Touch the Dot Every Time

Learn from mistakes. Implement habits and procedures that ensure that those same mistakes aren’t repeated.


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A while ago, an apprentice in my shop put a CAT 40 holder into the mill turret backwards. It then then got stuck when the machine fault error stopped the program. This is a simple mistake I also made when I first started learning about CNC machines and toolholding. But I was self-taught on that same machine. He was the first person I had taught to use the machine. In his case, he had been shown how the notches were different so that orientation mattered and that the holder always goes in with the orientation dot facing out.

His mistake made me wonder: “Why is it so hard to pass on my experience?”

I used to believe my style of self-learning was to be sufficiently embarrassed by my mistakes as to not repeat them. As a manager, mentor or teacher, however, I realized that embarrassing my staff so they would learn in similar fashion was not a very good option. Without thinking about it, I used that tactic by discussing or even yelling about the consequences of a mistake in terms of cost, lost time, reputation and so on. But in most cases, mistake-makers know the consequences of their mistakes, so unless I believe there are other subtle consequences they may not recognize, I now avoid discussing consequences and the resulting embarrassment—both for them and for me.

What has become obvious to me now is that embarrassment was not, in fact, my secret to self-education. The embarrassment at making a mistake is not what directly prevents me from making that mistake again. Instead, this is what drives me to implement procedures that ensure the mistake is not repeated. Basically, I form good habits, and the habits are what prevent the mistakes. I used to operate my business assuming everyone did the same. Growing my shop and dealing with multitudes of different types of people enlightened me about my ignorance. I think all quick learners use similar tactics, but some who say they learn from their mistakes don’t form habits to back up that claim.

So when the CAT 40 incident arose, I avoided mentioning the consequences and instead went straight to asking the apprentice to think about the steps that led to the problem and to identify how he could avoid making that same mistake in the future. I told him we would meet the next day and discuss the procedure he was to create for himself. In the morning, he came to me with this list:
1. Print a list of tools being loaded.
2. Carry the list to the machine during setup.
3. Insert the tool into the carousel.
4. Check off each tool on the list when the orientation is noted correctly.
5. Close the carousel.

I considered this Option A. I was glad to see that he had taken it seriously and had actually come up with a procedure. He even had it written down, which I thought was good. (I should note here that our code has a tool list, however, we have a computer right next to the machine, so we don’t typically print it.)

I took him over to the machine and asked, “How are you going to make sure you will follow this procedure on every job?” He gave me a bit of a funny look, so I clarified, asking, “How will you remember to stop what you are doing if you forget to print the list or checkmark the printout about orientation?” He then started to talk about making a form with a checkbox for orientation and making a spot at the machine for the form, but I stopped him and said, “This is what I came up with.” I grabbed a toolholder, opened the turret and set in the tool. Then I raised my right index finger in a dramatic fashion, touched the orientation dot on the holder and closed the door. “Force yourself to touch the dot every time you put a holder in, and you will never make that mistake again,” I said.

I called this Option B. I now teach Option B to everyone learning to operate the mill, and I have drilled orientation marks into a couple of holders that surprisingly didn’t already have them. Not only did the apprentice learn a good habit from that exercise, but my teaching methods improved, and so did his ability to implement processes.

While what gets printed and filed for quality purposes is a whole other discussion, and one my management people and I discuss often, suffice it to say that, if there is no value to finding it later, it probably shouldn’t be printed. In this case, if the job is run successfully, we know the tools were installed correctly. Filling out a form is a valueless burden (although this apprentice can be forgiven for suggesting it, because of his inexperience).

However, understanding that the answer won’t always be this obvious, the question to be considered by all ages and ranks is this: “How do we prevent Option A, the complex procedure, from getting into our processes when Option B, the simple habit, has not yet been suggested?”

I believe continuous improvement doesn’t have to be much more complicated than contemplating this question in the pursuit of finding the Option B to our problems, acting on it when it gets revealed and reclassifying it as Option A after it has been implemented. 

Qsine Corp. was founded in 1968 by Kevin's late father, Mick Saruwatari. The custom machine design and manufacturing firm specializes in industrial product development, prototypes and short-run work. More at qsine.ca.