Homicide by Example?
My LEI colleague Dave LaHote is fond of saying that managers - and especially senior managers - overestimate their effectiveness, particularly as they seek to improve their organizations through formal initiatives. And they underestimate the impact (often negative) of their daily personal actions on employees. Recently I witnessed a striking example while visiting a metal casting plant in a developing country owned by a multi-national headquartered in a highly developed country. (I hope you will understand why I'm careful not to identify places I visit unless I can offer praise. I try to show respect for my hosts when they allow me to be a guest at their gemba and I truly want them to do better. Public shame and blame can never be an effective means to that end.)
The plant was in an inherently dangerous industry and I was surprised and pleased to see a visual display at the entrance to the shop floor showing the causes of reportable injuries in the past month. It was very detailed and up to date. The senior plant managers accompanying me stated that it truly focused everyone's mind on safety and was part of a comprehensive safety-awareness program mandated by headquarters to reduce injuries.
But then I did some math. The chart showed that in the last month 12 percent of the plant's workers had lost days from work due to injuries! And the chart also indicated that this was a typical month. Simple arithmetic showed that the average worker could expect to be injured to the extent of losing time from work once every 8 months! There seemed to be a yawning gap between the goals of the safety initiative and the results, and I wondered why as I continued my walk through the facility.
As it happened, the plant was experiencing a serious quality issue with its massive engine castings for heavy-duty vehicles. As a result a senior manager from headquarters had just arrived. Our paths crossed at the shaking table designed to knock the remaining sand out of the castings as they tumbled down a chute from the molding operation. Just as I walked up, the senior manager was explaining that to solve a problem it was important to trace it to the source, which might be the shaking table. And suddenly this very large man mustered surprising strength and agility to swing himself by an overhead bar up onto the shaking table while it operated, as massive castings tumbled down the chute and bounded across the table toward him.
At first I thought this was a crazy risking of this senior manager's own life. But then, as I turned to see the looks on the workers' faces as they stood watching him, I realized that it was more likely that he was risking their lives in the future. The official message of the company's senior management was that injuries were a top priority for management, to be reduced through a comprehensive safety program. But the actions of one senior manager -- well intentioned in the sense that managers certainly should go to the source of problems rather than talk about them in a conference room -- sent an opposite and much more powerful message: If you want to get ahead around here you need to dive in and take action without regard to risks. Will this become, I wondered, a case of homicide by example?
This was a single and blatant instance, of course, and especially upsetting for me because I had just driven through the remote shanty town where the front-line workers lived, with little chance for good wages beyond this one plant. But as I thought about what I had seen I realized that I see less salient and dangerous examples all the time in my travels.
For example, recently I have seen many instances of managers trying to turn over a new leaf by deploying hoshin kanri, A3 analysis, and standardized work (including for line managers) as part of comprehensive lean programs. And the workforce usually responds very positively. But then something goes wrong in the operation or the newly minted "lean" managers just get tired after a long day. And the modern manager that lurks in us all springs forth to give top-down direction, to prescribe a solution before there is any agreement on the problem, or to resort to workarounds without documentation that undercut all efforts to impose standards. (I could relate more than a few examples from our own organization involving its leader -- me -- but will spare myself the pain. Suffice to say that I am often guilty as charged.)
Fortunately, I sometimes see counter examples as well. A few weeks ago I spent a day with a CEO I will call Bob as he struggled to stick with his efforts to manage and improve his company's core processes by A3. He was going against an entire work life of giving orders from his office and managing by results and his A3's really weren't very good. He struggled in particular with getting to the root cause. And I noted that the other elements of his company's lean initiative were pretty rough as well, especially efforts to achieve basic stability in core processes.
But I was struck by Bob's doggedness, even at the end of a long day when many things had gone wrong and he was tempted to revert to old ways. And I saw the remarkable effect he was having on his direct reports, who were getting out of their offices and asking questions they had never asked before, while struggling with their far-from-perfect A3s. What I was seeing was the powerful impact of positive personal example in a situation where the formal elements of the company's lean initiative did not yet appear to be sophisticated or effective. I knew that a year or two from now, Bob's organization will be far down the path toward a lean enterprise while the casting plant will still have a glossy safety program with nothing to show for it.
So I urge everyone, and I certainly include myself, to do a bit of hansei (critical self-reflection) at frequent intervals. Ask a simple question: Is the message that I and the other leaders of my organization are sending through formal rules, programs, initiatives, and new management tools like A3, the same as the message we are sending daily through our personal example? And if not, what can we do to make our walk consistent with our talk?
Founder and Chairman
Lean Enterprise Institute, Inc.