Air Travel — Results vs Process

If you’re a results thinker, you should feel reassured that 2007 had zero U.S. air travel fatalities for the first time in a long time, the continuation of an apparent downward trend.

2007 a safe year for U.S. airlines

If you’re a process thinker, you’re probably scared to death of a disaster that seems bound to happen. Near misses have tripled, news reports highlight how air traffic controllers are fatigued and overworked (not a good condition for safety).

Another Near Collision Rattles Newark Liberty

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Thankfully this most recent near miss prompted an “emergency meeting” with the FAA. I hope that leads to real root cause problem solving and prevention instead of blaming individuals. In this case, a controller is being blamed for giving the wrong tower frequency to a flight. How did that happen? Why could that have occurred? Can that be error proofed and prevented in ways other than saying “be careful?”

Fix the process folks, or the results won’t continue.

Good results aren’t always the indicator of a good process. You can have a bad process and get lucky for a while.

The right process brings the right results. That’s true in business, in Lean, and in aviation.

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This hits close to home since I flew into Newark on Wednesday. Not one of the near miss flights, but still… a bit scary.

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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an book titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.


  1. David says

    The article wasn’t very enlightening. Normally, when the Tracon hands off a flight to the tower, the pilot/copilot calls the tower and says something like “Newark, this is Air Carrier 3333 inbound.” If the frequency had been incorrectly set as Teterboro, the normal response would have been something like “This is Teterboro, Newark is xxx.xx”

    I’ll see if I can find something more substantive on this incident.

  2. David says

    Can’t find much. The comment here
    about landing procedures at Newark makes me wonder if maybe there’s a procedure there wherein the flight crew waits for a call from the tower, rather than initiating the call.

    There *is* some error proofing even if communication with one of the planes is totally lost, due to wrong frequency or other reasons:

    1)Planes will still be on radar, and the tower controller can direct the other plane away from the conflict.

    2)Airliners and large cargo planes are equipped with TCAS, an autonomous system which displays nearby traffic and recommends evasion procedures

    3)Finally, there is visual detection of the traffic.

    It will be interesting to find out more about what really happened here.

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