In this podcast, Mick Holly and Brian Smith have an insightful conversation about the importance of fire prevention and root cause analysis in organizations. They highlight how rewarding firefighting over fire prevention can lead to recurring problems and offer practical solutions to redirect talent towards prevention. They also share a real-life success story of how they helped an organization release $50 million of product by eliminating variation in their manufacturing process. This podcast episode is a great resource for anyone interested in improving their organization’s performance and reducing downtime.
Mick: Welcome to Change in Sustain, where we discuss driving sustainable change in your organization through enabling people, process, systems and technology. Today we’re focusing on process in particular how to get to the root cause of your problems. This is Mick Holly and I’m joined from the trenches by Brian Smith. We’re recording this in February and there have been blizzards in the United States. Brian is calling in from location. Tell us a little bit about your journey in.
Brian: Yes, so we’re currently working in a mine in Wyoming. Yesterday my entire crew had to drive down the highway in a blizzard. So it’s an interesting travel.
Mick: Right, right. And the interstate was pretty clogged. Was it snow and very slow?
Brian: Yes, it was difficult at points in time to actually see the sides of the highway and several times I had to come to a complete stop, almost a write out. Now I’m not recommended.
Mick: I’m calling from a nice warm office.
Brian: Look at this, even if it’s 30 below our side, it’s always warm in a mine.
Mick: Very good, very good. Well listen Brian, we’re going to be talking about a subject. Here, the title of the podcast was, are you in firefighting or fire prevention business? When we go into a lot of organizations, typically we get called in when there’s some kind of challenge, some kind of problem. Do see a lot of fires as it were. But you must be in your experience in organizations in firefighting versus fire prevention mode.
Brian: We often see the situation where supervisors in particular are asked to diagnose and fix things rather quickly. And once they do, they get an entire organization back up on running, whatever it might be, your production line, your conveyor belts, your process, whatever it is, they are sort of universally celebrated as being heroes. Look at what a great job Fred did. He got the whole plant back up and running and it only cost us 10 hours kind of thing. Which is interesting because that’s the sort of tail end of the issue if you like. What you really need to understand is why did the thing break in the first place and what can you do to prevent that from happening again? You might like it to being a fire prevention officer. But the fire prevention officers in most organizations are just not celebrated at all. It’s rather a boring and mundane thing to run around and solve problems that haven’t actually happened yet and then never going to happen because you did your job right. People tend to celebrate the guy or the gal who who solves the issue and comes out greasy from the other end of the process and says, hey, look at all those great stuff we did. We solved the issue. If that’s what your organization is paying attention to, the folks who fix it when it’s broken rather than preventing it from breaking in the first place, you’ve got a cultural issue.
Mick: Yeah, I’ve read the phrase, your best firefighters can also be your worst arsonist because you celebrate that firefighting mentality and so they’re constantly looking for more fires to put out. And in that whole process, you’re not solving the root cause is you’re just making matters worse. They almost can be have negative consequences to doing their job and celebrating their job really well. They’re arsonists in effect. And then that’s a little bit of a stalk, but just to add a little bit of color to our conversation and stimulate thinking a little bit. Have you got some examples of that, Brian?
Brian: Yes, we see it all the time. I was in an organization rather recently where they under extreme pressure to get product out of the bank door. I think that a lot of folks would recognize that situation. Anytime somebody fixes an issue, particularly if it’s maintenance, for instance, the scene as a hero, I would like in the situation to, you know, Scotty on the enterprise. The captain clerk would say, hey, Scotty, the engines are down. What are you going to, oh, captain, this is going to take me three weeks to repair, but give me a paper clip on a hybrid done in 10 minutes kind of thing. And once it’s all running again, Scotty, you’re here, what a genius, you’re the best mechanic in the fleet. I don’t know what I would do without you kind of thing. But captain Kurt never calls Scotty into his office and says, Scotty, why do my engines keep breaking? And why are you using paper clips to fix them? That isn’t, of course. I’m just going to say sexy. It isn’t sexy at all. And it’s a human behavior to reward the folks who pull out of a jam. But you shouldn’t be doing that.
Mick: Some of the reasons why do you think that organizations don’t get down to solving the root cause.
Brian: The multiple reasons why that might happen. But if you can imagine the situation where you’re blowing and going, as again, as a lot of organizations are now, it becomes difficult to devote the time and the resources to say, OK, why did that happen? What was the root cause? Why, why, why, we teach most of our clients, simple root cause analysis five wise, we can do complex root cause analysis as well. But most folks don’t need it. You can teach people to figure out what went wrong, why it went wrong. That’s the key thing. Why did that go wrong? And then take that extra step of what are we going to do to make sure that that does not happen again, I found in organization after organization, people either don’t do the root cause analysis because they’re too busy. We don’t have time to stop and think about that. We’re on to the next issue. Or if they do have a root cause analysis process, they’ll say, OK, what went wrong, why did it happen? And then I’ll stop there. They won’t turn that into action and go fix something. They won’t take the time to actually put something in place that prevents the reoccurrence. And what you think about it, Mick, that’s something that really makes the difference, is if I stop that from happening again, and then I stop this from happening again, and then I stop the other thing from happening again, I do that 25 times, my Pareto of downtime or less is, looks very different after a while.
Mick: And you also mentioned brain behaviors. I think there are some behavioral aspects of why we can’t solve some of these root causes. I’ll give you an example. I think sometimes everybody tries to do the best that they can and they want to succeed. And if I have a functional span of control, I know I can affect that. So I’ll drive change in that area. And because I’ve been in an organization a while, I’ve got friends, I know people, my sphere of influence is wider, but the issues that they’re dealing with, that create these perennial problems about an entire organization. Those processes are very wide. And one example was that we were called into an organization. It was manufacturing a medical drug product. And in any drug manufacturing operation, you need to conform to certain quality standards that are set by the FDA, the federal drug administration. And what was happening in this particular plant was they were failing to be able to produce the quality documentation that would allow that drug batch to be released and to be sold. So their response was to monitor the situation more closely and put more checkpoints in place. And every time there was a variation in that manufacturing process, it generated an incident report. And that incident report was logged. And every incident then triggered an investigation by the quality team. And then all of that paperwork had to be put together at the end. And what we found was the elapsed manufacturing cycle for this drug was five days, but the product wasn’t being released for 55 days. So for 50 days, they were trying to put all of these different pieces of paper and collect all of this information. And they were not able to do it. And the response of just putting more checkers in, who were checking the checkers, checking the checkers, then denuded the supervisors who were just filling in boxes yet we completed this form. And we talked in our last episode about a day in the life of study. So I actually did a day in the life of study of one of the operators on the line. He was the Phil finish operator. And after a few minutes, the temperature spiked. And so that’s the manufacturing variance. And he noted it in his log. And I asked him, I said, do you know what happens? He said, well, are you wearing a watch? I said, I am. He said, I would venture to say it’s 807. I said, you spot on. And he says, that always happens at 807. I said, really? Because, okay. So, you know, why it happens? Yeah, well, we did the shift change over and we operate the machine at different settings and it comes back down to its normal after a while. I said, so when the quality team come in and do their investigation, do they ask you why it happened? And he said, Mick, no, they don’t ask me. They think I’m a bit of an idiot. I said, what, what, it, it seemed pretty articulate to me. I said, how long have you been here? I said, well, I’ve been in this facility 10 years and I’ve been the Phil finish operator for the last three years. I said, wow. I said, well, what kind of training do you get? I said, well, we get two weeks on how to record manufacturing variances and to fill out all the paperwork when there’s a problem. I said, I said, did you get any training on the five wise or root cause analysis? You said, what’s that? So, what we did in this case was we convened a conversation, an element in the process where operations and quality got together to talk about that what was causing that variation and eliminating that variation by putting in a standard operating procedure for when they did the shift change over, which reduced the amount of manufacturing variances, which reduced the number of quality investigations, which reduced the amount of paperwork, which allowed them then to meet their quality goals. And I think in 23 weeks, we were able to release $50 million of product to the market. But the point is that the learned behavior of this operator was people don’t want my opinion. I’ve noted the problem. It’s somebody else’s problem to fix it. You’ve also got to cultivate that cross functional collaboration because these root causes span multiple departments. And if the departments don’t come together and coalesce, then you’re never going to fix it. People just start doing the firefighting. It was a real revelation for me that particular project.
Brian: I’ve heard you tell that story before and I’m always fascinated by it. At the end of the day, what you did there, Mick, how difficult was that?
Mick: The organization that had a number of warnings from the FDA, you need to get your situation under control. And they’d spent a lot of time putting in complicated systems and checks and checkpoints and reports. The manufacturing director called me one day and said, Mick, he said, I’m reading the FDA root critique and they said issues are not technical. They are largely behavioral. He said, you talk about behavior change. Can you go and have a look? So yes, Brian, it’s really about how do you get people working together effectively? There was a learned behavior of I work in my silo. Nobody asks me my opinion. I assume that people don’t want to know my opinion and you’ve got to break that. So it’s a leadership issue. It’s about how you get everybody in the organization collaborating. It’s not hard, but it needs to be thoughtful as to how you encourage people to open up. Because the heroes are all the ones that put in out the fires. Poor Phil finished operator. He’s no hero. He’s just doing his thing.
Brian: Absolutely. I think we see that a lot. Particularly in organizations that have pretty technical processes, if you like. You get technical folks who rise to the top and they want to solve problems with technical solutions and paperwork or process, if you like, which and do the wrong. There’s a management concern. I love paperwork and processes, but there’s a limit to what those things can do. The thing that ties organizations together is the fact they’re all populated with people. If you can find the person at the call face that the person who actually pulls the lever presses the button, they know far more about what’s causing the fires in the first place than you might think. So it’s always worth. Something we always do. Always go to their call face and talk to the people pulling the lever because they know. They often know what the issue is.
Mick: So let’s give our listeners some pragmatic things they can do to help their organization solve those persistent and perennial issues and get to root cause. What would your thoughts be there?
Brian: One of the first things you’ve got to do as an organization to my mind is to be honest with yourselves. Be really honest about what your culture is and your behaviors as a leadership team, etc. Are you the kind of culture, the kind of organization that rewards firefighting, the guys who run into the building and solve the problems and come out greasy? Or are you the kind of organization that rewards the fire prevention officers, the folks who work day in and day out to stop those fires that ever starting in the first place? You have to be brutally honest. And if you find that you are the kind of organization that rewards the heroes, the apparent heroes anyway, then you’ve got a glamour problem. You are glamorizing the wrong things. So be honest with it. If you are in genuine firefighting, if that’s what you’re glamorizing, then everything becomes an emergency. The same problems will keep popping up again and again and again. They just don’t go away. And it’s always the same people who are solving those issues.
Mick: What a great point, Brian, because one of the biggest objections we get when we advocate or an organization wants to prove or to take on a new initiative, their lament is we don’t have enough talent. We don’t have enough people to lead this project, to lead this initiative because they’re all going out and fighting fires. And these people have gifted people, but we just need to redirect them so that frees up more of our capability to move forward on the growth initiatives, the improvement initiatives.
Brian: Yeah, this transition is not something that happens overnight because your fires don’t stop overnight. You can’t just say, well, we’re not going to respond to that anymore. But you have to change what you’re glamorizing and glamorize the processes, the boring process is unfortunately the things that stop all of that stuff happening in the first place. So give recognition and reward to the folks who are doing that. It would be the second piece of advice. The third piece of advice that you need to treat every emergency, every problem what we’re describing here is the fires. You have to treat it like a diamond. You have to treat that as your system teaching you something. And you can either put the fire out and walk away, go on to the next emergency or you can pick up that diamond and say, okay, what am I going to do with this? What did I learn? How do I go figure out what the root cause is and how do I put in place a systemic fix? So we often advocate putting in what do you call them after action reviews, root cause analysis reviews, whatever it might be, something where you take the time to learn the lesson and then do something about it. I’ll be the third thing. The final thing that you need to do is to be able to track your progress. So if you are successful in glamorizing the right folks, promoting the right behaviors, not putting the fires out, but stepping those fires from occurring in the first place, you should have a net effect. It might be measured in downtime, being reduced, number of incidents, duration of incidents, whatever it might be. You have to make sure that your folks who are in that fire prevention game understand what effect they’re having on your systems and your processes so that they can judge their success.
Mick: This conversation stimulated another thought, Brian, Eisenhower famously said that if you can’t solve a problem, make it bigger. And Brian, example that I gave you, the problems may manifest themselves as fires in functional domains, but the problem is much bigger and spans your enterprise. It could even span your supply chain. So the bigger that you make it, the more chance you’ve got at understanding the causality and then assembling a multifunctional team to resolve that issue. So don’t think too small, think big.
Brian: Absolutely. Couldn’t agree more.
Mick: All right, well, great conversation, Brian, we did talk a little bit about Supervisors today. If you didn’t listen to the first episode on turning your Supervisors into Difference Makers, I would encourage that. And look, if you’ve got persistent or episodic issues, plaguing your organization, you know, we can help. We have a complimentary coping session. You can learn more at auderepartners.com.
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