In today’s post, I am looking at “hitozukuri” from the famous Toyota saying, “monozukuri wa hitozukuri.” This can be translated as “making things is about making (developing) people”. To me, this encapsulates the idea of a sociotechnical system. When organizations attempt to business process reengineer, there is a tendency to focus on improving processes only from the technical standpoint. Their focus is on – How to make the process flow better or how to make the operation faster by removing waste? Toyota does focus on this, but at the same time, they also focus on developing their people. Unfortunately, as the lessons from Toyota got copied, the emphasis became more on the tools and not on the people development.

While we can translate monozukuri as craftsmanship, it also represents the spirit of creativity, doing more with less and not wasting valuable resources. Japanese culture has a strong emphasis on harmony, and this can also be seen with monozukuri. Monozukuri is the art of making things in the most harmonious way possible, with minimal waste, and maximum aesthetics. At the same time, we can also look at hitozukuri as lifelong development. Kozo Saito, Director of the Institute of Research for Technology Development at the University of Kentucky, describes hitozukuri as:

Hitozukuri … stresses a life-long process of learning. Hitozukuri emphasizes several different steps of human development, whose original form was emphasized by Confucius in his famous six different human development stages. It goes: ‘‘when I (Confucius) was fifteen years old, I decided to study; at thirty I became independent; at forty I focused; at fifty I realized my mission in my life; at sixty I became able to listen to people without bias and prejudice; finally at seventy I attained the stage that my thinking and action are harmonized with nature. Hitozukuri is a continuous life-long process of human development.

Hitozukuri aligns with the second pillar of the Toyota Way – respect for people. As part of developing people, Toyota focuses on teaching them to see waste and come up with ways to fix the problems. They are challenged with improving their processes, and in the process improve and develop themselves. This is all done in an environment of mutual respect, again based on the concept of harmony.

The technical aspects of monozukuri resides in the simple and complicated domains of order. It is like saying, follow this recipe exactly, and you will make a delicious food item. The social aspects of hitozukuri resides in the complex domain. There is no one best way of “developing” a person. As the famous saying goes, humans do not come with manuals. One heuristic that Toyota uses is – do not tell exactly how to solve a problem. As part of their development, the trainee identifies a problem. The trainer challenges the trainee to start experimenting, identifying patterns and to come up with countermeasures. The trainer provides the various concepts to help the trainee understand the problem, and works with him to find the root cause(s) and thus potential solutions.

In the delightful book, “Not Always So”, about the great Zen Teacher Shunryu Suzuki, Jusan Kanei tells a beautiful anecdote. Kanei was struggling with sitting still for meditation. Suzuki Roshi sat next to him and without saying a word rested his hands on Kanei’s shoulder. Soon, Kanei’s breath softened and lengthened, and he was able to stay with his breath. Kanei later asked Suzuki Roshi what he was doing when he had his hands on Kanei’s shoulders, and Suzuki Roshi responded, “I’m meditating with you.” Suzuki Roshi did not say to do this or do that. His touch did not say “Go over there” or “Get over here”, “Straighten Up” or “Calm down.” Kanei stated that the touch said, “I’ll be here with you wherever you are.”

This is a beautiful story that encapsulates the idea of not telling people what to do, and instead develops the person. When you have to tell someone what to do, the responsibility of their actions become yours. You are also stealing their opportunity to learn from the experience. We learn more from failures than from successes.

Always keep on learning…

In case you missed it, my last post was Distrust Simplicity:


Distrust Simplicity:


In today’s post, I will be looking at the famous quote from the famous English mathematician and philosopher, Alfred Whitehead.

Seek simplicity, and then distrust it.

This quote comes from his 1920 collection of lectures, The Concept of Nature. The quote is embedded in the paragraph below:

Nature appears as a complex system whose factors are dimly discerned by us. But, as I ask you, Is not this the very truth? Should we not distrust the jaunty assurance with which every age prides itself that it at last has hit upon the ultimate concepts in which all that happens can be formulated? The aim of science is to seek the simplest explanations of complex facts. We are apt to fall into the error of thinking that the facts are simple because simplicity is the goal of our quest. The guiding motto in the life of every natural philosopher should be, Seek simplicity and distrust it.

I like this idea a lot. We are all asked to keep things simple, and to not make things complicated. Whitehead is asking us to seek simplicity first, and then distrust it. Whitehead talks about “bifurcation of nature” – nature as we perceive it, and the nature as it is. Thus, our perception of reality is an abstraction or a simplification based on our perceptions. We need this abstraction to start understanding nature. However, once we start this understanding process, we should not stop. We should build upon it. This is the scientific method – plan the prototype, build it, assess the gap, and continue improving based on feedback.

As I was reading The Concept of Nature, several other concepts came to my mind. The first one was Occam’s razor – the idea that Entities should not be multiplied unnecessarily. Seek the simplest explanation, when all things are equal. At the same time, we should keep Epicurus’ Principle of Multiple Explanations in mind – If more than one theory is consistent with the observations, keep all theories. I also feel that Whitehead was talking about systems and complexity. As complexity increases, our ability to fully understand the numerous relationships decreases. As the wonderful American Systems thinker Donella Meadows said:

We can’t impose our will on a system. We can listen to what the system tells us and discover how its properties and our values can work together to bring forth something much better than could ever be produced by our will alone.

Seeking simplicity is about the attempt to have a starting point to understand complexity. We should continue to evolve our understanding and not stop at the first abstraction we developed. One of the famous Zen story is about the teacher pointing his finger at the moon. I have talked about this here. We should not look at the finger and stop there. We should look at where the finger is pointing. The finger is the road sign and not the destination itself. The simplicity is a representation and not the real thing. We should immediately distrust it because it is a weak copy. Seeking simplicity is not a bad thing but stopping there is. Simplicity is our comfort zone, and Whitehead is asking us to distrust it so that can keep improving our situation – continuous improvement. Whitehead in his later 1929 book, The Function of Reason, states:

The higher forms of life are actively engaged in modifying their environment… (to) (i) to live, (ii) to live well, (iii) to live better.

Final Words:

In seeking simplicity, we are trying to be “less wrong”. In distrusting our simplified abstraction, we are seeking to be “more right”. I will finish with a Zen story.

A Zen master lay dying. His monks had all gathered around his bed, from the most senior to the most novice monk. The senior monk leaned over to ask the dying master if he had any final words of advice for his monks.

The old master slowly opened his eyes and in a weak voice whispered, “Tell them Truth is like a river.”

The senior monk passed on this bit of wisdom in turn to the monk next to him, and it circulated around the room from one monk to another.

When the words reached the youngest monk he asked, “What does he mean, ‘Truth is like a river?’”

The question was passed back around the room to the senior monk who leaned over the bed and asked, “Master, what do you mean, ‘Truth is like a river?’” Slowly the master opened his eyes and in a weak voice whispered, “OK, truth is not like a river.”

Always keep on learning…

In case you missed it, my last post was Cannon’s Polarity Principle:

Cannon’s Polarity Principle:


I recently read the wonderful book “On the Design of Stable Systems”, by Jerry Weinberg and Daniela Weinberg. I came across a principle that I had not heard of before called “Cannon’s Polarity Principle”. Cannon’s Polarity Principle can be stated as the strategy that a system can use to overcome noise by supplying its own opposing actions. If a system relies on an uncertain environment to supply the opposing factor to one of its regulatory mechanisms, that mechanism must have a much more refined model. By supplying its own opposing factor, it can get away with a much simpler model of the environment.

This principle is one of those things that is profound yet very simple. The Weinbergs give the example of a sticky knob on a gas stove to explain this idea. If the knob is sticky then it is tricky to raise the flame to the precise point we would like it to be. Due to the “stickiness” we will try to apply much more force than needed and inadvertently overshoot, going past the desired point. The result is that the flame is at a much higher setting. When we try to turn the flame down we are still in the same situation and again go past the point where we would like to be.

What we can do instead is to use one hand to push against the direction we would like and then slowly try to turn the knob with our other hand. With this approach we can be much more refined and be at our desired position. By working “against” our own goal, we make precise adjustment possible in the face of an unknown, but small, amount of stickiness.

This got me thinking. There are several times where we apply opposing forces to slow us down, to take the time to reach the correct decision (precise adjustment). One of my favorite Toyotaism is – Go slow to go fast. This makes a lot of sense in the light of the Polarity Principle. Any time we are doing a root cause analysis, we are prone to a plethora of biases including confirmation bias – selectively looking for ideas that reinforce our thinking, and availability bias – latching on to the first idea because that was the immediate idea we came up with. These biases might make us jump to unwarranted conclusions to address symptoms, and not addressing the root problem(s). The Polarity Principle would advise us to slow down.

I will finish this short and sweet with an apt Zen saying:

The one who is good at shooting does not hit the center of the arrow.

Always keep on learning…

In case you missed it, my last post was Contextual Why:

Contextual Why:


One of the scientists that I have referenced in my posts a lot is the American physicist Richard Feynman. I particularly love his imaginary depiction of Mayan astronomy. Feynman went to Mexico for his second honeymoon and came across a copy of the Dresden Codex (one of the oldest surviving books from the Americas). He was particularly interested in the bars and dots in the codex. He was able to decipher the number system that the Mayans used to depict Venus’ trajectory in the solar system. He was so good at it that he was able to find that some of the versions were actually fakes. Feynman imagined the Mayans counting and putting nuts in a pot to make predictions of where Venus would be on a given day. Feynman was curious whether the Mayans actually knew what was happening (why it was happening) or whether they were going by the rules and making predictions based on a rule-based system of counting and manipulating numbers. Feynman stated that the Mayans may have gotten really good with counting but they must not have understood how the celestial bodies worked.

The push for following rules without understanding the context is unfortunate. Yet this is very prevalent. The rigidity of the rules cannot be sustained when a complex situation arises. The rigidity of rules indicates a direct linear relationship where cause and effect are clearly noted. This is the push for standardization and having one best way of doing things. This leads to stagnation, since this stymies creativity and the push for innovation. Rigid rules always break. Another way to look at this is as the push for robustness – avoiding failure by any means. We will put redundant steps, perform multiple inspections and implement punishments for not following rules. In the complex world, we should accept that things will fail – the push should be for resilience, getting back up in a short time. The rules are dictated top-down since the rules are created by the experts. These rules do not have the requisite variety to tackle the uncertainties of day-to-day dealings. The contexts of these rules do not match the actual context where the action takes place – the context at the gemba. Context is what brings out the meaning in a situation. The focus on rules and efficiency through best practice does not lead to having the requisite variety to change the context as needed to address a problem when it arises. We are involved in complex adaptive systems on a day-to-day basis. We need to change context as needed and adapt to respond to unanticipated events. Evolution requires that we have variety. This response is not always rule-based and is developed depending upon the context. We should allow room for bottom-up heuristics, since these are based on experience and local context.

As a simple example, let’s look at 5S, one of the most commonly identified lean tools, to look into this more. 5S is translated from Japanese as Sort, Straighten, Shine, Standardize and Sustain. The rules are provided to us and they are clear cut. Similar to the Mayan story, do we actually know the context for 5S? Toyota did not have 5S. The last few S’s were added on later. This has now changed into 6S and even 7S. The “sort” step in 5S is to have only the required tools needed at the station. The “straighten” step is to identify/label the tools so that operators from other shifts or job rotations can easily find the tools. The third step is “shine” where the work station is cleaned by the operator. This allows the operator to find any spills or other signs of wear and tear that may not be seen by a cleaning crew. These three steps help the operator to identify problems as they occur, raises awareness and helps to take pride in the work. The fourth step is “standardize” and this is mainly a regulatory function to ensure that the first three steps are followed. The last step is “sustain”, which means to integrate the first three steps so that they become the normal routine and if they are not followed, one feels like something is missing. The context is to help the operator do his or her job better and be effective. The context is that a problem is made visible immediately so that it can be addressed and people can be developed. The context is not following rules. The context is not applying 5S in areas where it does not make sense. The context certainly is not policing people. When the context of what the operator does is not made clear, they do what makes sense to them in their context – at that time with the limited information they have. Empty actions do not have context and are thus meaningless and non-value adding.

Seek to understand the perspectives of your employees. Seek to understand their local context. Seek to make them understand your context, and the context of the shared goals and objectives. Heed to their stories. Develop your employees to see problems.

I will finish with an interesting question that was posed by some French researchers in the late 1970’s.

“On a boat, there are 26 sheep and 10 goats. What is the age of the captain?”

Perhaps, you might see this as a trick question. Perhaps, you may use the two numbers given and come up with the answer as 36. The answer 36 sounds right. The answer that the researchers expected was “I do not have enough information to give the answer.”

To the researchers’ surprise, very few subjects challenged the question. Most of them reasoned in their context and came up with a number that made sense in their mind. We are not trained to ask the contextual questions.

Always keep on learning and ask contextual questions…

In case you missed it, my last post was MTTF Reliability, Cricket and Baseball:

Mismatched Complexity and KISS:



In today’s post, I will be looking at complexity from the standpoint of organizational communication and KISS. For the purpose of this post, I am defining complexity as a measure of computational effort needed to describe your intent. This idea of complexity is loosely based on Kolmogorov’s definition of “Complexity” from an algorithm standpoint.

To give a very simple example, let’s say that I would like to convey two messages, M1 and M2:

M1 = 010101

M2 = 100111

From the complexity standpoint, M2 requires more effort to explain because there is no discerning pattern in the string of numbers. M1, on the other hand, is easier to describe. I can just say, “Repeat 01 three times.” For M2, I have no choice but say the entire string of numbers. In this regard, I could say that M2 is more complex than M1.

Let’s look at another example, M3:

M3 = 1415926535

Here, it may look like there is no discerning pattern to the string of numbers. However, this can be easily described as “first 10 decimal values of pi without 3. Thus, this message also has low complexity. We can easily see a direct linear relationship or know the content just by observation/empirical evidence.

The examples so far have been examples of low complexity messages. These are easy to generate, diffuse and convey. From the complexity standpoint, these are Simple messages. If I were to create a message that explained Einstein’s relativity, it may not be easily understood if the receiver of the message does not have a good grasp of Physics and advanced math. This is an example of medium complexity or a complicated topic. The relationship is evident with all of the information available.

Now let’s say that I would like to create a message about a complex topic – solve poverty or solve global warming. There is no evident relationship here that can be manipulated with an equation to solve the problem. These are examples of wicked problems – there are no solutions to these problems. There are options but none of the options will fully solve the many intricate problems that are entangled with each other. Such a topic is unlikely to be explained in a message.

The common thread in communication or solving problems is the emphasis on KISS (Keep It Simple Stupid). However, in an effort to keeping things simple, we often engage in mismatched complexity. Complex ideas should not be exclusively conveyed as simple statements. The ideal state is that we use the optimal message – adjust complexity of the message to match the complexity of the content. This is detailed in the schematic below. The optimal message is the 45 degree line between the two axes. A highly complex topic should not be expressed using a low complex message such as a slogan or policy statement. In a similar fashion, a low complexity topic does not need a high complexity message method such as an hour-long meeting to discuss something fundamental.

message diagram

The highly complex topic can use both low and medium message methods to ensure that the complex idea is conveyed properly. The diffusion of the highly complex topic can build upon both low and medium message methods. The diffusion of a highly complex topic also requires redundancy, which means that the message must be conveyed as many times as needed and use of metaphors and analogies. One definition of “communication” from the great Gregory Bateson is – Communication is what the receiver understands, not what the sender says.

A good example to explain this is Toyota Production System. The concept of a production system for the entire plant is a complex concept. Toyota Production System was once called “the Ohno method” since it was not implemented company-wide and there was doubt as to the success of the system being a long-term plan. Ohno’s message was not written down anywhere and the employees did not learn that from a manual or a video. Ohno conveyed his ideas by being at the gemba (actual work place), implementing ideas and learning from them. He also developed employees by constantly challenging them to find a better way with less. Ohno used to draw a chalk circle on the floor for supervisors/engineers to make them see what he saw. He developed the Toyota Production System and with continuous mentoring, nurtured it together with the employees. Today there are over 1000 books at Amazon regarding “Lean Manufacturing”. When top management is looking at implementing lean, the message should match the complexity of the content. Low complex message methods like slogans or placards will not work. Medium complex message methods like newsletters, books etc will not work. This will require constant on-the-floor interactive mentoring. At the same time, slogans and newsletters can aid in the diffusion process.

Final Words:

I have always felt that KISS and Poka-Yoke have a similar story to tell from a respect-for-people standpoint. Poka-Yoke (Error proofing) was initially termed as Baka-Yoke to indicate “fool proofing”. Shigeo Shingo changed it to Poke-Yoke to indicate error proofing after an employee asked him “have I been such a fool?” In a similar fashion, KISS was initially put forth as “Keep It Simple Stupid” (without the comma). Nowadays, this has been changed to “Keep It Short and Simple” and “Keep It Simple Straightforward”.

It is good to keep things simple and to view at a problem from a 10,000 feet level. However, we should not stop there. We need to understand the context and complexity of the problem and then create this information in such a manner that it can be diffused across the organization. This can be repeated as many times as needed. Do not insist on simplicity without understanding the complexity of the problem. Asking to keep things simple is an attempt to keep round pegs in familiar square holes. When there is a mismatch of complexity it leads to incorrect solutions and setbacks. As Einstein may have said,everything should be as simple as it can, but not simpler”.

We can also view the complexity/message diagram in the light of the Feynman (Nobel-prize winning physicist Richard Feynman) technique of studying hard subjects. Feynman came up with a method where he would start studying and making notes pretending to prepare a lecture for a class. He would use simple terms and analogies to explain the subject. When he got stuck he would go back and try to understand it even better. He would then proceed with making notes. He would repeat the steps many times until he got the concept thoroughly. Moving from High to Medium to Low in the diagram, and going back-and-forth helps to connect the dots and gain a better understanding.

I will finish with another quote, attributed to Lotfi Zadeh (father of Fuzzy Logic):

“As complexity rises, precise statements lose meaning and meaningful statements lose precision.”

Always keep on learning…

In case you missed it, my last post was Flat Earth Lean:

Flat Earth Lean:


How many interpreters does it take to change a light bulb?

It depends on the context!

In today’s post, I will be looking at what I call “Flat Earth Lean” and “Contextual Lean”. I recently came across the concept of “Flat Earth View” in organizational communication. Matthew Koschmann, currently an associate professor at the University of Colorado, talks about the one-dimensional approach to organization communication where the big picture is not used. It is a linear approach without looking at the contexts or the social aspects. Koschmann explains – What I mean by a flat earth approach is a perspective that seems correct from a limited vantage point because it works for much of our day to day lives, but ultimately it fails to account for the complexity of a situation. For much of human history we got by just fine thinking the earth was flat, even though it was always round. And even with our 21st century sophistication where we know the earth is round, most of us can actually get by with flat earth assumptions much of the time. But what about when things get more complex? If you want to put a satellite into space or take a transcontinental flight, flat earth assumptions are not going to be very helpful. Remember in elementary school when you compared a globe to a map and realized, for example, that it s quicker to fly from New York to Moscow by flying over the North Pole instead of across the Atlantic? What seems counter intuitive from a flat earth perspective actually makes perfect sense from a round earth perspective.”

I would like to draw an analogy to Lean. Perhaps, the concept of flat earth exists in Lean as well. This could be looked at as the tools approach or copying Toyota’s solutions to apply them blindly. The linear approach implies a direct cause and effect relationship. From the Complexity Science standpoint, the linear relationship makes sense only in the simple and complicated domains. This is the view that everything is mechanistic, utilizing the metaphor of a machine – press this button here to make something happen on the other side with no unintended consequence or adverse effects. In this world, things are thought to be predictable, they can be standardized with one-glove-fits-all solutions, and every part is easily replaceable. Such a view is very simplistic and normally cares only about efficiency. This is an approach that is used for technical systems. There is limited or no focus on context. Hajime Ohba, a Toyota veteran, used to say that simply copying Toyota’s methods is like creating the image of Buddha and forgetting to inject soul in it. In Flat Earth Lean, the assumption is that end goal is clearly visible and that it is as easy as going from HERE to THERE. The insistence is always to KISS (keep it simple stupid). In many regards, this reductionist approach was working in the past. Information generation was minimal and the created information was kept local in the hands of the experts. In today’s global economy, organizations do not have the leisure to keep using the reductionist approach. Today, organizations not only have to ensure that information is diffused properly, they also have to rely on their employees to generate new information on a frequent basis. The focus needs to be shifted to organizations being socio-technical systems where things are not entirely predictable.

Here to There

Karl Weick, an American organizational theorist, advises to “complicate yourself”. He cautions us to not rely on oversimplification. We need to understand the context of what we are doing, and then challenge our assumptions. We have to look for contradictions and paradoxes. They are the golden nuggets that help us to understand our systems. In Contextual Lean, we have to understand our problems first and then look for ways to make things better. Implementing 5S with the aim of being “Lean” is the Flat Earth Approach. Implementing 5S and other visualization methods to make sense of our world, and making problems visible so that we can address them is “Contextual Lean”. If there is such a thing as “going Lean” for an organization, it is surely a collective expression. “Lean” does not exist in isolation in a department or in a cabinet; let alone in one Manager or an employee. To paraphrase the great philosopher, Ludwig Wittgenstein, the meaning of an expression exists only in context. Context gives meaning. Toyota’s “Lean” has limited meaning in relation to your organization since it makes sense only in the context of the problems that Toyota has. Thus, when the Top Management pushes for Lean initiation, it has to be in the context of the problems that the organization has. Understanding context requires self-reflection and continuous learning for the organization. This again is a collective expression and does not exist without involving the employees. Interestingly, Contextual Lean has to utilize Flat Earth approach as needed.

Flat Earth and Contextual Lean have some similarities to the late American business theorist Chris Argyris’ ideas of Single and Double Loop learning. Single Loop learning is the concept of correcting an error by using the existing mental models, norms and practices. Argyris gives the example of a thermostat to explain this – Single loop learning can be compared with a thermostat that learns when it is too hot or too cold and then turns the heat on or off. The thermostat is able to perform this task because it can receive information (the temperature of the room) and therefore take corrective action. Double Loop Learning, on the other hand, involves a reflective phase that challenges the existing mental models, norms and practices, and modifies them to correct the error. In Chris Argyris’ words –If the thermostat could question itself about whether it should be set at 68 degrees, it would be capable not only of detecting error but of questioning the underlying policies and goals as well as its own program. That is a second and more comprehensive inquiry; hence it might be called double loop learning. Single Loop Learning has some similarities to Flat Earth Lean in that it wants to take a simplistic approach and does not want to modify the mental models. It wants to keep doing what is told and to use an old analogy – only bring your hands to work and leave your brains outside. Single Loop Learning is a superficial approach to solve problems symptomatically. Double Loop Learning has some similarities to Contextual Lean in that it is not one-dimensional and results in modifying the mental models as needed. It is a continuous learning and adapting cycle. Argyris also believed that organizations learn when its people learn – Organizational learning occurs when individuals, acting from their times and maps, detect a match or mismatch of outcome to expectation which confirms or disconfirms organizational theory-in-use.

I will finish with a fitting contextual story about change.

Mulla Nasrudhin was now an old man. People used to gather around to hear him talk. One day a young man asked for some words of wisdom.

Mulla replied, “When I was young I was very strong minded- I wanted to awaken everyone. I prayed to God to give me the strength to change the world. As time went on, I became middle aged and I realized that I did not change the world. Then I prayed to God to give me strength so that I can at least change those close around me. Now that I am older and perhaps wiser, my prayer has become simpler. I say – God, please grant me the strength to change at least myself.”

Always keep on learning…

In case you missed it, my last post was The Purpose of Visualization:

Hammurabi, Hawaii and Icarus:


In today’s post, I will be looking at Human Error. In November 2017, The US state of Hawaii reinstated the Cold War era nuclear warning signs due to the growing fears of a nuclear attack from North Korea. On January 13, 2018, an employee from the Hawaii Emergency Management Agency sent out an alert through the communication system – “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” The employee was supposed to take part in a drill where the emergency missile warning system is tested. The alert message was not supposed to go to the general public. The cause for the mishap was soon determined to be human error. The employee in the spotlight and few others left the agency soon afterwards. Even the Hawaiian governor, David Ige, came under scrutiny because he had forgotten his Twitter password and could not update his Twitter feed about the false alarm. I do not have all of the facts for this event, and it would not be right of me to determine what went wrong. Instead, I will focus on the topic of human error.

One of the first proponents of the concept of human error in the modern times is the American Industry Safety pioneer, Herbert William Heinrich. In his seminal 1931 book, Industrial Accident Prevention, he proposed the concept of Domino theory to explain industry accidents. Heinrich reviewed several industrial accidents of his time, and came up with the following percentages for proximate causes:

  • 88% are from unsafe acts of persons (human error),
  • 10% are from unsafe mechanical or physical conditions, and
  • 2% are “acts of God” and unpreventable.

The reader may find it interesting to learn that Heinrich was working as the Assistant Superintendent of the Engineering and Inspection Division of Travelers Insurance Company, when we wrote the book in 1931. The data that Heinrich collected was somehow lost after the book was published. Heinrich’s domino theory explains an injury from an accident as a linear sequence of events associated with five factors – Ancestry and social environment, Fault of person, Unsafe act and/or mechanical or Unsafe performance of persons, Accident and Injury.


He hypothesized that taking away one domino from the chain can prevent the industrial injury from happening. He wrote – If one single factor of the entire sequence is to be selected as the most important, it would undoubtedly be the one indicated by the unsafe act of the person or the existing mechanical hazard. I was taken aback by the example he gave to illustrate his point. As an example, he talked about an operator fracturing his skull as the result of a fall from a ladder. The investigation revealed that the operator descended the ladder with his back to it and caught his heel on one of the upper rungs. Heinrich noted that the effort to train and instruct him and to supervise his work was not effective enough to prevent this unsafe practice.  “Further inquiry also indicated that his social environment was conducive to the forming of unsafe habits and that his family record was such as to justify the belief that reckless tendencies had been inherited.

One of the main criticisms to Heinrich’s Domino model is its simplistic nature to explain a complex phenomenon. The Domino model is reflective of the mechanistic view prevalent at that time. The modern view of “human error” is based on cognitive psychology and systems thinking. In this view, accidents are seen as a by-product of the normal functioning of the sociotechnical system. Human error is seen as a symptom and not a cause. This new view uses the approach of “no-view” when it comes to human error. This means that the human error should not be its own category for a root cause. The process is not perfectly built, and the human variability that might result in a failure is the same that results in the ongoing success of the process. The operator has to adapt to meet the unexpected challenges, pressures and demands that arise on a day-to-day basis. The use of human error as a root cause is a fundamental attribution error – focusing on the human trait of the operator as being reckless or careless; rather than focusing on the situation that the operator was in.

One concept that may help in explaining this further is Local Rationality. Local Rationality starts with the basic assumption that everybody wants to do a good job, and we try to do the best (be rational) with the information that is available to us at a given time. If this decision led to an error, instead of looking at where the operator went wrong, we need to look at why he made the decisions that made sense to him at that point in time. The operator is in the “sharp end” of the system. James Reason, Professor Emeritus of Psychology at the University of Manchester in England, came up with the concept of Sharp End and Blunt End. Sharp end is similar to the concept of Gemba in Lean, where the actual action is taking place. This is mainly where the accident happens and is thus in the spotlight during an investigation. Blunt end, on the other hand, is removed and away in space and time. The blunt end is responsible for the policies and constraints that shape the situation for the sharp end. The blunt end consists of top management, regulators, administrators etc. Professor Reason noted that the blunt end of the system controls the resources and constraints that confront the practitioner at the sharp end, shaping and presenting sometimes conflicting incentives and demands. The operators in the sharp end of the sociotechnical system inherits the defects in the system due to the actions and policies set by blunt end and can be the last line of defense instead of being the main proponents or instigators of the accidents. Professor Reason also noted that – rather than being the main instigators of an accident, operators tend to be the inheritors of system defects. Their part is that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking. I encourage the reader to research the works of Jens Rasmussen, James Reason, Erik Hollnagel and Sydney Dekker since I have tried to only scratch the surface.

Final Words:

Perhaps the oldest source of human error causation is the Code of Hammurabi, the code of ancient Mesopotamian laws dating back to 1754 BC. The Code of Hammurabi consisted of 282 laws. Some examples of human error are given below.

  • If a builder builds a house for someone, and does not construct it properly, and the house which he built falls in and kill its owner, then that builder shall be put to death.
  • If a man rents his boat to a sailor, and the sailor is careless, and the boat is wrecked or goes aground, the sailor shall give the owner of the boat another boat as compensation.
  • If a man lets in water and the water overflows the plantation of his neighbor, he shall pay ten gur of corn for every ten gan of land.

I will finish off with the story of Icarus. In Greek mythology, Icarus was the creator of the labyrinth in the island of Minos. Icarus’ father was the master craftsman Daedalus. King Minos of Crete imprisoned Daedalus and Icarus in Crete. The ingenious Daedalus observed the birds flying and invented a set of wings made from bird feathers and candle wax. He tested the wings out and made a pair for his son Icarus. Daedalus and Icarus planned their escape. Daedalus was a good Engineer since he studied the failure modes of his design and identified the limits. Daedalus instructed Icarus to follow him closely and asked him to not fly too close to the sea since the moisture can dampen the wings, and not fly too close to the sun since the heat from sun can melt the wings. As the story goes, Icarus was excited with his ability to fly and got carried away (maybe reckless). He flew too close to the sun, and the wax melted from his wings causing him to fall down to his untimely death.

Perhaps, the death of Icarus could be viewed as a human error since he was reckless and did not follow directions. However, Stephen Barlay in his 1969 book, Aircrash Detective: International Report on the Quest for Air Safety, looked at this story closely. At the high altitude that Icarus was flying, the temperature will actually be cold rather than warm. Thus, the failure would actually be from the cold temperature that would make the wax brittle and break instead of wax melting as indicated in the story. If this was true, during cold weathers the wings would have broken down and Icarus would have died at another time even if he had followed his father’s advice.

Always keep on learning…

In case you missed it, my last post was A Fuzzy 2018 Wish

A Merry Happy Christmas and Attractors:


I originally hail from India. My relatives are still living in India. I called them yesterday for Christmas and talked for a while. One thing I kept noticing in the call was that they were saying “Happy Christmas” and my family here in America kept saying “Merry Christmas”. I was curious about this and thought I would research the differences in the phrases. It turns out that the difference is based on which side of “the pond” you are. “Merry Christmas” is quite common in America and “Happy Christmas” is quite common in England.

The phrase “Merry Christmas” has a not-so-merry origin. In 1534, King Henry VIII condemned Bishop John Fisher to death for not recognizing the king as the Supreme Head of the Church of England. The bishop was imprisoned in the Tower of London, and he wrote a letter to Thomas Cromwell, the then chief minister of King Henry VIII. In the letter, the bishop requested Thomas Cromwell provide him a shirt, a sheet, good food, and a priest to hear his confession. The bishop also requested him to talk to the king to have him released. The bishop ended the letter with a “Merry Christmas” wish. The bishop was executed on 22nd June 1535. The king showed the bishop mercy by beheading him instead of hanging him. The phrase caught on and was even used by Charles Dickens in his 1843 classic story, “A Christmas Carol”. Coincidentally, Sir Henry Cole in England commissioned the first Christmas greeting cards in the same year. The card stated “A Merry Christmas and a Happy New Year To You”. Sir Henry Cole produced 2050 Christmas greeting cards that year that were sold for a shilling each.

The credit to replacing “Merry Christmas” with “Happy Christmas” in England should perhaps go to King George V. King George V gave the first Royal Christmas Broadcast through the BBC in 1932. In his speech, King George V wished everybody a Happy Christmas. One of the hypotheses regarding the change of phrase is that the word “merry” has a negative connotation as in being associated with inebriation. The word “happy” on the other hand, is a description of a state of mind and associated with luck (hap = luck). Thus, the people were encouraged to be happy rather than be merry. The royal family started to use Happy Christmas and this caught on to become the favorite holiday greeting in England.

The story of “Happy Christmas” reminded me of “Attractors” in Complexity theory. A social system is a complex system that has propensities and dispositions. An attractor is a pattern that is formed within the system based on the interaction of its numerous entities. Since the Royal Family started saying “Happy Christmas” instead of “Merry Christmas”, the upper class started using “Happy Christmas”. This then started to become quite popular across the classes.  The phrase “Happy Christmas” became the attractor pattern in England, whereas in America, there was no impact or interaction from King George V, and “Merry Christmas” stayed as the popular Christmas wish.

I will finish off with another example of an attractor. Jack Cohen and Ian Stewart in their 1995 book, “The Collapse of Chaos”, talks about two ice cream vendors at a beach. Lets say that Vendor A and Vendor B are both located equidistant from one another between a pier at one end and a rocky point at the other end. Just by luck, Vendor A got more customers than Vendor B on the first day. Seeing this, Vendor B moved a little closer to Vendor A and got more customers. Vendor A now moved a little closer to Vendor B. Soon enough, both the vendors were now next to each other in the middle of the beach. The vendors were not moving towards the physical center of the beach due to the location. Their interaction with each other caused the attractor pattern to form.

Have a Merry Happy Christmas, and Holiday Season!

Always keep on learning…

In case you missed it, my last post was The Information Model for Poka Yoke:

Which Way You Should Go Depends on Where You Are:


I recently read the wonderful book “How Not To Be Wrong, The Power of Mathematical Thinking” by Jordan Ellenberg. I found the book to be enlightening and a great read. Jordan Ellenberg has the unique combination of being knowledgeable and capable of teaching in a humorous and engaging way. One of the gems in the book is – “Which way you should go depends on where you are”. This lesson is about the dangers of misapplying linearity. When we are thinking in terms of abstract concepts, the path from point A to point B may appear to be linear. After all, the shortest path between two points is a straight line. This type of thinking is linear thinking.

To illustrate this, let’s take the example of poor quality issues on the line. The first instinct to improve quality is to increase inspection. In this case, point A = poor quality, and point B = higher quality. If we plot this incorrect relationship between Quality and Inspection, we may assume it as a linear relationship – increasing inspection results in better quality.

Inspection and Quality

However, increasing inspection will not result in better quality in the long run and will result in higher costs of production. We must build quality in as part of the normal process at the source and not rely on inspection. In TPS, there are several ways to do this including Poka Yoke and Jidoka.

In a similar fashion, we may look at increasing the number of operators in the hopes of increasing productivity. This may work initially. However, increasing production at the wrong points in the assembly chain can hinder the overall production and decrease overall productivity. Taiichi Ohno, the father of Toyota Production System, always asked to reduce the number of operators to improve the flow. Toyota Production System relies on the thinking of the people to improve the overall system.

The two cases discussed above are nonlinear in nature. Thus increasing one factor may increase the response factor initially. However, continually increasing the factor can yield negative results. One example of a non-linear relationship is shown below:


The actual curve may of course vary depending on the particularities of the example. In nonlinear relationships, which way you should go depends on where you are. In the productivity example, if you are at the Yellow star location on the curve, increasing the operators will only decrease productivity. You should reduce the number of operators to increase productivity. However, if you are at the Red star, you should look into increasing the operators. This will increase productivity up to a point, after which the productivity will decrease. Which Way You Should Go Depends on Where You Are!

In order to know where you are, you need to understand your process. As part of this, you need to understand the significant factors in the process. You also need to understand the boundaries of the process where things will start to breakdown. The only way you can truly learn your process is through experimentation and constant monitoring. It is likely that you did not consider all of the factors or the interactions. Everything is in flux and the only constant thing is change. You should be open for input from the operators and allow improvements to happen from the bottom up.

I will finish off with the anecdote of the “Laffer curve” that Jordan Ellenberg used to illustrate the concept of nonlinearity. One polical party in America have been pushing for lowering taxes on the wealthy. The conservatives made this concept popular using the Laffer curve. Arthur Laffer was an economics professor at the University of Chicago. The story goes that Arthur Laffer drew the curve on the back of a napkin during dinner in 1974 with the senior members of then President Gerald Ford’s administration. The Laffer Curve is shown below:

Laffer curve

The horizontal axis shows the tax rate and the vertical axis shows the revenue that is generated from taxation. If there is no taxation, then there is no revenue. If there is 100% taxation, there is also no revenue because nobody would want to work and make money, if they cannot hold on to it. The argument that was raised was that America was on the right hand side of the curve and thus reducing taxation would increase revenue. It has been challenged whether this assumption was correct. Jordan used the following passage from Greg Manikiw, a Harvard economist and a Republican who chaired the Council of Economic Advisors under the second President Bush:

Subsequent history failed to confirm Laffer’s conjecture that lower tax rates would raise tax revenue. When Reagan cut taxes after he was elected, the result was less tax revenue, not more. Revenue from personal income taxes fell by 9 percent from 1980 to 1984, even though average income grew by 4 percent over this period. Yet once the policy was in place, it was hard to reverse.

The Laffer curve may not be symmetric as shown above. The curve may not be smooth and even as shown above and could be a completely different curve altogether. Jordan states in the book – All the Laffer curve says is that lower taxes could, under some circumstances, increase tax revenue; but figuring out what those circumstances are requires deep, difficult, empirical work, the kind of work that doesn’t fit on a napkin.

Always keep on learning…

In case you missed it, my last post was Epistemology at the Gemba:

Epistemology at the Gemba:

plato 2

In today’s post, I will be looking at Epistemology at the Gemba. Epistemology is the part of philosophy that deals with the theory of knowledge. It tries to answer the questions – how do we know things and what are the limits of our knowledge? I have been learning about epistemology for a while now and I find it an enthralling subject.

The best place to start this topic is with “Meno’s paradox”. Plato wrote about Meno’s paradox as a conversation between Socrates and Meno in the book aptly called “Meno”.  This is also called the “paradox of inquiry”. The paradox starts with the statement that if you know something, then you do not need to inquire about it. And if you do not know something, then the inquiry is not possible since you do not know what you are looking for. Thus, in either case inquiry is useless. Plato believed that we are all born with complete knowledge and all we need to do is recollect what we know as needed.

Today, philosophers point out that knowledge is possible through two ways;

  • Rationalism –knowledge comes from within and does not need to rely on experience.
  • Empiricism – knowledge comes from experience using our senses.

One of the great empiricist philosophers, David Hume classified all objects of human inquiries into two categories, which aligned with the two above-mentioned sources of knowledge.

  • Relation of Ideas – These are tautological statements that are true by themselves. These can also be called “analytical statements” or “necessary statements”. Examples are “all bachelors are unmarried men” or “dogs are mammals”. We can know this just by looking at the statement and no further inquiry is needed. These ideas and observations do not rely on the world.
  • Matters of Facts – These are statements that needs further confirmation by evidence. These can also be called “synthetic” or “contingent” statements. Examples are “it is sunny today” or “the Eiffel Tower is 15 cm taller in the summer”. These rely on the world and experience in the particular matter.

As Science progressed, epistemology also progressed. There was more value placed on empiricism and one of the most famous of these philosophical movements was Logical Positivism. The central theme of Logical Positivism was verificationism which meant that all claims must be verifiable to make sense cognitively. This approach required an objective look at science and empiricism, and relied on the concept of positivism. Positivism was an approach to explain the world objectively and deterministically. It treated the nature of reality as objective, single and fragmentable. This promoted the idea of reductionism where everything can be taken apart and studied. The world was viewed as a machine where direct cause and effect relationships existed. One of the main criticisms of Logical Positivism was that the claim of verificationism itself was not empirically verifiable. Another main criticism was ignoring the observer as being part of the system. The world cannot be viewed independently of the observer. The world is in fact a social construct relying on multiple interpretations. The knowing and the knower are always interacting, and cannot be separated. This type of approach to creating the reality of the world is called interpretivism.

Stephen Pepper was one of the critics of Logical Positivism. He believed that it is not possible to have pure objective facts. He proposed the idea of worldviews or world hypotheses through which we create the meaning to reality in his 1942 book, World Hypotheses: a study in evidence. Four of his worldviews are:

  • Formism – the worldview where we make sense of things by identifying similarities and differences, and thus putting things in categories.
  • Mechanism – the worldview where we make sense of the world as if it were a machine. We assume that there are direct cause and effect relationships and we can take things apart to make sense of things.
  • Organicism – the worldview where importance is placed on creating an organic perspective of the world, where parts come together to create a coherent whole.
  • Contextualism – the worldview where we place value in the context of the world and its parts. This allows us to see the complexity of the world. Pepper identified the context through the two fundamental categories – quality and texture. Quality refers to the total character of an event and texture refers to the details and relations that make up this total character. Viewing the world in terms of context helps us to adopt the required strategies to meet the unpredictability of the world.

My own thoughts on epistemology favors empiricism but also relies on interpretivism. The four worldviews proposed by Pepper helps us to understand the reality from multiple perspectives. This brings me to some concepts in Toyota Production System. One of the main tenets of Toyota Production System is “Grasp the Situation”. This is preceded by going to the gemba, the actual work place where the action is. Once at the gemba, one has to grasp the reality – what is really going on. This requires one to keep personal biases aside and view gemba through the eyes of the operators. I like the use of the verb “grasp” – this indicates a tactile nature, as if you are actually trying to physically “feel out” the problem. Observation is the first step for empiricism. This can be achieved only by going to gemba.

Most of the time when we are informed of a problem, we do not have a clear understanding. Sometimes, the problem statement can be – “it does not work. Again!” This vague problem statement does not help us much. The problem is experienced by the operator and is external to you. Once we are at the gemba, we can start asking questions and even feel the operations by working at the station where the problem occurred. One of the Toyotaisms is – look with your feet and think with your hands. This tactile nature of learning helps us understand the implicit knowledge of the operator.

Another Toyotaism that is meaningful to this discussion is – There is a difference between Toyota Production System and Toyota’s Production System. Toyota Production System is static. It can be treated as explicit knowledge where every single tenet, every single tool and every single concept is written down. However, what Toyota does on a day-to-day basis is personal to the Toyota plant. This cannot be written down. Toyota’s Production System is dynamic where the solutions are unique to the problems that the specific Toyota plant experiences. Another concept that Toyota emphasizes is gaining consensus. This ensures that multiple perspectives are utilized to create the common reality. The concept of “wa” or harmony is important in the Japanese culture.

Final Words:

How do you know what you know? This is an epistemological question. If you are asked to implement 5S or any other lean tool, you need to know why it needs to be implemented. Do you know which problem it is trying to address? If you are asked to help solve a problem on the floor, how would you know what needs to be done? Empiricism is a great way to gain knowledge. This implies using your senses to gain knowledge. The best way to do this is to go to the actual place where the action is. In addition to this, be open to others’ perspectives. The reality must be built upon multiple perspectives.

I will finish with a Zenful story of mine.

The student was in awe of his master. One day, he told the master, “Master, you are truly wise. Do you have any words of wisdom for me?”

The master replied, “I may be wise today. However, wisdom is a habit. Wisdom comes with knowledge only through experience. Thus, I may no longer be a wise man tomorrow.”

Always keep on learning…

In case you missed it, my last post was Meditations at the Gemba: