Entropy in the Manufacturing World:


In today’s post, I will be looking at Entropy in the Manufacturing world. Entropy is generally defined as disorder. This general definition can sometimes be inadequate. Let’s look at the example of a desk in an office; One could say that if the desk appears to be in order (neat and tidy), then it has low entropy. However, the concept of orderliness is very subjective. Entropy can be referred to as the measure of disorderliness. To me, if I am able to know where everything is, and I can access each item quickly, then my desk has low entropy. It may not seem “ordered” to an outsider, and he may conclude that my desk has high entropy. The second law of Thermodynamics can be loosely stated as – the entropy always increases. Thus, a desk will always get messier. There is a probability aspect to entropy. There are many different ways the things on my desk can be arranged, and only a very small number of those arrangements can be concluded as “ordered”. There is a multitude of more ways a desk can be seen more disorderly than the small number of ways it can be seen as orderly. Thus, from a probability standpoint, it is always likely that a desk is messy unless there is a consistent process in place to keep it back to the “ordered” state at frequent intervals. This line of thinking also shows that the more things you have on your desk, your desk is always most likely to be in a state of “messiness”. Interestingly, 5S in Lean requires you to limit the number of items in an area to only those items that are needed. All of the extra items are encouraged to be removed.

Entropy can also be explained in terms of the element of surprise. For example, a brand new deck of playing cards in order has low entropy because one knows exactly where every card is. There is minimal element of surprise. If one were to riffle shuffle the cards once, there is still some form or order maintained in the cards. For example, the order of the cards from Ace to King is not disturbed. There may be some different cards in between, but the Three of Hearts is still above Four of Hearts, even though there may be other suit cards in between them. This concept is known to magicians and used in several magic tricks. When the cards are shuffled again and again, the knowledge of any form of order is lost, and the entropy thus increases. With a good shuffled deck of cards, any card presents an element of surprise – new information. With the same logic used in the previous paragraph, it is very unlikely that continuous shuffling will bring a deck back to the original new deck order. There is always more ways for the deck to be in a different order than a new deck order. In the new deck order, if you are required to produce the King of Hearts, it is simple to do it since you know the order of the cards. You can do this fairly quickly. However, when the deck is shuffled, this becomes harder. You will need more time to look through every single card until you get to the King of Hearts. Although it is not exactly the same, it is stated that as entropy increases, it causes decaying of energy. In other words, the useable energy becomes less and less. Thus if one were to put the concept of value with regards to entropy, one could say that high entropy states do not yield value. Jeremy Campbell, in his wonderful book “Grammatical Man” states;

“At the heart of the second law (of Thermodynamics) is the insight has order has value.”

From this light, one can understand the need to maintain order in the manufacturing plant. The management strives to maintain low entropy within the manufacturing system, and they surely do not appreciate elements of surprises. From their viewpoint, painting all cars black does make sense. Producing the same item in big numbers using the principles of mass manufacturing is an attractive proposition for management. More number of products and components bring disorder and increase in entropy. Thus minimizing the variety of products manufactured also will be an attractive proposition for management.

However, the world has become smaller globally, and the market is asking for variety. From a Complexity Science standpoint, one can say that the manufacturing processes are ordered or complicated. There are good cause and effect relationships, and these can be easily controlled. However, the complexity outside a manufacturing plant is increasing with the advent of the information age. A manufacturer in China can sell his goods in America, and vice-versa easier. The demand for variety from the market is increasing and the manufacturer cannot make only black cars anymore to stay in business.

The management has to realize that the organizations are not technical systems, but sociotechnical systems. When you treat an organization as a technical system you assume that direct, linear cause and effect relationships exist, and that it is able to control the system through hierarchy. The most important requirement in this case becomes to minimize entropy. Entropy has a negative relationship with efficiency in mechanical (technical) systems. The goal of a sociotechnical system is not primarily to lower the entropy at all times. Complexity lies between low entropy and high entropy. Complex problems require complex dynamic solutions. Organizations should become complex adaptive systems and be able to move between phases in order to thrive. “Everything changes” is the reality, and thus the organization should be able to change and adapt the actions to meet the needs posed by the environment. The idea of order implies a state of permanence. The organization has to go through phases of permanence and impermanence to be able to thrive. Analogically, this is similar to the idea of kaizen in the Toyota Production System, where kaizen requires standards. Kaizen, the idea of change to improve, requires order (standards).  This is also the going back and forth between permanence and impermanence. In the complex world today, nothing should be set in stone.

I will finish with a wonderful lesson from Shunryū Suzuki-roshi;

“Suzuki Roshi, I’ve been listening to your lectures for years,” a student said during the question and answer session following a lecture, “but I just don’t understand. Could you just please put it in a nutshell? Can you reduce Buddhism to one phrase?”

Everyone laughed. Suzuki laughed.

“Everything changes,” he said. Then he asked for another question.

Always keep on learning…

In case you missed it, my last post was Minimal Critical Specification.


Minimal Critical Specification:


In today’s post, I will be looking at Cherns’ second principle of Sociotechnical Design – Minimal Critical Specification. Albert Cherns, the late famous social scientist who founded the Department of Social Sciences at Loughborough University, documented nine principles for designing a sociotechnical system (1976). I discussed one of these nine principles, the Forth Bridge principle earlier here.

The principle of Minimal Critical Specification has two aspects, negative and positive, according to Cherns;

  1. The negative aspect states that no more should be specified than is absolutely essential.
  2. The positive aspect states that we need to identify what is essential.

Cherns continued – “While it may be necessary to be quite precise about what has to be done, it is rarely necessary to be precise about how it is to be done… It is a mistake to specify more than is needed because by doing so options are closed that could be kept open.”

This is quite an enlightening lesson from Cherns. A common misconception about leadership and managers is that it is the manager’s responsibility to determine what needs to be done, and then tell the employees exactly what needs to be done. This type of thinking is a leftover from Tayloristic Management from the turn of Twentieth century. Frederick Taylor’s brilliant contribution that worked at the time, was to focus on the labor activities and improve efficiency by streamlining motion and eliminating wasted motions. An unavoidable consequence from this was to view the operator as any other equipment. This meant that the operator was asked to bring his pair of hands to work and not his brains. The brains were provided by the managers and engineers. From a complexity science standpoint, this is using the perspective of a complicated system. There is some form of a cause and effect relationship, and with the help of experts we can control how the complicated system works. In other words, this is viewing an organization as a technical system in some regards. This leads to relying on a small group of experts to determine how the system should be designed. This worked at that point in time because, to put simplistically, the world was not complex then or not as complex as it is currently. The demand for variety from the market was easily attained by the variety that was able to be offered by the manufacturing plants. Tayloristic thinking paved the way to mass manufacturing and great hikes in productivity. However, the information age changed the world landscape, and the use of complicated thinking did not seem to work anymore. There came a realization that all organizations are sociotechnical systems. In Cherns’ words, the realization was that the organizational objectives were best met not by the optimization of the technical system, and the adaptation of a social system to it, but by the joint optimization of the technical and the social aspects.

It is said that the management style at Toyota is not to tell the subordinate exactly what needs to be done. The manager’s role is to develop the subordinate by allowing him to come up with solutions, and in turn develop oneself through the process. This concept aligns neatly with the principle of Minimal Critical Specification. Telling exactly what needs to be done is managing people, however developing them by giving them the minimal critical specification is managing the interactions that act on the subordinate. Russell Ackoff, the great American Systems Thinker, advises us that the most important role of a manager is not to manage people, but to manage the interactions between the people, making it easy for them to do their job. Toyota also talks about their production system as the Thinking Production System. Toyota does not see their employees simply as a pair of hands, but as a valuable resource which allows Toyota to grow.

Another aspect that Cherns talked about with the principle of Minimal Critical Specification was regarding bureaucracy. He complained that most organizations have too much specificity regarding how things should be conducted. He even says that “working to rule” can bring the whole system to a grinding halt and that employees have to contrive to get the job done despite of the rules.  Dave Snowden, the great thinker of modern times and creator of the Cynefin Framework, has talked about the dangers of using too many constraints on an ordered system where there is a strong cause and effect relationships. The employees create informal structures and processes to work around the strict constraints. This means that the problems, when they arise, do not always come to the surface. They stay hidden from the top management. Unfortunately, this means that when the system ultimately breaks down, it is generally catastrophic because the system is not prepared and the informal structures are simply not capable.

I will finish with a Zen story;

Zen teachers train their young pupils to express themselves. Two Zen temples each had a child protégé. One child, going to obtain vegetables each morning, would meet the other on the way.

“Where are you going?” asked the one.

“I am going wherever my feet go,” the other responded.

This reply puzzled the first child who went to his teacher for help. “Tomorrow morning,” the teacher told him, “when you meet that little fellow, ask him the same question. He will give you the same answer, and then you ask him: ‘Suppose you have no feet, then where are you going?’ That will fix him.”

The children met again the following morning.

“Where are you going?” asked the first child.

“I am going wherever the wind blows,” answered the other.

This again nonplussed the youngster, who took his defeat to his teacher.

“Ask him where he is going if there is no wind,” suggested the teacher.

The next day the children met a third time.

“Where are you going?” asked the first child.

“I am going to the market to buy vegetables,” the other replied.

 Always keep on learning…

In case you missed it, my last post was The Incomplete Solution.

Three Reminders for 2017:


As 2017 is unfolding, I wanted to write a post to remind myself of three pieces of advices for this year. They are from Epictetus (55-135 AD), Marcus Aurelius (121 – 180 AD) and George Pólya (1887-1985). Epictetus and Aurelius are two famous Stoic philosophers of the past, and Pólya is a famous Hungarian mathematician.

1) Epictetus:

Epictetus spent his youth as a slave which laid the backdrop for his stoicism. His original name is unknown. The name “Epictetus” in Greek means “acquired”. Epictetus himself has not written any books, however his follower, Arrian, wrote down his teachings. One of the most famous quotes attributed to him is;

“It’s not what happens to you, but how you react to it that matters.”

Epictetus’ famous work, The Enchiridion (Translated by Elizabeth Carter), starts off as;

“Some things are in our control and others not. Things in our control are opinion, pursuit, desire, aversion, and, in a word, whatever are our own actions. Things not in our control are body, property, reputation, command, and, in one word, whatever are not our own actions.”

In the same book, Epictetus continues;

“With every accident, ask yourself what abilities you have for making a proper use of it.”

My thoughts:

The above quotes gel together to form an important lesson. Not all of my ventures are going to be successful this year. There may be several setbacks. However, all setbacks are experiences to learn from. They provide lessons that I can only learn from the school of life. They increase my knowledge and prepare me for the next harder setback. My triumphs are built on the setbacks I faced before. The setbacks provide an opportunity for reflection. To loosely paraphrase a lesson from Information Theory, failures have more information content. They provide a reason to challenge our hypothesis. Successes do not necessarily challenge us to take a second look at our hypothesis. We thus learn more from failures. The point is to not look for failures, but to keep an open mind. This is a great lesson to remember as a new year starts.

2) Marcus Aurelius:

Marcus Aurelius, on the other hand, was a Roman Emperor. His famous work is “Meditations”.  My lesson from this book, translated by Maxwell Staniforth, is as follows;

“Were you to live three thousand years, or even thirty thousand, remember that the sole life which a man can lose is that which he is living at the moment; and furthermore he can have no other life except the one he loses. This means that the longest life and the shortest amount to the same thing. For the passing minute is every man’s equal possession, but what has once gone by is not ours.”

My Thoughts:

Far too often, we let the past dictate our present actions. Either we stay complacent and stay in our comfort zones by relying on our past victories; or we let our past failures control our actions and we remain in the comfort zone. Both these thought processes keep ourselves from taking risks or venturing outside our comfort zone. The past is past and the future is not yet here; what we truly have is the present moment. This Zen-like teaching is an important lesson for this year. We can only change the present moment by taking the right action. Of course, not all of our actions will lead to tremendous successes. This is covered under the first lesson above.

3) George Pólya:

George Pólya was born in Hungary and later came to America and taught at Stanford University.  One of the famous quotes attributed to him is;

“If you can’t solve a problem, then there is an easier problem you can’t solve: find it.”

This quote was written by the famous Mathematician John H Conway in the Foreword to a 2004 printing of Polya’s book “How to Solve It”.

My Thoughts:

“How to Solve It” is a gem of a book written in 1945 by Pólya. The above quote attributed to Pólya is a great lesson when we are trying to solve a problem and we get stuck. Pólya offers two different plans of action. One is to find a similar but easier problem to solve. He says;

If you cannot solve the proposed problem do not let this failure afflict you too much but try to find consolation with some easier success, try to solve first some related problem; then you may find courage to attack your original problem again. Do not forget that human superiority consists in going around an obstacle that cannot be overcome directly, in devising some suitable auxiliary problem when the original one appears insoluble.

The second plan of action he offers is called as the Inventor’s Paradox. Loosely put; to prove what you want, try proving more than what you want so that you get the flow of information to work properly. George says that “the more ambitious plan may have more chances of success”. This idea is quite paradoxical. He advises that going to a more general problem is going to create more questions that may be easier to answer than just one question. This approach may lend us a new view at the problem that will help us solve the more general problem along with the original problem.

The two plans lead us to step back from the current problem and look at the problem from a different light. Pólya points to us the importance of “some vision of things beyond those immediately present”.

Final words:

The three lessons above have a common theme – obstacles. We can be certain that this year will come with obstacles; it is up to us to decide how to treat them. I wish all of you a great year, one that will make you a better person.

I will finish off with a great lesson in Zen from the great Zen Master Shunryu Suzuki Roshi. In his book, “Zen Mind, Beginner’s Mind”, Suzuki Roshi talks about the story of four horses. He recalls the story from Samyuktagama Sutra. It is said that there are four kinds of horses: excellent horses, good horses, poor horses and bad horses. The best horse will run as his master wishes before it sees the shadow of the whip. It can run fast and slow, right and left and always at the master’s will. The second best horse runs as well as the best horse and he does that just before the whip reaches its skin. The third best will run when it feels the pain on its body. Finally the fourth one will run after the pain penetrates to the marrow of its bones. You can imagine how difficult it is for the fourth one to learn how to run!

Almost all of us want to be the best horse. If that is not possible we want to be the second best horse, and so on. However, in Zen this is the wrong approach. When you are determined to practice zazen (a form of sitting meditation), it is valuable to be the worst one. In your imperfections you will find the basis for your firm, way-seeking mind. Suzuki Roshi continues that those who can sit perfectly physically usually takes the most amount of time to obtain the true way of Zen. But those who find great difficulties will find more meaning in it and thus obtain the actual feeling of Zen – the marrow of Zen. Thus the “worst one” may be the best student.

Always keep on learning…

In case you missed it, my last post was Clause for Santa – A Look at Bounded Rationality.

The Value of Silence:


Today’s post is an introspective post for me. I will be looking at “silence”, its cultural implications in Japan, its use as a form of self-improvement and some stories about silence in the Toyota Production System. I was in a meeting recently, and during my self-reflection time at night, I observed that I did not learn or try to understand the perspective in the meeting. I was not listening because I was trying to prove my knowledge to the other side. I was not being silent or listening. Perhaps, I am a harsh critic of myself. But I have made up my mind that I will be practicing silence more.

One of my favorite sayings about silence is;

Knowledge speaks and wisdom listens.”

This is sometimes attributed to the great musician Jimi Hendrix. However, there is no proof that he did say this. There is a similar quote by Oliver Wendell Holmes;

“It is the province of knowledge to speak and it is the privilege of wisdom to listen.”

I am an avid fan of Japanese Culture and interestingly, silence is an important facet in Japanese culture. It is said that it is tough to negotiate with Japanese businessmen since they employ long periods of silence that others are not used to. In the West, silence is generally unbearable. It is viewed as a break in communication. In Japanese culture, silence is viewed as a communicative act. Silence can be effectively utilized in negotiations since it can make the other side nervous. In the Japanese culture, however, silence has several positive attributes which includes being respectful and polite, and avoiding confrontation.

I am looking at silence in four regards as a practice of self-improvement;

  • Respect for others:

Stephen Covey said “Seek first to understand and then to be understood.” He identified this as the fifth habit of his Seven Habits of Highly Effective People. In Zen, there is a great lesson that you are given two ears and one mouth, and that their use must be in the same ratio – listen two times more than you speak.

  • Self Reflection:

Engaging in silence is a pre-requisite for self-reflection. This allows the mental fog to clear out and the mind to organize better. Think of silence as an act of clearing up space in your mind to allow deep-felt thoughts to come in.

  • Teaching:

Being silent sometimes prompts the other side to keep on talking and perhaps encourage them to come out of their comfort zone. This can have the effect of being a good sounding board for their ideas. This is similar to the Socratic teaching method of asking questions. But in this case, remaining silent allows the other side to focus on their thoughts more and find the solutions to the problems at hand.

  • Effectively Communicating:

This may seem counterintuitive, but engaging in silence can improve your communication. In Japanese calligraphy, the empty space is as important as the written words. This empty space is quite similar to the “negative space” in design. It is the valleys that point our attention at the hills. The same is applicable for the use of effective silence in communication.

Silence in the Toyota Literature:

There are two instances I have seen where “silence” jumped out at me. The first one was in Masaaki Sato’s “Toyota Leaders”, where Sato talked about the ex-President and Chairman of Toyota. Eiji was a person who employed silence in his communication; he considered each question seriously and provided responses after much thought. EIji is hailed by Forbes as the creator of the Modern Version of Toyota. EIji was also a strong supporter of Taiichi Ohno, the father of Toyota Production System, and his “out of the ordinary” methods.

The second instance is from the book “Just-In-Time For Today and Tomorrow”, co-authored by Taiichi Ohno. In the book, Ohno talked about how the other employees were against his methods that would later become the Toyota Production System. All the hate and resentment were absorbed by his two managers, Eiji Toyoda and Saito Naichi. They both allowed Ohno to continue with his methods and to find ways of reducing manufacturing costs. Ohno referred to their relationship as a silent relationship of mutual trust. They both did not question Ohno and in turn Ohno did not ask for their approvals.

“I knew all too well how they worried about me and what I was doing. Yet they never said “Do This!” or “Do that!” For my part, I never had to say “I’d like to do this” or “Please let me do that.”I just did everything I thought had to be done. Had I asked permission, my resolve would have weakened because of the pressure to prove what I was doing. Had either side said anything, the relationship would have collapsed.”

Final Words:

This post was written as a reminder to myself to use silence more. I will finish with a great Zen story on silence;

There once was a monastery that was very strict. Following a vow of silence, no one was allowed to speak at all. But there was one exception to this rule. Every ten years, the monks were permitted to speak just two words. After spending his first ten years at the monastery, one monk went to the head monk. “It has been ten years,” said the head monk. “What are the two words you would like to speak?”

“Bed… hard…” said the monk.

“I see,” replied the head monk.

Ten years later, the monk returned to the head monk’s office. “It has been ten more years,” said the head monk. “What are the two words you would like to speak?”

“Food… stinks…” said the monk.

“I see,” replied the head monk.

Yet another ten years passed and the monk once again met with the head monk who asked, “What are your two words now, after these ten years?”

“I… quit!” said the monk.

“Well, I can see why,” replied the head monk. “All you ever do is complain.”

Always keep on learning…

In case you missed it, my last post was The Spirit of Mottainai in Lean.

Dorothy’s Red Shoes and Toyota:

Silver red shoes

Today’s post is about the theme of adapting and not blindly copying something. Lean is the Western cultural interpretation of what is known as Toyota Production System (TPS). Many companies try to implement TPS by simply copying the tools without understanding the context behind them.

Dorothy’s red ruby shoes are cultural icons from the movie “The Wizard of Oz”. All Dorothy had to do to go home was click the heels three times and command to go home. Poof, like magic she returned home. It is not a widely known fact that Dorothy’s shoes in the actual L Frank Baum’s 1900 book were Silver. The shoes’ color got changed to look “iconic” using the new technology in those days – Technicolor. The shoes appeared extra magical when they were ruby red in the movie. In other words, the movie makers adapted the story to the new technology in order to bring out the best.

What did Toyota Do?

Toyota started off as a Loom Company. Kiichiro Toyoda, son of the founder of the Toyoda Automatic Loom Works, was interested in automobiles. Kiichiro started the Toyota Motor Corporation with little experience in large scale manufacturing. Toyota Production System has been tremendously studied and almost everybody tries to emulate Toyota. In those days, the best production system was Ford’s Mass Production System. It was very much akin to the lean manufacturing system today. In fact, Toyota sent Engineers to study the Ford Production System so that they could come back and implement it. One of the two Engineers sent was Eiji Toyoda, Kiichiro’s cousin, and later the Chairman of Toyota. Eiji was a strong supporter of Taiichi Ohno, the father of Toyota Production System.

Toyota was founded from the very beginning with aspirations to become the “Ford of Japan”.(Source: The Toyota Leader, Masaaki Sato 2008)

Toyota discovered that the Ford System as a whole did not work for them. The idea of a moving assembly line and the idea of an employee suggestion system were two concepts that Toyota adopted and started using. However, Toyota could not implement the “large scale” production practices that Ford was using. The Ford System was focusing on producing a limited product line in large quantities. It also focused on increasing the efficiency of each operation by making the lot sizes as large as possible. Inventory was considered as a buffer and a blessing to cover any production interruptions. Toyota simply did not have the capabilities to maintain a large scale production.

Taiichi Ohno found two main flaws in the Ford’s Mass Production System:

  • Only the final assembly line achieved anything resembling continuous production flow. At the component level, there were piles of inventory and very limited flow.
  • Ford was unable to accommodate customer preferences for product diversity. This is akin to the famous quote attributed to Ford – “You can have any color as long as it’s black.”

Source: The Japanese Automobile Industry, Michael Cusumano 1985.

Taiichi Ohno created the Toyota Production System by adapting ideas from Henry Ford, Sakichi Toyoda, Kiichiro Toyoda, and numerous others, including the inventor of the Supermarket System. He learned from failures and the production system evolved through numerous trials and errors. The Toyota Production System is a custom fit tailored suit that fits only Toyota, and nobody else. However, like Ohno did, we can certainly learn and adapt from it.

Why Should I Copy Toyota?

The short answer is – you should not blindly copy Toyota. You have to understand your problems, and then adapt the Toyota Production System and address the solutions to your problems. In an interview in 2001, Hajime Oba, a retired TPS Sensei said the following about blindly copying Toyota:

Big Three managers, he says, use lean techniques simply as a way to slash inventory and are satisfied with that. “What the Big Three are doing is creating a Buddha image and forgetting to inject soul in it,” he says.

My Final Words:

I will finish off with a lesson from the famous martial artist Bruce Lee and a funny story about the dangers of blindly copying. Bruce Lee is also considered to be a great philosopher as well.

His four steps for efficiency were;

  • Research your own experience
  • Absorb what is useful
  • Reject what is useless
  • Add what is essentially your own.

And now the story I heard as a kid in India;

A father was worried about his son’s lack of ability when it came to the English language. English was his son’s second language and he always had trouble with essay writing in the test. The father made his son memorize a short essay “My Best Friend”, since he was sure it would be part of the essay component of the test. The son learned the essay verbatim, and felt good about writing his essay for the test.

Unfortunately, the essay topic was “My Father”. The boy thought for a bit, and then started writing based on what he had memorized.

“I believe I have many fathers. Shankar Pramod is my best father. He lives a few blocks from my house. He comes to visit us every day. My mother loves him very much. A father in need is a father indeed.”

Always keep on learning…

In case you missed it, my last post was The Anatomy of an Isolated Incident.

The Anatomy of an Isolated Incident:


I read about the death of Bob Ebeling today. He was a NASA contract Engineer from Morton Thiokol who tried to stop the launch of the space shuttle Challenger in 1986. On January 26, 1986 soon after the launch, the Challenger was engulfed in flames. All seven crew members lost their lives in this terrible accident. Famous Nobel laureate Richard Feynman was part of Rogers Commission which investigated the Challenger accident.  Feynman wrote about this investigation in depth in his 1988 book “What Do You Care What Other People Think?”

In today’s post, I will be looking at Isolated Incidents. There are times in my career where I am taken aback by isolated events.  These events happen very rarely, and thus it is not easy to understand the root causes. I will use the Challenger accident as the primary example to look at this. There have been 135 NASA space shuttle missions between 1981 and 2011. Of the 135 missions, 133 flights went as planned, with two ending in disaster.

The O-Ring Fiasco:

The Roger Commission identified that the Challenger accident was caused by a failure in the O-rings that were used to seal a joint on the right solid rocket booster. Bob Ebeling was among the group of Engineers who had warned NASA against the launch based on his concerns about the seals. The O-rings were not proven to work under cold conditions. It was noted that the temperature was below freezing on the day of the launch. Feynman famously demonstrated this by immersing an O-ring in a glass of ice water, and demonstrating that the O-rings were less resilient and that it retained its shape for a very short amount of time. This lack of resilience caused the failure of the seals leading to the Challenger catastrophe.


The Roger Commission indicated the following issues led to the Challenger accident:

  • Improper material used for the O-ring.
  • Lack of robust testing – the O-ring material was not determined to function as intended by NASA. Even though the O-ring manufacturer gave data to prove the lack of functionality at low temperatures, NASA management did not heed this.
  • Lack of understanding of risk from NASA management.
  • Potential push from management to launch the space shuttle to meet a rush deadline.

Feynman also wrote about the great disparity in the view of risk by the NASA management and the engineers. NASA management assigned a probability of 1 in 100,000 for a failure with loss of vehicle. However, when Feynman asked the engineers, he got values as low as 1 in 100. Feynman reviewed the NASA document that discussed the risk analysis of the space shuttle and was surprised to see extremely low probability values for failures. In his words;

The whole paper was quantifying everything. Just about every nut and bolt was in there. “The chance that a HPHTP pipe will burst is 10-7”. You can’t estimate things like that; a probability of 1 in 10,000,000 is almost impossible to estimate. It was clear that the numbers for each part of the engine were chosen so that when you put everything together you get 1 in 100,000.

Feynman also talked about an engineer being candid with him about his probability value of 1 in 300. He said that he calculated the risk as 1 in 300. However, he did not want to tell Feynman how he got his number!

The Anatomy of an Isolated Incident:

I have come to view the Isolated Incident cause-effect relationship as an equation. This is shown below.

Isolated Incident = Cause(s) + System weak points + Enabling Conditions

The Challenger Accident can be summarized:

Challenger Accident = Material limitation of the O-ring + NASA Management Policies + Cold conditions

The System Weak Point(s) are internal in nature. The enabling conditions, on the other hand, are external in nature. When you combine all the three factors in a perfect storm, you get an isolated incident. If we do not know all of the three factors, we are not able to solve the isolated incident. By itself alone, none of the factors above may cause the problem.

Another example is – when demand goes up, and production doubles. If the process is not robust enough to handle the spike in production, then isolated events can happen.

Pontiac’s Allergy to Vanilla Ice Cream:

I will finish this post with a fantastic story I read from Snopes:

The Pontiac division of General Motors received a complaint in the form of a letter. The letter was from a frustrated customer. He had been trying to contact the company for a while.

He wrote in the letter that he and his family were used to buying ice cream after dinner on a frequent basis. The type of ice cream that is purchased depended upon the mood of the family. He had recently purchased a new Pontiac car, and he had been having issues on his ice cream trips. He had figured out that the new car is allergic to vanilla ice cream.

If he purchased any other flavor, his car would start with no problem. However, if he purchased vanilla ice cream, his car will not start.

“What is there about a Pontiac that makes it not start when I get vanilla ice cream, and easy to start whenever I get any other kind?”, he asked in the letter.

The letter was delivered to the Pontiac President who was very amused by it. He sent an engineer to investigate the fantastic problem. The engineer went with the family three nights to get ice cream in the new car. The first night the family got chocolate ice cream, and the car started with no problem. The second night, they got strawberry. The car again was fine. On the third day, the family got vanilla ice cream; lo and behold the car would not start.

This was repeated on multiple days, and the results were always the same. The engineer was a logical man, and this stumped him. He took notes of everything. The only thing that he could see was time. The family always took the shortest amount of time when they purchased vanilla ice cream. This was because of the store layout. The vanilla ice cream was quite popular and was kept at the front of the store. Suddenly, the engineer identified why the isolated incident happened. “Vapor lock”, he exclaimed. For all the other flavors, the longer time allowed the engine to cool down sufficiently to start without any issues. When the vanilla ice cream was bought, the engine was still too hot for the vapor lock to dissipate.

Always keep on learning…

In case you missed it, my last post was Kintsukuroi and Kaizen.

What is my purpose?


Peter Drucker declared in his 1954 book “The Practice of Management” that the purpose of a business is to create a customer. In today’s post I will talk about purpose, specifically what do I think my purpose is at work? There is of course the utilitarian answer about my purpose at work – to fulfill my job duties/responsibilities. However, fulfilling the job duties/responsibilities does not always complete my purpose.

The purpose is to create/increase value in anything I do:

Peter Drucker in the book “The Practice of Management” talks about understanding customers. He notes that the manufacturer of gas kitchen stoves should not consider himself to be in competition with only other gas kitchen stove manufacturers. The customer is not just buying a stove. The customer is looking for the easiest way to cook food. There are many forms of stoves/utensils available to the customer that are in direct competition. There are several different ways to cook food including microwave ovens, cooking ranges, grills, etc. Ignoring them will result in loss of business. This example may be outdated. However, the core idea is applicable here. If you are simply fulfilling just your basic job duties/responsibilities, you are like the gas stove manufacturer. You will not grow and develop yourself if you just stick to your defined duties/responsibilities and you will eventually get passed by.

Your purpose is to create/increase value in anything you do. From a Toyotayesque philosophy, this is similar to the Continuous Improvement attitude. You are always trying to improve what you are doing. You are expanding your boundaries and you have a responsibility to develop yourself. One of the two pillars for the Toyota Philosophy identified in the Toyota Way 2001 is “Continuous Improvement”. The first key concept for “Continuous Improvement” is the “Spirit of Challenge”. In Jeffrey Liker’s “The Toyota Way to Lean Leadership”, Liker talks about the Spirit of Challenge as follows;

“Like the two founding Toyoda family members, every Toyota leader is expected not just to excel in his current role but to take on the challenges to achieve a bold vision with energy and enthusiasm.”


The two Toyoda family members are Sakichi Toyoda and Kiichiro Toyoda. I have referenced them in my last two posts. It is likely that Liker meant every Toyota employee when he said Toyota leader. This type of thinking is instilled from an organization standpoint. To quote Peter Drucker again;

“Most people need to feel that they are here for a purpose, and unless an organization can connect to this need to leave something behind that makes this a better world, or at least a different one, it won’t be successful over time.”

Toyota has a core concept of True North. True North is your ideal state. You can never truly achieve this. However, it is your responsibility to strive moving towards your True North.

Final Words and a story on purpose:

I am a firm believer of taking responsibility and authority to do the right thing, and to develop yourself. One must always try to increase/add value in what they do. Increasing value in what you do ultimately increases your value. This is the Spirit of Challenge. This is your inner purpose.

I will finish off with an anecdote, I heard from the Indian author Shiv Khera (in his words).

16 years ago in Singapore I gave a taxi driver a business card to take me to a particular address. At the last point he circled round the building. His meter read 11$ but he took only 10.

I said Henry, your meter reads 11$ how come you are taking only 10.

He said Sir, I am a taxi driver, I am supposed to be bringing you straight to the destination. Since I did not know the last spot, I had to circle around the building. Had I brought you straight here, the meter would have read 10$. Why should you be paying for my ignorance?

He said Sir, legally, I can claim 11$ but ethically I am entitled to only 10. He further added that Singapore is a tourist destination and many people come here for three or four days. After clearing the immigrations and customs, the first experience is always with the taxi driver and if that is not good, the balance three to four days are not pleasant either. He said Sir I am not a taxi driver, I am the Ambassador of Singapore without a diplomatic passport.

In my opinion he probably did not go to school beyond the 8th grade, but to me he was a professional. To me his behavior reflected pride in performance and character. That day I learnt that one needs more than professional qualification to be a professional.

Always keep on learning…

In case you missed it, my last post was Toyota Production System House – Just-in-Time (JIT) and Jidoka (Part 2).

Wizard of Oz, Camel’s Nose and Being a Change Agent:


In my last post, I talked about learning from Dr. Seuss’ quotes. In his “Greens Eggs and Ham” book, one of the characters(Sam) tries to persuade the other character to eat green eggs and ham. “Try it, try it, you may like it”, Sam says.

Aldean Jakeman commented on this post and stated that the “Green Eggs and Ham” book was her first change management book. This got me thinking about the “Wizard of Oz” story, and the story of the camel’s nose.

Learning from the Wizard of Oz:

There are four main characters in “Wizard of Oz”, written by Frank Baum. These four characters represent a quality characteristic that every change agent needs:

  • Dorothy – the main protagonist of the story. She was swept into the wonderful fantasy land of Oz by a cyclone. All she wants is to go back home to Kansas.
  • Scarecrow – the first friend Dorothy makes on her journey home.
  • Tin Woodman – a character who originally was a real human, but now is completely made of tin. Tin Woodman is the second friend that Dorothy makes.
  • Cowardly Lion – the third and final member of Dorothy’s team.

True North (Home):

“True North” is a strong concept in Toyota Production System (TPS). True North depicts our ideal state. True North is what we are striving towards. We are trying to reach True North. In a TPS/Lean way, Dorothy represents the characteristic of True North, our ideal state. All she wants is to go home (True North). A change agent should form his/her team, like Dorothy did, to reach their goal (true north).


The scarecrow represents the quality of “the heart”. A change agent should have his/her heart in the game. This allows you to think from the other person’s viewpoint. Having the heart characteristic makes you realize that this is a win-win, non-zero sum game. The heart represents empathy and compassion, without which you cannot gain the buy-in from your team. You should be open for suggestions and ideas for improvements. Toyota has identified “Respect for Humanity” as one of the two pillars of Toyota Way.


Tin Woodman represents “the brain” characteristic. A change agent should never stop learning. You should be smart enough to try things out and learn from your mistakes. You should also be smart enough to realize that you need to train and develop more change agents. A change agent should know how to approach when he/she is trying to implement a change. Here, Brain represents both knowledge and wisdom. A wise change agent will request his/her team to try things out at first. The “for trial only” approach eases them into the actual implementation.


Cowardly Lion represents “courage”. A change agent should be brave enough to look back at himself/herself with a critical eye and challenge assumptions. A change agent should be open about the problems, and transparent in communication. At Toyota, they talk about the importance of “Hansei”. “Hansei”, a Japanese term, loosely translated means “self reflection”. This can act as a strong and effective feedback loop that will steer you back on course towards True North. Having courage also means that you are capable of saying “No”. Ultimately, a change agent should be brave enough to stand up for what he/she thinks is right. Winston Churchill, the former UK prime minister, said the following about courage:

“Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen.”

Final Words:

I will finish off with an Arabian story that goes by the name “The Camel’s Nose”. The story has created the phrase “camel’s nose” in English language that is a metaphor for allowing a larger change in the pretense of small incremental changes. This phrase has a negative connotation since the change represents something that is not desirable. Here, I will be presenting it as a tactic for a change agent to encourage their team to implement the change. This story is about a wise camel, and the importance of implementing a change little by little at a time.

It was an unusually cold night in the desert. The camel was outside, tied to the tent. The master was inside the tent, comfortable and getting ready to sleep.

“Master,” the camel said putting his nose under the flap, “it is so cold outside. Can I at least put my nose inside the tent?”

“Sure,” the kind master replied, and rolled over.

A little later, the master rolled over and found that the camel had his whole head inside the tent.

“Master, it feels so nice here. Can I please put my front legs inside the tent too?”, the camel asked.

“Okay, you may”, the master said moving a little toward the edge since the tent was small.

The master again rolled over trying to sleep. A little while later, the camel again said “Master, Master, can I come inside the tent all the way? I will stand inside. It is very cold outside.”

“Yes,” the master said unwittingly. The master went back to sleep.

The next time the master woke up, he found himself outside the tent and cold.

I am not suggesting here that the change agents should be the camel kicking out the master. I am presenting the story to show the importance of taking things a small step at a time.

Always keep on learning…

In case you missed it, my last post was Learning from Dr. Seuss.

Learning From Dr. Seuss:


Dr. Seuss (Theodor Seuss Geisel), the renowned children’s book author, was born on this date (March 2nd) in 1904. Interestingly, he used “Dr.” in his pen name since his parents really wanted him to be a doctor. In today’s post, I will look at eight great quotes from him to learn from.

I immigrated to America from India. I did not know Dr. Seuss until I met my wife here in America. I grew up with Enid Blyton, the English author. I very much enjoyed reading the Dr. Seuss books with my kids because of his unique writing style. As I was introducing my three children to his books, I was also learning from Dr. Seuss at the same time.

Here are eight lessons from Dr. Seuss:

  • From there to here, and here to there, funny things are everywhere.(Source – One Fish, Two Fish, Red Fish, Blue Fish)

As Lean practitioners, we can translate this as “from there to here, and here to there, wastes are everywhere”! The funny things are the different wastes! Everything we do has waste in it. Taiichi Ohno is a big proponent of eliminating waste. He made managers stand inside a circle and look for wastes. Wastes forces us to be non-value adding, and increases overall cost.

  • Why fit in when you were born to stand out? (Source – Unknown)

If you try to copy the best, you will only come in second. Trying to copy Toyota does not make sense unless you have the same problems as Toyota. You should try to create your own system – Company XYZ Production System rather than a frail copy of Toyota Production System. Understand your problems and then address them, creating your own production system.

  • Sometimes the questions are complicated and the answers are simple. (Source – Looking Tall by Standing Next to Short People)

This is a true gem. The insurmountable problems become ant hills once they are solved. This is akin to Occam’s razor in some sense. Occam’s razor can be loosely stated as “the simplest answers provide the best explanations”. We have a tendency to complicate things. As an Engineer, I can vouch for this. At Toyota, they talk about using automation as the last resort to improve a process. They push for simple solutions.

  • You have brains in your head. You have feet in your shoes. You can steer yourself in any direction you choose. You’re on your own, and you know what you know. And you are the guy who’ll decide where to go.” (Source – “Oh, the Places You’ll Go!)

You have brains in your head – you need to use them. You have feet in your shoes – you need to go to the Gemba. This is a perfect summation of Genchi Genbutsu – going to the Gemba to learn the actual facts. You have to go to the source, where the action takes place and see for yourself.

  • You’ll miss the best things if you keep your eyes shut.(Source – I Can Read With My Eyes Shut!)

You have to keep your eyes open but you have to observe. Seeing and observing are two different things. When you keep your eyes open, you start to see things. When you see more things, you start to observe things. When you observe things more, you start to understand things more.

  • “It is better to know how to learn than to know. (Source – Unknown)

It’s not the tools system, it is the thinking system. To know and to understand are two different things. To know something makes you rigid in your thinking. To understand something makes you flexible in your thinking.

  • How did it get so late so soon?(Source – Poem by Dr. Seuss)

There is no better time than now to start improving and to start learning. Do not wait for the best idea to happen. Do not wait for the new and improved machine. Do not wait for next month. Now is indeed the right time. As Hillel the Elder said, “If not now, when?”

  • Try them, try them, and you may! Try them and you may, I say.(Source – Green Eggs and Ham)

This is the best way to implement process improvement activities. You can say “try them, try them, you may like them”. All you need them to do is to try the idea out. Once tried, they will provide ideas to improve and make them better. The lesson here is that you should not try to force your ideas, rather ask them to try it out. After all, what is the harm in trying it out? Brian Fitzpatrick, and Ben Collins-Sussman recommends saying “let’s try this for 30 days. If this does not work, we will go back to the way it was.” This approach helps in getting buy-in. Almost always, they will start using the new method. If they do not, at least you will get feedback as to why the new method does not work.

Thank you Dr. Seuss for everything you have done.

Happy Birthday!

Always keep on learning…

In case you missed it, my last post was Be an Amateur at the Gemba.

Who is right?


I came across a great graphic that I thought I should share.


The graphic above shows the importance of understanding the perception of the other party involved. This helps us in understanding their viewpoint.

It is also important as a leader in your organization that when you are trying to spread your vision, to make sure you understand how your employees view your vision. The view at the top of the organization may not match the view at the bottom of the organization.

The view at the top of the organization may not match the view at the bottom of the organization.

Alexander the Great and the monk:

There is a great story I heard from Devdutt Pattanaik, that explains this really well. I have paraphrased it.

Alexander the great reached India after conquering a lot of nations. On his path to conquer India, he met a monk. The monk was sitting on a rock enjoying the beauty of nature. The monk was naked, and belonged to a sect of Jainism.

Alexander watched the monk for a while. The monk was just sitting and smiling, totally oblivious of Alexander watching him.

“What are you doing?” Alexander asked the monk.

“I am enjoying being nothing.” the monk looked at Alexander, and said.

“What a fool to sit there and do nothing?” Alexander laughed at him. Alexander saw the monk as wasting his life away, doing nothing.

“What are you doing?” the monk asked Alexander.

“I am conquering the world”, Alexander replied with great pride.

Now the monk started laughing at Alexander.

“What a fool to pursue such a futile effort?” the monk thought to himself.

The next time, you face an opposing view; try to understand where the other party is coming from. What is his viewpoint? Are you the monk or Alexander?

Always keep on learning…

In case you missed it, my last post was Lean and the Mountain.