While working in large automotive and aerospace companies there was always the same question I heard asked by upper management when something that had gone well for a long period suddenly went wrong. That question was “who went on vacation?” This was humorous to me as a young engineer. In later years I began to ask why someone going on vacation should matter. After all there were manuals for every type of work. I recall one manual about the size of a Reader's Digest Magazine that was solely for the proper application of tape. It included insightful instructions as - apply tape in a manner in which it will not become un-taped. I paraphrase due to the passing years but that in essences is what it said. So with so much detail why does a vacation day make operations go off the rails?
Dr. Deming’s research concluded that 94% of the errors/problems are due to the system and not the workers. So if the system worked fine and the problem happens when someone is on vacation was it not the replacement worker not following procedures – not always.
What I have found as an engineer, supervisor, manager, and later a director is that really good workers mask really bad systems. Regardless of what the written procedure said – if there is one, what management thinks the procedure states – if there is one, the good worker knows what needs to be done. This dedication to the task cuts both ways. Operations go well day in day out for years then suddenly they hit a wall. The lesson here is that not only does the process needs to be written down but - now the hard part – it needs to be reviewed on a regular bases to make sure it is still valid. Does it state to use a particular piece of equipment - which was replaced 2 years ago?
Depending on the dynamics of the environment every 2-5 years someone should take an objective look and do a walk through to see if the process is correct and clear enough for anyone to follow. The level of detail to include is always in question. What is obvious to a veteran is not always obvious to a novice. It may be best to have a new employee follow the system. They are usually the best for finding the implied meaning by missing it entirely.
If you have comments about this article I am eager to hear them.