The Feynman Gemba

The True Story of Leveraging Gemba to Prevent Death By Committee

On Tuesday, January 28, 1986, a dramatic event unfolded: the Challenger space shuttle exploded immediately after lift-off, instantly killing seven people.

The Nobel-prize-winning scientist Richard Feynman read about the disaster in the newspaper but didn’t give it much further thought apart from the tragedy of losing seven people.

A few days later, Feynman received a phone call from NASA, asking if he wanted to be on the committee of twelve experts to investigate what had happened.

Feynman immediately thought: hell no!

Feynman hesitated to join the committee as he liked staying as far away from politics as possible. He found the prospects of joining a committee extremely boring and unappealing. Why talk endlessly as part of a committee about what happened if you could discover what really had happened?

His wife finally convinced him to join the committee by telling him the following:

“If you don’t do it, there will be twelve people, all in a group, going around from a place to place together. But if you join the commission, there will be eleven people - all in a group, going around from place to place together - while the twelfth one runs around all over the place, checking all kinds of unusual things." There probably won’t be anything, but if there is, you’ll find it.”

He thought her explanation made sense, and he told his wife Gweneth: “I’m gonna commit suicide for six months,” and with that, he communicated to NASA that he was in.

After Feynman arrived at NASA, he quickly began getting annoyed by all the pre-planned meetings as part of the commission. Things were moving too slowly for his taste, and more importantly, he wanted to talk to the engineers.

The first moment there was a five-day break planned, he kept pushing to talk to the engineers until the commission reluctantly agreed.

After talking to the engineers, he discovered that the O-rings sometimes leaked. The O-rings were responsible for maintaining a seal in the joints of the shuttle to prevent hot pressurized from leaking and potentially causing an explosion.

General Kutyna, who was also part of the committee, asked Feynman the following question: “Was it colder than usual on the launch day, and what would the effect of the cold on the O-rings be?'

Feynman also discovered by watching video footage that smoke was already coming out of the joints just after ignition and before the shuttle had lift-off. Even more interestingly, during the flight readiness review, the O-ring problem had already been flagged. NASA was told by an engineer with expertise in these joints that they shouldn’t fly if the temperature was below 53 degrees Fahrenheit, while on that morning, it was 29.

Feynman took a model of the joint apart to remove the O-rings and put it in ice water to see what happened. The O-rings became stiff and brittle and could not act as a joint sealant.

On national television, Feynman showed the effect of the cold on the O-ring (see picture) and showed how the weather caused the tragedy with a simple experiment.

What can we learn from this story?

It’s tempting to talk over all the plans and talk about all the documents that everybody has already read.

Feynman intuitively practiced something similar to the ‘Gemba walk, ' where he went to the actual crime scene and talked to the people who did the work to find out what really happened.

And when he did that, he quickly gathered the evidence necessary to show what had happened.

If you’re a manager or leader, ask yourself the following question: when was the last time you talked to the people doing the work instead of blindly trusting the information and reports being relayed to you?

Maybe it’s time for some ‘walkie lookie’ and to talk directly to the people actually doing the work. That’s where value is created and where the obstacles to creating value often reveal themselves, which don’t end up in your pristine reports and deserve your attention.