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.