A Lot More Than You May Think.
For over 45 years, Dr. W. Edwards Deming taught his management theory through his “red bead” experiment. This simple yet powerful demonstration shows how the American management system evades continual improvement by putting an emphasis on maintaining the status quo.
For his experiment, Deming set up the audience for a role-playing experience by inviting volunteers to play the role of workers, inspectors and a recorder. Deming acted as the foreman and explained to the workers that their job was to make white beads. No other color would do — the customer accepts only white beads.
Deming then explained the procedures and showed the workers how to dip their paddles into a container filled with 3,200 white beads and 800 red beads. He constantly reminded the workers their job was to “make white beads only.” If they couldn't make only white beads, management would close the plant down.
The workers must adhere to these strict procedures. They dipped their paddles to acquire beads and their results were recorded and passed on to management. When a worker produced a higher number of red beads than the other employees, Deming chastised him. If a worker produced a lower number, Deming heaped praise on him. At the end of each day's work, Deming talked to the workers and reminded them they must improve.
Finally, at the end of the fourth day of work, Deming said he could not see any improvement and the plant would have to be closed.
Deming then analyzed the results for the audience. He pointed out that some workers' results were above average and some were below. One worker might have gone from being the worst worker to the best in just 1 day, which made Deming wonder why the other workers couldn't show such improvement. He feigned dismay with their effort. He just couldn't understand what went wrong.
The message becomes clear: Even when provided with identical tasks, tools, instruction and talent, production outcomes will vary. Deming performed this experiment hundreds of times and the results always were the same. That is, the outcomes of each worker varied even though the imaginary factory always was set up the same way. Some of the workers were above average and some were below average. This happened every time, and there was nothing anyone could do about it. The workers cannot control the system in which they work.
Deming also pointed out the red beads are different. They are painted red, which means they are somewhat larger because of the coating. They feel different to the paddle. He used different paddles over the years, which produced slightly different results because every paddle had variation in it. It might have been too small to be detected by just a quick look, but it still was there.
The moral of the red bead experiment is as follows:
- Variation exists in every process. You can never eliminate all of it.
- Past performance guarantees nothing in the future.
- The work system has things in it that are beyond the workers' control. It is the system, not the workers' skills, that determines how they will perform.
- Managers are the only ones who can change the system. It is best for management to enlist the help of the workers to do this.
- Some workers are above and some are below average. There's nothing you can do about it and the difference may not mean anything.
RED BEADS AND SAFETY MANAGEMENT
The red bead experiment is a good example of how bad management leads to bad results. Most people who watch the experiment understand the foreman is making some really stupid mistakes. Ironically, they are exactly what American managers do in various degrees every day.
Deming began by employing extra layers of managers whose only job was to watch what the workers did and report the results. Then he held workers accountable for their mistakes, for which they had no control. The audience could see the red beads were built into the system and beyond the control of the workers. But the foreman could not. His solution was to force the workers to follow rigid procedures with no way of letting them make any kinds of suggestions for improvement. In short, he was the perfect command and control manager.
Deming conducted this experiment for over 45 years, and many of his associates continue using it today. The feedback from current audiences shows this style of management still reigns. It's as though American managers have a genetic code that instructs them to follow the theory of command and control. They truly believe they have no other option when it comes to managing employees.
So what does all of this have to do with safety?
Let's start with the fact that safety management takes its lead from command and control. To this day, foremen are told employee injuries mostly are the result of the unsafe actions or at-risk behaviors of the individual workers. The most basic assumption management makes about safety is that workers can control their performance — and their performance is why most accidents happen. They either ignore or deny that variation exists in workers and instead treat them as though they are bionic machines.
Managers also can be ignorant about variation in the common causes in the system that result in accidents. Some managers believe holding workers accountable for their own accidents is good management. In other words, if employees only would make an honest effort to “do things right the first time,” their safety would be guaranteed. Thus, management must keep motivating workers to stay on guard and be alert because for some unknown reason, workers are lax when it comes to their own safety. The sign of a good manager is someone who is not afraid to hold people accountable for their actions.
Deming exhorted the workers to do better work or the company would go out of business. We employ the same technique to prevent accidents — management tells workers they are responsible for their own safety and will be held accountable for any accident or safety violation. This allows management to ignore any deficiencies that may exist in the system. Management uses positive re-enforcement tools such as incentives to help workers stop committing unsafe actions or at-risk behaviors as though they consciously and willingly are doing so.
Managers don't understand employee injuries are the same as the red beads in the experiment. The workers did not put the red beads in the bin. Most accidents, the same as defects, are built into the system in the same way. All processes have byproducts that include waste, scrap and defects. The worst kinds of defects in any work system are employee accidents.
COMMAND AND CONTROL VS. THE SYSTEM THINKER
Deming understood that the majority of accidents occur due to variation of common causes in the system. This thinking is contrary to traditional command and control theory where managers believe most employee accidents are caused by the unsafe actions and at-risk behaviors of workers themselves.
Peter Senge said, “When placed in the same system, people, however different, tend to produce similar results.” It's important to understand management structures actually create behaviors. By becoming a systems thinker as opposed to a command and control manager, you come to realize why it is necessary to look beyond individual mistakes or misfortunes to truly understand safety problems. We need to look beyond single events to examine the structures or common causes in the system that shape individual actions and generate the conditions where events (accidents) are more likely to happen.
If employees are guilty of committing unsafe actions, it is more than likely they do so because of the system. Why? Because people do not knowingly try to inflict pain upon themselves. The fact is, employees don't design the work system — management does. Therefore, management must own up to its responsibility and accountability for the outcomes of the system, including accidents. People who stay focused on event explanations, such as unsafe actions, always are going to work from a reactive mode and never get to this higher level of understanding. They also will mistake symptoms — in this case, unsafe actions — for causes.
FOUR LEVELS OF SAFETY
Four levels of safety management drive the thinking and actions of managers and workers:
The Superstitious Level — In this level, managers pay very little attention to safety. As far as they are concerned, accidents are a result of fate, chance, luck or magic. They believe all it takes for workers to be safe is a little common sense.
The Neo or New Taylorism Level — At this slightly more sophisticated level, managers focus on events and end up taking action after an accident happens. They are content to believe this is being proactive. Their safety credo should be: “There's never enough time to do things right but always plenty of time to do things over.” Most companies operate at this level.
The Learning Organization Level — Managers at this level are starting to understand the systems. They try to identify common and special causes, but their knowledge is limited so they alternate between Level 3 and Level 2, sending mixed messages to workers.
Profound Knowledge — In this final level, managers have attained what Deming referred to as “profound knowledge” and look at safety through a different lens. At this level, managers and employees work together on teams to constantly fix the system so accidents are kept to an absolute minimum.
Deming estimated that as much as 99 percent of accident causes stem from common causes in the system and only 1 percent from carelessness. These kinds of accidents will not be eliminated until the system is corrected. The only place the system is being worked on is Level 4. In the experiment, the red beads represent defects created by the system. They just as well could be accidents.
Focusing on fixing a defect or changing an unsafe behavior is similar to a doctor prescribing an aspirin for a headache caused by a brain tumor. Instead, we should look at the common causes in the work system to determine how their variation results in employee accidents.
We first should ask, was the accident a result of the common causes or was it because of a special cause? The only way to make any kind of valid determination is with the aid of statistical thinking, which ultimately is what Deming told us to do.
Look for the patterns of things that cause the red beads (employee accidents) in your operations. Then have teams use the check, plan, do, study and act cycle to study the system and find ways to prevent them in the first place. That's what continual improvement is all about.
Thomas A. Smith of Mocal Inc. is the author of System Accidents: Why Americans Are Injured At Work And What Can Be Done About It. He works with management and hourly employees to help them learn about new theory of management to obtain team skills and work on culture change. He can be reached at firstname.lastname@example.org, http://www.mocalinc.com or 248-391-1818.
Senge, Peter. The Fifth Discipline: The Art & Practice of The Learning Organization. Doubleday, 1990. p. 42.
Deming, W. Edwards. Out of the Crisis. MIT, 1995. p. 479.