Tools and Methods
The Mechanisms of Reflection
In Toyota, reflection is not just a “meeting” or a single moment after success or failure.
In its fullest form it is a structured organizational mechanism that captures experience, verifies learning, and closes the loop between production, engineering, and management.
Even when reflection is not an official “step” in the problem-solving process, it lives within the company system through a disciplined set of reporting and feedback tools.
One of the easiest ways to explain this in the 1990's was the Major Incident Report — a concise, A4-sized document used whenever a significant safety, quality, or downtime event occurred.
Each report documented the event, causes, and countermeasures, and often included supplementary pages of data, photos, or sketches.
More importantly, it triggered reflection meetings and multi-level reviews that connected people, functions, and even continents.
The Major Incident Report System
During my years at the Kentucky Engine Plant and earlier at Kamigo, I personally wrote dozens of these reports.
Every serious equipment breakdown or production interruption required one. I was entirely in the engine production world of Toyota but all manufacturing sites worked in a similar way.
The process served two distinct but linked purposes:
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Inside the Plant – Immediate Reflection and Recognition
The report became the focal point for local hansei.
Teams reviewed what had happened, verified technical findings, and recognized the extraordinary effort often required — overtime, weekend work, or coordinated action across maintenance and production.
Reflection in this context was both factual and human: what failed, why it failed, and how people responded to restore stability. -
Outside the Plant – Organizational Learning Loop
Once finalized, the report was transmitted back to Production Engineering Division #1 in Japan — the group historically responsible for specifying and procuring machine tools to evaluate the more systemic implications.
Their review determined whether the event reflected:- a process-planning oversight in production engineering, or in the actual build of the process
- a deficiency in the Machine Tool Standards (MTS), or
- a broader issue requiring change in the Toyota Manufacturing Standards (TMS) or Toyota Manufacturing Regulations (TMR).
This created a formal PDCA cycle at the organizational level — from manufacturing plants → production engineering → standards → OEM's and back again.
It ensured that learning flowed upward and outward, linking technical discovery at the Gemba to corporate planning and procurement.
Why This System Worked
This mechanism functioned in Japan particularly well because Toyota maintained long-term relationships with its core machine-tool builders and technology suppliers. And the majority has offices near Toyota City outside of Nagoya.
These partners were part of the extended Toyota technical circle, often collaborating for decades.
Reflection and yokoten thus operated across company boundaries — a feedback system that continuously improved both the internal standards and the external ecosystem.
For most firms, replicating this depth is difficult.
Frequent vendor turnover, lowest-bid procurement, and fragmented ownership of technology break the feedback loop.
Without continuity, reflection collapses into isolated problem reports rather than a continuous organizational learning process.
The Pattern of Reflection in Practice
Although there was no formally documented “Hansei meeting procedure,” the reflection sessions that followed a major incident all followed a recognizable pattern.
Managers and engineers typically asked:
- What happened, and how did it happen?
- What did we assume to be true that was not?
- Were our standards, drawings, or process documents adequate?
- Did this reveal a weakness in planning, design, or supplier understanding?
- What must be communicated — and to whom — so this never recurs elsewhere?
Years later, when I encountered Gibbs’ Reflective Cycle in academic literature, I realized how closely it mirrored Toyota’s informal process:
Describe → Feel → Evaluate → Analyze → Conclude → Plan Next Steps.
Toyota’s version skipped the “emotional” stage but shared the same logical flow — experience, analysis, learning, and application.
It was reflection by manufacturing personnel for manufacturing, but the structure was the same: understand, internalize, and improve.
Tools That Supported Reflection and Sharing
- Major Incident Reports (A4 format): concise, visual summaries of key events, root causes, countermeasures, and responsible parties.
- Follow-up Review Meetings: internal cross-functional gatherings for factual verification, recognition, and alignment.
- Gibbs Cycle of Reflection: some form of reflective review to highlight want we really learned
- Feedback Transmission: forwarding the reports to Production Engineering in Japan for system-level evaluation.
- Standards Revision Process: when appropriate, incorporation of learnings into MTS, TMS, or TMR.
- Knowledge Retention Archives: organized storage of incident reports for future reference — an internal learning library long before the era of digital knowledge management.
Together these tools formed a closed learning loop that reinforced technical competence and organizational memory.
They ensured that reflection was not a theoretical step but a visible, tangible part of how Toyota learned from its own experience.
Closing Thought
Reflection at Toyota has always been a mechanism and not just a mindset.
Through structured reporting, disciplined feedback, and continuity of relationships, Toyota embedded Hansei and Yokoten into the fabric of its operations.
The real genius of the system was not the paper itself but the conversation it forced — connecting the moment of failure to the process of improvement at every level of the organization.