“Simplicity is the ultimate sophistication.”

So said Leonardo Da Vinci. 

I was beginning to conclude that we would never be sophisticated.  I had just stepped onto the production floor when I saw two of our best managers going at it again.  It was a typical fight between QA and Production.  A good operator, Louie, had made an error.  We had just revised the procedure that he was following when the error occurred.

The procedure had come back from QA with more markups than original content.  Production was raging that the procedure was already too complicated.  “The operators know how to do this job.  Why do you think we spend all that money on training?”

“Then why didn’t Louie do it right?” retorted QA.  It was such a familiar shouting match that I couldn’t stand to listen any more. 

“Ya can’t get good people anymore,” growled Production.

Without being present I knew exactly what had happened.  We had evaluated the cause of Louie’s error and then

1. added another verification step into the procedure,
2. thus making a long procedure even more complex and,
3. increasing the chances of an error next time.

I knew it because it was happening ever more frequently.  We were the victims of our own compliance, actually.  Through the best of intentions our error rate was increasing, not decreasing.

How could we get ourselves out of this death spiral?

The answer, amazingly, came from Louie.  I was new in production management.  I was trying to think about how to prevent the error from happening again. 

I asked Louis for his thoughts.  “I’m glad you told us about the wrench immediately, Louie.  It could have been disastrous if somebody had started the blender.”

“It’s a bad design," said Louie.  "We have to reach over an open hatch and tighten that coupling.  The wrench flipped out of my hand and fell into the blender before I could grab it.”

“I know.  We’re trying to get the capital for a new system, but it won’t be quick.  What can we do to prevent this from happening again?”

“Well, the only tool we use in this area is that wrench.  What if we said that no other tools are allowed in here?”

“I can make that happen.  But what about the wrench?”

“What if we weld the wrench to a stainless steel wire and weld the other end of the wire to that I-beam over there?”

I swallowed once and then, “Uh, I think that would work.”

Slowly I wandered away, muttering something about getting maintenance to put our welder on the job.  My mind was preoccupied with bigger possibilities. 

We re-wrote the SOP, incorporating Louie’s idea.  Instead of being a little longer, it was now shorter.  More importantly, the possibility of a repeat error had virtually vanished.

A few weeks later we had some customers by the plant.  As usual I gave them the nickel tour.  As we walked past the blender one of them noticed the wrench welded to the wire.  Coincidentally, Louie happened to be in the area.

“Louie, got a minute?  Can you explain your idea to these folks?”

You should have seen Louie straighten up as he showed the customers how his idea prevented errors.  I sold a lot of product that day.  And, do you think Louie felt like he owned a piece of the plant?

The other employees saw that they would not be punished when errors occurred, but would rather be judged on the quality of their responses.  More small innovations began to appear around the plant.  Ultimately it became part of our culture.

So there it was.  The way to shorten our procedures was to simplify our work.  And the way to do that was to unleash the creativity of our workers.

Later I was to discover that this technique is called poka yoke, Japanese for error proofing.  It was invented by an engineer at Toyota.  It’s a terrific way to simplify your operation.

There’s only one problem.  You need a distinct culture in order for it to work.  The employees with their hands on the work need to:

• Be empowered to create innovations within their sphere of work
• Have the time to think about improving the process
• Be free from criticism when their idea doesn’t work

Depending on your management style, you may find it difficult to let go enough to create this type of culture.  But if you don’t, you will get beat by those who do.

How about you?  Do you have a similar story?  What has worked best for you?  Comment below.