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Supply Chain News: Lean Thinking Means Blaming Process, not People


Lean Legend Isao Yoshino on His Own Experience Making a Major Mistake in the Paint Shop

Oct. 14, 2020
SCDigest Editorial Staff

The following column comes through special arrangement with the Lean Enterprise Institute. It was authored by consultant Katie Anderson, author of the new book Learning to Lead, Leading to Learn:

"Managers need to create a culture where people are not afraid of making mistakes. Everyone makes mistakes. We can learn many things from the mistakes we make." –Isao Yoshino (Lean expert who spent 40 years at Toyota)l

Most people come to work with the intention of doing a good job. And, more often than not, mistakes are the result of a bad process rather than mal-intent on the behalf of the person who made the error. But, even knowing that in theory, what is more common: blame the person or blame the process? Most of us probably answer that our first instinct is to "blame the person." What does it look like, instead, to work in an environment where leaders take ownership of failures in the system rather than blame people when mistakes happen? Where they see it as their responsibility as leaders to create the conditions for people to be successful in their work?

During his gemba orientation, Yoshino had his first significant experience with what the concept of "we make people while we make cars" actually meant. This encounter left an indelible imprint on Yoshino about the choices that leaders have in creating a people-centered culture based on respect and learning, and strongly influenced the type of leader he became.

Supply Chain Digest Says...

Yoshino learned invaluable lessons from these shop-floor managers about how leaders are responsible for creating conditions for success—and for not blaming people when a system issue is to blame:

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Yoshino Makes a Big Mistake

During an orientation in the Motomachi Paint Shop, Yoshino was given the responsibility of preparing paint to be sprayed on the newly assembled car bodies as they came down the moving line. This task consisted of pouring products from two different cans—the paint and the solvent—into a giant mixer, and repeating the process every two to three hours as the tank started to get empty. Yoshino admits that waiting for the tank to get empty was a pretty boring job…that is, until one day when a shop floor worker ran into the mixing room shouting that the paint was not sticking to the cars.


More than 100 cars were dripping with paint mixture and would have to be repainted! Shortly after, the Paint Shop manager rushed into the mixing room where Yoshino and a few others were standing to see what had gone wrong.

"Blaming is your power as a boss. But if you start with blaming, it is hard to go back. It may make you feel temporarily happy, but is not good in the long run." –Isao Yoshino

Yoshino immediately knew that he had made a mistake when doing his task. He remembers that first moment:

I was so scared. I thought, "Are they going to fire me?" My mistake created a huge problem – they would have to repaint all those car bodies!


Much to Yoshino's surprise, instead of immediately shouting at Yoshino or blaming him for the 100 cars that would have to be repainted, his manager instead calmly asked, "What did you do?" Yoshino tentatively picked up the cans and demonstrated the process by which he had poured the mixtures into the tanks, holding up one can and then the next. It quickly became evident to both the manager and the Paint Shop workers that while Yoshino had indeed mixed up the cans and put the wrong products into the mixer, it was easy to see how the mistake had happened. The cans looked nearly identical, and the writing on the labels was small and difficult to differentiate at a glance.

Blame the Person Or The Process?

Upon seeing and hearing all of this, not only did Yoshino's boss not blame him for the mistake, he apologized for not setting up the work environment so that a mistake like this would not have been so easy to make! Yoshino describes his surprise about the Paint Shop manager's response:

My boss did not blame me directly, which made me feel so relieved. Instead he said, "Don't worry, mistakes can happen. You are just a beginner and you did your best. Thank you very much for making this mistake, as we are so familiar with the process here in the Paint Shop that we didn't label the area very clearly. I am sorry.

(Article Continued Below)



At first, he probably thought inside of his head, "You screwed up!" But then he realized that, "We should have prepared a much clearer process for this newcomer so that he could not make any mistakes." It's only natural that I made a mistake as a new employee because the cans had such small labels.

The response from the Paint Shop's manager was not one that Yoshino expected. When he recalled this memory for the first time in decades, during our first interview for this book, Yoshino exclaimed:

Can you believe it? My boss was not only not blaming me, he said "I'm sorry" and "Thank you!" I was so surprised and happy! That was my first encounter with Toyota workers. It is a great memory and had a great impact on me.

Young Yoshino learned many important lessons from that experience. Yes, of course, he learned the procedure of how to put the right paint mixture in the tank, but, more importantly, he learned invaluable lessons from these shop-floor managers about how leaders are responsible for creating conditions for success—and for not blaming people when a system issue is to blame:

When I look back to where I learned how to be a people-oriented leader, I realize that it started with this experience in my first months in the Paint Shop. It was my first encounter with Toyota leaders. Their reaction to my mistake showed me the Toyota culture – and the type of leader I wanted to be.

What are your thoughts this story about Yoshino - and Lean thinking? Let us know your thoughts at the Feedback section below.


Your Comments/Feedback

John Walker

IT Director, H&M Bay, Inc.
Posted on: Oct, 14 2020
Thanks for sharing your mistake with us, that does make you think about how to best handle such issues. 



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