The check was not performed.
These words were spoken today during a meeting to review an ongoing and complex problem solving effort within Gemba. These words chilled me to the bone. The failure to perform a check is far more dangerous than failures due to errors of inattention, lack of knowledge or poor communication. We also have these faults in abundance within our company, but in this instance the responsibility to insure that checks were in place and being performed was solely mine.
Possible root causes for this missing check include not caring enough to check, caring but not understanding the process thoroughly enough to establish a correct check point, and not setting the expectation for others to set in-process checks closer to the work and at an earlier stage. It all goes back to the need for standard work at all levels, from routine process to leader standard work.
Taiichi Ohno both scolded and redeemed us for failing to check when he said “Check is to do hansei.” When we check and find fault we need to reflect back on ourselves and how we can improve both the process and ourselves. In lean circles we say “a problem is a gift”. I must stop buying such expensive gifts for myself…