OPS Stories & Articles

When the Fix Isn’t in the Conference Room

How often has another meeting changed what really happens at the point of work?

Leave the room, observe, listen.

Editor’s note: Based on a real incident; nonessential details were changed to protect privacy. Adapted from Origin Problem Solving™.

The story

We were flooding the warehouse with odd lot. Coated paperboard kept coming off the line with wrinkles. Meetings multiplied, theories flew, nothing stuck. The late-night calls kept coming.

So I did the one thing I had not done well: I went to the Gemba.

Go to the machine, not the memory

Instead of debating in a room, we stood at the coater during start-up, asked questions of the operator, and watched together. The operator had not been able to operate and watch at the same time, so I followed his lead and instruction and watched for him.

That is where a thread began to show itself. During the sequence, one end of the applicator touched down a hair early. That tiny asymmetry created a bead in the coating at one end, and the downstream wrinkle we were chasing soon showed itself.

While asking questions to understand, I also learned there was an adjustment wheel under twenty years of coating. Hidden to me, not to the operator.

Observe first. Listen. Speak second. That moment changed more than a defect rate. It reset how I thought and how I approached issues.

What we did differently (and why it worked)

• Observed real conditions. Not to command or control but to listen and understand what the process actually did during start-up.
• Respected expertise. We treated the operator as the expert in the process. His insight into the hidden adjustment and the timing sequence was the key to the whole problem.
• Fixed the cause, then protected the fix. We cleaned and indexed the adjustment, verified parallelism at contact, and documented the check in the start-up standard so it would not disappear again.

Why this story is in the book

Chapter 2 of Origin Problem Solving™ shows that durable improvement comes from small, disciplined changes built on real observation, not slogans. The wrinkle story is a clear example. One overlooked contact sequence, one bead, one standard that needed to be made visible and verified, found only because we went to the Gemba to listen.

The Missing Link in Lean: Middle Management

When your calendar is full of reviews and updates, are you leading a system?

The story

Not long ago, I asked a middle manager a simple question: “What do you do on a day-to-day basis?”

He said, “I attend operating reviews. They set the tone and direction for the day.”

“Okay. Then what?”

“Then we go out and target the areas that need attention and execute where we need to execute.”

“Right, but what do you actually do as a manager?”

He paused. “I hold a variety of meetings.”

That was it.

Weeks later, I told this story to someone else. He laughed and said, “He’s not setting direction, he’s chasing fires. Every day’s a new one. He’s solving issues four days old while today’s already blowing up.”

What we call management has drifted into fire control.

The real problem

Middle managers are stuck reacting. They manage symptoms, not systems. Days fill with reviews, updates, and meetings that at best document problems instead of stabilizing them.

By the time they circle back to Monday’s issue, three new “top priorities” have arrived. Urgent wins. Important waits.

We taught them to work this way. In many Lean deployments, we train the front line to see waste and ask executives to sponsor the change, then skip the layer in between, the clay layer everything rests on.

Where the change has to happen

Front-line employees do not need to become Lean experts. They need access, permission, and support to improve the work they already know best.

Executives do not need to be on the floor every hour. They need visibility and confidence in a system that links daily work to strategic goals.

The middle layer is where Lean either lives or dies.

Managers must become disciplined problem-solving practitioners. Their job is to coach, enable small experiments, and stabilize processes before scaling improvements.

A large share of their time, roughly 30 to 40 percent, should go to verifying standards, observing process adherence, and developing supervisors through structured feedback.

From periodic to daily

Many organizations still run on periodic problem solving. A few projects each year, often led by a Lean office, deliver results, check boxes, and move on. It is a start. It is not maturity.

Daily problem solving is the next step, and it only happens when middle managers own it:

• Supervisors and crews run daily experiments to close performance gaps.
• Managers review patterns weekly and invest half their time in coaching and removing barriers.
• Leaders above them review trends monthly.
• Executives focus on annual targets.

Building trust through standards

Coaching in chaos does not work. Middle managers need a clear rhythm, and that starts with Leader Standard Work, not the idealized version, the honest one.

Before we improve leadership behavior, we need to see it as it is: What meetings exist now? How is time actually spent? What is being checked, and what is ignored?

Write it down. Standardize the current state, especially if it is ugly. Once you can see the pattern, you can improve it.

Trailer Fire: From Crisis to Process

How often has a write-up improved a process?

Editor’s note: This account is based on a true event; details edited for anonymity. Adapted from Origin Problem Solving™.

When fear replaces facts

A wheel bearing failed on a blistering summer day. The trailer caught fire. When the flames were out, only a black outline of a semi remained. No injuries, thank God, but fear moved in fast across multiple departments. The employee at the center was union represented. Blame, discipline, and fallout arrived almost instantly.

The usual path would have been write-ups, suspensions, and a process that never changes. We chose a different path.

From reaction to reconstruction

We went out to the work site. We walked the process. We checked the equipment, the paperwork, the handoffs, and how the job actually runs when the pressure is on.

It became clear that the written standard and the real work were not the same thing. The technician did not wake up intending to burn a trailer to the ground. He did what the system had trained him to do.

Together, we rebuilt the standard around how the work really happens:

• Clarified inspection points on the trailer and wheel assemblies.
• Reworked pre-trip checks so they fit real-world time and constraints.
• Updated training so new employees learned the real risk points, not just generic rules.

Clarity, Cause, Control

Clarity: everyone involved could now see the same process, the same risks, and the same expectations.

Cause: we moved past “human error” and into the actual conditions that made the failure possible.

Control: we rebuilt the standard, trained to it, and put checks in place so the new way of working would stick.

A Near-Miss, a Saw Blade, and the Standard

“We almost lost a hand.”

The near miss

A technician was operating a saw when a board kicked back and his hand came dangerously close to the blade. The guard was in place. PPE was being worn. On paper, everything looked fine. Yet the near miss still happened.

Go and See the method

Instead of stopping at “operator error,” we went to the floor and walked the process. We watched how boards were staged, how cuts were set up, how parts flowed in and out. We checked the written standard against what actually happened in production.

It did not take long to see the gaps:

• The standard described an ideal sequence that assumed perfect material and flow.
• Real boards arrived warped, twisted, and out of spec.
• Space around the saw was tight, so operators improvised how they handled larger pieces.
• Throughput pressure meant shortcuts felt normal, not exceptional.

Rewriting the standard

The near miss became the trigger to rewrite the standard with operators at the table. We defined safe handling steps for warped or oversized boards. We adjusted staging so operators had room to maneuver without reaching across the blade path.

The new standard matched reality instead of pretending the real world would conform to the old document.

We React After the Failure

“We are great at reacting. We struggle to prevent.”

The pattern

Ask most leaders about major incidents and you will hear detailed stories: the line that went down, the outage that drove complaints through the roof, the safety event that shook everyone. In those moments, the organization responds: war rooms are formed, teams swarm the issue, executives are on calls at all hours.

Ask the same leaders to tell a story about a risk that was discovered and removed before it turned into an incident, and the answers are thinner.

Shifting the spotlight

The first step is not to shut down incident response. When something serious happens, we should respond strongly. The shift is in what we celebrate, track, and ask about.

Instead of only reviewing what went wrong last week, build a cadence that asks: What risks did we discover this week before they hurt someone or a customer? Where did a front-line employee raise a concern that led to a change? Which checks or audits caught something early?

Building discovery into the system

To move from reaction to prevention, we need structures that make discovery part of normal work:

• Leader Standard Work that includes time for Go and See, not just meetings.
• Layered Process Audits that check how work is done, not just whether forms are filled out.
• Simple channels for employees to raise concerns without fear of blame.
• Regular review of leading indicators, not just lagging incident counts.