Comments on: The System Failed, 49 Killed http://www.leanblog.org/2006/08/system-failed-49-killed/ Mark Graban's leanblog.org - Lean Healthcare, Lean Thinking, Lean Manufacturing, Toyota Production System Thu, 09 Feb 2012 15:26:57 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Many Causes, Which is "Root?" — Lean Blog http://www.leanblog.org/2006/08/system-failed-49-killed/#comment-22695 Many Causes, Which is "Root?" — Lean Blog Wed, 27 Jul 2011 23:49:14 +0000 http://leanblog.bigbigdesign.net/2006/08/the-system-failed-49-killed/#comment-22695 [...] up to the Lexington crash and more contributing factors. I think part of the lesson here is 1) lack of proactive problem [...] [...] up to the Lexington crash and more contributing factors. I think part of the lesson here is 1) lack of proactive problem [...]

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]]> By: Joe Wilson http://www.leanblog.org/2006/08/system-failed-49-killed/#comment-938 Joe Wilson Tue, 29 Aug 2006 19:45:00 +0000 http://leanblog.bigbigdesign.net/2006/08/the-system-failed-49-killed/#comment-938 The thing that hit me watching this on the news on Sunday as I prepared to leave an airport similar to the one in Lexington was the inevitability of it all. Most of these systems are based on humans not making errors and human beings make errors. This means that not only are these failures likely, they are a certainty. No wonder they always blame it on an individual...it's a lot easier than realizing that it was going to happen eventually and it's going to happen again. The thing that hit me watching this on the news on Sunday as I prepared to leave an airport similar to the one in Lexington was the inevitability of it all. Most of these systems are based on humans not making errors and human beings make errors. This means that not only are these failures likely, they are a certainty. No wonder they always blame it on an individual…it’s a lot easier than realizing that it was going to happen eventually and it’s going to happen again.

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]]> By: Lean på Dansk http://www.leanblog.org/2006/08/system-failed-49-killed/#comment-936 Lean på Dansk Tue, 29 Aug 2006 09:54:00 +0000 http://leanblog.bigbigdesign.net/2006/08/the-system-failed-49-killed/#comment-936 We all know the curve goes down before it goes up...most stockholders won't tollerate the dip.<br/><br/>The man is blamed because he no longer is around to commit the same error. <br/><br/>The system still exists. If the system were blamed this would cause panic...or in the least lack of confidence in the system. <br/><br/>Less sales vs. a continued risk of failure. We all know the curve goes down before it goes up…most stockholders won’t tollerate the dip.

The man is blamed because he no longer is around to commit the same error.

The system still exists. If the system were blamed this would cause panic…or in the least lack of confidence in the system.

Less sales vs. a continued risk of failure.

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]]> By: Sam http://www.leanblog.org/2006/08/system-failed-49-killed/#comment-935 Sam Tue, 29 Aug 2006 05:07:00 +0000 http://leanblog.bigbigdesign.net/2006/08/the-system-failed-49-killed/#comment-935 Aviation systems typically get put into place after enough people have died to justify the expense. That sounds pretty backward but if people aren't dying, then the powers that be assume the existing systems are safe enough and any expenditure is a waste. Of course once 49 people are dead, suddenly it doesn't seem like it would've been such a waste, eh?<br/><br/>The ironic thing here is that any airport-based system that could've prevented this human error would be expensive enough that you'd find it at a major airport; however, many of the likely factors in this accident (poor lighting & markings, confusing layout, short runway, undermanned ATC tower) are unique to small airports that couldn't affort such a system. On the other hand, more affordable solutions - more visible paint, markings, lighting - could be cheaply deployed at small airports and would've had a very good chance of preventing the pilots from making their fatal mistake.<br/><br/>The airlines have become extremely safe in this country over the course of the last 20 years. This is the result of a two pronged approach: deploying technology when the advantages outweight the significant costs (GPWS and TCAS are examples) and focus of human factors training to help eliminate human error in other cases. Each effort has yielded great dividends at a cost that has allowed air travel to remain affordable. Aviation systems typically get put into place after enough people have died to justify the expense. That sounds pretty backward but if people aren’t dying, then the powers that be assume the existing systems are safe enough and any expenditure is a waste. Of course once 49 people are dead, suddenly it doesn’t seem like it would’ve been such a waste, eh?

The ironic thing here is that any airport-based system that could’ve prevented this human error would be expensive enough that you’d find it at a major airport; however, many of the likely factors in this accident (poor lighting & markings, confusing layout, short runway, undermanned ATC tower) are unique to small airports that couldn’t affort such a system. On the other hand, more affordable solutions – more visible paint, markings, lighting – could be cheaply deployed at small airports and would’ve had a very good chance of preventing the pilots from making their fatal mistake.

The airlines have become extremely safe in this country over the course of the last 20 years. This is the result of a two pronged approach: deploying technology when the advantages outweight the significant costs (GPWS and TCAS are examples) and focus of human factors training to help eliminate human error in other cases. Each effort has yielded great dividends at a cost that has allowed air travel to remain affordable.

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