Questions about and Lessons from a Steering Wheel Falling Off

Photo: Car and Driver

In the news yesterday, a General Motors recall over what could be just one isolated steering wheel problem in an Ohio-built Chevrolet (don't call it Chevy) Cruze.

Most news stories about the recall just mention that one steering wheel came off while an owner was driving down the road (yikes!)

The Wall Street Journal story has some interesting details that might raise some interesting questions about the assembly line production process.

As I went for a morning walk, I listened to my old favorite morning radio show from Detroit (Drew and Mike and WRIF radio) via an iPhone app… I heard their news reporter talk about the story and she added her commentary of “They need to find THE IDIOT who did that.

It's so tempting to blame an individual, whether it's an assembly line defect or a medical error. But the world and organizations are far more complicated than that. We need to be “hard on the process, not on the people,” as former Toyota guy Pascal Dennis says.

From the WSJ article:

In documents filed with the National Highway Traffic Safety Administration, the car maker said it traced the problem with that particular car to a case in which the wrong wheel was put in a car and replaced later in the assembly process with the correct one. But the new wheel wasn't attached properly, the car maker says.

Questions that Should be Asked at Gemba

First, the wrong wheel was installed in the vehicle. It would be interesting to go to the “gemba”, the factory floor to see what really happened. Was this not properly error proofed? Why did the wrong steering wheel get into the wrong vehicle? Why isn't this prevented or detected?

I'd be curious to know the details behind “was replaced later in the assembly process with the correct one.” I'd hope, in a way, that the problem was just not detected until later. If the defect HAD been discovered, the good practice from Lean and the Toyota Production System would be to stop the line so it didn't have to be fixed later. Some Big Three (Detroit Three) plants have struggled with the culture change required to allow workers to “stop the line” when they see a problem (like this fairly recent story about a Ford truck plant).

When I worked at GM in the mid-90s, my plant was still trying to recover from the “don't stop the line” mindset. The old non-Lean mindset was to keep cranking out stuff, we'll fix it later. Old habits die hard.

Back to the steering wheel, ff they found the defect, they should have fixed it immediately and worked to understand the root cause of the defect. We can't be sure if they didn't FIND it or didn't FIX it. Either way is a different sort of bad process.

If they didn't find it, what can they do different to detect or prevent these defects?

Well, error proofing was put in place, after the fact, according to the WSJ:

Chevrolet says it has changed the production  process to make sure  the machine used to  attach the steering wheel can accommodate only the correct one. The company is recalling cars that were built before it made the change.

That's error proofing. Better late than never, I suppose. Has this ever been a problem at other GM plants? Is this still a problem in other factories? How is the learning spread throughout the organization? I'll give GM credit for doing something, as a response, that's more effective than “writing someone up.”

Thoughts for Healthcare

When errors happen in healthcare, there's still a tendency to wrongly look for “the idiot.” We often throw people in jail or ruin their careers. This approach probably does little to improve quality. In fact, the punitive approach to quality and safety arguably HARMS quality as people become afraid to raise issues, as they can in aviation or a good Lean factory.

As my friend Naida Grunden, author of The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods, points out – there are about 30 different ways and places a healthcare professional can report an error or a problem, most of which end up running the risk of being punitive.

There's not a single place for healthcare, as there is in aviation. This topic doesn't seem to have been a huge part of the “healthcare reform debate,” unless I'm wrong on that.

Virginia Mason Medical Center has done great work on putting in a “Patient Safety Alert” system within their organization, as described here and in their book Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience. ThedaCare is another system that has worked hard to move away from the old fashioned “blame and shame” culture that so often dominates healthcare (as described on page 116 of their book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry). There are many other examples of hospitals moving in the right direction, but as with GM, old habits and cultures take a long time to change.

What lessons do you take away from this situation? Are there folks still working in the auto industry who share a more modern perspective on what happened or what likely happened? Sorry for my non-Gemba speculation here…

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. More “after the fact” error proofing, this time involving Applebee’s error proofing against serving alcohol to babies:

    A mixed alcohol drink was mislabeled as juice…

    Is the new policy change for *all* Applebee’s or just that location? Seems like the same systemic risk everywhere.

    More detail via my dad, sounds like this *is* systemwide:

    It’s on their web page, so when they say they are changing, it is implied the headquarters are speaking for all locations.

    They didn’t say anything about firing anyone.

    How does healthcare respond when there’s a systemic risk identified? Granted, Applebee’s is a single corporation, but how do the huge healthcare systems respond when they find a risk like Applebee’s did? Why can’t we communicate across organizational boundaries the way aviation does?

  2. Hi Mark,

    Well, this is interesting! So, after dragging a Japanese company that happened to be kicking GM’s butt through the mud for the better part of a year without knowing the facts or having HARD evidence (is it pedal design, is it floor mats, is it electronics? Gremlins?!) will the government subject GM to the same public embarrassment for having a steering wheel, literally – I think I read this correctly…fall off!? The government doesn’t even need to employ NASA to replicate the failure and waste taxpayers money to verify that the steering wheel FELL OFF. Will our fearless leaders subject the CEO of GM to public embarrassment in hostile, televised NSTA hearings?

    I’m not going to hold my breath.


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