After graduating university, my first real job was a supervisor at General Motors’ V6 engine plant in St. Catharines.  This was a new state-of-the-art production line equipped with the latest automation and advanced statistical process control.  It was 1988 and Total Quality Management was spreading across North America.  Having just completed an undergraduate thesis on advanced manufacturing systems, it felt like the perfect first job.

Despite all that attention to quality, engines still failed post-production.  Sometimes at the car assembly plant, more disastrously in the hands of a customer.  Though rare, these events were significant enough to become the focus of a quality assurance meeting chaired by the plant manager.

Failed engines were returned to the plant, stripped down by experienced technicians who identified the root cause and assigned the follow-up to the appropriate department.  And one time the issue was my department.

The cause was eventually traced to a loose connecting rod nut inside the engine cylinder, resulting in a catastrophic engine failure.

Our immediate solution was swift and definitive. We added an extra person to the assembly line with a flashlight and a magnet on a long rod to look inside every cylinder on every engine before sealing them with the intake manifold.

But our work wasn’t finished.  Within six months, we were expected to come back with a longer-term solution. The use of the flashlight and magnet could continue, but everyone understood that they were temporary. It added labour, slowed production, and depended on someone doing the job correctly every single time. Instead, the plant manager wanted an Irreversible Corrective Action.

At the time, I didn’t think much of it. I was new, still learning, and simply accepted that this was part of the process. We had contained the problem; now we needed to engineer a better solution.

But from the plant manager’s perspective, those two steps weren’t equal.  Only one solved the problem.

It took me years to appreciate the difference. While the flashlight solved the immediate problem, the irreversible corrective action changed the system, so the flashlight was no longer needed. That way of thinking gradually found its way into other parts of my work.

As an instructor, when students repeatedly struggled with the same concept, I found myself asking whether the lecture needed to change rather than simply explaining the material one more time. The goal wasn’t to become a better explainer. It was to design a better learning experience.

As my work gradually shifted from managing organizations to thinking about how they are designed, I kept encountering the same pattern. Organizations devote enormous energy to solving recurring problems – poor communication, weak accountability, ineffective meetings – without ever asking whether those problems are simply the predictable result of the way the organization itself has been designed.

Every recurring problem presents two opportunities. One is to fix today’s issue. The other is to redesign the system that produced it.

In 1988, at General Motors, I thought I was learning quality management. What I was really learning was organizational design.