How a $50 gasket cost a company $5M

View profile for Alejandra Hernandez

Operations Advisor|Lean Practitioner| Lean Transformation | Operational Excellence Mentor|

I was called in after a company lost a $5M shipment because of a $50 gasket. By the time I arrived, the shipment was gone, the line was down, and the customer was angry. The question on everyone’s mind was: how could such a small part create such a big disaster? On paper, the company looked strong. Process maps were spotless, SOPs were clear, metrics were tracked daily. If you only looked inside the process boxes, everything was fine. The problem was never in the process boxes. It was in the lines between them. That gasket request fell into a gray area. Maintenance thought supply chain had it. Supply chain thought production was on it. Three unanswered emails. No clear owner. The part slipped through the cracks, and the cost of silence was millions. When I came in, we didn’t rewrite every process, we zoomed in on the handoffs, we clarified ownership at every transition, we made the gray zones visible, so nothing could hide there. Small changes, but powerful ones. And that’s what I’ve carried forward ever since. Whenever I work on process improvement, I spend as much time on the lines as I do on the boxes. Because that’s where processes really live. It’s easy to admire a clean flowchart. But protecting your shipments, your customers, and your reputation depends on what happens in the gray.

Doug Rabow

Business Analyst | Process Improvement Specialist | ERP & Data Analysis | Operations Management

2w

Love it! It's amazing how many problems are simply the result of a lack of clear ownership. I've seen this in other environments as well where teams will kick support tickets back and forth saying "nope not ours" until one team finally just abandons it and the customer problem goes unresolved. Ownership is such a simple but critical thing to fix!

Micheal Gardner

Lean Transformation Practitioner at NEXT LEVEL Partners®, LLC

2w

Challenger. One o-ring. Seven astronauts dead.

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