A Nearly Apocalyptic Workaround?


Inside the Apocalyptic Soviet Doomsday Machine:

There was a fascinating article in a recent WIRED Magazine about Cold War nuclear response and defense systems. This one sidebar struck me as a classic workaround, if the story can be believed.

When: 1960s

What: Midway through the Cold War, American leaders began to worry that a rogue US officer might launch a small, unauthorized strike, prompting massive retaliation. So in 1962, Robert McNamara ordered every nuclear weapon locked with numerical codes.

Effect: None. Irritated by the restriction, Strategic Air Command set all the codes to strings of zeros. The Defense Department didn't learn of the subterfuge until 1977.”

Isn't it amazing to see how clever people can be in working around a top-down management mandate? Would Secretary McNamara been more successful if he had involved all of the stakeholders and gotten buy in instead of issuing an order? How did DoD not know about the “subterfuge”? Because they weren't going to the “gemba”??

I'm sure if you look around your organization (hospital or otherwise), you can find a similar dynamic in place somewhere… maybe everyone's job this week should be to find a workaround?

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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. Andy Wagner says

    Father of the Edsel, McNamara is the epitome of the non-gemba manager.
    In Vietnam he tracked progress by counting aircraft sorties. Short on bombs, the Air Force flew a dozen aircraft with one bomb each instead of reducing the number aircraft and flying a full load.

  2. Mark Graban says

    Andy – what a great (I mean sad) example of "gaming the numbers" to give the manager what he's looking for. Different type of workaround, something that also often exists in most organizations where managers don't look at process and they don't go to the gemba.

  3. Jeromy Timmer says

    The USSR was worried about officers launching strikes because they mistook a flock of geese for a U.S. attack. Their solution: Build a doomsday device. That way the officers with twitchy trigger fingers could rest easier that nuclear Armageddon would take place after their demise. Would that be a Poka-Yoke?


  4. Mark Welch says


    Maybe we should have cut McNamara some slack. Maybe he was just beginning Lean and saw "One Bomber/One Bomb" as one-piece-flow :-)

    Just kidding. A little tongue-in-cheek humor.

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