The Field Guide › Paper
The andon system is the closest thing manufacturing has produced to psychological safety cast in hardware. Originating in Japanese total quality control, it gives any worker on the line the unambiguous authority to signal a problem and, in its fuller forms, to halt production altogether, and it treats that intervention as the mechanism by which quality is achieved rather than as an interruption to be minimised. Everett and Sohal examine how the system has been adopted in Western organisations, drawing on cases from three sectors of Australian manufacturing, setting out the various types and mechanisms the andon can take, and working through what its use actually demands of both management and employees. The number that makes the argument concrete is the frequency: on a healthy line the cord is pulled around fifty times in a single eight-hour shift. That figure is easy to misread as evidence of a process in trouble, and the whole point is that it is the opposite. Frequent pulling means problems are being surfaced while they are still small, cheap and fixable, and a line where nobody pulls the cord is not a line without problems but a line where the problems are being hidden. For a corpus about psychological safety this is a foundational case for two reasons. It demonstrates that the willingness to speak up can be engineered structurally rather than merely encouraged, by building an explicit, low-friction, low-status-cost channel for intervention and then honouring it; and it demonstrates that the measure of a healthy system is not the absence of reports but their abundance. It is also the precise inverse of Piper Alpha, where the neighbouring platforms went on pumping oil into a burning rig because the men in charge did not believe they had the authority to stop. Everett and Sohal are clear that transplanting the mechanism is not enough, and that its Western adopters must reckon with what it asks of managers, who have to accept a subordinate stopping the line and respond to the pull as good news. Its limits are those of a short operations-management paper from a specific industrial moment: it is descriptive and case-based rather than theoretical or statistical, and its concern is quality rather than safety or voice, which are connections this map makes on its behalf. (Text drawn from the 1991 International Journal of Quality & Reliability Management paper, 8(2).)