Psychological Safety in Manufacturing: How Silence in Aerospace Factories Can Turn Deadly

01/13/24 • 7 min

Lean Blog Audio

Blog post link

Psychological Safety is not some nice-to-have touchy-feely concept.

Psychological Safety means that you feel safe speaking up in the workplace. That could mean:

Asking questions
Pointing out problems
Admitting mistakes
Disagreeing with your manager
Sharing ideas for improvement

It's been pretty well proven that organizations with a higher level of Psychological Safety perform better.

A lack of Psychological Safety in a factory can turn deadly. A lack of it has proven deadly in healthcare settings too, of course.

If workers and engineers are punished for speaking up about quality problems in aerospace factories, that puts customers (and passengers) at great risk.

When people are pressured into being silent, that's a management problem and a culture problem. I'm not blaming the individuals who keep quiet to save their jobs. I do admire those who take great professional and personal risk to speak up anyway.

This WSJ article (which should be a free-reading link) talks at length about workers being punished at Spirit Aerosystems (a key Boeing supplier, formerly part of Boeing) for speaking up about quality concerns and problems.

There's so much to potentially dig into regarding decisions made by past Boeing executives about spinning off factories or outsourcing work. But I'll keep this post focused on the psychological safety elements.

I saw the punchline of this one story coming a mile away. It's not a funny situation, but I did literally laugh out loud:

“At one point, Dean said, [Spirit] threw a pizza party for employees to celebrate a drop in the number of defects reported. Chatter at the party turned to how everyone knew that the defect numbers were down only because people were reporting fewer problems.”

It's so predictable. It's happened before, and it will happen again.

Dr. Deming wrote about this dynamic 40 years ago, with a story of a factory that offered an incentive for “zero injuries.” Guess what, people stopped reporting injuries, even though people could be seen walking around with arms in slings and such.

Remember, including in healthcare, that “reported incidents” are not the same as “incidents,” especially when Psychological Safety is sorely lacking. In a true Lean Manufacturing environment, people are REWARDED for raising concerns and pointing out problems. We need more of that good Lean culture. Lives are at stake.

More from the WSJ article about people being punished for putting quality first:

The result, some current and former employees say: a factory where workers rush to meet unrealistic quotas and where pointing out problems is discouraged if not punished. Increasingly, they say, planes have been leaving Wichita with so-called escapements, or undetected defects.

“It is known at Spirit that if you make too much noise and cause too much trouble, you will be moved,” said Joshua Dean, a former Spirit quality auditor who says he was fired after flagging misdrilled holes in fuselages. “It doesn't mean you completely disregard stuff, but they don't want you to find everything and write it up.”

And also:

On the Spirit factory floor, some machinists building planes say their concerns about quality rarely get conveyed to more senior managers, and that quality inspectors fear retaliation if they point out too many problems.

Union representatives complained to leaders last fall that the company removed inspectors from line jobs and replaced them with contract workers after they flagged multiple defects. “This is leaving them with great quality and safety concerns,” one of the representatives wrote in an email to union officials. “Also feeling retaliated against for doing their jobs.”

That doesn't give me more confidence about flying on Boeing airplanes. I hope the culture at Airbus isn't as dysfunctional.

‘This Has Been Going on for Years.' Inside Boeing's Manufacturing Mess.

Blog post link

Psychological Safety is not some nice-to-have touchy-feely concept.

Psychological Safety means that you feel safe speaking up in the workplace. That could mean:

Asking questions
Pointing out problems
Admitting mistakes
Disagreeing with your manager
Sharing ideas for improvement

It's been pretty well proven that organizations with a higher level of Psychological Safety perform better.

A lack of Psychological Safety in a factory can turn deadly. A lack of it has proven deadly in healthcare settings too, of course.

If workers and engineers are punished for speaking up about quality problems in aerospace factories, that puts customers (and passengers) at great risk.

I saw the punchline of this one story coming a mile away. It's not a funny situation, but I did literally laugh out loud:

It's so predictable. It's happened before, and it will happen again.

More from the WSJ article about people being punished for putting quality first:

And also:

That doesn't give me more confidence about flying on Boeing airplanes. I hope the culture at Airbus isn't as dysfunctional.

‘This Has Been Going on for Years.' Inside Boeing's Manufacturing Mess.

Previous Episode

Congrats to Four Podcast Guests Who Were Named to the “Thinkers50” List

Blog post with more info and links

Congratulations to my podcast(s) guests who were named to the Thinkers50 list of influential management thinkers!

I am thrilled to extend my heartiest congratulations to a remarkable group of individuals who have recently graced the stages of my podcasts, “Lean Blog Interviews” and “My Favorite Mistake.” These brilliant minds have been recognized on the prestigious Thinkers50 list for their groundbreaking contributions to the field of management thinking. Each has shared their invaluable insights with us, and it's a true honor to see them receive this well-deserved accolade.
⭐ Amy Edmondson (both podcasts)
⭐ Erica Dhawan (MFM)
⭐ Daniel Pink (both podcasts)
⭐ Zeynep Ton (Lean podcast, twice)

Next Episode

Mastering Mistake-Proofing: Insights from Toyota's Poka Yoke Approach

Blog post

This post is built around excerpts from the book The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. Read more about Toyota, including stories and key lessons learned in the book.

Download a free preview of the book

From the book:

Fear and punishment drive people to get better at hiding mistakes when they could channel that energy into preventing them. When they can't be hidden, repeated mistakes illustrate how punishment accomplishes nothing beyond deflecting blame from leaders.

One of my heroes, W. Edwards Deming, who also deeply influenced Toyota executives, shared what may be the most important recommendation in his famed “14 Points for Management”:

“Drive out fear, so that everyone may work effectively for the company.”[i]

Driving out fear means, in part, that everyone can feel safe to speak up about mistakes and improvement ideas, as discussed in Chapters Five and Six. Leaders can also alleviate the fear of making mistakes, to begin with, when they combine the right methods and mindsets.

Starting with mindset, as former Toyota leader Darril Wilburn says,

“It's a leader's responsibility to create a system in which people can be successful.”

Therefore, it's the leader's responsibility to drive out fear. This includes creating work systems where it's easier to do the right thing and more difficult to make a mistake. This responsibility doesn't fall solely on the shoulders of leaders. They also engage their team members in designing effective mistake-proofing methods.

Mistake-proofing, or “poka yoke” in Japanese, is a core method within the Toyota Production System. It's a mindset based on the idea that people want to do good work but are imperfect. So, leaders have an obligation to help.

You might not think of Toyota as an entrepreneurial company today, but it started small in 1926 as a manufacturer of weaving looms based on patents held by founder Sakichi Toyoda. One of his key innovations was a mechanism that would automatically stop a loom when a thread broke, preventing it from cranking out more defective cloth. This innovation also led to huge productivity increases. One worker could now oversee upward of 30 to 50 machines, walking over to respond to problems when they were detected instead of having to hover over a single machine continually.

Toyota originally used the phrase “baka yoke,” which means “idiot-proofing.” Many decades ago, that term upset a Japanese factory worker who, correctly, complained that they weren't an idiot. We should also avoid saying “fool-proofing” or “dummy-proofing,” regardless of how often we hear them spoken around us.

Professor John Grout, the former dean of the Campbell School of Business at Berry College, is an expert on mistakes, receiving some of his early education in the field from Toyota leaders. He thinks mistake-proofing should be called “slip-proofing,” as it's easier to prevent execution errors than bad decisions (planning mistakes). One common slip is closing a file without saving it. The “Are you sure?” dialogue box tries to protect us, but as John points out, we're likely to click “Yes” out of habit. That's a slip on top of a slip–one that's hard to prevent. Using software that continually autosaves your work eliminates that risk (to my benefit, as I write this book in Google Docs).

This post originally appeared at mistakesbook.com.