix the system, more than individual employees.

So, I was, in a way, pleasantly surprised to see this editorial and analysis in the Chicago Tribune today, talking about an accident on the CTA Blue Line train last year, where 150 passengers were hurt.

The federal government came and investigated the accident and the conditions that led up to it.

"...the "worst" he's ever seen. That's how one NTSB official regarded the CTA's track inspection and maintenance non-system. The train derailed because the track was deteriorating, because no one noticed, because inspections weren't done, or not done well enough, and if they were, the problems weren't getting reported and those that were, weren't getting fixed. Lucky no one was killed. Riders and taxpayers have a right to be enraged at the "Chicago Way" of doing things.

The investigation, citing a deficient safety culture, noted "a series of latent conditions and active failures at many levels through the CTA corporate structure, which is characteristic of an organizational accident." That's bureaucratese for: This is one pathetic, dangerous operation.

It's not often when you see somebody pointing at "latent" and systemic problems. I'd say responsibility for the accident goes all the way to the top of the CTA, and the CTA leadership can probably blame the state government for lack of funding or oversight. Whose responsibility is it that tracks aren't inspected or maintained? It's not enough for leaders to say "my people didn't do their job." It's the role of leadership to MAKE SURE their people are following Standardized Work (or it's leadership's role to make sure the Standardized Work is even there to be followed). It's the same reason Mattel can't be excused for their China quality problems by saying, "Our suppliers let us down."

Ironically, the CTA originally responded to this train accident with blame. They fired five employees. Did those employees really have the power to impact the system? I'm sure the CTA President felt good for firing them. Problem solved, eh?

As the CTA stated:

CTA officials said today that following an extensive internal investigation, five employees were terminated for rule violations that allowed track conditions to degrade and cause a derailment. The terminated employees included two track inspectors, their foreman, the engineer responsible for monitoring the foreman’s
work performance and the manager of track maintenance.

The CTA President continued grandstanding:

“These employees were entrusted with jobs that are critical to providing safe,
reliable service for CTA customers and they let us all down. By abdicating their
responsibilities, they put customers and other employees at risk,” said CTA
President Frank Kruesi. “We take safety seriously at the CTA and have no room for employees who don’t.”

Again, where was Mr. Kruesi? The rules were being violated before the accident took place, why wasn't anyone paying attention or holding employees accountable earlier? That's a leadership failure, I would argue.

The CTA responded to the accident with reactive repairs and other things that they should have been doing before the accident had even occurred. That would have been proactive. That would have been Lean thinking and Lean leadership. Not that I would expect to find either of those things at the CTA... it's just sad to see how common that blame thinking is.

Subscribe via RSS Lean Blog Main Page Podcast Message Board

"Bad Systems in the News" Update

Here are some updates on the "Bad Systems" I featured last week, Northwest Airlines and the NBA. I know I promised more positive posts, but let me follow up on these stories...

First, the NBA. I don't have a link (now I do), but I heard an interview on ESPN Radio with one of their expert NBA analysts, Rick Bucher, about the NBA referee oversight system. As I wrote about before, the refs have observers (allegedly poorly trained) who review games and second guess calls. The refs get performance reviews and their scores/rankings are used to determine playoff assignments and, I assume, pay raises.

It's a classic "performance review" system, in the model of most Western management. It's a "continuous review" (so it is better than an annual review), but the feedback is very slow. Bucher said the refs might not get "feedback" about their calls until eight days after a particular game. Bucher passed along the refs' frustration that they are second guessed by people they feel aren't qualified to do so. That could be almost any workplace, where technical people (the refs) are "supervised" by pointy-haired Dilbert boss types.

Bucher talked about the increase in players "flopping" to try to draw calls (think most of the San Antonio Spurs, particularly Manu Ginobili). Many fans (yet alone the players) get frustrated with this and the impact it has on the game. Bucher said the referees "aren't fooled" by the flopping, but their observers tend to "ding them" for what the observers (who are fooled, I guess) would consider "non calls." So, the performance management system appears to harm the game, as refs are making calls based on how they will be evaluated, not based on how they were taught to referee. A bit dysfunctional, eh? For fun, here's an ESPN list of the Top Ten floppers of all time. And here's an obvious NCAA flop, via Youtube.

The other thing that struck me, and again reminded me of Deming and he problems with "Management by Objectives" and performance management systems, was Bucher's comments that many refs are complaining about losing their "passion for the job." Deming said everyone had a right to joy in their work, and here's a classic example of NBA management stripping referees of that joy or passion. Sad. Deming also said (page 54 of Out of the Crisis):

"Leaders must know the work they supervise.... In most organizations, this is only an idle dream, as the supervisor knows nothing about the job."

Now, to Northwest. The airline has a systemic problem, at least the last two months where the company has to cancel flights at the end of the month because they don't have enough pilot flying hours remaining. The company blamed the pilots, but, oh yeah, management also took away pilot overtime pay, so the pilots aren't exactly in the mood to voluntarily work additional hours.

In this WSJ article ($$), CEO Doug Steenland throws out the ridiculous excuse that they had an "unforeseen pilot shortage." What? Again, this makes me think of Deming, but it's management's job to forsee such things.

Steenland, himself, admits that the company erred in increasing flight capacity by 4% without increasing the number of pilots, and, oh yeah, that overtime plan wasn't too popular with the pilots. So, they're cutting capacity, adding pilots, and have reinstituted the overtime pay.

I'm really trying hard to keep my "respect for people" hat on, but I'm still going to call Northwest management a bunch of morons. This is the kind of great management talent that you pay huge "retention" bonuses to? "Bollocks," as my friends in the U.K. would say.

Final thought, a quote from an industry analyst:

"It's great that they're finally coming to an agreement, but it's an absolute shame that thousands of vacations had to be ruined to settle their differences," said Terry Trippler, an airline consultant in Minneapolis.

"Northwest Airlines has unbelievably bad employee-management relations and it's going to take a long time to repair it, if it can even fix things," Trippler said.

Not to mention their customer relations, at this point. CEO Steenland says they are going to try to "mollify" their customers (that's his favorite word, apparently). Back in June, they promised to mollify everybody and I guess they still haven't learned how. How about you stop angering employees and customers first? That sounds like good business to me.

Another great quote from a NY Times article on the industry mistreating customers:

“Previously, airlines worried about dissatisfied customers,” said a Wharton professor, Serguei Netessine. “Now I don’t think they worry about it because the customer service at all airlines is so horrible.”

Subscribe via RSS | Lean Blog Main Page |Podcast | Message Board

Bad Systems in the News: PHX TSA

Serious Security Questions at Sky Harbor Airport

New interim security director named at Sky Harbor

Here's another story from last week about bad systems, and bad management to boot. This one hits close to home since I used to fly out of Phoenix's Sky Harbor airport quite regularly.

In the first linked article, the local Phoenix ABC affiliate did an investigative piece about how the "secure" terminal was basically left wide open all night, with guards who were either sleeping or not checking people who came through. Part of the story:

"We've discovered a 4.5 hour time frame each night when virtually anything can be brought into the secure side of Phoenix Sky Harbor Airport. There's no metal detector, no X-ray machine, and it's apparently not a problem.

Afraid to show her face, one long time Sky Harbor employee talks about the security most people don't see.

Lisa Fletcher: "You're telling me Sky Harbor's not safe?"

Employee: "I'm telling you Sky Harbor's not safe and hasn't been for a long time."

It's what we discovered in the middle of the night - TSA agents going away, and security guards taking over. It's 4.5 hours - every night - when an employee badge becomes an all-access pass."

What makes this a "bad system?" The fact that so many employees knew about this glaring weakness and TSA management did nothing about it. Apparently, the TSA isn't a "Lean" organization where management appreciates employees bringing up problems. It's probably more of a "keep your mouth shut" environment, I'd guess. It's a bad security system, on the surface, but deeper (and more importantly) it's a bad management system.

I'm sure employees tipped off the TV station, who came to watch:

"In the time we watched, dozens made it past this checkpoint, bags unchecked."

Yikes! The station claims that airport officials had known about the security problems for TWO YEARS.

The airport employee we talked with said she is afraid.

"No one's doing anything about it," she said. "Management knows. I know management knows. I know my superiors know. I know the security guards know. Everybody knows what's going on, but nobody's doing anything about it."

I wonder how high the "chain of fear" runs? Why wasn't anyone willing or able to step up and say "we have a problem, we need help"? Here's an illustration of what happens when an organization's people are afraid to speak up. Deming always said that management needed to eliminate fear from the workplace. I think that might have helped the TSA.

So, as the second linked article says, the Phoenix TSA director was placed on administrative leave as they investigate. I wonder if the TSA will just blame that person or look for more systemic causes for the inaction? Why stop at just the local Phoenix level? Who knew, higher up in the TSA?

The response from the TSA and the City of Phoenix (scroll down in the second link) has a lot of doublespeak. No rules were being violated, but they're changing the practices to make sure the terminals are secure 24/7.

Subscribe via RSS | LeThean Blog Main Page |Podcast | Message Board

Bad Systems in the News: Northwest

NWA blames pilot absences: Detroit Free Press

Updated: NWA calls back all its pilots as cancellations mount

In another example of media/management blaming, Northwest Airlines is blaming pilots for forcing the airline into canceling flights at the end of July.

Northwest Airlines blamed a spike in canceled flights Friday on pilot absenteeism and warned that it would probably cancel more flights over the weekend.

Blame, blame, blame. Of course management would blame pilots instead of their own mismanagement. It's much harder to look in the mirror than it is blaming others. How might you guess this is somewhat of a systemic problem? The fact that they had the same problem at the END of JUNE. Same bad pilots? Ha, more likely the same bad management.

The union points the finger (which one, I'm not sure) back at the management team that led the airline into bankruptcy (shame on them) and out of bankruptcy (bringing big retention bonuses).

"We continue to maintain that this is a staffing issue," said union spokesman Monty Montgomery. "We notified the airline months ago that there isn't adequate staffing to fly the summer schedule."

As The Consumerist points out, Northwest hasn't brought back enough pilots after the bankruptcy and schedules are heavy. They quoted business writer Joe Brancatelli:

Northwest is trying to operate with about 25 percent fewer pilots and co-pilots than it employed in 2000. The inevitable result: massive crew shortages at the end of June when Northwest's remaining pilots "timed out" and could no longer fly. (According to federal regulations, pilots cannot fly more than 100 hours a month.) Northwest canceled more than 1,200 flights during the last 10 days of June. The final 10 days of July and August won't be much better.

Northwest is playing the usual airline game of sticking it to the employees. The pay for pilots and flight attendants gets slashed, while corporate execs feed at the greed trough. Where is "respect for people" in the airline biz? Can you blame pilots for not volunteering to fly beyond their normal schedules when the airline isn't bringing back their colleagues? It's like the scene in the movie Office Space where the boss tells Peter that they're a bit short on people (after a layoff), so he's going to have to work Saturday AND Sunday.

That's why so much of leadership comes back to basic human psychology, as Deming was fond of pointing out. You often have to step back and ask, "How would you expect people to react?" Sort of like when we talk about the need for a "No Layoffs Due to Lean" pledge. When lean efficiency improvements lead directly to layoffs, why would you expect employees to remain enthusiastic for Lean? Would you expect pilots to rebel by calling in sick to Northwest? Why should they go out of their way to help the company when they're continually dumped on? It's a shame when companies get focused on fighting internally instead of fighting the competition.

On a somewhat related industry note, American Airlines was fined about $250k for safety violations at O'Hare. As the site The Consumerist said:

We don't know about you, but it makes us uneasy to hear that an airline is being irresponsible with the safety of its employees. How then, does it feel about the safety of its customers? If the employees aren't doing their jobs in a safe environment, what makes you think you're flying in one?

Well said!

What a messed up industry. If you look at the "old" carriers, it's probably a more across-the-board mess than the Detroit Three.

Updated: The updated link I posted at the top says that Northwest is trying to bring back the rest of their furloughed pilots, but:

"A significant percentage is choosing to not come back," Montgomery said, though he was unable to provide a specific number.

The way management treats them, can you blame them if they have other options?

Previous contracts considered anything above 80 hours of flight time overtime. Pilots are no longer paid overtime.

"We're having all our pilots fly overtime with no extra pay," Blaufuss said.

Subscribe via RSS | Lean Blog Main Page |Podcast | Message Board

Bad Systems in the News: NBA

Last week, I saw a number of news stories that caught my eye, non-manufacturing stories about systems (or lack thereof) and blame. What do the Transportation Safety Administration, the National Basketball Association, Detroit Public Schools and Northwest Airlines have in common? Poor systems... read on.

National Basketball Association (NBA):
You might have read about the NBA ref, Tim Donaghy, who accused of betting on (or possibly even fixing the outcome of games). The USA Today had an interesting article about the oversight (or lack thereof) with NBA officials:

An ineffective system for training and evaluating game officials helped allow possible illegal betting to go undetected, according to two veteran NBA referees and another who recently retired.

It's interesting to me that this article doesn't just point the finger of blame at the "bad ref." If the charges against Donaghy are true, he must be held accountable, by his employer (well, he's already quit) and by the law. Looking for systemic causes or enablers isn't inconsistent with holding people accountable.

How many businesses have an "ineffective system for training and evaluating" employees? That's what the Training Within Industry program is supposed to help address right? Could that approach be applied to the NBA? Possibly.

The referees make it sound like the rules and guidelines for calling fouls are so open to interpretation that it's hard to teach and hard to hold refs accountable for not calling plays the right way. I reffed intramural basketball for two years in college and it's a very tough thing to learn and get good at. There's so much action, so fast (even in a typical college gym), that you can't possibly see everything or call everything consistently.

Can you use TWI rules to "break down" the job of a referee? There's a certain "art" to officiating, but that's true of so many other jobs. There are judgment calls, but it's also possible to have others validate or calibrate the judgment of each referee, to make sure they are calling games as consistently as possible.

I read in some other article (and now I can't find the reference) that the NBA *does* have "observers" who travel and rate the officials -- were "calls" correct, were "non calls" correct even (basing a "non call" on the reaction of a bench or coaches). Unfortunately, it sounded like the qualifications for being an observer were pretty weak -- no basketball refereeing experience was necessary.

No wonder that was called an "ineffective" system. Hiring observers with no experience makes about as much sense as a manufacturer hiring an engineer, fresh out of college, to supervisor workers in a department he or she knows nothing about (which probably still happens, it's not the Toyota Way approach to supervisor, where you'd tend to promote from the front line workers).

Next: Northwest Airlines

Subscribe via RSS | Lean Blog Main Page |Podcast | Message Board

Bad Systems in the News: Detroit Public Schools

I've fallen behind in my blogging the past few days, but I'll be back on track. I saw a number of news stories that did catch my eye, non-manufacturing stories about systems (or lack thereof) and blame. What do the Transportation Safety Administration, the National Basketball Association, Detroit Public Schools and Northwest Airlines have in common? Poor systems... read on.

Detroit Public Schools:
Lets start with Detroit, since the situation is spelled out pretty clearly by the new superintendent. Since I grew up outside of Detroit, I still scan the papers online sometimes and ran into this article in the Detroit Free Press, which starts with:

Detroit Public Schools Superintendent Connie Calloway said Friday in a candid conversation with the Free Press that she inherited a system in which there are no administrative procedures in place for seemingly basic functions and rules are not respected.

We often take for granted, in manufacturing, that a business has processes. These processes often are full of waste (are "not Lean") but there is a process. It seems, while a generalization, that people in industries outside of manufacturing really aren't taught to be "process thinkers" (yet alone "value stream thinkers").

Calloway is really having to shake up the school district, so rumors spread when a new leader comes in:

The new superintendent, who started on July 1, said that contrary to rumor, she is not a “my way or the highway” type of leader, but one who expects stakeholders to follow standards and procedures.

I think the same could be said for a "Lean leader." Lean leadership isn't a dictatorship, but you do have to set expectations that people follow "standardized work." Again, the school isn't trying to "be Lean," I'm just looking for parallels here. A "Lean leader" would go a step further than just following standards -- they would also expect people to make suggestions for improving said standard.

An editorial in the paper spells out more, including Calloway quoted as saying:

The system, she says, seems "unaccustomed to process" of any kind.

She also uses the word "apalling." As a leader, you have to be careful in telling people how bad things are. It might all be true, but people might not necessarily trust an outsider. People often have pride in how they've done things, even if it's all wrong. Think of the challenge of an Alan Mulally coming into Ford, trying to talk about how bad things are and how Toyota is doing so much better. He runs the risk of being tuned out or demonized by those with an interest in maintaining the status quo. This happened in the DPS before:

Think of Deborah McGriff, hired in the early 1990s to shepherd the school system through the early days of reform. She was blunt, too, about how awful she found things to be here, and she refused to back away from tough assessments or unpopular prescriptions.

She lasted less than two years, though, because those who don't want to hear the truth were allowed to cast her as the enemy. Nearly 20 years later, no one can credibly argue that things are better than they were when she left.

I saw similar attempts when I was at GM and we had a new plant manager with a NUMMI background come in to fix things. I wrote about it here in this post about Mulally. The union tried to make him the enemy, that he was criticizing the workers, when that wasn't the case, at all. Spin and politics can get in the way of change in any environment, unfortunately. Hence, the challenge of leadership!

An example of the broken processes:

A few examples: Calloway notes that Detroiters have argued for years over the way the school system doles out contracts. Rather than focus on the accusations, she has asked the district's procurement office to outline its standard operating procedures, so she can check to see that the proper safeguards are in place. She said she'll do the same with every department.

Again, this reminds me of "Lean leadership" -- not pointing the fingers of blame but, instead, focusing on defining processes. Without a process defined, how can you tell if people are following the process or not?

I really wish Calloway a lot of luck with her journey. Maybe Mulally and other Lean leaders in Detroit can help out. First off, by setting a good example, but secondly, getting involved and helping bring "Management 101" practices (yet alone Lean) to the school district.

Coming Next: Bad Systems in the News: the NBA

Subscribe via RSS | Lean Blog Main Page |Podcast | Message Board