A tale of two envelops and Continuous Improvement

I was one of the millions of people who watched the Oscars last Sunday.  I was getting ready to turn off the TV when I noticed some disturbance behind the man talking, people fast walking behind the celebrating group and then a man with a headset walking across the stage with a red envelope, looking for the envelope and the card just used to read the winner for the most important category of the night.  After that, there was chaos, confusion, and surprise as it was informed that there was a mistake and the wrong movie was announced as the winner. How that happened?  It was the first time in the 89 years of the Academy Awards Ceremony.

Mr. Horowitz, a producer on that film spoke first and step aside to let speak Berger, another producer.  It was at that moment when people with headsets walk across the stage.  A man with a headset ask Horowitz to see the envelope he had on his hand and up to that point, he hasn’t read it.  They open the envelope, and it says “Emma Stone, “La La Land.”   That was the beginning of the end for La La Land as the winner for best picture.

After all the dust settles, in a backstage interview after the ceremony Emma Stone indicated that she was holding her “best actress card the whole time.” It turns out that this was part of the problem: there are two sets of envelopes for each category — so while Stone walked off with one card, Beatty was handed the other.

Why two envelops?  For more than eighty years, PricewaterhouseCoopers has been in charge of the Oscars balloting process.  The only two people who know the results are the two balloting leaders, who in James Bond style; memorize the winners so there’s no list that could leak out early.  On Oscar night, each of them stations themselves on opposite sides of the stage throughout the ceremony and one of them hands the envelopes to the presenters, depending on which side of the stage the presenters enter from.

How we can improve this process?  I will start by asking, do we really need two envelopes?  I bet there is a rundown of for what side of the stage the presenters will enter from and based on that the balloting leaders would have to sort the envelopes between them.  If this is too complicated or risky, then another solution could be the use of a second briefcase or a box to drop the envelopes of already announced categories.

Then it comes to what we know as Quality at the Source.  I know, presenters are expecting to receive the right envelope, but we already see there are chances of mistake.  They can read the outside of the envelope which is labeled with the name of the category and double-check that they received the right one.

What about using visual management? We can see in these pictures that the font size for the category name on the envelope label and the card is not big enough.  Considering that the card content is what the presenter will read in front of millions of people, I would increase the font size for the category, at least to the same size of the winner’s name.  I would also move it to be on top of the winner’s name, so is the first thing the presenter will see.  Maybe we can highlight to ensure they see it, after all, reading the category name will make no harm to the process.  After the investigation that PwC is doing, the most important part is what will be done to avoid these from happening in the future.  Hopefully, the root cause of the problem would be identified and after that, the process will be revised and improved.

Are you trying to ignore problems?

Facts do not cease to exist because they are ignored. ~Aldous Huxley

A key principle critical for continuous improvement success is to make problems visible. You cannot fix what you cannot see, that is why the 5S program is the foundation of the Lean effort.  Making problems visible is easier said than done.

I remembered those days when our warehouse was full and there was no space for more finished goods. Sales were slow but we were working overtime to produce enough cases to meet the daily cases per day target. Unevenness in production that is not related to the customer’s needs is Mura, a type of waste.

We did not practice any visual management in the warehouse area.  We did not have any type of visual aids other than the traditional floor marks to indicate the lanes.  The warehouse was the home of finished goods, rework product, employee sales and sometimes when there was no space on the designated area, quality held products.  Because there was no designated area for each of these categories of products, the forklift driver comes with pallets and left them on the first available space.

Living with this chaos was part of their daily work, nobody bothered anymore and that was the real problem.  When we asked to stop production in the area for one day to do a 5S event our boss did not let us do it.  When you have to convince your boss that we need to make the problems so obvious that everybody will see them you know something is really bad.

It took some time to get him into walking with us the area while explaining the risks of our current situation, why none of our employees believed leaving pallets on the first empty spot was wrong and the benefits of establishing clear areas for each category with the maximum level of materials like wooden pallets and wrap film.  When we finished our walk-through he understood and we did our event.  Since then, every time something is out-of-place, everybody knows and the responsible person fixes it.  Problems do not go away miraculously or stop just because we ignore them.

 

 

Making Problems Visible

Recently we have an external audit at our plant and while the results were good, they were not as good as expected.  The audit results did not match the excellent team effort and great preparation work done during the whole year.  The auditor managed to see a good amount of non-conformance, most of them were very simple things.

During the staff meetings right after the audit, we reviewed all the observations, some of us were pretty upset by the results.  At the end of the meeting our general manager pointed out the teamwork done and how hard we worked during all last year and the current to make the plant visible which helped the auditor to determine what was out of standard.  Of all people, I failed to notice that our plant is so visible that basically, we made the auditor job easier!

Lesson learned this story is now part of our Five S and Visual Management training.  These programs work, the audit as proof of that.  Visual standards make easier to understand when situations are out of standard.  The next step after detection is to fix the situation, that is where we need to work more.  Daily follow-up is important, training for new employees and why not? Maybe we need to revise the standards and go back to the drawing table after all the Plan-Do-Check-Act cycle never ends!