KANBAN……Saving lives?

KANBAN……Saving lives?

The latest Quality Assurance trends are simply basic, lean, 6 sigma, Hoshi Kanri...etc. I learned about at a recent AME conference in Toronto. I realized it applied to the true story illustrated in this post. 

Dr. Joseph Juran says, “Everything should scream it’s identity..” KANBAN is concerned primarily with process flow and the proper identification of parts as they progress through the manufacturing process. In order for processes to flow properly, we must have a map of the process. Something that tells us what is the sequence of events and what should take place at each sequence. By having a process flow, we can then determine the regulatory requirements that MUST be accomplished along the process route. The following is a true account of how KANBAN can affect safety. In the aviation business there are companies that perform maintenance on aircraft. They are referred to as Aircraft Maintenance Organizations or , AMOs. One such company has a process for replacing parts that is mapped out in great detail. The following map is just a portion of the process flow:

This is a portion of the Part install process in the AMO

The following event occurred during a work shift change at this AMO. The second shift came into the maintenance area and one of the workers discovered a part on a bench near an in-process repair job. The part had no tag or identification. He checked the aircraft and found that the aircraft was missing that particular part. The technician assumed that part was ready for install and did so. The aircraft was released with other repairs complete. On the initial flight after the maintenance, the part failed prior to departure and the aircraft was again rendered out of service. It was obvious that the part was the defective part removed on the prior shift. The unidentified part was a violation of the flow procedure and a violation of aviation regulations. If this part had intermittent failure, it was possible this part could have failed in flight and which could have been disastrous.

The fact that KANBAN was used at this company did preclude the failure of a flow and the misinterpretation of parts identity. It happened anyway.  It is important to anticipate, proactively, what could affect the processes and anticipate possible mitigations in the procedures for the processes.  KANBAN can not work unless there is a culture to support the system.  The workers must know WHY they have to follow procedures. In the case of aircraft maintenance, not following procedures could lead to catastrophe.

Your thoughts..................