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Employee Push Back when asked "why" an issue happened...

Discussion in '5S, 5Why, 8D, TRIZ, SIPOC, RCA, Shainin Methods...' started by Nikki, Nov 19, 2015.

  1. Nikki

    Nikki Well-Known Member

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    Hello All -

    There are a couple employees that I work with, whom push back whenever I try to ask how an issue happened...

    For example, and for real, the wrong material was sent to Ireland (lots of $$$$$ to ship).

    The difference between the correct material and the wrong material sent was one single letter. This should have been caught by our incoming inspectors when it arrived at our plant, and then it should have been caught by our shipping department.

    When I ask the employee in our shipping department why they didn't catch this, they give me a simply "I don't know how we missed it."

    I even explained the 5 Why's process, and she still could not give me an answer.

    This employee has been here over a decade... She understands the importance of reviewing code numbers and materials closely, as a single letter or number can mean a completely different product.

    I am getting some push back and I feel she is annoyed with my approach - but in reality - we are out a lot of money as the shipping cost from the States to Ireland is HUGE and also - we have to pay to get it back here now!

    Thoughts on how I can get these employees to take part in the root cause analysis of this problem?

    Thank you,
    Nikki
     
  2. Claes Gefvenberg

    Claes Gefvenberg Moderator Staff Member

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    I feel your pain. Obviously, it is less than amusing to make and have to face up to that kind of costly mistake, but as you say: You need to know why it happened. What kind of reaction do you think you would get if you ask for ideas on how to prevent it from happening again (which would be hard to do without getting into the why)? As for serious money: Bar code readers are not expensive, but could save you serious money. Would that be an option?
     
  3. Ganesh Sundaresan

    Ganesh Sundaresan Active Member

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    What is in place to prevent them from messing up look-alike part numbers? Find a culprit in the Process, not in the People.
    Trust a Management professional from Ivy league to commit the same error.
    As for your last question, explain them, root cause analysis is about "how things work" and not really about "who works"
     
    Bev D likes this.
  4. Jennifer Kirley

    Jennifer Kirley Moderator Staff Member

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    That sounds like a lot of risk! Getting one letter wrong can cost so much. When we ask the employee, the employee feels responsible (because they are?) and maybe that they will get in trouble (is that a valid concern?). When asking what went wrong, I can imagine it would be difficult to make the employee feel safe and answer honestly. After all, the answer is simple. It was a simple human error. I could easily have done the same.

    The thing is, that can keep happening. Yikes! The employees know that.

    I put a Safety Cost Calculator in the Resource Forum. It could easily be adapted for quality costs - in fact, the safety costs calculator started out its life as a COPQ calculator. This sounds like a great subject for a cost-benefit analysis for installing a bar code system.
     
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  5. RoxaneB

    RoxaneB Moderator Staff Member

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    If an error happens because of something in our area, we do take it personally. That's human nature. Actually, I'd be more concerned if she DIDN'T push back. ;-)

    I could be completely off-base here, Nikki, but in reading some of your posts I'm sensing finger-pointing is a fairly common occurrence within your organization (e.g., your boss asking YOU to improve the company).

    Sometimes it's a pairing of body language and phrasing.

    Grab a cup of coffee with her to chat about what happened:
    • How is she feeling? About the error...about her life...sometimes, as much as we try to leave the personal life in the parking lot, it follows us in to the building.
    • What could have happened if the material had been used by the customer (if that is possible)
    • Is there anything you can do to help her (or her team) so that it doesn't happen again - larger font, more spacing between letters, etc.
    You also mentioned it should have been caught by the incoming inspectors. I'd suggest having the same conversation with them. By focusing on Shipping, it appears that they're the reason the process did not work, but you did indicate in the original post that the incoming inspectors should have caught it.

    There's a phrase that I love - "If you don't have time to do it right, when will you have time to do it over?"
     
  6. Candi1024

    Candi1024 Well-Known Member

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    It seems like that poor person is stuck in the "WHAT DO YOU WANT ME TO SAY? I MESSED UP!" cycle.

    After what Roxane suggested, some other methods could be colored font (certain letters in certain colors), writing down what is on the box on a form rather than just looking, One person reading the box and calling out to the other person reading the form. ect.

    Bar coding is the most foolproof though. If you get push back on the cost, just show them the cost of this one mess up. I'll bet if you could have avoided this the cost would be covered already.
     
  7. Bev D

    Bev D Moderator Staff Member

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    All good feedback.
    I strongly suggest that you read about the Apollo method by Dean Gano. It deals with these types of Problems really well.

    In the meantime, instead of asking why (which implies a deliberate action was taken) you can use the words what happened and how could it have happened.
    the other really important thing is to ensure that you are clear that this isn't about blame it's about the process system that allowed an error to occur. and then you must look for system causes
    and conditions and correct those - not the employee or their behavior.
     
  8. James

    James Active Member

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    I'm also a big fan of looking at the system not the people. Sounds like a good opportunity to brainstorm some ideas, and now you have a good expensive cost to justify an expenditure like barcode scanners.
     
  9. Sidney Vianna

    Sidney Vianna Well-Known Member

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    Agree with Bev. You've received a LOT of great feedback. Why do you stop the upstream issues at receiving inspection? What about your purchasing process? Did the material get misidentified by the supplier? Did it get mis-purchased? Why did you receive the "wrong material" in the first place?

    Bar coding is definitely one of the best mistake proofing techniques to avoid this type of mistake. I believe that there are smartphone apps that do the work, at a very inexpensive price point.

    Overall, if the culture of the organization is, like Roxane mentioned, looking for guilty people, instead of system failures, people will always be reluctant to cooperate if they think the root cause will end up with "operator mistake".
     
  10. Andy Nichols

    Andy Nichols Moderator Staff Member

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    I'll add my 2 cents worth: In addition to feeling guilty - whether justified or not, they will - another aspect of discovering what happened is that people have different styles when it comes to thinking about fixing things. Some can't see anything but a clean sheet of paper and get overwhelmed, others can see the simple things which need to be done to correct the issue. Maybe the first response was what you got - overwhelmed, guilty kinda thing...
     
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  11. Jennifer Kirley

    Jennifer Kirley Moderator Staff Member

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    This could provide a powerful tool for finding the right options to deal with human performance issues.

    It is a delicate thing to ask, in whatever terms, "So what happened?" Already the message has been delivered that the person is at fault when it's possible he or she has been set up for failure, either immediately or eventually.

    Therefore, it might be more productive to ask "What might have helped - what could we have done to make the difference for you?" But be careful, for this approach tends to remain in the context of conditions as they were, whereas instead we are trying to explore what should be changed.

    In so many cases, performance can be about a mix of technology, process and human performance. There will always be a mix to some degree. Our task is to figure out the right balance, and how to make it work best. Where technology can take over in terms of bar coding and a database, maybe it is time to do that. How is your product's status tracked? Could such a system help with that too? Could a system like that help provide a "gate" that bars shipment until approved/cleared by authorized people, and show with a simple "beep" a product's status? There are so many possibilities.
     
  12. normzone

    normzone Well-Known Member

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    If a digit difference can get past two gates (receiving inspection and shipping review), then there may be an additional place in the middle that missed it as well. I'd evaluate if the numbering system is written in stone or could be revised to make variants more apparent.
     
  13. Golfman25

    Golfman25 Well-Known Member

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    I have dealt with these types of issues a lot. Many of our part numbers are virtually identical, except for a number/letter or two. It is very easy to make a mistake. We use as many verification steps as we can, with the operator initialing the part number every time just to clue his/her mind in on the need to be careful and check. Every so often, one gets out. Given the number of parts and shipments, it's surprising more don't escape. Thus, we take more of a "brain fart" approach and don't over react. No harm, no foul. We just make sure all of the procedures are followed.

    In the OP case, we probably need to define lots of money before we react.
     
  14. R. Webb

    R. Webb New Member

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    Have had the same issue , with a -4 and a -5 being the only difference in the material description. Visually the materials are identical. I added a step in the process.
    1 The Operator is responsible for using the correct material and brings the material tag to the inspector.
    2 The inspector is responsible for reading the tag and verifying the correct material.
    3 I also have the inspector mic the material and write the measurement down on the router. (Have caught many right materials but wrong thickness)
    4 Final inspection reviews the operator and inspectors sign off.

    When human error occurs I write up what happened and have the Operator write down what they can do to prevent it from happening again. I am not looking for 5 y's or 8D's but just for the Operator collect and organize their thoughts on the issue so they can write something down. I feel there is a better chance of them remembering the process going forward if they do this. I do the same of the Inspector.

    I might add that at the first operation the Operator and Inspector are responsible to check that the information on the router, drawing and machine program to ensure they match regarding part number, revision and material. It is not perfect but for a small shop it avoids many problems.
     
  15. ncwalker

    ncwalker Well-Known Member

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    I was bad and didn't read all the responses above, but it sounds like you need to get the individual involved in the process and they are resistant. My sneaky trick is I approach them like I need their expertise. "Our customer is kicking my ass over this and I need your help. I understand this 5 why process but have no idea how to fit it into your world. I want to get this done before it gets escalated and we both get it...." People generally LIKE to help other people and it makes them feel good when you come to them for help. But if you walk up to someone and say "THIS IS A REQUIREMENT AND I AM HERE TO ENFORCE UPON YOU THUSLY" in your approach, they are going to fight you every step of the way. It doesn't even matter who is right.
     
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  16. Scott Catron

    Scott Catron Member

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    If it's that easy to mix up part numbers, change the numbers.
     
    Last edited: Jan 13, 2016
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  17. Donald

    Donald New Member

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    "When I ask the employee in our shipping department why they didn't catch this, they give me a simply "I don't know how we missed it."
    Thoughts on how I can get these employees to take part in the root cause analysis of this problem?"


    The root cause is never a person. Asking why should only be process related, ie, ask them Why did our materials identification process fail.
     

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