A Lean Guy Reads the Globe and Mail – Shoelaces & Plane Crashes


I was in Canada a few weeks back and two articles from the Globe and Mail newspaper caught my eye – stories from England and Russia.

The first was what could be considered a lighthearted story about the excesses of a Prince. There's a better online article from Glamour magazine that includes this tidbit about Prince Charles about his clothing valets (he has three of them):

A valet's other duties include ironing the Prince's shoelaces whenever his shoes are taken off.

Maybe I am fashion-impaired, but that sounds like the “waste of overprocessing to me.” Then again, I guess the royal family isn't under much pressure to reduce wasted motion amongst their staff.

The next story is much more serious…

 You might have heard about the Russian plane crash in September that claimed 44 lives, including the entire  Lokomotiv Yaroslavl hockey team (including former Detroit Red Wing Brad McCrimmon, who I cheered for years ago.

The article,  “Plane crash that killed Russian hockey team blamed on pilot error,” maybe should have had the phrase “management error” in the headline, actually.

From the piece:

A Russian jet crash that killed 44 people, including an entire professional ice hockey team, was caused by pilot error, investigators said Wednesday, putting the blame on poor training and safety standards.

End of story – bad pilot… he's dead, it's a tragedy, but that bad pilot won't harm anybody again. But wait… poor training… poor safety standards… that's not all the pilot's fault, right? There's more to the story:

Alexei Morozov, who led the investigation, said the crew still had enough time to abort the takeoff safely at the moment when they realized that it had gone wrong.

He blamed the plane's owner, Yak-Servis, for failing to observe safety standards and adequately train the crew.

You can blame the crew for not aborting the takeoff (bad pilot!!!) or maybe the owner has some responsibility for the system… including what sound like some glaring problems with management and culture — (the online version of the Globe and Mail piece is shorter, so I'll now reference this ESPN article with the same content):

…one possible reason the pilot obstinately still tried to take off was a fear of reprisals from his employer.

Industry experts say when Russian crews abort takeoffs, make second runs or divert their planes to other airports they can risk losing their bonuses or face other sanctions as carriers focus on cutting costs.

“Many pilots say that those who cause delays in flight schedules … run into various problems at many carriers,” Morozov told a news conference. “Company management doesn't like it.”

If the pilot feared for his job or feared for his financial wellbeing, it's understandable how the system would drive him to take risks. Yet the headlines scream “pilot error.”

There are some training issues or complications caused by the pilots flying an unfamiliar plane:

Morozov said both pilots had flown another type of plane with a slightly different cockpit layout and apparently had never learned the correct position for their feet on takeoff. He said in the Yak-42, like most other Russian and Western planes now, a pilot steers the aircraft by pressing the lower part of pedals and activates the brakes by pressing their upper part.

But instead of putting their heels on the cockpit floor as regulations require, one or both of the pilots left their feet resting on the pedals in line with old habits, inadvertently activating the brakes and slowing the plane down on takeoff.

At first they didn't notice the brakes were on, and then they made the fatal mistake of failing to halt the takeoff, he said.

“A properly trained pilot would have immediately aborted the takeoff when he saw the nose failing to lift,” said Ruben Yesayan, a highly decorated test pilot who took part in the probe. “The plane would simply have rolled past the runway and everyone would have been safe.”

As if those system problems aren't bad enough, it sounds like there were some cockpit dynamics of the type the aviation industry (and some in healthcare) are trying to drive out through the practice of “Crew Resource Management,” or CRM:

A clash of egos could also have been a factor, Morozov said, noting that the second pilot felt like the real leader.

The article points to the fact that one pilot was taking a medication that was not allowed for pilots… so again, easy to pin the blame on bad pilots and “pilot error?” Big huge headline – PILOT ERROR. Details of the article – it's largely the system. Hardly seems fair, does it?

The piece ends with an indictment of the Russian airlines for “widespread neglect of safety in the pursuit of profits.” Unless they fix those problems, it seems that another air disaster is just waiting to happen.

As we work to improve healthcare quality and safety, what are some parallels or lessons learned that you would draw from this tragedy? How can similar errors be prevented in healthcare?

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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. What a tragedy. With the article pointing to the problem at the pilot versus the system it reminds me of a situation I have freqently seen in my various organizations. A lot of leaders like to say they are in charge and are fully responsible until something goes wrong then they point fingers and blame. Somehow the irony of this behavior is lost on many leaders and is often reinforced in the media like this article.

    In healthcare, I think there is a strong “product out” mentality that leads to or risks defects. Too keep providers or exam/operating rooms “optimized”/busy people often feel like they can’t always stop the line. The impact to stopping a surgery for the rest of the patients that day and/or a sterotypical screaming surgeon can be enough to encourage moving along instead of stopping.

    I also think defects and errors are not fully defined and agreed to in healthcare. There are some defects that are obvious like patient harm and clear regulation violations, but many things are not defined as defects. Individuals often have to make judgment calls on if something is a defect or not. Without a culture where problems are gems to be discussed and brought up, many people keep their mouths shut if they think something “could possibly be” a defect.

  2. Hi Mark

    Another example of how broken systems are covered up, by placing blame on other people. Whether it is a Russian airline, heathcare in most places, or many of our factories, broken systems are what cause the vast majority of problems, not the people involved in doing the work.

    Poorly trained staff are not to be blamed the executives and owners that do not invest in proper training are. I have spent most of my life working in or around small to medium sized enterprises, those that invest in keeping their people trained and up to speed benefit not only from gaining better performance, but from gaining better customer relations good staff are a key to good customer relations and good staff only result from good training. Today the world changes at unprecidented speed, if you do not keep your staff up to date with their training you will find yourself in the dust.

    Safety is always one of the first areas that show poor training, and poor systems. If we would fix the flaws in the systems, instead of pointing fingers everything would get better, and in the end so would profits. A good system, will allow staff to deliver good results, and with good results the profits will follow.

    Decades ago men like Deming knew and advocated fixing the root cause of most problems the defective system first, and then fixing the defective people. Not much value in having good people in a bad system.


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