Lean Blog Audio: Practical Lean Thinking, Psychological Safety, and Continuous Improvement

The Problem (737 MAX and Beyond) at Boeing Isn't "Idiots." It's Far More Complex Than That... But Fixable


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The blog post

As we sit in seat 26A, mindlessly watching a movie, we take for granted that our cell phone (or the shirt off our back) won't be suddenly sucked out through a gaping hole in the side of a plane. That's because the odds of this happening are unimaginably low. Until now, that is. Are we entering a new era where shoddy manufacturing (or maintenance) exposes us to more risk, reversing a decades-old trend of greatly improved aviation safety?

On January 5th, an Alaska Airlines 737 MAX-9, designed and assembled by Boeing, safely executed an emergency landing after a “door plug” blew out of the plane's left side. Thankfully, the resulting hole and loss of pressure didn't suck out any passengers or crew. 

Now, the window and middle seats next to the door plug were thankfully empty. That raises questions about what Alaska knew and what chances they were taking by continuing to fly the plane after previous complaints about “whistling sound” and alerts about cabin pressures on previous flights that plane took.

The crew performed valiantly in these circumstances, and we should celebrate them. This incident creates an opportunity for the aviation industry (including regulators) to learn how to ensure this sort of door plug failure never happens again.

Instead of blaming human error, people should ask why the company didn't have better systems to prevent or detect the mistake or mistakes that led to this incident. Some leaders throw up their hands and lament,

“It's human error… we'll never be perfect… so what can we do?”

Instead of leaving that as an unanswered rhetorical question, we need to work at it seriously. What can we do to prevent mistakes and protect ourselves from human error?

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Lean Blog Audio: Practical Lean Thinking, Psychological Safety, and Continuous ImprovementBy Mark Graban

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