What, why, how?

Came across three great questions that capture the essence of root cause analysis and preventative action the other day. These famous three questions also appear in another order in popular knowledge today, of which I will make some mention at the end. But first take the three questions in this order to get at the essence of root cause analysis and corrective/preventive actions. These are powerful techniques to error-proof virtually everything.

“A car tipped over and crashed in Winnipeg.”

What happened? Why did it happen? How can you prevent cars from tipping over in the future?

Let us use the same strategy to a general ecological question.

“Lake Winnipeg is in the early stages of invasion by Zebra Mussels.”

What happened? Why did it happen? How can we get rid of them?/ How can we prevent zebra mussels from reaching other lakes of Manitoba?


Now, let me phrase a few business situations.

Received wrong parts.

Ordered 10 pieces, but received only 8.

The parts received are torn and scratched.

The surface finish is poor.

Well, we could apply the three questions to best effect in every question above.

Question-1, What? : Describe the situation.

Question -2, Why?: What is the root cause?

Question-3, How? : What is the corrective and preventive action?

Now that reminds me of the golden circles, popularized by Simon Sinek. Anything one does must first have a reason for doing. Reason is the motivator.




That may be true for people’s actions, particularly when selling a new product or an idea.

Question-1, “Why?”: Need to get in shape. I love outdoor.

Question-2, “How?”: Aerobic exercises are good for getting in shape.

Question-3, “What?”: I should jog half an hour every day.





Inspiration from death of a colleague


Mickey Boreham

Across my glass window, days of

Hissing and thudding and pressing

Of the Industrious Rubber pass.

I am a quality spider,

Mending machines is Mickey’s job.

Ten times a day loudspeaker shouts:

“Mickey Boreham to the XYZ;”

No more.

Worked from 16 to 66,

And then retired, in sleep.

Memories galore:

Christmas turkeys distributing

(On behalf of the company),

Researching on my computer –

Equipment, old radio, grizzly, Boreham,

Under the machines,

Oil and dirt covered,

Floor scrubbers driving,

Quick pacing despite the knee…

And more:

In the dining room with Tims,

Mornings when I enter,

And greeting every time,

Were Lisa and Mick,

No more.

Late separation shocker –

Shocker to me ‘cause

The calls…

So caring were they!

And more:

Crisp voice and kid-laughs,

On the phone from here,

To buddies

Jokingly –

“Where the hell are you?”

Boss taunts –

“Are you still alive?”

O’ premonition –

Why did you bring up

These words so timely?

Born December 8th, 1947, Braintree Essex, England,

Untimely whisked into the good night-

In Winnipeg, Canada, June 29, 2015;

Fringe festival begins tomorrow,

New Horizons flyby Pluto,

Birds sing, lovers kiss

And the machines squeal:

Good enough reason to

Rage on against the dying light!


Plan everything before beginning to do, and make sure to consider the important-but-not-so-urgent tasks for the planning.PDAC-TIME MATRIX

The new version of ISO 9001 is more into Plan- Do-Check- Act cycle. Compare it with the Time matrix in Stephen Covey’s book First Things First. 

5 choices

The above book talks about the Q2 – quadrant 2 – of planning in the time-matrix. Why I included the PDAC chart side-by-side with the time matrix is because PDAC is the essence of Q2 planning.

And guess what, that is the essence of the new ISO 9001:2015 version. Understand the context, plan the objectives, anticipate the risks, plan the risk mitigation, and then do stuff.

I also bumped into this press kit for the 5 choices book in pdf format, which is excellent stuff too. The 5 Choices Press Kit.

Plan everything before beginning to do, and make sure to consider the important-but-not-so-urgent tasks for the planning.

Toyota Production Systems

It is a timely topic as the Globe and Mail reports today that a Toyota Motor Manufacturing Canada Inc. plant in Cambridge, Ontario led the global rankings in annual survey by J.D. Power and Associates that measures vehicle safety.

I hear that in Japan the quality culture is so pervasive that if anyone makes an error, he/ she must go around saying sorry to everyone in the company! In North American business culture this is simply unimaginable.

Toyota Production Systems is famous worldwide because of the effectiveness of the system. The major underpinnings are excellent operational procedures and a culture of continuous improvements. In the above article the president of the Toyota Motor Canada said that the Toyota mantra of continuous improvement helped the plant to reduce the number of customer complaints to a low of 12 per 100 vehicles compared with the industry-wide average of 116!

Key to Toyota system of continuous improvement is the seriousness attached to such initiatives. Processes are shut down and large investments of time are invested in resolving identified problems. The non-Toyota approach to continuous improvement, though, is lackadaisical or ritualistic.

Improving the processes

Continual improvement of the organization’s performance is one of the quality objectives per ISO 9001 standard. Some evidence of continuous improvement is a mandatory check point for third party auditors. As well, it has become routine for customers to not only demand replacements or credit for defective parts, but to ask for documented corrective and preventive actions. A recent development is to demand penalty for each defective part.

“Clause 8.5.1 Continual Improvement: The organization shall continually improve the effectiveness of the quality management system through the use of the quality policy, quality objectives, audit results, analysis of data, corrective and preventive actions and management review.”

Are the corrective and preventive actions addressing process approach and systems approach?

Processes transform the input materials into the desired outputs aimed at achieving customer satisfaction. Systems approach must make sure all the inter-related processes are considered. The tendency for the customers and for the suppliers is to play the blame game. If there are reasons to believe that a major value improvement must come from order desk, design, Bill of Materials, fixtures, machines, that is what must be attempted. In lots of cases, some of these issues are the holy cows and never even addressed. it may be surprising that the overall cost will only come down with a systems/ process approach to continuous improvements.

Quality Myths – 3: All employees are fully involved in the processes assigned to them.

Statement of Myth
..that people are always involved or engaged in the works and processes they are assigned to do.

What does the principle of Quality Management System say?
Third of the eight principles of Quality Management Systems is ‘Involving the People.’

Formula For Defeat
According to Sun Tzu, the author of the ancient treatise ‘Art of War’ (possibly 5th century BC), one of the six mistakes that lead to failure is war is failure to use the people.

“These are the six ways of courting defeat – neglect to estimate the enemy’s strength; want of authority; defective training; unjustifiable anger; nonobservance of discipline; failure to use picked men . . . ” Sun Tzu, The Art of War, Ch. X.

Lots of times, the it is a fact that workers are not fully engaged with the work they do. It could be simply eyes and mind not being on the task, or a sense of disconnect with the management objectives. It will be surprising to note that in many work environments there are exceptionally talented people whose services are under-utilized, which is a formula for defeat.
A real company puts out the logo ‘involve the people, improve the product, and impress the people’. That is a very good statement of how quality works by involving the people. I am not very sure if they live by what say, though. Good for them, if they do.

Quality Myths-2: Leadership is doing everything right

One of the key management system principles is effective leadership. Let me begin with the myth below.
Leadership ensures a holistic approach, weaving together the interests of customers, suppliers, employees, local community and society at large, setting clear vision, goals and targets, providing sufficient resources – manpower and equipment, reviewing quality policy, and implementing improvements in quality systems. Ideally each employee must be trained and empowered to work with freedom, responsibility and accountability. Leadership encourages and recognizes personal contributions; it works on trust and avoids fear.

Now it is a tall order. Let us face the realities.
If the above were entirely true, there will be right processes and equipment for every job, every employee will be adequately trained for his job, decision making will be decentralized, motivation is by positive reinforcement and not by fear.

Usually when there is a customer complaint, the default option is to find blame with a person, materials, or environment, in that order. The test of good leadership lies in the courage to face errors originating from the holistic systems approach, such as wrong or inadequate processes/ equipment, improper selection of materials, insufficient training, low-morale of workers, etc.

Quality Myths -1: ‘Customer Focus’ – what is it?

What does customer focus mean? Let us examine some perspectives. I will quote below some oft-heard pieces of conversation.
“Customer focus is providing superior quality products and services exceeding customers’ expectations.”
“When customers snap, the suppliers have to jump.”
“When customer has a problem on the assembly floor, supplier should be willing to crawl on all fours and meet all their demands, even in the night or on holidays.”
“Customer is always right.”

Let us examine the ISO 9001-2008 view on this.

Section #5.2: Top management shall ensure that customer requirements are determined and are met with the aim of enhancing customer satisfactions (See 7.2.1 and 8.2.1).
7.2.1 Determination of requirements related to the product.
8.2.1 Measurement of customer satisfaction

Lean Six Sigma

How about looking at Lean Six Sigma as bringing the design process into the purview of quality? This is the idea in my post.

There are lots of systems like Quality Function Deployment, House of Quality, Total Quality Management, 100 PPM or ‘zero-defects’, concurrent engineering, and on and on and on. At one time, it was thought that Total Quality Management would solve everything! But alas! It didn’t. The simple reason, I think, was that we set up silos around design and insulated it from all quality initiatives, until the Lean Six Sigma bottled the old wine in a new bottle!

Again, visual imagery works better to tell the point. Here is a story about how the horse, a free-spirited runner became a domesticated animal, courtesy of Rabindranath Tagore. I read this story a long time ago. The characters in the story are God, looking down from heaven, crafty man on the ground, and the free-spirited horse. The man hogties the horse in such a way that it can’t run free-spiritedly any more. God, looking down from heaven, has only the top view and doesn’t notice the ropes! Man then reasons with God that He had better assign horse to him as a domestic animal, to which God reluctantly agrees!

Well, the point of my story is that any system can work only as well as its design. Most of the time, faulty design is the reason for quality problems.

Lean Sixsigmaists, donning different colors of belts or not, are SUPPOSED to be mindful of the quality being integral with the design process.