TheKaiZone is back with the second post of our three-part series on the dynamics of accountability in Lean organizations (read Part 1 here).
Accountability. We all want it. In fact, we DEMAND it, especially when things go wrong. Yet, few of us understand what it is and how it works. Could it be that our misguided attempt to hold others “accountable” is the root cause that underlies our seeming lack of accountability? And if so, can this accountability paradox be reversed?
Lisa’s Story: A Case Study in Holding Others Accountable
Ladies and gentlemen, the story you are about to read is true . . . and – to our great dismay – all too common. The names and titles have been changed to protect the “accountable” parties.
Several years ago, a major quality issue came to bare at a large chemical manufacturing facility. With production at a standstill on one of the company’s workhorse production lines, and with the cause of the issue unknown, pressure from the Plant leadership team to restart production was tangible. Experts who had worked on the troubled line for decades were stymied as all of their best efforts to reverse the problem were for naught. Consultants were flown in from around the country, but none were able to shed light on the problem. The situation was bleak – until a talented, young engineer named Lisa stepped forward with an idea.
Lisa was employed as a chemical engineer with responsibilities in a production department that was several steps upstream in the process. She had heard the details of the ongoing investigation while conversing with a colleague over lunch, which triggered recollections of a similar issue she had encountered in the course of her graduate school research. She managed to communicate a hypothesis to the plant leadership team that centered on the occurrence of an undesired chemical reaction. If Lisa was right, the problem could be addressed simply and quickly. The laboratory testing needed to confirm the hypothesis, however, was decidedly neither simple nor quick.
Despite having no responsibilities in this particular area of the plant, Lisa understood the cost of the lost production to the company and knew she was the best resource to lead the experiment needed to confirm her hypothesis. Without hesitation, she volunteered to take the lead, working overnight and into the weekend in hope of generating the data needed to restart production on Monday. By Sunday night, Lisa had all the evidence she needed to confirm her suspicions.
With the root cause known, plant leadership enlisted all hands on deck in a massive effort to implement the solutions as fast as was possible. Production was operating at full capacity by Monday morning with no traces of the problem that crippled the line. When the dust settled on Monday afternoon, Lisa was called to a meeting by the Plant Manager and was lauded as a shining example of dedication to her colleagues. On Monday, for all her efforts, Lisa was a hero.
By week’s end, however, for those same efforts Lisa was fired. Why? Let’s rewind for a moment.
Amidst the frenzied push to restart production on Monday, Lisa took the lead to clean up from the weekend’s experimentations in the production area. An unfortunate byproduct of Lisa’s study was a large carboy full of waste chemicals that had been the proof she needed. However, working in an unfamiliar area of the facility, Lisa found herself unaware of the procedures for disposing of the waste. She sought assistance from the department’s supervisors; however, all of her requests for assistance went unanswered as all personnel were wrapped up in the restart efforts. She looked for signage or other visuals that might guide her to the right actions, but found nothing of relevance in the area. Finally, with the restart deadline looming, Lisa was able to briefly corner one of the area’s production for technicians, who removed a large binder from a desk drawer containing the department’s standard operating procedures. As the technician hurried back to his production responsibilities, Lisa quickly skimmed through the binder and found a short paragraph on “disposal of routine production waste water”. Following the procedures carefully, she emptied the entire carboy of chemical waste into the drain as directed.
It did not occur to Lisa, however, that the SOP provided direction on the elimination of “routine” byproducts of processing; unbeknownst to Lisa, disposal of the remnants from the experiment – anything but routine – were governed by a separate SOP, one that was not in the binder provided by the production technician. The chemicals flowed down the drain, mixed with waste water streams from across the plant, and were released into a large creek that bordered the north side of the plant site. Highly toxic to the animals living in the creek, the chemicals would go on to trigger a loss of aquatic life that resulted in a major investigation by the local environmental authorities.
Upon being made aware of the incident, Lisa stepped forward and took responsibility for inappropriately sending the chemicals to the sewer system. She explained the circumstances, but the facts of the matter were that the facts didn’t matter. It was irrelevant that none of the area supervisors were available to provide the correct guidance. It was inconsequential that the area was bereft of visual controls to guide the appropriate actions. That she was provided by an area technician a binder of standard operating procedures which did not contain the relevant procedure was irrelevant. Why? Because in the dictum of modern management, someone had to be held accountable.
To resolve the incident, the plant leadership took the all-too common NAME, BLAME, SHAME and RETRAIN approach. Amidst mounting pressure from the authorities, plant management used Lisa’s willingness to take responsibility to represent her as the scapegoat for the incident. She was promptly fired for her efforts and framed to the rest of the plant’s employee’s as a “rogue” employee who deliberately chose to “cut corners”, “failing to follow appropriate procedures” with grave consequences. As penance for the incident, all plant personnel were retrained on proper waste handling procedures, and a small fine was paid to the local environmental officials. The event passed with little consequence to anyone but Lisa. That was, until about six weeks had passed.
Just several weeks after the close of the investigation, the Department of Environmental Protection was alerted to a second and similar loss of aquatic life at the same location on the creek. Officials were quick to react and, supported by federal officials, acted swiftly in response. This time, with Lisa’s termination still at the forefront of mind, no one stepped forward to accept responsibility for the incident. With no identifiable root cause or individual action to point to, the authorities shut down the plant effective immediately until a large and very costly was treatment system could be installed in the plant. The large fines levied on the plant were second only to the massive costs of the lost production time. Ultimately, the plant manager would lose his position as a result of the incident. After all, someone had to be held accountable, right?
The Accountability Paradox
Lisa’s story is a real world case study into what researchers had dubbed The Accountability Paradox:
Responsible interpretation and application of external accountability demands depends on the cultivation of the virtues that support good administrative judgment, but the institutions and mechanisms that are used to communicate these external standards, and that monitor compliance with them, often threaten the very qualities that support responsible judgment.
Get all that? Neither did I. Let’s break it down, shall we?
- Accountability requires the development of the right conditions in which people will accept responsibility.
- However, by imposing and monitoring compliance to mechanisms that force others to be accountable, we undermine the conditions that create accountability from taking root.
Simply put, accountability comes from within. When we place external force on others to take accountability, we make it much less likely that they – and others – will ultimately be accountable.
Lisa’s story exemplifies this paradox. On Monday, Lisa’s actions made her a hero. Just days later, those same actions led to her being held solely accountable for an incident in which there was plenty of responsibility to go around. As a consequence of management’s action, no one accepted accountability to improve the conditions that created the incident and that likely would have prevented recurrence of the issue. And the next time a similar incident occurred, the plant’s employees were even less willing to take accountability. And with the firing of the plant manager, the vicious cycle that is the accountability paradox continued.
TL;DR – What Have We Learned So Far?
In Part 1 of this series, we were introduced to the myth of accountability and why others cannot be held accountable using external forces. In Part 2, Lisa’s story showed us how our efforts to hold others accountable actually diminishes organizational accountability through the Accountability Paradox. Yet, the question still remains, if we cannot make other accountable, how exactly are we to create a culture in which others will hold themselves accountable? As with many of Lean’s greatest lessons, the answer is simply a matter of RESPECT.
To be continued in the next post in this series: Lean & Accountability, Part 3: A Matter of RESPECT