Don’t Allow Deviance to Become Normal

It’s how ships get blown up and workers lose fingers and hands

Royal Navy Archives

Bio

Levinson Productivity Systems

Most quality practitioners, as well as process engineers, are familiar with management of change (MOC). This means that any significant change to a process factor, such as the familiar ones in cause-and-effect diagrams like manpower, machine, material, method, measurement, and environment, can have unforeseen and undesirable consequences. This is why MOC reviews must take place prior to deploying the changes in question.

However, in the Quality Digest webinar “Management of Change (MOC) for EHS: Preventing Incidents Before They Exist,” presenter Stephanie Ojeda raised the issue of changes that never get reviewed because they happen outside the organization’s formal MOC review process. As my notes taken during the webinar summarize, “Workarounds and shortcuts are a frequent cause of problems, especially when the workaround is effective and becomes normalized—the new way of doing the job.”

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Management of Change

Thanks Bill for this review. I had forgotten the bricklaying story and some of the rest. With a PhD in Industrial Engineering, I certainly know of Frederick Taylor's, "One Best Way" of manufacturing, and of Frank Gilbreth. With 40 years of technical work in manufacturing I also have lots of "lived experience" (a pleonasm or tautology from my perspective). While agreeing that some ways are better than others, I have always thought Taylor's One Best Way was too restrictive, not allowing for new ideas. Indeed, that enforcing One Best Way was almost Un-American. Bring on the robots.

My own practice was to notice small differences in material, process, and product details, investigate differences, particularly from one shift to another. Over time we came to use process control charts, following Demings, "Uncontrolled variation is the Enemy of Quality". Later when demanded to produce "Uniformity, Uniformity, Uniformity", I expressed a corollary, "Uniformity is the Enemy of Knowledge". The best process operators I have known all kept personal notebooks in their lockers. If you approached as a friend rather than as a policeman, they would often share their thoughts as to best practices. Sometimes this would lead to new work instructions, training, and acknowledgments.

PS: I was a classmate and fraternity brother of chemical engineer, Alan McDonald who as a Director for Morton Thiokol warned NASA it was too cold in Florida for the twelve-foot-diameter rubber O-rings to seal, prior to the launch of Challenger in 1986. Unfortunately, his warning was ignored.