For those of you who haven't, here is Terrence's post:

A toothpaste factory had a problem. They sometimes shipped empty boxes without the tube inside. This was caused by the way the production line was set up, and people with experience in designing production lines will tell you how difficult it is to have everything happen with timings so precise that every single unit coming out of it is perfect 100% of the time. Small variations in the environment (which can't be controlled in a cost-effective fashion) mean you must have quality assurance checks smartly distributed across the line so customers all the way down to the supermarket don't get angry and buy another product instead.

Understanding how important that was, the CEO of the toothpaste factory got the top people in the company together and they decided to start a new project in which they would hire an external engineering company to solve their empty boxes problem since their engineering department was already too stretched to take on any extra effort.

The project followed the usual process: budget and project sponsor allocated, RFP and third-parties selected. Six months (and $8 million) later, they had a fantastic solution - on time, on budget, high quality and everyone in the project had a great time. They solved the problem by using high-tech precision scales that would sound a bell and flash lights whenever a toothpaste box would weigh less than it should. The line would stop and someone would have to walk over and yank the defective box out of it, pressing another button when done to restart the line.

A while later, the CEO decides to have a look at the ROI of the project and sees amazing results! No empty boxes ever shipped out of the factory after the scales were put in place. There were very few customer complaints and they were gaining market share. "That's some money well spent!," he says, before looking closely at the other statistics in the report.

It turns out the number of defects picked up by the scales was zero after three weeks of production use. It should have been picking up at least a dozen a day, so maybe there was something wrong with the report. He filed a bug against it and after some investigation, the engineers came back saying the report was actually correct. The scales really weren't picking up any defects because all boxes that got to that point in the conveyor belt were good.

Puzzled, the CEO travels down to the factory and walks up to the part of the line where the precision scales are installed.

A few feet before the scale was an inexpensive desk fan blowing the empty boxes out of the belt and into a bin.

"Oh, that," says one of the workers, "one of the guys put it there 'cause he was tired of walking over every time the bell rang."

What followed was a number of posts, mine included, that made comments such as, "That's what's wrong with industry" and "Those closest to the problem," or "Keep it simple."

The general consensus was that the CEO was in the wrong and there was no doubt the worker had done the right thing and we need more of those types of solutions. On the face of it, this appears to be true, but what happens if we take a deeper look at this story.

First of all, the worker just ignored a system that the company had paid a lot of money for - that was set up to capture information that would help measure the extent of the problem and maybe, just maybe, prompt further investigation. Or at least it might have, but the worker didn't know or care to know.

The project took six months - this must have meant people were in and around the area - ample opportunity for the worker to give input. Why didn't he give it? Why wasn't he asked for it? (Isn't that what some consultants do - come into your plant, ask the operator what the problem is and then write a report stating that?)

I've worked for Ma and Pa shops and Coca-Cola and I can state categorically that there was never a problem such as this - in consumer packaged goods, the biggest crime is for a faulty product getting to the marketplace as the empty boxes did - when the CEO was the only person who knew about the problem. This type of problem is the biggest stick that CEOs will use to beat those below them. So what happened to the plant manager, quality group, etc.? Did they show up and the worker ignored them too?

Next, an inexpensive fan was installed. Whenever I've seen such solutions, they are plain unsafe! The cord runs across the floor, or even worse, is draped about head high onto the machine. Did anyone check if the fan could fall into the conveyor? Did maintenance know they now had another strategic piece of equipment to take care of?

The engineers visited the site to ensure the scales were working correctly. Didn't they see the fan?

So what at first seemed to be a case of a stupid CEO and a much maligned worker turns into a comedy of errors. Would you want any of those people - CEO, plant manager, quality, engineers, or even line worker - working for your company?

Before you answer that question, did you see the biggest mistake of all? The one most prevalent in North American industry? The one that most often gets missed?

They were all dealing with SYMPTOMS; the actual problem they all needed to address was WHY WERE THE BOXES EMPTY?

No one was upset that what the worker had done was just maintain waste - empty boxes that had been printed, cut and formed ending up in a bin.

There was no mention of the missing toothpaste tubes - waste also?

So many times in accident reports, downtime analysis, etc., we look at the story at the level that Terrence posted it - and never dig deeper - never get to root cause - never eliminate the defect.

So maybe when we next see a story or read an incident report, we won't take it at face value and instead probe a little deeper.

Later on I posted a "Happy Ending" for this fairy tale - and it goes like this:

So the CEO returned to his desk very happy that at least the empty packages weren't getting to the customers. He continued to monitor the results, and for a couple of weeks there were still no empty packages causing line stops. However, on the third week, there were 15 instances of alarms, but the CEO believed this might just be a blip.

When the next week revealed another 15 alarms, he decided to visit the shop floor again. When he got to the scales, he noticed the fan was no longer there.

"Hey Bill, what happened to your fan?"

"Don't talk to me about that fan. Your new safety officer came down here and decided that the fan was unsafe. The cable was on the floor and the fan was held in place with electrical ties. He said until we had a conduit run and a proper mounting for the fan, we couldn't use it. Knowing how long projects take in this place, that will be a couple of months!"

"Well, you know that safety is #1 Bill, keep up the good work."

"Oh, one other thing before you go back to your office."

"What's that Bill?"

"My name is Bob!"

So the next week, the CEO saw the alarms at a rate of 15 again and took solace in the fact that it wasn't increasing.

When he saw the following week's report with no alarms, he was intrigued. Even he knew that the electrical group never did anything that quickly and he was afraid that they had ignored the advice of the safety officer, so he headed back down to the scales.

"Hi Bill, er Bob, I see the fan's not ready yet, but you didn't seem to have any empty packages last week, how come?"

"Come with me," and Bob started off up the line. "I got so fed up with that bloody alarm that I called Joe the mechanic to see if he could do anything. Well he asked me a stupid question, 'Why are they empty?' When I told him I didn't know, he said, 'Let's go find out,' so we did and that's where we're headed now."

Bob and the CEO finally reached the area where the toothpaste tubes were fed into the boxes and the CEO could see two pieces of plastic tie wrapped around the feeding chute.

"When we got here, Joe noticed that every now and then a tube wouldn't enter the package and so he started to take stuff apart. He seemed happy when he told me the problem was really a simple one yet at the same time one that wouldn't go away. He said the feeding chain for the boxes stretches as it gets used and that's normal. The problem is when it stretches to the point of not quite lining up with the chute. The chain still has plenty of life though, so he put those pieces of plastic there so the tube wouldn't fall over and would find its way into the box!"

The CEO just laughed and shook his head. "I guess that's what you call getting to the root cause of the problem. Bob, can you talk with Joe and figure out when would be a good evening for me to take you both out to dinner - this is great work. Oh, and don't forget to cancel the fan project!"

Cliff Williams is a 30-year veteran in the maintenance world. Cliff is a sought after speaker at maintenance conferences around the world. He is currently the Corporate Maintenance Manager for ERCO Worldwide, a Canadian-based specialty chemical producer.