Why Do We Blame?


Jetliner taking off at O'Hare barely clears 747 on runway | Chicago Tribune

As a frequent flyer (I landed at O'Hare on Monday), and an aspiring “lean thinker,” I pay close attention to this sort of thing. Look at the above headline from the Tribune… not so “blame-y” But other headlines frequently blamed a single Air Traffic Controller right in the headline. The Tribune article placed the same blame in the body of the article:

“The FAA blamed errors by an unidentified veteran O'Hare controller.”

Now, the NTSB is coming out to investigate. What is there to investigate if it is so cut-and-dry the fault of a single individual? Fire that person, let's move on. We're now safe, right? It was a “veteran” ATC who was reported close to retirement. So we're blaming an old guy?

Why is it that we are always so quick to blame an individual? If something goes wrong (or almost goes wrong), we are quick to ask “who did it?” This happens in manufacturing environments, it happens in healthcare. When I teach people about lean, one of the cultural things that we work on is shifting from blaming people to identifying real root causes and fixing the systemic problems that really cause most process defects. The Toyota Production System recognizes that humans are human and that we make mistakes, hence the need for error proofing (poka yoke)

I don't know what happened with this O'Hare near miss, other than what was in the news. But, I would bet my house that it wasn't just the fault of ONE individual. There is a complex system at play — multiple planes, pilots, ATC's. The fact that O'Hare has had FIVE near misses this year would indictate that there is/are systemic problem(s). Was it the same ATC person involved in all five cases? I doubt it.

So far this year, five runway incursions have taken place at O'Hare out of approximately 540,000 total flights, the FAA said. Seven such incursions occurred at O'Hare last year.

Wendy Abrams, a spokeswoman for the city's aviation department, says the incidents are rare, considering the airport handles roughly one million flights a year.

“This is abnormal,” she said.

I'm glad it's abnormal. It seems like O'Hare is on the path to having a real collision soon, even if they were to fire the “bad” ATC in this case. They are on a pace to exceed last year's seven incursions. The trend is going in the wrong direction. I'm glad this is “abnormal.” I don't care that they handle one million flights per year. Each and every flight deserves a safe take off and safe landing. A “six sigma” quality level would mean that an average of 3.4 collisions would occur each year. That would clearly be unacceptable.

So what we need isn't “six sigma” quality — they already have that, with zero collisions. What they need is lean thinking — get away from the blame and start error proofing the processes. There is ground radar technology that will help pilots anticipate if there is a risk of collisions on taxiways and runways. I know we can't rely on technology, but I would trust good technology and good systems over punishing individuals and telling people to “be careful.”

So why do we have this human need to lay blame? As an air travel, is it more comforting to think:

A) “somebody did a bad job, so we fired them, problem solved” or
B) “there are systemic problems that allows this to happen 5 to 10 times per year and it will likely happen again.”

“A” is reassuring, even if it's false. “B” can keep you up at night. It's easy to comprehend the idea of “someone screwed up.” It's much harder to get a handle on the idea that the mysterious “system” caused the problem.

I recognize that ALL problems aren't caused by the system. You might have gross incompetence that leads to an accident. But most any human error can be traced back to a preventable systemic problem. Let's say a pilot hears “turn left” when the ATC said “turn right?” Human error, right? Blame the pilot, right? Well, ask why….. why did we rely on verbal messages? Why did we not have better confirmation of the proper instruction, etc.?

Here is a more detailed analysis of airport runway incursions, in general, which lists many systemic causes of runway incursions. The data also show that the problem was, in general, getting worse from 1988 to 2001. Are people getting “less careful” or are the systemic problems growing?

Look at the results of an NTSB investigation of O'Hare in March:

The NTSB sent a team of investigators to O'Hare after the two O'Hare runway incursions in March. A safety board report issued in May concluded that lack of sleep among O'Hare controllers may have been partly responsible for the incidents, along with excessive noise and unnecessary conversations in the tower cab, infrequent safety briefings conducted by FAA managers and inadequate training for some controller jobs.

These sound like systemic problems to me. I'm not making excuses for people…. it really is the system that is at fault, in most cases.

Have you worked on fixing the “culture of blaming” in your lean implementations? How successful have you been?

More on this topic, blaming vs. root cause, on the excellent Curious Cat Blog

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.



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