Don, forklift operator for a large timber company in south central Oregon, told Session 2B of the Leadership Development Lab:

“In 1993, I was working as a lathe operator at the Weyerhaeuser plywood plant in Klamath Falls, Oregon. One of my responsibilities as the lathe operator peeling veneer was to stop and change the cutting knives at appropriate intervals. This of course required that we completely shut down the operation. We needed to be as quick as possible to keep the logs from piling up behind us, and the processes in front of us from running out of supply. On this particular day, I hurried down to change the knives, and quickly restored the operation. We were up and running in less than 30 minutes. After an hour or so, I noticed that I had forgotten to change the thickness on the instrument panel and had been peeling veneer that was too thick, way too thick for the past hour. I called my foreman as soon as I discovered what I had done, and admitted my mistake. I really had egg on my face. Even though any operator should have known better, this was a common error; it could and did happen to other operators ever so often.

“I wanted to find a solution to the repeated problem so it wouldn’t happen to any operators in the future. I came up with a simple idea, an easy cost effective way to help solve the problem. I asked our electrician to attach a permanent reminder label to each of the switches on the instrument panel. These labels would remind us to

reset the cutter depth before restarting the peeler. I began using a ‘micrometers’ to double check measurement settings every time we shut down to change knives or go on break.

“Using the micrometer, which checks thickness to a close tolerance improved our veneer consistency. I turned my mistake into a learning experience, which lead to a permanent process improvement. Work stress was reduced and we had more confidence in our procedures, which kept me from repeating the mistake and assisted my fellow operators. We all performed at a higher level. “The lesson I learned from this experience is to be more careful, to take the necessary time to avoid mistakes. Two or three extra minutes in careful adjustments can avoid costly wastes of time and material. More importantly, I learned to look a little deeper, to look for and find ways to improve our processes so that human error can be eliminated.

“The action I call you to take is when things go wrong, mistakes are made, ask yourself, ‘What can be changed in our process to eliminate the cause, eliminate the probability of the mistake happening again?’

“The benefit you will gain is mistakes will be your workshop, your learning LAB mistakes, will lead to process improvements that will insure continuous improvement in the quality and productivity of your team. Your customers will receive quality every time, on time, and you will make more profit.”