Bad Systems in the News: Not the Worst "Oops" Possible with Nukes


The Lean Thinker » What Nukes?

I had been mulling over trying to do a post on this story since the original story broke in August that some nuclear-armed cruise missiles were “accidentally” or “mistakenly” moved from one base in North Dakota to another in Louisiana.

I've read a number of stories, and there doesn't seem to be a clear story about what happened. The most recent stories are more about punishment and blame. I'm more interested in “root causes.” There are different theories:

  1. A mistake occurred. Procedures got lax, airmen weren't following procedures and leaders didn't notice or didn't take action. The system didn't have enough controls or oversight.
  2. A mistake like this couldn't possibly have happened. The systems are too air tight and there are too many controls in place.

So which is it? I'm not sure. If you read too far into possibility #2, Google search results quickly get you to conspiracy theories worthy of the show “24.” The systems are too tight for this to have happened unless someone was trying to send a message to a foreign country or somebody was trying to steal a nuke. I'm not endorsing those theories and I quit reading when I realized I was getting close to the lunatic paranoid fringe.

There are some really interesting underlying issues here, related to Lean concepts of standardized work, error proofing, and the role of leadership. Heck, if Air Force personnel were really coming up with their own unauthorized process, there's a horribly astray attempt at “kaizen,” perhaps.

I've linked to a lengthy post from the new “Lean Thinker” blog. Check it out. Who has some insight into this? This story makes my head spin.

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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

1 Comment
  1. Bob Graban says

    Right, things could get worse. Did you see that the navy accidentally bombed Virginia Beach – oops!

    (link to NY times)

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