Operational Systems

Errors are systemic. And that's why they're systemically preventable. But the cost isn't just some rework; a substantial portion of most organizations exists just to deal with errors. And it's not just a cost problem; it's a capacity problem. Every error creates work that wasn't in the plan. Rework, re-inspection, re-setup, re-order (with overnight expedite), injuries, broken machines, scrap replacement, the extra changeover to go back and fix a run. None of it adds value,

We've all heard of the butterfly effect. It's real and it's important. Here's a fact: you're more likely to make errors when you're rushing, frustrated, fatigued, or interrupted. And errors make you rushed, frustrated, fatigued, and interrupted. That's a loop... and it compounds. This is how small errors change the world. But you can absolutely beat them with the right systems. It starts small. A scheduling error: one patient double-booked into a 30-minute slot at 9:00 on an

Paint the fence. Sand the floor. Wax on, wax off. If you've seen The Karate Kid, you remember Daniel's frustration. He shows up wanting to learn karate, and instead Mr. Miyagi has him doing chores for days. Daniel thinks he's being used for cheap labor. Then Mr. Miyagi throws a punch at him, and Daniel blocks it perfectly with the motion he learned by sanding the floor. That scene works because it's not just a movie trick. It's a correct description of how the brain actually

If you run a series manufacturing line (a sequence of machines that each perform one step and hand the product to the next) you already know the frustrating truth, the line is only ever as fast as its slowest link. What's less obvious is which link that is, why it keeps changing, and what to do about it once you know. This is Theory of Constraints applied to the plant floor. It's not complicated in principle, but it's easy to get wrong in practice, and getting it wrong is exp

For years, one machine dominated my downtime report. Not because it was old, or exotic, or particularly complicated... it dispensed a single component into the product. The machine's job was to cut this component from a web and drop it into the product. That's all it did. But it produced two failure modes which appeared on the daily report almost every day: it would cut the component in the wrong spot, or the line would have been down and this machine's name would be listed

Studies on Lean and Six Sigma initiatives routinely put failure-to-sustain rates in the 60–90% range. Six Sigma failure post-mortems keep landing on the same three culprits: poor training, weak buy-in and bad change management. So let's dissect that. Poor training: Your training system has to overcome 3 things to work. 1) You have to get people to listen. This only happens if they think they need to. 2) You have to get them to remember. People forget 90% of the information

Walk any plant floor eighteen months after a new SOP rollout and you'll find the same story: the binder is still on the shelf, the laminated job aid is still on the wall, and nobody follows either one anymore. Leadership calls it a discipline problem. Retrain, write someone up, rework some bad product, deal with the personnel fallout, explain it up the chain, move on. But it isn't a discipline problem. It's really not even willful. The workers are departing from expectation

Processes don't fail because people ignore them. They fail because people follow them for a while, and then a little less, and then only when it's convenient. This is process decay, and it isn't a discipline problem. It's a predictable, mechanical outcome of how habits and procedures interact. And it's 100% preventable. The stabilizing force that only stabilizes some of the process Habits are what make a process survivable in the real world. Once a step becomes automatic, a p

Training a process-change doesn't work. It's a mechanics problem. It doesn't really matter how good the slides are. The problem is how people learn. 1. People don't pay attention. Put a room full of people in front of a PowerPoint and most of them aren't actually listening. In 2025, 70% of employees admitted to multitasking during training, up from 58% just a year earlier. Flip that around: on a good day, only about 3 in 10 people in the room are giving the material real atte

I was on the floor when an operator ran by me with a bucket. I followed him to the lithographic printing press where I watched him dump the bucket of chemicals into a chiller by hand. I asked why. He said he was having trouble setting his color. This was how they dealt with it. The top downtime in the factory was color setting time, the top quality defect was color variation, and the top waste was color setting waste. We had the Pareto charts. Everyone in ops knows the 80/20

Your organization has a structural problem that's destroying productivity. It looks like this: train the workforce, then hold supervisors accountable for adherence. It sounds reasonable. It fails reliably. Training doesn't transfer the way we assume it does. You can almost pick your study, they all say the same thing: the average transfer rate of training is between 10-15%. And what little does transfer, doesn't stay: Hermann Ebbinghaus mapped this in the 1880s with his for

It was already July and we were set to miss our quality target for the year. The quality manager asked if I had any ideas. In truth, I didn't. But I love a challenge. I'd just read The Power of Habit and I was enamored with the idea of using habits to improve process. So I set about building a method, and it came out pretty simple. I proposed that people break rules for 2 primary reasons: They don't know the standard or they don't think the standard is important. I proposed

My best operators had the worst OEE. Not because they were bad, but because they were the only ones who could run the hard jobs. OEE was the metric. On paper, my strongest people looked like my weakest. They knew it, I knew it and it made performance discussions impossible. We had over 200 dies in that department. Every SKU had its own die, some were easy to run and some were not. And more than that, OEE didn't tell me what to do. It was a number that described a problem wit

I was new to the factory. The day I showed up I found out the plant was in danger of being closed. Division published a plan for "plant consolidation"... and we were the bottom performer. They didn't mention that in the interview. My department had four maintenance techs. One on each shift. 24/7 coverage. And they were good. They knew their trades. We always had someone there for emergencies, but we never had enough people there to compete with emergencies. Every schedul

A core function approach to eliminating maintenance reactivity. Walk into almost any industrial facility and ask the maintenance manager how things are going. You will hear some version of the same answer: "We're getting killed and everyone is mad at us.”
 It's typically not a laziness or staffing problem. It's usually an organizational issue and sometimes a matter of technical knowledge. But it's fixable.
 Running maintenance is like driving through a forest. It's easier

Hiring a maintenance planner can set a maintenance shop back. I see it too often. As soon as a planner is hired, techs stop making parts lists. Because that's planning, and they want support. Techs are overworked. They want a planner so they can stop doing paperwork and get back to the floor. That's how it should be... right? Nope. If you're doing it that way, you're better off without the planner. Making parts lists... that's not a planner. That's a very expensive assista

Most manufacturers implement Lean too early. And it costs them. If you need to improve now, do not implement Lean. When a plant is under pressure to improve, the instinct is to reach for Lean. Kaizen events. Value stream mapping. 5S blitzes. It looks like action. It feels like progress. But plants that are under pressure to improve have something in common: they always have known problems they aren't solving. And if you have problems you aren't successfully solving, the pro

Most leaders think about errors one at a time. One mistake → one fix. Done. But that's not how it works on the plant floor or anywhere else people execute complex work under pressure. Every error you DON'T prevent creates the conditions for many more. Here's how: A team member skips a verification step. The product gets made wrong. Now you have rework. Rework eats time, disrupts the schedule, and puts people in a state of rushing. Maybe not just your facility, maybe materials

I recently received a DM asking what 180 OPEX actually does. We fix process compliance problems. So what's a process compliance problem? That's when habits, convenience, distraction or disinterest at any level derail success because your team isn't in full alignment with your process. Now, there are really 3 ways to be out of alignment with the process: 1) Complacency - We don't follow the process because we don't think it's important (or it's inconvenient and nobody cares

And why the difference between the two always compounds Every plant manager has watched it happen. A changeover gets rushed at the start of second shift. The operator swaps the change parts but doesn't verify something critical. Maybe it's a standard that's been written down, maybe it's not. The line runs for forty minutes before someone notices there's something wrong (bottles dented, labels crooked, wrong materials, wrong print, etc). Now there's a quality hold, a financial