{"id":36668,"date":"2024-04-26T06:00:00","date_gmt":"2024-04-26T10:00:00","guid":{"rendered":"https:\/\/www.lean.org\/?p=36668"},"modified":"2024-04-25T09:15:55","modified_gmt":"2024-04-25T13:15:55","slug":"more-crisis-control-at-boeing-and-the-faa-some-lessons-on-building-in-quality-from-nummi","status":"publish","type":"post","link":"https:\/\/www.lean.org\/the-lean-post\/articles\/more-crisis-control-at-boeing-and-the-faa-some-lessons-on-building-in-quality-from-nummi\/","title":{"rendered":"More Crisis Control at Boeing and the FAA \u2013 Some Lessons on Building in Quality from NUMMI"},"content":{"rendered":"\n

Be among the first to get the latest insights from LEI\u2019s\u00a0Lean Product and Process Development<\/a>\u00a0(LPPD) thought leaders and practitioners.\u00a0This presentation was delivered to subscribers of\u00a0<\/em>The Design Brief<\/a>, LEI\u2019s newsletter devoted to improving organizations\u2019 innovation capability.<\/em>\u00a0It is the fourth of five in a series on\u00a0process<\/a>\u00a0development entitled \u201cMaking Things Well<\/em>,” focused on developing superior processes as part of the product development process, specifically the skills of tool, mold, and fixture makers, special machine designers, manufacturing engineers, and everything that goes into knowing how to turn a concept into reality.<\/em><\/p>\n\n\n\n

\n
Subscribe to the Design Brief<\/a><\/div>\n<\/div>\n\n\n\n
<\/div>\n\n\n\n

Boeing\u2019s MAX 737 is grounded again. This time the problem (the known problem) was with a manual assembly operation (four very missing bolts) in the factory. Everyone from Boeing execs to the FAA to congressional leaders is apologetic: \u201cWe thought we fixed everything in 2020\u201d when the problem with the MCAS flight stabilizing system was fixed. The root cause they identified at that time was that \u201cover trusting the pilots\u201d led to software design decisions that were risky, that left the door open (sorry) for serious things to go wrong.<\/p>\n\n\n\n

<\/div>\n\n\n\n

The problem and the fix<\/strong><\/h4>\n\n\n\n

If the problem was \u201cexcessive trust,\u201d what is the fix? If trust is the problem, you\u2019d think the fix would deal somehow with it. Currently, the fix being proposed and accepted by all hands on deck is to add more inspectors. We can also, the logic goes, add more quality inspection steps in the design and development phase. Add more inspectors in the plants, and more audits in engineering. That will fix the problem. Or so goes the assumption.<\/p>\n\n\n\n

But will adding inspectors and inspections fix the problem? What if, rather than adding inspectors (whether from the outside, from the FAA, or inside) at the end of the process, each of the 12,000 operators in the factory could be an inspector? Upstream, what if each engineer (software or hardware) were responsible for ensuring that quality is built in at each step?<\/p>\n\n\n\n

To assure the needed quality of both design and build, Boeing needs effective mechanisms\/processes and skills along with the right mindsets and behaviors. Together, these will ensure better quality performance and lead to an overriding culture of quality. Additional inspectors may be a necessary redundancy (to some degree, after-process inspection will still be necessary), but they will not replace the need for building in quality at the source.<\/p>\n\n\n\n

\n

But will adding inspectors and inspections fix the problem? What if…each of the 12,000 operators in the factory could be an inspector…what if each engineer (software or hardware) were responsible for ensuring that quality is built in at each step?<\/p>\n<\/blockquote>\n\n\n\n

The good news is that we know the means to achieve quality at the source at Boeing. But, while adopting the means is possible for Boeing, doing so will require much more than merely adding more inspection \u2013 it will require a massive effort that is both top to bottom (of the enterprise) and beginning to end (of the process of developing and delivering the product).<\/p>\n\n\n\n

<\/div>\n\n\n\n

Building quality into the product and the process <\/strong><\/h4>\n\n\n\n

A lean business system begins with assuring quality by building it in at the source. The factory tools and practices to achieve built-in quality are well-known among lean aficionados, if not manufacturing professionals in general. The design and engineering practices to ensure the same are much less widely understood or practiced.<\/p>\n\n\n\n

Speaking of \u201cprocess,\u201d we should note that there is a process to produce the product and there is a process to develop the product (the product development process), and, sorry, a process to develop the processes to develop and produce the product. Finally, there is a management process that (hopefully) makes it all work together.<\/p>\n\n\n\n

It is obvious that you\u2019re in trouble if you can\u2019t manufacture your product. Cars may not start. Worse, they may not stop. Planes may fall out of the sky. And if we make products that that no one wants (think Nokia and Blackberry after Apple introduced the iPhone) your business won\u2019t be in business for long (Boeing is lucky to have only one competitor in the global commercial aerospace business).<\/p>\n\n\n\n

In his book Producing Cars at Toyota \u2013 Exploring Product Development (in Japanese only), Toyota\u2019s former head of Body Engineering and president of Toyota Technical Center USA (TTC, where he was my boss) Kunihiko Masaki describes the Toyota way of developing vehicles. According to Masaki, the entire process begins with the principle of (you guessed it) building in quality at the source. Everything follows from that. Each step is designed and executed according to the principle that each process will deliver perfect (as designed) quality output to the next step (person) in the process.  <\/p>\n\n\n\n

Operating that way has obvious benefits and those that are less so. Most obvious and important, product quality delivered to the customer will improve. This will delight customers (who will hopefully purchase from us again) and lower costs (service and warranty costs, obviously, but also production costs, through eliminating rework). Moreover, operating this way also motivates each employee by providing meaningful work \u2013- work is designed such that each individual owns the quality output of his or her effort, in service of providing great value for customers.<\/p>\n\n\n\n

In factories, this condition is achieved by designing each job so that quality output is knowable and achievable. Work is standardized<\/em> according to the best-known method and given to the operator along with the instruction to make it better, solve problems, and make improvements. But the first and foremost instruction is simply: \u201cStop and call whenever you encounter any kind of abnormality; someone will come to your aid immediately, within the cycle of your job.\u201d This is known inside Toyota as JIDOKA \u2013 a principle that entails infusing each process with ownership of quality output (more on jidoka later).<\/p>\n\n\n\n

On an assembly line, this means the timing, the work sequence, the amount of parts\/components (and all stuff), as well as the output, are specified with clarity. Any situation outside the specified parameters is an abnormality. At the first sign of any abnormality \u2013 stop, contain, notify, and wait for help. Boeing has long been trying to break its\u00a0production floor habit<\/a> of breaking the sequence of work traveling along its assembly lines, a practice that creates opportunities ripe for things to go wrong.<\/p>\n\n\n

At Boeing, there is a term for situations such as this one, when work is completed out of the production line\u2019s ordinary sequence: traveled work.<\/p>\n

“The folks on the line, they know what it is,” Boeing Chief Executive Dave Calhoun said in a Wednesday address to employees. “It\u2019s uncomfortable. It creates opportunities for failure.”<\/p>\n

For years, Boeing executives\u00a0have tried and failed to break the habit<\/a>. Four years ago, in the aftermath of a\u00a0pair of fatal MAX crashes<\/a> , Boeing laid out five values central to improving safety. Number three on the list: eliminate traveled work.<\/p>\n\n\n

Boeing\u2019s traveled work could not be further from Toyota\u2019s jidoka concept \u2013 stop for any abnormality, contain and whenever possible fix it on the spot, even if it means bringing production to a halt. A complex socio-technical subsystem in its own right, the technical and managerial intricacies of Toyota\u2019s \u201cfixed-position stop-system\u201d for moving conveyor line production is the topic of one of\u00a0Harvard Business School\u2019s most used case studies<\/a>\u00a0over the past three decades and described by Steven Spear as four key rules in use in his seminal Harvard Business Review article \u201cDecoding the DNA of the Toyota Production System<\/a>.”<\/p>\n\n\n\n

But what about design or engineering work which consists of much more than a simple standardized and repeatable sequence of steps (such as designing software for a new airplane)? The time span for this kind of work is typically much longer than the 60 seconds of an automobile assembly line \u2013 the span may well be closer to 60 months<\/em>. The variety of tasks and the variation in conditions with which to contend is also much greater; worse, many tasks may be performed only once. Perhaps most challenging is that most of the work may take place in the mind of the worker, invisible to the casual observer \u2026 or inspector.<\/p>\n\n\n\n

And consider this: \u201ctraveled work\u201d happens in the engineering office as well as the factory. The biggest difference is that it is harder to see, and worse, constantly shifting work around in the office is pretty much universally accepted, not just at Boeing, as normal. If the \u201cnormal\u201d work sequence isn\u2019t known and made visible, how do you even know that engineering design work is traveled? Answer: you don\u2019t.<\/p>\n\n\n\n

But the dangers of traveled work in the engineering design studio can be as serious as in the factory. Think of your own work \u2013 when do you make mistakes, forget a step, forget whether you completed a process or not? When we\u2019re interrupted, from working in rhythm, working in a state of flow \u2013 then when we turn our attention back to the task that had been at hand, we forget where we were. We often get stuck. We sometimes make mistakes.<\/p>\n\n\n\n

\n

And consider this: \u2018traveled work\u2019 happens in the engineering office as well as the factory. The biggest difference is that it is harder to see.<\/p>\n<\/blockquote>\n\n\n\n

In most engineering offices or any office, there is no overhead rope to pull, no production line to bring to a mechanical halt along with the immediate sense of urgency that it brings. The useful question to be asked in such settings is: \u201cWhat functional equivalents might we identify to accomplish the same ends?\u201d These ends include:<\/p>\n\n\n\n