This post shares a story I heard at the Michigan Lean Consortium annual conference earlier this week. They've been kind about sharing ideas and doing a book club discussion around my new book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.
There was a Q&A session with me on Tuesday and on Wednesday, I moderated a panel discussion about learning from mistakes. I had a great time and I appreciated the stories and insights from the panelists.
During a book signing session at the conference, an attendee, Cori, told me a story that's too good to not pass along. I'll do my best to be true to the details of the story.
Cori's friend worked at, I think, a commercial meat-producing facility. The company had a large meat grinder that could hold up to 50 pounds of meat.
Listen to Mark read the post (subscribe to Lean Blog Audio):
A worker added 50 pounds of meat and then dumped in spices. He grabbed a large spoon and started mixing that all together before needing to walk over to a button on the wall that would start the grinder.
While the spoon was in the meat, there was some distraction. The worker was pulled away.
Coming back, forgetting that the spoon was still in the grinder, he hit the button to start it up.
The spoon “got thrown through the side of the grinder,” damaging it if not destroying it.
What did the company do?
Cori said he told his friend:
“Firing the worker won't really help. This problem will happen again.”
I'd agree with that assessment.
What happened next?
The company hired a new worker. Trained them. Put them on the job.
I think he said it was a matter of weeks later…
As predicted by Cori.
With a different person, the same mistake was made, with the same result. Spoon left in the grinder… turned on… ruined.
Cori said he recommended that the spoon holder on the wall needed some sort of “interlock” so that the button to start the machine would only work if the spoon was in that place.
Now that sounds like “mistake proofing.”
Instead of telling people to be careful and then blaming them when they make a mistake, it's better and more effective to focus on improving processes and systems — if our goal is preventing mistakes.
Make it difficult, if not impossible, to do the wrong thing. That could involve technology, like an interlock, or a procedural fix, such as training employees to never leave the spoon unattended in the grinder. The interlock, while more expensive, would be more effective.
But that might very well be cheaper than ruining an expensive meat grinder every so often.
Oh, and imagine the benefits of not putting employees through the proverbial meat grinder anymore.
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