Page 34 - MetalForming April 2012

Mistakes Happen
...because your procedures are not in charge, your people are. Management must not mistake written procedures for compliance.
BY DAN EASTMAN
I’m amazed that anything gets done correctly in most metalforming plants. In this era of massive amounts of information, certifications, work instructions, committees and instant communications, why do so many things go wrong, and go wrong continually? Almost all organizations have the same problem.
Let’s back up a step. In my earlier days, I was an above-average basketball player. Later in life, I mused about why, when I attempted to toss a piece of paper or empty coffee cup into a trash can 3 ft. away, it didn’t go in. Had I really lost the touch?
I give a lot of serious consideration to inaccurate outcomes such as this. For example, what would happen if basketball was played with a deflated ball? How would that impact accuracy? And, if I take the time to wad the paper or coffee cup into a ball, my accuracy should improve, right? Guess what, it does. And for those times where you
Dan Eastman has worked in the pri- mary metals and stamping industries since 1964, and is principal of Eastman Consulting, LLC, Sinking Spring, PA, specialists in change and turnaround management; dgeastman@gmail.com.
can’t wad objects into a ball, we turn to the slam dunk.
There is a Metalforming Analogy Here
The basketball analogy to business will become clearer later. For now, let’s get back to business. Several years ago, while managing a materials service center, we had one customer that would regularly return scrap to the casting mill for recasting. This ordi- narily was not a big deal, and every- thing went well for years. Then one day, the quality director at the mill called and said the scrap contained another metal mixed in—a dangerous metal that could cause a serious health problem from the vapors and smoke produced during the casting process.
We and the mill followed all of the prescribed procedures to investigate the issue. We sent a letter to the cus- tomer explaining the seriousness of the event. Forms were sent requesting the scrap procedure be reviewed and a formal corrective-action reply issued.
The customer was a major global player. Its response: All necessary pre- cautions were in place. A book of pro- cedures was sent outlining each step of the process. Even the containers for
collecting the scrap were color-coded and storage was segregated. Our scrap went into blue scrap containers, and the more dangerous scrap went into red scrap containers.
There was no corrective action. In fact, its people claimed that workers in the casting mill must have mixed up the materials, which sent the mill oper- ators into a tizzy. Threats of lawsuits emerged.
Time for a More Serious Investigation
Six months later, the same problem reoccurred. This time the union at the casting mill held us responsible for any future health effects of the event, and even threatened to personally sue me.
Since my name came up, this called for a more serious investigation. Several of us from the service center visited the customer and reviewed all of the paperwork. Everything in the process was documented based on its ISO reg- istration. We met with the plant man- ager, general foreman and shift fore- man. Everyone could recite the procedures by heart.
We next visited the shop floor. The written procedures were in a three- ring binder and available at each
32 MetalForming/April 2012
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