Good process designers know that you dare not make assumptions about tool availability or working conditions. Business Reporter’s resident U.S. ‘blogger shares the tale an innocent worker who almost got himself smushed thanks to a easily-predictable process failure.
A consultant once lectured me that designing a new business process was like trying to construct a tower out of baked beans cans: the longer and more complex the process is, the more likely it was that the something would fail and the tower would come crashing down. It was always best (she said) to build isolated and controllable processes that can be chained together as-needed rather than to design overextended mega-processes where one glitch could cause the entire workflow to fail. She wasn’t wrong. In hindsight, though, I think her analogy would have been much more impactful if she’d used different stacking material.
That’s why this week’s story involves spills, chills, danger … and toilets. New ones, though, still in the box. Safe to talk about at work. Also, much more dangerous than tins of beans thanks to remorseless physics and Rube Goldberg-like implausibility.
The fellow who shared the story with me works in a large warehouse complex. His employer has extensive rules governing how materiel is handled from the time it’s ordered to the moment it leaves a store in a happy customer’s pickup. We were talking process improvement over lunch, and he related this tale of how one of his mates nearly got killed at work because a team member deliberately ignored a safety reg.
In this company, whenever a certain amount of product gets sold, the company’s supply chain orders replacement stock. New content arrives in palletized lots via lorry. After the customers have cleared out, the night crew re-stocks each aisle from caches of new items that are stored on top of the giant industrial racks, above where each product is displayed. As new content comes in, the replenishment crew lifts boxes, bins, or sometimes entire pallets of new goods to the emptied spaces atop the racks – preferably as close to where the for-sale items are displayed as possible.
The idea is that the first 2-3 tiers on each rack are for customers to pick from, and everything above that is pre-staged resupply.
This is easy most of the time. If customers buy a lot of, say, light bulbs, then the stockers take a fresh box off the top of the rack and fill in the display space on a 1-for-1 basis. A night later, a replacement box goes atop the rack where the re-supply box had been. Repeat this process forever, and you have a highly-efficient stock management system.
Whenever the resupply people need a forklift to shift a pallet of heavy items up to the top of the racks, the company has additional rules for ensuring that both loading and downloading are performed safely. Loads of bulky and/or heavy stuff can only be placed where they’re free of obstructions. Each heavy load must be signed off by the forklift driver so that he or she is held accountable for meeting all mandatory safety requirements. It’s a good system. Better than what we had in the Army, for certain.
So, there’s the context. Let’s talk execution: a few nights ago, one of the restocking crew discovered that customers had bought a surprising number of toilets. He needed to replenish the display, and the inventory system showed that there was a complete pallet of new-in-box toilets atop a rack a few aisles down. He signed out a forklift, drove to the right spot, and went to pull down the pallet so that he could restock the display at customer level. It should have been a normal operation, except for one thing: someone had put the pallet right next to a hanging light fixture in a prohibited space.
That is to say, the pallet had been lifted ten metres up to rack-top height directly under a fixture hanging down from the warehouse roof. This was strictly prohibited by policy (for reasons that shall become obvious), and someone had done it anyway. The frustrated driver was caught in a Catch-22: he had to get the resupply pallet down, but there was only one way to get it off the rack and that meant he’d hit the light fixture. Clearly, the previous forklift operator had brute-forced the fixture up and out of the way during the lift using the boxes like a piston. That wouldn’t work on the way down.
Just look at it loitering up there … biding its time … waiting to strike …
Sure enough, no matter how much he jiggled and slid the pallet to manoeuvre it out of the light fixture’s way, he couldn’t nudge the obstacle to where it wouldn’t catch on the top edge of the teetering toilet tower. With a 3 X 3 X 3 arrangement of boxed commodes atop the wooden pallet, the two-and-a-half metre tall stack caught the lights … pulled, applying lateral force to the stack… and tipped the assembly off the end of the forklift’s tines. The driver struggled to pin the load to the side of the rack, but the machine just wasn’t responsive enough to arrest the pallet’s momentum. The ponderous potty plinth plummeted … and all 2,100 pounds of precious porcelain promptly proceeded to pelt the poor prole with piercing projectiles. 
The driver’s fine, by the way. If this scene had been lifted from one of the Final Destination horror movies, then the poor block would probably have been impaled a hundred times (and possibly set on fire for good measure). Fortunately, reality doesn’t operate on Hollywood horror logic. This company had invested in steel-reinforced safety cages for their forklifts to protect against this exact sort of danger. The driver walked away without a scratch (although I cannot say the same for his apparel).
When management finished sweeping up the debris and analysed the incident, they worked out how the core process had failed. The safety lead determined that several overlapping safety steps should have prevented it from ever happening:
- Mandatory forklift driver training emphasized that tip-able content must not be lifted up to or stacked near obstacles (like hanging lights)
- Every pallet lift requires the forklift driver to digitally ‘sign’ an auditable log that he or she put a specific pallet in a specific location This gets recorded on a computer that every worker carries. A copy of that record gets printed and attached to the stacked pallet.
- Managers audit all stacking reports to ensure that safety regulations were followed and take disciplinary action against any driver violating standards.
- Replenishment workers check the printed records on pallets before they pull them to see who did the original placement, and report stacking violations.
Usually, knowing that you’ll be fired for violating company safety regs is enough of a disincentive to keep rational workers from taking dangerous shortcuts. The process failed at this warehouse this time because the process designer made an innocent assumption: that is, the process writer assumed that all warehouses would maintain a minimum of one working portable computer for every worker present every day, and that managers would require all workers to use their computers to ensure that daily auditing requirements could be met.
This process designer couldn’t have ever worked ‘the floor’ before coming up with this idea. I have never seen a plan that depended on fielding fragile electronics survive a deployment into a rough-and-tumble industrial environment.
In this site’s reality, there weren’t enough computers to go around. The people that needed them the most carried them. Workers would borrow them as-needed to record task completions. Management knew that the name associated with a work entry was the assigned computer user’s, not any actual worker’s. So ,if a line worker wasn’t caught in the act, safety violations could never be pinned on a specific miscreant. No one would get reprimanded, thereby de-fang-ing the entire enforcement mechanism.
I argue that this was a process design flaw, not a management failure. The way that the situation was described to me, the managers knew that they weren’t properly equipped and couldn’t meet company standards. They were put in an impossible position: they could either slow down work to accommodate the number of computers on-hand (which would cause the site to fail inventory management every single night) or they could count on the workers’ self-discipline. Human nature being what it is, whenever you take away an enforcement mechanism, only the conscientious workers will faithfully follow rules and avoid taking dangerous shortcuts. As for the others … one thing inevitably leads to another and eventually a ton of toilets come-a-crashing down.
The key takeaway here is that process designers must factor in manual backup techniques to ensure that critical performance steps can always be followed. It’s folly to assume that technology-dependent functions will always run as-intended. Stuff breaks. Power goes out. Life happens. If you’re designing a workflow where people might get seriously injured (or die!), be sure that there’s always a reliable way to execute the process safely when the preferred tools aren’t available.
 I’m not apologizing for any of that because it was waaaaaay too fun to type.
Title Allusions: Glen Morgan and James Wong, Final Destination (2000 film and subsequent franchise)
POC is Keil Hubert, firstname.lastname@example.org
Follow him on Twitter at @keilhubert.
Keil Hubert is the head of Security Training and Awareness for OCC, the world’s largest equity derivatives clearing organization, headquartered in Chicago, Illinois. Prior to joining OCC, Keil has been a U.S. Army medical IT officer, a U.S.A.F. Cyberspace Operations officer, a small businessman, an author, and several different variations of commercial sector IT consultant.
Keil deconstructed a cybersecurity breach in his presentation at TEISS 2014, and has served as Business Reporter’s resident U.S. ‘blogger since 2012. His books on applied leadership, business culture, and talent management are available on Amazon.com. Keil is based out of Dallas, Texas.