Lessons from a Crazy Taxi Ride: Improving Processes in Unpredictable Environments


When I was leaving the recent Shingo Prize conference, last week, I had what can only be described as a taxi ride from hell on my way from Covington, Kentucky to the CVG airport.

The taxi driver, who had been called for me by the hotel, was acting primarily as a rolling dispatcher, constantly answering his phone and radio, taking his eyes of the road to write down or read notes from a notepad on the center console. It scared the crap out of me and it ended with me cursing him out, a fair reaction in the “fight or flight” sense.

I'll share details and reflections here. My point is not to trash the taxi driver, but to raise some issues related to workplace safety, including healthcare. Although, I should probably post the company's name and phone number as a public service to help others avoid this guy…

As I realized what the driver's mode of operation was, spending more time focusing on dispatching than driving, I was so surprised and flummoxed… I thought about asking him to stop to let me out after we had traveled just a few blocks on surface roads. I should have gotten out, refused to pay, and gotten a new, safe driver. But, I froze. We ended up on the freeway and it got worse.

Knowing that confronting a taxi driver, even calmly, can end up in an ugly situation of getting yelled at by the driver (at least from Boston experience), I kept quiet, made sure my seat belt was buckled, and took two video clips from the backseat as evidence of what was happening.

In this first video, when we are already on the freeway, the driver takes 3 phone calls and 3 radio calls in 90 seconds, looking down from the road at least 17 times by my count (play along and count with me!):

In the second video, he takes  2 phone calls and 5 radio calls in 1:47. There's quite a stretch just after 1:30 into the video where he's looking down way more than he's looking at the road for a good 10 second stretch.

Here is an annotated picture for those who can't see YouTube at work:

You see how the radio handset is hanging down in easy reach? Maybe he thinks he is being clever? It's clearly unsafe distracted driving either way. He really came up close on the bumper of a minivan at about 70 MPH. Had there been any reason for that van in front of us to brake, we would have plowed into them.

Here is a screen grab of one of those times he was looking down to read or write on that notepad:

About halfway to the airport, between calls, the driver says to me,

Sorry I can't talk with you, I'm kinda busy.

Well, I just lost it. I didn't want him to chat and be my friend, I wanted him to drive safely. I told him as much and I lost control and cursed him out about how he needed to just focus on driving or he was going to kill us both or some innocent family.

I basically just got silence as a response. And then the phone calls started again. I tried making noise while he was on these calls, asking him to get off the phone and drive. Then, I shut up, realizing that he wasn't going to change and I was probably just causing more of a distraction. I thought about calling 911, but I decided to just try to flag down an officer at the airport if I could.

When we got to the airport, he got out to get my suitcase and I yelled at him (trying to make a scene in case there was an officer nearby). I told the driver he was unsafe and a danger to himself, his customers, and everybody else on the roads. I told him it was just a matter of time before he killed somebody. He is a “Darwin Award” winner in the making.

The driver's lame response?

“But I didn't hit anyone.”

So that put me further over the edge and I yelled some more about his faulty thinking and worse driven. Joe Pesci in the movie “Casino” would have been proud of my yelling, my mother not so much.

My taxi driver didn't ask for money and he drove off. I've never been more angry about a free taxi ride. A town car driver who overheard our curbside verbal altercation said he saw my driver drifting and swerving a bit as they arrived to the airport and he couldn't believe my taxi driver was acting as dispatcher from behind the wheel. I need to call that town car service in the future.

I found an airport police officer and told him what happened, but he couldn't do anything since he didn't see the unsafe driving.

I called the city of Erlanger, Kentucky, where the taxi was based out of. Unlike big cities, they didn't have a taxi licensing department. So they transferred me to the police department. I talked to an officer, who asked me to send the video. The officer said he would likely call the driver in for a “come to Jesus meeting” about his driving behavior.

The taxi didn't have a posting as you'd see in New York or Boston (or a big city) about a medallion number and how to complain. I've found that cities that don't put that “how to file a complaint” info in the taxi typically have lousy drivers.

How Do We Judge Safety?

I hope everybody would agree that “I didn't hit anybody” is not a good rationalization for unsafe behaviors. Safety is more about ongoing practices than it is about a binary “did I hit anybody or not?” question.

If a pilot skipped their pre-flight checklist, would the FAA accept “But I didn't crash the plane” as an excuse?

If a surgeon skips the “universal precautions” before a surgery, is it ok to say:

“But I didn't operate on the wrong body part”?

At the Shingo Conference, I had an attendee who worked in manufacturing, who told me about a recent multi-day hospital stay. One day, his nurse was about to give him the medication without checking his patient ID verbally. The patient spoke up, as hospitals often encourage patients to do, and asked the nurse to wait and check his name and birthdate. He said the nurse seemed shocked that he would challenge her that way.

To her credit, the nurse didn't say, “But I didn't give anyone the wrong medication.” That's not a good excuse for not following a process.

Thinking back to taxis, do hospital rooms typically have a sign posted telling a patient how they can report an unsafe condition or how they can complain, as he could with taxis and certain cities?

As the Alcoa safety pyramid demonstrates, and as patient safety advocates point out, the best opportunity for catching and preventing errors comes when identify an unsafe condition or a near miss, as opposed to waiting for any patient harm to occur before reacting.

I was shocked at my taxi driver's behavior. I was stunned by his reaction and brushing off of my complaint. I was even more stunned by my latent ability to scream and curse somebody out. I didn't think I had that in me.

See this recent NY Times piece on distracted driving…

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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.


  1. This is so scary. And so sad at the same time.

    Here the danger is tangible and we can picture it very easily. What happens when doctors, nurses and other medical practitioners are engaging in the same kind of multitasking that might endangers the lives of the people they are entrusted with?

    • I think my story here goes to show that even when the danger is very visual and imminent that people have a great capacity for denial.

      That capacity must be even greater when the dangers aren’t as in-your-face?

  2. This is an interesting article and when I first saw your tweet a few days ago about this situation my eyebrows raised. Coming from an aviation and healthcare background (What a combination!) I have a real passion for Human Factors and erradicating the “Dirty Dozen” causes of error. Out of the 12 factors I’ve listed below, I wonder how many affected that driver. Some are plainly visible…the ones that concern me are hidden, because they are more difficult to remove!

    The Dirty Dozen:
    1. Complacency
    2. Lack of Knowledge or Understanding
    3. Poor Communication
    4. Lack of Teamwork
    5. Fatigue
    6. Lack of Resources
    7. Self-Induced Pressure
    8. Lack of Situational Awareness
    9. Lack of Assertiveness
    10. Norms (I’ve always done this)
    11. Stress
    12. Distraction

    Thanks, great blog! Chris

  3. A few thoughts:

    I agree that “I didn’t hit anybody” bad justification.

    By his giving a free ride reminds me of a story in Joiner’s 4th Generation Management (page 81) regarding traps to avoid in order for a 100% satisfaction policy to work. “(A company) gave the customer their money back but didn’t seek further information, make improvements, or practice prevention. This annoyed the customers even more.” It does not appear the driver will change and that is extra salt on the wound of bad service.

    I will say that Lean thinking does say we have to blame the process/system and not the person. Obviously the company has a bad system that forces someone to make a workaround of driving and dispatching at the same time. The fact that there are permanent dispatch fixtures in the car doesn’t seem to indicate the dispatcher was just filling in for a sick driver and looks like it is common practice to do both. Maybe the company refuses to hire enough people to meet demand.

    In a hospital setting, real or perceived pressures do cause people to multitask in ways that can make things unsafe.

      • Thinking back to Dr. Deming, he never said 100% of problems are caused by the system… it was more like 94% of the time.

        I think this jerk of a driver was part of that 6% where we should blame the person and hold them accountable for their choices and behavior…

  4. Great story and illustration of how we can freeze-up even when we know what to do.

    I wouldn’t have guessed you had it in you either.

  5. Deep inside, you have the capacity to be the dinosaur non-Deming plant manager that you always wanted to be! So reassuring that you have skill to fall back on in case this “lean fad” goes away. ;-)

  6. I heard the story last night from an engineer who had the first accident in a Chevy Volt development car. The crash data recorder says he had accelerated to 12 MPH when he was rear ended with an impact measured that indicated the driver was going 40 MPH without braking. (He saw it coming.) The woman was distracted looking for her cellphone. Fortunately nobody was injured though the Volt driver got quite a (non-electrical jolt). He said the Volt came out remarkably well with little visible damage and the hatch back window was not broken.

  7. Interesting that we both went to the same airport (maybe even same cab company) and noticed different things. I put a post on my on-line journal about “customer standard work” and the apparent focus on efficiency and continuous flow. You noticed “inattention to safety” . so, I’m thinking about the systems that management puts in place (or allows to develop). Looks like the focus on one part is continuous flow and in the other is “mulit-tasking”. Maybe they don’t devote $ to central dispatching? Maybe each driver has to “fend for himself”? Not excusing the behavior, just wondering about the effect of the system on the individual.

    • I’m glad you had a better experience getting to CVG.

      I understand the urge to look behind the driver/dispatcher to the system. Supposing (I don’t know this as fact) that the driver/dispatcher is the owner of this small cab company and he’s just being cheap… he would be guilty of short-term thinking over long-term, among other problems.

      If he’s being “forced” to do this by a cab company owner, it’s a different story.

      But I think back to Deming saying about 94% of the problems are with the system. Again, this guy might be part of the 6%.

      I’m more forgiving of situations where somebody is a product of their job design, such as air traffic controllers having to work alone at night in a dark room. It’s inevitable that some would fall asleep. We are human. That’s the Toyota “respect for humanity” principle in part to respect that human nature and to design systems accordingly. Good lessons for healthcare in that idea too, I think – designing systems that don’t require people to be perfect.

  8. I’ve been in a cab like that before.

    This is one of the reasons I like using a rideshare service like Uber. There is a built in rating system for the driver and the rider. This type of rapid feedback appeals to me. You can also go to their website and there is a short but detailed list of common problems or issues that you can make them aware of when they occur.

    When I first started riding Uber, I would tell the driver, “Hey thanks, that was a five star ride!” On one trip, the driver said, “Hey thanks, you too!” So I asked him about the ratings and he showed me where the drivers rate the riders as well.

    I pretty much avoid taking taxi cabs now and opt for using Uber when traveling. The attention to detail and customer satisfaction combined with relatively lower costs make it a better choice for me personally.

    I imagine that as more people have this type of experience in taxi cabs, the more people will opt to use rideshare services. Not all taxi cabs are bad, the majority of them are respectful, courteous, and freindly. Unfortunately it just takes one bad experience (or good experience) for people to vote differently with their wallets.

    • I feel like there’s FAR more accountability for Uber drivers than there is for taxi drivers.

      The worst experience I’ve had with an Uber is a relatively beaten up car and a driver with B.O. But that happens all the time with taxis.

      Sure, not all taxi drivers are bad, but the taxi monopoly has protected bad drivers and excused bad service far too long.


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