Could An Andon System Have Prevented The Gulf Oil Spill?

[caption id="attachment_527" align="aligncenter" width="300" caption="Image: AP and Salon. Photograph released by BP this morning. "][/caption]

Salon has a disturbing article describing what may have happened on the Deepwater Horizon before the Gulf oil spill.  It's an interesting account of possible failures that led to the disaster and full of lessons for any team that needs to react quickly and effectively to emergencies.

One item particularly caught my eye.  According to this account, the accident might have been prevented if workers hadn't delayed engaging a disconnect switch:

Steve Bertone, the chief engineer for Transocean, wrote in his witness statement that he ran up the bridge and heard the captain screaming at a worker for pressing the distress button. Bertone turned to Pleasant, who was manning the emergency disconnect system, and asked whether it had been engaged.

Pleasant told Bertone that he needed approval first, according to Bertone's sworn statement. Another manager tried to give the go-ahead, but someone else from Transocean said the order needed to come from the rig's offshore installation manager.

Ultimately who gave the order is a matter of dispute. Donald Vidrine, well site leader for BP, said he did it. But Bertone said it was Jimmy Harrell of Transocean.

By the time the workers obtained the approval and got started, Pleasant said he "got all the electronic signals but no flow on meters," meaning hydraulic fluid wasn't flowing to close the valves on the blowout preventer.

A distress button and emergency disconnect system might be considered  part of an andon system, a Lean tool that allows line level workers to signal for help, and if necessary, stop production in order to correct a defect or problem.  The traditional "andon cord" in a Toyota factory could be pulled by any worker to request help from a team leader.  Buffer spacing was built into the line to allow for problem solving, but if the issue couldn't be resolved quickly, the line would stop.

But on the Deepwater Horizon there may not have been enough buffer between the initial signal for help and the time to shut down the operation completely.  Salon also quotes an engineer on when workers may signal for help:

Gene Beck, a petroleum engineer at Texas A&M at College Station, said companies typically have criteria that allow any worker to engage the system if problems get bad enough.

The ambiguity of what constitutes "bad enough" might prevent workers from engaging the system in time. If there's insufficient buffer in the process, workers will be reluctant to signal for help, knowing it will halt production. And if the organization lacks a culture of respect (e.g. screaming at workers for hitting a distress button), employees may be unwilling to risk making those sorts of decisions, even when their own lives are at risk.  Tragically, that may have been the case here.

Reports From Shingo Prize Conference

(updated) Just a quick note to be sure and check out Mark Graban's reports from the Shingo Prize Conference.  In comments, Mark writes that he plans on interviewing Stephen Covey tomorrow.

In his report on Day 1, Mark relays this nugget from Bruce Hamilton about Shigeo Shingo's priorities for improvement:

1. Easier
2. Better
3. Faster
4. Cheaper

That makes a whole lot of sense from a Lean perspective, for reasons Mark goes into.  But of course this priority list would be completely inverted for most managers.

Update: Mark's interview with Stephen Covey can be read and heard here.

Saving Lives By Reducing Medical Errors

Chasing Zero: Winning the War on Healthcare Harm is airing on the Discovery Channel and available for viewing online.

The "war" metaphor seems inappropriate, and casting error as the "enemy" doesn't resonate for me. It's just not an accurate description of quality culture, which stresses collaboration, humility, and careful thinking. Nevertheless, the show features some interesting interviews with quality leaders in the healthcare industry and a look at some of their methodologies.

Does Technology Make You Complacent?

Is autopilot dangerous? The National Transportation Safety Board is holding a three-day conference in Washington, D.C. to discuss pilot and air traffic controller professionalism, including whether automation makes pilots complacent.  The New York Times reports:

Automation is generally considered a positive development in aviation safety because it reduces pilot workload and eliminates errors in calculation and navigation. “The introduction of automation did good things,” said Key Dismukes, chief scientist for aerospace human factors at NASA. But it changed the essential nature of the pilot’s role in the cockpit. “Now the pilot is a manager, which is good, and a monitor, which is not so good.”

...

Finding the balance between too much technology and too little is crucial, according to William B. Rouse, an engineering and computing professor at the Georgia Institute of Technology. “Complacency is an issue, but designing the interaction between human and technical so the human has the right level of judgment when you need them is a design task in itself,” Mr. Rouse said. “When the person has no role in the task, there’s a much greater risk of complacency.”

Law offices certainly don't run themselves. But some functions are now automated, like document assembly, which utilizes software, templates, and the organization's knowledge base. There's no dispute this is a good development, reducing the time and expense of legal work and producing higher quality and more consistent work product.

Yet the danger of complacency exists. The technology makes it easy to produce good looking work product without dwelling on the details of the process. Professionals can be lulled into clicking buttons rather than thinking carefully.  They can overlook special circumstances or reasons for deviating from standard work.

Good countermeasures might include checklists to ensure people think through the issues. There should be a good review process to ensure final quality. And most importantly, as mentioned in the article, humans must maintain a role in the task -- important work shouldn't be completely automated.

Lean bonus: Discussing the Northwest Airlines flight that overshot its destination, the article quotes Chesley B. Sullenberger III, the captain who famously landed the US Airways plane in the Hudson last summer, reminding us to look for root causes of problems rather than reflexively blaming technology:

“Something in the system allowed these well-trained, experienced, well-meaning, well-intentioned pilots not to notice where they were, and we need to find out what the root causes are,” he said. “Simply to blame individual practitioners is wrong and it doesn’t solve the underlying issues or prevent it from happening.”

Also see this post by Mark Graban on aviation, standardized work, and automation.

Using Aviation Checklists To Improve Your Work

(updated below)

I've nearly finished reading The Checklist Manifesto by Atul Gawande. In developing his surgical checklist, Dr. Gawande looked at examples from aviation, which has a long and successful history of using checklists to improve safety. Below are checklists for the Boeing 747-400 and 737-600 (click on images for entire lists)(PDFs).

737-600 Normal Checklist

Boeing 747-400 Normal Checklist

Similarly inspired, I radically re-worked my GTD Weekly Review checklist. One of the major ideas I borrowed from aviation was to replace the checkbox with an abbreviated description of what "complete" means. For instance, an aviation checklist won't just list the landing gear next to a checkbox. Rather, the landing gear should be "down" on final approach, and that's how it's set out in the checklist.

Adapting this idea, my checklist omits the checkbox and instead describes what complete means. For example, my voicemail boxes should be "empty," my briefcase should have "no paper/items," and the prior week of my calendar should be "reviewed/updated." Here's a copy of my new checklist (click to enlarge).

Weekly Review

Hope this inspires you to create or improve your own checklists.

Update: Pilot and commentator Patrick Smith makes an important point:

My feeling is that boredom and automation have relatively little to do with one another. Or, better to the point, they haven't any more to do with one another than they've had in the past. Pilots are at times extremely busy; at other times there are long periods of quiet. Duties come and go, ebb and flow. It has always been that way. Boredom was a factor 60 years ago when planes had rudimentary autopilots and propellers spun by pistons. It's going to be a factor in any profession where there are long stretches of reduced workload -- such as when flying across oceans -- and when a large percentage of tasks becomes repetitive and routine.

GM's Plan For "Zero Waste" Operations

The New York Times reports:

General Motors said last week that 62 of its manufacturing plants (representing 43 percent of its global production) no longer send any production waste to landfills. The company’s goal, first stated in 2008, is for zero waste at half of its operations by the end of 2010, and it’s 87 percent of the way there.

Zero waste, or “Nil to Landfill,” has been a rallying cry in Europe, and it is national policy in New Zealand, but it’s still a fledgling movement in the United States. Still, some major corporations, including Wal-Mart, Nike and the carpet maker Interface, have embraced zero waste goals.

Physical waste indicates that a process contains one or more of the seven traditional forms of waste, or muda (transportation, inventory, motion, waiting, over-processing, over-production, and defects). For example, if you're throwing out a lot of spoiled food from your refrigerator, you should reconsider how you do your grocery shopping (over-production and excess inventory?), meal planning (defects and waiting?), and cooking (over-production and defects?).

However, GM and other companies are careful to clasify material sent to outside recyclers as non-waste. But being able to recycle waste is less a testament to an efficient manufacturing process than it is innovation by the recycling industry. Just because my paper waste goes into a recycling bin rather than the trash bin doesn't mean my processes have improved. Recyclable waste is still waste, and still a likely indicator of inefficiencies in the process. Still credit where credit is due.

Sleep On It

Brain imaging

Despite the various strategies I like to cover on this blog, the single most important thing we can do to improve our productivity is simple: sleep more. National Geographic has a great article on the latest in sleep research. Let's roll the stats:

Insomnia is at epidemic levels in the developed world. Fifty to 75 million Americans, roughly a fifth of the population, complain about problems sleeping. Fifty-six million prescriptions for sleeping pills were written in 2008, up 54 percent over the previous four years. The revenue for sleep centers is expected to approach four and a half billion dollars by 2011. Yet remarkably little is being done to understand the root causes of insomnia. Most medical school students get no more than four hours of training on sleep disorders; some get none. Family doctors' health questionnaires often don't even ask about sleep.

The social and economic costs from the undertreatment of sleeplessness are huge. The Institute of Medicine, an independent national scientific advisory group, estimates nearly 20 percent of all serious motor vehicle accidents are associated with driver sleepiness. It places the direct medical cost of our collective sleep debt at tens of billions of dollars. The loss in terms of work productivity are even higher. Then there are the softer costs—the damaged or lost relationships, the jobs tired people don't have the energy to apply for, the muting of enjoy ment in life's pleasures.

Feeling drowsy yet?  As important as sleep is, don't spend too much time trying to figure out why you need it:

At Stanford University I visited William Dement, the retired dean of sleep studies, a co-discoverer of REM sleep, and co-founder of the Stanford Sleep Medicine Center. I asked him to tell me what he knew, after 50 years of research, about the reason we sleep. "As far as I know," he answered, "the only reason we need to sleep that is really, really solid is because we get sleepy."

On that note, I wish you good sleep over the weekend, and lot's of it. What better way to get ready for another week.

(hat tip: Kottke)

5 GTD Best Practices For Doing

David Allen and his associates have an excellent and free podcast on the Best Practices of Doing. I encourage you to listen to the whole thing. The discussion presumes you understand how to, and have spent time, capturing projects and next actions. Now, the issue is how to decide what to actually do from these lists. Here are five best practices:

1. Create a "hotlist."  People with long lists of next actions feel overwhelmed. David discusses a client who had 100 telephone calls on his @Calls list. He can't scan this whole list every time he's ready to make a call. If you face something similar, or just need extra focus, create a daily secondary list of priority items. Just make sure your complete list of next actions stays up to date and that the "hotlist" doesn't become your only list
2. Be flexible. Remember that priorities change with time. What seemed like a priority at the beginning of the day may not seem like one ten minutes later. Things come up.  Circumstances change. Just go with the flow.
3. Choose wisely. What is your context (@Office versus @Home)? How much time do you have (do you have time ten minutes or one hour)? What is your energy level (are you fresh and energized or sick and exhausted)?
4. Be tactical. Assuming all your stuff is on next action lists, ask yourself: "What's most got your attention?" Look at your list and ask: "Which one of these things, if finished, would give me the highest personal payoff?"
5. Don't get bogged down in your lists. David Allen barely looks at his lists on any given day, just giving them a quick glance.  He estimates eighty percent of his day is ad hoc and unplanned.  But to work this way, he has to have confidence in the adequacy of his lists so that he doesn't have to worry about things blowing up on him.  To do this, he does a "deep dive" into his lists during his weekly reviews.

I'd add one more best practice: no matter how busy your day, look at your next actions lists once. Doing this probably won't change what you do, but you'll be more relaxed and focused knowing you're not missing anything.

The iPad And "Closed" Workspaces

In case you missed it, Markos Moulitsas (aka "kos") has a wonderful review of the iPad. But its actually more of a "day in the life" of an iPad user, which I think makes it more valuable for anyone thinking about buying one. The part I found most interesting was his discussion of the relative reliability of "open" hardware  (i.e. PCs) versus "closed" (i.e. iPhone or iPad) hardware:

My Mac, while not perfect, is far more solid than my PCs of old. While the software isn't locked down, The hardware homogenization of Apple's lineup means fewer hardware-related crashes. And given how few third-party apps I run, my software-related crashes are kept to a minimum. The day HTML 5 fully kills off Flash will be the day that 95% of my infrequent crashes are eliminated. Currently, I reboot my MacBook Pro about once every 2-3 months . . . .

On a network level, we've also learned to appreciate the benefits of locking things down. We've experienced this both in deploying virtualized workspaces as well as our desktop management system. The key seems to be allowing the right amount of user customization while keeping the overall system highly standardized.

From a lean perspective, standardized tools means less error and lower variability when carrying out standardized work. It also reduces a great deal of waste for IT engineers, avoiding the time consuming process of fixing problems caused by user downloaded applications.

Is Legal Project Management Going Mainstream?

Jordon Furlong charts recent press on legal project management and thinks it's about to burst on center stage.  He writes:

The day of the haphazard lawyer, who pursues a solution by intuition, experience and the loosest possible timetable, is drawing to a close. In his place is emerging the process-driven lawyer: disciplined, procedural and systematic, who understands that madness lies not in method, but in its absence. Most of us don’t like that idea. We’d much prefer to maintain the image of the ingenious lawyer who triumphs by intellect rather than by procedural discipline. It confirms our belief in our innate intellectual advantage over non-lawyer competitors — and, frankly, it makes us feel better about ourselves.

....

The truth is, much of what lawyers do can be charted, diagrammed and proceduralized, and both the quality and the cost will be better for it. But that doesn’t mean there’s no room for smart, creative lawyers in the future. For one thing, systems don’t need to be straightforward and monotonous. More often than not, especially in the law, they’re complex and challenging, and they can easily be made elegant, precise, finely tuned, honed to a keen edge — the imagery of swordsmanship is intentional. And even within systems, a lawyer’s unique judgment, analysis and creativity can emerge.

I think this right and the whole post is worth reading.  And as I've written before, good processes and standardized work facilitate, rather than hinder, creative thinking.

Will Increasing Complexity Lead To Collapse?

Clay Shirky writes a facinating post describing the erosion of complex business models. He recounts a talk he gave to TV executives worried whether online video will generate enough revenue to cover production costs. Drawing on Joseph Tainter's The Collapse of Complex Societies, Shirky examines whether media will simplify, or instead collapse:

Early on, the marginal value of this complexity is positive—each additional bit of complexity more than pays for itself in improved output—but over time, the law of diminishing returns reduces the marginal value, until it disappears completely. At this point, any additional complexity is pure cost.

Tainter’s thesis is that when society’s elite members add one layer of bureaucracy or demand one tribute too many, they end up extracting all the value from their environment it is possible to extract and then some.

The ‘and them some’ is what causes the trouble. Complex societies collapse because, when some stress comes, those societies have become too inflexible to respond. In retrospect, this can seem mystifying. Why didn’t these societies just re-tool in less complex ways? The answer Tainter gives is the simplest one: When societies fail to respond to reduced circumstances through orderly downsizing, it isn’t because they don’t want to, it’s because they can’t.

His conclusion is probably right. But I think the argument has two problems.

First, increased complexity doesn't necessarily create drag on the system. Put differently, increased complexity sometimes costs less than the status quo. My favorite example is virtualization. The back end is indeed complex, requiring advanced and well-designed software. But virtualized servers actually use resources more efficiently. And a properly configured Citrix desktop environment is faster and easier to work in than a thick client environment. Complexity is more efficient.

Second, improvements need not add complexity. Managing from a lean perspective, I'm always looking for ways to simplify. Those who identify and eliminate waste from a system make it less complex.

In other words, the best solutions are elegant, reducing complex problems to simple yet correct answers.

So on a fundamental level, I agree with Shirky: success lies ahead for those who can add value by making things simpler. The future is poetry, not prose.

Why Process Improvement Should Matter To All Lawyers

One thing is now clear: for serial litigants, developing efficient processes for handling e-discovery is critical. Joan Goodchild at Computerworld sings a common refrain heard at the The Sedona Conference Institute e-discovery conference I attended last week:

NBC Universal is one of the largest media and entertainment companies in the world. Chief Information Security Officer Jonathan Chow and his team manage information security for several business lines within NBCU, including its broadcast and cable television to film production, online ventures and its two theme parks in Hollywood, California and Orlando, Florida. Among one of the biggest challenges in the last few years has been the incredible explosion in demand for e-discovery services, according to Chow.

Since different legal teams handle the needs of each line of business, the workflows associated with managing electronic discovery vary as well, adding another layer of complexity. And because of the growing number of cases, and increases in both the amount of electronically stored information and hours spent supporting the process, demand for e-discovery services has increased 30 to 50 percent annually. The costs were spiraling out of control and this sent Chow looking for a way to manage the process internally.

Chow . . . tackled the costly and time-consuming process and turned it into a cost-effective and more efficient system that has seen a 40-45 percent gain efficiency since its implementation.

I spoke with several in-house teams who've done a remarkable job developing standardized workflow for handling e-discovery. In doing this, they've discovered how wasteful the processes were when handled by outside counsel.

But the lesson isn't that in-house teams are necessarily more cost effective than outside lawyers. Outside counsel can do this too. The lesson is that process matters. Efficient processes allow in-house teams to save money for their companies. And outside counsel can give their clients the service they deserve.

Reducing Stress With Checklists and GTD

In the ABA Journal, Martha Neil writes:

A sense of impending doom is a common feeling for many attorneys in practice: From the mistake made when drafting a document or taking a deposition to a transgression that you may not even be aware of yet, there's always something lurking in your consciousness to produce a feeling of being "in trouble."

She goes on to quote a psychotherapist and former lawyer who believes on-the-job stress can cause diagnosable disorders. I'll leave that question to the mental health professionals. But this will certainly sound familiar to any litigator.

While it's probably impossible to avoid stress in law practice entirely, checklists make a huge difference in addressing anxiety levels. If you've done a good job developing your checklist, you're much less likely to feel like you're forgetting something critical. And getting "In to zero" with GTD eliminates that feeling that something bad out there is waiting to bite you.

4 Reasons To Use A Checklist

Atul Gawande's The Checklist Manifesto has arrived, and sits in my kitchen until I get my first free moment to enjoy it. I hope to read it, fittingly, on my upcoming cross-country flight. I meant to post about this earlier, but Dr. Gawande was on the The Daily Show back in February. From the interview, here's four reasons to use a checklist:

1. Complexity. The complexity of our work has skyrocketed.  Aviators implemented checklists because airplanes became too complicated to fly safely otherwise. One of the best test pilots in the world crashed the B-52 on its inaugural flight because he forgot a simple yet critical detail in the pre-flight procedure. For many of us, we've reached a B-52 level of complexity with our work.
2. Forget your pride. Pilots embrace them, despite thousands of hours of training and having rehearsed routine procedures many times. Increasingly, surgical teams use them. So should you in your work.
3. People like them.  Most people actually enjoy using checklists. It eliminates that nagging feeling you're forgetting something and lets you concentrate on doing the work well.
4. They're useful. Almost all medical providers who have tried using checklists say they would want their doctor to use one, were they the patient.

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