It Wasn’t The Pilot, It Was The Process

By on July 8, 2013

The headline in the July 8th issue of the Wall Street Journal Online read “Pilot Error Eyed in San Francisco Plane Crash.” I think it’s predictable that many of the stories we read about the crash of Asiana Airlines’ Flight 214 at the San Francisco International Airport will reflect a similar perspective. The pilot made a mistake. It was “pilot error.” If, on its final approach to landing, the Boeing 777 would have maintained proper airspeed, the accident wouldn’t have happened. Why didn’t the pilot maintain proper airspeed? If, on its final approach to landing, the pilot would have maintained the proper glide slope, the accident wouldn’t have happened. Why didn’t the pilot do this? Etc. Etc. The WSJ headline is a perfectly predictable outcome of a focus on the pilot.

The only problem with a focus on the pilot is that it leads nowhere in terms of understanding what happened and how to prevent it in the future. Captain Sully Sullenberger, of Hudson River landing fame, knows this. In an interview on CBS This Morning, Capt. Sullenberger observed that in trying to determine what caused this accident, the following issues needed to be carefully looked at regarding their quality:

  • Crew training programs
  • Airline policies and procedures
  • Crew member supervision
  • Crew member teamwork

In other words, Sully Sullenberger realized that understanding the causes of this tragic accident depended upon really understanding what the defective processes were that caused it. He understands that it’s all about processes, not people. The Wall Street Journal headline should have read “Process Weaknesses Eyed in San Francisco Plane Crash.” Unhappily, the way most of us think doesn’t often lead us in this direction. We want to keep asking “who is responsible?” until we’ve identified the guilty party. And when we’ve done this, we rest, thinking we’ve taken care of the problem. Unhappily, we haven’t. The road we’ve taken is a dead end.

Taking a different road, a road that will lead to process improvements that can prevent accidents like the one that occurred in San Francisco, requires a change in the way we think. It requires the development of a way of thinking about problems that many of us find quite unnatural. Lean thinking and Lean work processes shift the focus in problem analysis away from people and toward work processes. Doing this isn’t easy.

Old modes of thinking die slowly, as Hiroyoshi Yoshiki experienced in the early stages of his work with Toyota in the United States. When asked what stood out the most about the difference in culture between Toyota in Japan and what he saw at Toyota’s Camry plant in Georgetown, Kentucky, he observed, “We were most surprised by the reaction of the people when we asked them about problems. The reactions from Americans were very, very negative. We were surprised. It does not have any negative connotation for us in Japan. What is the problem? When we asked that question of a person it was like ‘Oops’ in the United States. People think ‘I messed up.’ … (We were faced with the challenge of) how can we make the word problem a positive word rather than a negative word? We worked hard to separate the problem from the person.

Jeffrey Liker, in his widely acclaimed book, “Toyota Culture: The Heart and Soul of the Toyota Way,” defines the key distinctions between traditional Western thinking and the thinking that drives Lean manufacturing:

Traditional Western Lean Thinking
What is a problem? Result of someone messing up Deviation from standard
What is the cause? An individual’s error A process weakness
Who is responsible? Person who made mistake Everyone
What should an individual who makes a mistake do? Solve the problem on their own, if possible, so management doesn’t find out about it. Call attention to the problem for assistance and to fix the process that caused the problem.


These distinctions are not in any way trivial. In fact, moving the focus from people to processes is one of the primary drivers of employee engagement. As Gallup’s 2012 “State of the American Workplace” study demonstrates conclusively, it is levels of employee engagement that mark the difference between organizations that are profitable and those that are not.

Yes, the Wall Street Journal headline should have read, “Process Weaknesses Eyed in San Francisco Plane Crash.”

I’d appreciate having the opportunity to discuss with you the ways in which our Lean transformation resources could be used to make sure that all of your employees think the way Sully Sullenberger does. Call me anytime at 314-303-0612 and let’s talk.

About George Friesen

George Friesen serves as Business Practice Leader - Lean Manufacturing for the Workforce Solutions Group of St. Louis Community College. He has led the College's Lean business practice area since 2000. Prior to joining the College, George worked for Maritz Performance Improvement Company. Over the past 35 years, he has served a wide variety of Fortune 500 companies, specializing during the past eleven years in Lean Manufacturing, focusing especially on the 5S System, Lean leadership and thinking processes, Value Stream Mapping, and Lean team building. George is a graduate of Washington University (AB), Webster University (MA), and United States Air Force Flight Training.

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