Chapter 8. Build a Culture That Stops to Fix ProblemsCase Example: Errors in Faxing Orders
During an activity to improve order processing throughput time in an
office setting, it was discovered that order approvals were often
delayed by several days because of errors made during faxing to dealers.
Orders were to be returned to the dealer for review and approval prior
to submitting for production. The normal procedure was to return
the preapproval proposal via fax to the dealer for final approval. The
required response time from dealers was two workdays. If the proposal
was inadvertently sent to the wrong dealer, two or three days would
pass before follow-up was initiated to see if the dealer approved the
proposal. During the follow-up it was discovered that the fax was never
received. Investigation of the fax transmittal records showed that faxes
were in fact inadvertently being sent to the wrong dealers.
Further investigation also revealed that certain employees made a higher
number of mistakes, and the conclusion was that they were “more
careless.” As a possible “solution,” instructions to employees were posted
by the fax machines telling them to “Pay attention” and to “Be care-
ful” and “Verify that faxes were sent correctly.” Of course, this did not
solve the problem, and the conclusion was that certain employees
would always “be problems” and that more checking was needed.
When the Toyota Way of thinking was suggested, the response was,
“Human error is a reality. You will never eliminate human error.” Here
is the issue. A person who develops a system generally understands it
well and assumes that others should also. The developer (or even a
person that has used it for years) believes that the system is simple
and understandable. They have difficulty recognizing that others may
have a different experience with the system and that people have
different capabilities. Anyone who does not perform as well is considered
to be incapable. Rarely does anyone consider the system. Let’s look
at the method in this example to find the causes of errors in the
system.
Due to the large number of incoming and outgoing faxes, four
machines were used. Each machine could store 100 fax numbers and
use a “shortcut” code to automatically dial the phone number. A list
of all dealers was posted behind the fax machines so employees could
locate the dealer and the correct code (Figure 8-6). The list was sep-
arated into three sheets that were each very large (20 by 20 inches).
They were also posted on the wall behind the fax machines, some
distance from the employee.
When we evaluated the method in which work was performed and
tried to understand why the errors could occur, we saw that while all