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

Somewhere along the way, "leader" became the junk drawer of the org chart. Develop people. Set direction. Coach performance. Manage conflict. Hit the number. Communicate the strategy down and the reality up. And, quietly tucked in underneath all of it, inspect and catch every process deviation before it becomes a problem and deliver accountability and retraining as needed. Oh, and as you do all that, we want your people to be happy too. So you better go build some strong re

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

The video game industry spent forty years solving one of the hardest problems in human systems design: how do you make a task so attractive that a person will pay you for the privilege of doing it? The underlying motivational analysis in modern game design is a masterclass in systems design and thinking. Think about all the things in sport/games that aren't inherently fun... and nobody argues that they are. Running 26 miles, for instance, why is that fun? Or chasing an oblong

“Shared accountability" is one of the most misused phrases in manufacturing leadership. Most of what gets called shared accountability is actually shared blame. They are not the same thing. Blame is divisible. Accountability is not. If you're assigning percentages: 50% operator, 50% supervisor, that's blame. You're dividing a fixed quantity of fault until it adds up to 100%. Accountability doesn't divide. When something goes wrong on the floor, the operator is 100% accountabl

In 2006, I was deployed with a unit that set a record for the best AH64 Apache maintenance performance in Army history. I was a platoon leader. If you know the aircraft, you know it's a maintenance pig. It takes relentless, disciplined effort to keep one flyable. You don't get reliability by accident. You get it because people believe in the checks they're running and do them right, every time. That deployment, my battalion set the record for the highest fully mission capab

In Afghanistan back in 2008, I was a battle captain and an aviator in an aviation task force. I was on night shift so I could plan the next day's missions while my team ran operations. That worked fine during the winter until the passes thawed in the spring. Operational tempo spiked when it started to warm up. Suddenly I was managing live operations all night and trying to produce a full day's worth of mission planning. Something had to give. I'd come off shift scrambling to

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

A supply chain expert in my network told me something today that I thought was worth discussion: he plans better when he can visualize how his schedule actually unfolds on the floor and that only happens when he's out there, talking to the people running it. He said he thinks great organizations always have leaders on the floor. He's right. Leadership is just a relationship, and relationships start with interaction. If there is no relationship there cannot be leadership. W

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

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