Solutions without Root Cause Analysis

The Toothpaste Box Story

I read this story in a forum on LinkedIn. This story would sound very familiar.

A toothpaste factory had a problem. They sometimes shipped empty boxes without the tube inside. This challenged their perceived quality with buyers and distributors. Understanding how important the relationship with them was, the CEO of the company assembled his top people. They decided to hire an external engineering company to solve their empty boxes problem. The project followed the usual process: budget and project sponsor allocated, RFP, and third parties selected. Six months, and eight million dollars, later, they had a fantastic solution, on time, on budget, and high quality. Everyone in the project was pleased.

They solved the problem by using a high tech precision scale that would sound a bell and flash lights whenever a toothpaste box weighed less than it should. The line would stop, someone would walk over, remove the defective box, and then press another button to restart the line. As a result of the new package monitoring process, no empty boxes were being shipped out of the factory.

With no more customer complaints, the CEO felt the eight million dollars was well spent. He then reviewed the line statistics report and discovered the number of empty boxes picked up by the scale in the first week was consistent with projections. However, the next three weeks were zero. The estimated rate should have been at least a dozen boxes a day. He had the engineers check the equipment, and they verified the report as accurate.

Puzzled, the CEO traveled down to the factory, viewed the part of the line where the precision scale was installed, and observed that just ahead of the new eight million dollar solution sat a twenty dollar desk fan, blowing the empty boxes off the belt and into a bin. He asked the line supervisor what that was about.

"Oh, that," the supervisor replied. "Bert, the kid from maintenance, put it there because he was tired of walking over every time the bell rang."

The Real Lesson

In my view, it is not a solution in itself. It is only a quick fix to prevent poor quality from going to the customer. There was no root cause analysis, and the solution does not aim at preventing the production of empty boxes.

Managers often get carried away by the promises shown by such advanced equipment, which is either made redundant on the floor or not used, because of so many factors. This is often the case when the solution and investment take an "end of pipe" approach.

It may sound exaggerated or irrelevant, but I somehow relate this story to the approach of managing diabetes by taking insulin without worrying about diet management. If the diet is managed, the insulin itself may not be required.