Psychological Safety: The Andon Cord

The Andon Cord: Stopping The Line

Being able to “stop the line” to prevent an issue getting worse, stop a defect passing downstream, suggest an idea for improvement when it can endow maximum benefit, or ask for help in the heat of the moment, is crucial for success. It’s also analogous to psychological safety: by “pulling the cord”, you’re interrupting their work, asking for their help, possibly pointing out bad news, and most importantly, improving something.

“A Bad System Will Beat a Good Person Every Time.”

W E Deming

The Andon Cord

The Andon Cord is one of my favourite examples of psychological safety as a real-world practice. The word itself comes from the Japanese for “paper lantern”, or a burning lamp, referencing the flashing light that indicates that the cord has been pulled. It’s an essential part of the Toyota Production System (TPS).
 

Invented by Taiichi Ohno and Eiji Toyoda, in the period between 1948 and 1975, the TPS was the “miracle” by which the Japanese car manufacturing industry was able to catch up with, and overtake, the behemoth of the pot-war US automotive industry. After the war, the manufacturing capability of Japan was almost completely destroyed: factories were bombed out, machines broken or destroyed, and many of the workforce, in particular engineers, had been killed. Japan had very little in terms of people, resources, money, or political influence. But, with the help of a certain chap called W. E. Deming who influenced and taught on statistical process control (SPC) and standardisation, Toyota worked on ways to do more with less: reduce waste whilst maximising efficiency and quality. This was the birthplace of Lean.

The US adopted more Taylorist and Fordist approaches to manufacturing, with the emphasis on production volume over quality: being able to open more factories, employ more people, and consume more raw materials, the US where able to scale relatively easily. Simply by doing more of the same, the US motor industry was able to scale, albeit in a linear fashion.

Toyota, on the other hand, had embedded continuous improvement through the principles of Lean, and improving both quality and speed, little bit by little bit, every day. Whilst it took Toyota a little while to catch up with the US motor industry, by the time the Americans saw that Toyota were building cars at an equivalent rate and to a higher quality, the game had already been won years ago. Toyota were leaving them behind and still accelerating. 
 

A large part of this success is due to the principle of Jidoka: “automation with a human touch”. The principle of Jidoka means to automatically stop if a defect or problem is detected, which prevents the defect from passing downstream where it will cause bigger and more costly problems, and provides an opportunity to fix (and improve) immediately. The principle of Jidoka comes from Sakichi Toyoda, who invented the automatic power loom in 1924 which would automatically stop if a sewing needle broke, preventing any defective fabric being made, and providing operators with an opportunity to fix it without having to watch each loom. This is an example of “Poka-Yoke”, which means “mistake proofing” in English: eliminating defects by automatically preventing, correcting, or highlighting errors as they occur – making it near-impossible for humans to make mistakes, through effective design and automation.

The Andon Cord is the human touch element of Jidoka in the Toyota Way, or the Toyota Kata (Kata being the behaviour patterns instilled by following the Way). If someone on the production line finds a fault, defect, malfunction, shortage, tool issue or safety problem, they pull the cord. Originally, pulling the cord stopped the entire line, but over time, Toyota have optimised and decoupled parts of the production line such that now only part of the line stops, or it doesn’t actually stop at all. And whilst it used to be a cord, it was fairly recently turned into a button or other digital interface in most cases – largely to tidy up workspaces and improve safety by avoiding the presence of cords hanging from above. The cord is pulled (or the button pressed) for almost any improvement opportunity – even something as seemingly minor as a small optimisation to how tools are stored and laid out would be a valid Andon event. What I like about this is that even the Andon Cord itself is subject to Andon Cord events!
 

Swarming

After the cord is pulled, and that part of the line is stopped, coworkers “swarm” over, and one of the first things they do is thank the person who pulled the cord. This is crucial – and notable in its insight – because the interpersonal consequences of stopping the line and asking for help are significant. Without the psychological compensation for pulling the cord, it may not get pulled, and the defect or improvement opportunity would be hidden. 

A great illustration of this comes from NUMMI, the joint venture between Toyota and General Motors in the 1980s. NUMMI is often held up as proof that the Andon system works even in the most difficult environments: the Fremont workforce had been considered GM’s worst, yet within a year they became its best. But that transformation didn’t happen because Toyota installed a cord. It happened because Toyota invested heavily in the human side of the system. Hundreds of supervisors and team leaders spent weeks immersed in Toyota’s Takaoka plant, learning how to recognise problems, how to ask for help, how to support others who pulled the cord, and what “built-in quality” really means in practice. Managers made clear promises about what would happen when someone stopped the line, and then kept those promises. That deliberate groundwork is why NUMMI thrived. And it is also why attempts to copy the cord into other GM plants failed. The tool was easy to replicate; the psychological and relational conditions- the organisational substrate – that made it usable were not. Inkpen’s analysis of NUMMI shows this clearly. Without that foundation, the Andon Cord is just another tool.

As Deming says “Inspection is too late: the quality is already in the product.” What’s also interesting is that not only is pulling the cord praised, but it’s seen as a duty, and even a gift; a gift to colleagues, the organisation, and the customers of the organisation. Taiichi Ohno designed the TPS as a sociotechnical system (in contrast to Taylor and Ford, who thought largely only about the “technical”), and (maybe thanks to Deming?) considered psychology a fundamental element of the approach.
 

With help from coworkers, the work then takes place to fix the defect, make the change, identify the cause of an issue, or whatever else initiated the cord pull. If it can’t be resolved immediately, it goes on the Kanban, to be addressed as soon as possible. This continuous improvement approach (Kaizen, in the TPS and Lean terminology), and continuously improving the improvement mechanisms, is in part what facilitated the dramatic success of the Japanese automotive industry, and why, still to this day, Japanese manufacturing and Japanese cars, have a reputation for quality and reliability. 

What I love about the Andon cord is how it’s such a real, practical example of psychological safety: you pull it in order to raise a concern, ask for help, or suggest an idea for improvement. There are interpersonal consequences for doing so, but you do it anyway, because the environment has been created that makes it not only safe to do so, but the right thing to do.

Across Toyota, the cord may be pulled once every few seconds. In a typical plant, it could be pulled around 50 times in a single eight-hour shift. That’s more than 1500 times in a month!

Without a significant degree of psychological safety in the group, the Andon cord may not even get pulled, and the act of pulling the cord further fosters the psychological safety in the group for others, by demonstrating that it’s safe (indeed, it is praiseworthy) to do so. It’s worth noting that even false alarms are praised – an Andon pull that doesn’t identify an actual error is seen as a useful drill and a valuable learning opportunity to improve process. It may also surface improvements that may prevent false alarms in the future.

“Title and rank are irrelevant in discussions of quality. Confronting your boss is acceptable. Bringing bad news to the boss is encouraged. Ignoring the boss is excused in the process of coming to the right decision.” from Extreme Toyota: Radical Contradictions That Drive Success at the World’s Best Manufacturer, by Emi Osono, Norihiko Shimizu, and Hirotaka Takeuchi

Most of the teams we work with in my workshops adopt some form of the Andon cord that works for them – whether it’s simply using the phrase “I’m pulling the cord” as a statement in the team when required, an automated chatbot, a squeezy rubber chicken, a big red button that lights up, or something else, it’s a really simple and effective way to foster psychological safety and the practice of continuous improvement in a group.

To find out more about the Andon Cord, continuous improvement and Kaizen, attend one of our Management and Leadership workshops.

Further Reading:

Individual Involvement and Intervention in Quality Improvement Programmes: Using the Andon System. (1991) obert J. Everett, Amrik S. Sohal International Journal of Quality & Reliability Management: https://www.emerald.com/insight/content/doi/10.1108/eum0000000001635/full/html

After learning about the Andon cord story, I was awestruck.  The thought that an organization could be so immediately responsive to a defect changed my perspective on how we deal with patient safety issues in healthcare.  If a car manufacturer could respond so quickly and positively to an issue, why couldn’t we do the same in an industry where people’s lives are at stake?  I felt compelled to bring this practice to my organization as part of our journey to a Just Culture.
 
Over the course of a year, we introduced the Andon cord concept and worked with managers and front-line teams to develop similar practices in our Ambulatory Surgery Centers. Our key focus was creating a speak-up culture and immediate, positive team response.  As a result of our efforts, we have seen improvement in every domain of our Just Culture Survey from the previous year.  In some areas, we saw as much as a 30% improvement. 
 
Many of our staff and leaders reacted similarly to the Andon cord story as I did.  Staff are excited about the idea of a swarm response to a safety issue.  Imagine if we could provide the same safety net to our teams in the healthcare industry.  It could transform patient safety.

Eileen McCarthy, Patient Safety Program Manager at Kaiser Foundation Health Plan of the Mid-Atlantic States

Psychological Safety In the Workplace:

The Pac Man Principle

Conference season appears to be upon us again, and it reminds me of this excellent practice. When meeting people and chatting at conferences and meetups, we tend to form groups in circles; but this ends up excluding others and prevents people from joining the conversation. If there’s ever a time that we want people to join conversations, it’s at these events – we’re there to meet people, gain new ideas, and share information, but I’m sure we’ve all been in the awkward position of standing at a conference, looking around, and feeling like you’re on your own in a sea of people.

So, in groups. stand like a pac-man! Adopt the Pac Man Principle. Always allow space for one person to join the group. This means that people are given implicit permission, or encouraged even, to join new groups and introduce themselves. 
 

Originally coined by Eric Holscher, Dylan Beattie has created this excellent animation to demonstrate it too.