One of my favorite book genres are “whodunits”. There are many to choose from and they have been popular for decades. Great crime solvers such as Hercule Poirot, Sherlock Holmes or Nero Wolfe were always willing to pull apart fact from fiction to get to the truth.
Television has given us many additional detectives like James Rockford, Columbo, Jessica Fletcher, Quincy or more recently Monk. Each detective sets out to gain an understanding of the situation, gathers the evidence and finds out “who did it and why.”
In the same vein, I think “manufacturing spills” are like “whodunits”. Something happened that wasn’t intended to happen. There is investigating, questioning and more importantly listening, tediously poring over data, and brilliant insight. Like Abby on NCIS – data is gathered and a picture of what happened falls into place.
One tool that helps unravel the complexity of all the inputs is a fish bone diagram. It is a simple tool – you don’t need a fancy software package, or an expensive piece of measuring equipment. All you need is a piece of paper and a pencil. Heck, write it on the whiteboard, just don’t use a permanent marker.
First identify the main categories that could fail. In manufacturing the “usual suspects” are: man, machine, method, material. These become the main “bones” of your diagram.
Next – based on your investigation (i.e., going to the floor and having conversations with people, uncovering the extant data), you begin identifying what could possible fail for each category. These become the tributaries of the main bones. Then, using your “5 whys”, establish why these failures happen.
Using this data, each path can then be addressed:
- How likely is it?
- Who is a player, who is not?
- What is worth further investigation?
- Is a solution established?
Some of the paths may just be “innocent bystanders” pretending to be the real issue but are not. However until you lay it all out, the complexity of the moment can become an emotionally charged powder keg. Certainly you could yell at each other but who’d win? Nobody. So don’t do that.
Instead, like Columbo, Bones or Jethro Gibbs, gather the clues, pull them apart piece by piece, strip out the emotion and you can get to a focused, causal solution everyone can agree on. Then take action!
The deductive route is not easy and can be painstaking. But the changes are lasting.