Wednesday, February 24, 2010

What we can learn from Toyota and Failure Analysis

[The Purim edition of Toronto Torah is available here!]

[Note: This is a quasi-rant, but it is meant to be productive. I hope that shul presidents and rabbis and others in charge of Jewish communal institutions will read it through.]

I cringe when shuls encounter a problem and the board says, “We’ll just have to be more careful next time.”

I see two ways to understand that language:
1. I didn’t take things seriously before, or
2. I don’t think that making practical changes to our process is worthwhile.

Neither of those explanations appeals to me:
1. If you didn’t take it seriously before, we have big trouble and I have no way to know how seriously you are going to handle it in the future.
2. And if you did take it seriously before, and something unanticipated happened anyway, then why risk something unanticipated happening again?

It’s like the Toyota recall – I want to know why next time will be different. If the answer is, “We’ll be more careful,” you’ll never see me in a Toyota again.

This is stunningly simple – and yet I’ve seen Jewish community organizations (like businesses and manufacturers) make this mistake repeatedly. Failures abound: Programs that attracted tiny crowds. Dinners with bad food. Members who are turned off. Event entertainment that was inappropriate. Davening that is not inspirational. Fundraisers who fell short of their goals. Budgets that are not kept. Speakers who couldn’t reach their audience. Boards that were dysfunctional. Funds that disappear. And so on.

And, each time, the answer of, “We’ll be more careful next time.”

We don’t like to analyze failure, because it costs us time and effort, and sometimes funds.
We don’t like to analyze failure, because we don’t want to admit that we have failed.
We don’t like to analyze failure, because we are afraid of the results.

This remarkable website quantifies the problem, noting: Alexander Dunn, director of Assetivity Properties Ltd., in a paper posted on the Maintenance World web site, quotes a study which showed, "…that, when trying to prevent unacceptable events from happening again, 10 percent of participants immediately sought to place blame, 26 percent immediately expressed an opinion of the causes and offered an opinion without investigating the problem, and only 20 percent of participants examined the problem in sufficient detail to be able to identify an effective solution."”

How is Failure Analysis done? The method I favor, at least for relatively uncomplex operations, is the Six Sigma DMAIC approach.

To excerpt from the website cited above:

Define and Measure the Problem
- What does the company want to prevent from recurring? When and where did it occur? What is the significance of the problem?

Analyze Cause-and-Effect Relationships - Once the problem is defined, it is important to uncover the root causes of the problem and to understand how they interact with one another.

Implement and Control the Best Solutions - Identify solutions based on the results of the root cause analysis and perform a cost/benefit analysis. Solutions are specific actions that control root causes of the problem.

The key is that last point – solutions must control the root causes of the problem. Going back to that website yet again, here’s a great example:

As a simple example, picture a large block of very good Swiss cheese on a kitchen table a few feet away from an open screen door. The weather outside is warm. A man comes to the table for some wine and cheese and sees a mouse in the cheese.

Problem: There is a mouse in the cheese.

Solution: Throw out the cheese with the mouse and put a new block of cheese on the table.

As the site shows, that approach is foolish. So is the approach of “Be sure to close screen door,” and, “Put a note on door asking, 'Did you latch me?'” That amounts to, “Be more careful next time.”

A good solution recognizes that the root cause is the screen door being left open. The key is a solution that controls this factor – such as putting in a spring-latched screen door. This way, the door cannot be left open.

Example: If the entertainment at an event was inappropriate, saying, “We’ll be more careful next time” does not address the root cause. Dropping that form of entertainment, or educating the players about the propriety issues involved, or previewing the entertainment, is a more sound approach.

Failure is, as they say, an opportunity, a chance to learn how to do what we do better. Even if an event or project is, overall, a success, there are always small failures from which we can learn. Failure Analysis is not a dirty word; Failure Repetition is.


  1. This is communal or industrial cheshbon hanefesh. As with the personal type, these require introspection in detail. In organizations, people looking for a particular cause are often told "don't go there", because some important responsible party will be shown to have erred, or because its solution would be very costly. For example, I'm not sure Toyota will explore all evidence of electronic failure exhaustively.

  2. I agree that this kind of analysis should be done, but I also agree that if the decision has already been made that certain areas of potential change are 'off limits', it might not be worth spending the money. I have seen institutions pay outside consultants serious money for advice, and then refuse to implement any of the suggestions.

  3. El Talmido (?)-

    I agree; this is basic cheshbon hanefesh. But I do think Toyota will do it properly, because the price of future failure would be too high.

    Anonymous 5:37 PM-
    I agree that suggestions must be implemented - but if a company decides before the investigation that it won't spend on the solutions, then the company should be shut down. If you don't know the areas that need fixing, if you don't know the costs of fixing (and not fixing), how can you decide not to investigate?

  4. For this to work correctly, and it can and does work, there first has to be a recognition that a problem actually exists, one that needs to be dealt with. Using your Toyota example, the company knew about this problem years ago and did nothing, I guess sort of hoping that it would go away on its own, or if they didn't label it a problem it wouldn't be one.

    Lots of organizations that take the same attitude--"this is a one-off happening, it's really not so bad, people are making more of this then it's really worth etc.."

    Also agree with the commenter who stated that when people might be shown to have erred you are going to run into an ego problem that many times trumps analysis and change.

  5. The classic way a customer service department (or school or bureaucratic institution) deals with an inconvenient complaint is to try to convince the customer that the complaint is trivial or wrong or his own fault or never happened before.

  6. When they say "We'll be more careful next time" after finishing a failure analysis report, it's like they refuse to acknowledge that somewhere in their system, they've failed to anticipate that such a thing could happen which amounts to a disappointment on the part of the customer.

  7. Could you post a link to the Maintenance World article you reference. I am unable to locate it on the web. Concerned it might be bogus.

  8. Anonymous 4:47 AM-
    I've seen it cited in various papers, but you could contact the writer if you like.