Some time ago, I had a consulting project in a pharmaceutical plant in England. The company had a Lean culture, with a central Operational Excellence team and quite a bunch of Black Belts. A typical manufacturing company that is conscious of the need for quality, waste reduction and production efficiency.

One day, I was working with Simon, the Maintenance Manager, when the head of Production came into Simons’s office and said “Simon, that damn’ Pump X is dead again! It’s the 4th time this year (we were in May) and we had to stop the production one more time! How come we’ve had this problem for years and you still haven’t fixed it?” (the actual vocabulary was slightly more colorful…).
That time, the issue escalated up to the Plant Manager, who put pressure on Simon to fix it once and for all.

And yet another problem solving exercise

Simon gathered a team of people who knew about that pump and the process around it: some people from the Maintenance team, a production engineer, some men from the field… a team of 8 people overall.

I joined the meeting with Simon, and they started to follow a problem solving methodology, supported by an Excel template. I remember thinking “ok, this looks good. It seems they’re gonna fix their issue this time”.
Then the maintenance engineer started to describe the list of previous failures, and also the list of previous root-cause analyses on that very problem. To my surprise, there had been three problem solving exercises for that specific problem over the last two years only. None of these three exercises solved the issue.

When they started to look for possible causes, the facilitator went to the white board and opened the brainstorming session. I asked:
– “Why don’t you start with what you did last year?”
– “It didn’t work, why use it?” replied the facilitator (who wasn’t there last time).
– “Good, that’s already a clue. This means you don’t have to waste time in that direction today.”
– “Bah! I couldn’t find the A3 file anyway (A3 is a problem-solving canvas that follows a step-by-step methodology, such as 8D, ). I don’t think we kept it, so we might as well start with a blank sheet.”

problem solving

“On the fifth Day, at dawn, look to the East”

At that moment, a guy with a strong Italian accent, said:
– “In my plant in Italy, we’ve had a similar problem on the same type of pump. In our case, the root cause had to do with the reassembly process at the repair shop. We can call my colleague Gianni, he will explain better than me.”
It was Marco, an Italian maintenance engineer who, by luck was visiting this plant for a project, Simon asked him to attend and provide feedback on the efficiency of the meeting compared to those in Italy.

It eventually turned out that he was right. The same problem had been solved two years ago in Italy, with a similar root cause. In that timeframe, pump X had failed more than 10 times in England, leading to as many production stoppages and repair jobs.

I started to wonder about the probability that Marco attended this meeting on that particular problem, which by luck he faced two years before. Slim. Call it divine intervention.

Just think about it. In a large company, how many problems like these occur every day without any Marco to help? How much time and money is lost reinventing the wheel at different moments or in different places?

Since that day, I’ve seen the same situation in many different environments: manufacturing, safety, quality, customer services, even in management consulting… Basically, in every problem solving environment, even those quite advanced with Lean.

Is it something you also see? Why is it so and what can be done? I have my thoughts on these and I will share them in a future post.
But I’m really curious to learn from your experience and have other perspectives.