Process Problem: The NFL Super Bowl Coin Toss, A Defect & Rework


For the coin toss of the Super Bowl 48 (or XLVIII), the referee, Terry McAulay, handed the coin to Joe Namath to toss it… it appeared that McAulay realized when the coin was in mid-air that he had possibly forgotten to ask the Seahawks to call it. Oops!

Failing to stop Namath, McAulay caught the coin in mid-air and then asked the Seahawks, as the visiting team, to call it —  letting Namath then toss it again. You can also watch this on YouTube.

All we know from watching the video is that a mistake was made. Things didn't go the way they were supposed to — but why?

As we say in the Lean management philosophy, be hard on the process, not the people.

It goes to show we are all human. I'm sure the coin toss is practiced and rehearsed. They didn't have a checklist out there, but it might have been useful. McAulay went through most of what he was supposed to say, but not all of it. It reminds me of the first time President Obama was sworn in and Chief Justice John Roberts screwed up (I mean, there was a process problem).

Whether it's a coin toss, an inauguration, or surgery at a hospital — all the practice in the world can't prevent a mistake from happening in the heat of the moment if somebody gets nervous or there's a distraction.

The first coin toss is what we'd call a “defect” in the Lean terminology.  That led to “rework” for the referee and Namath.

Rather than blaming the referee (or blaming Namath), the NFL should look at the process — what caused this to happen? What can they do to prevent it in the future?

At least it wasn't as bad as this classic coin toss mix-up on Thanksgiving Day a few years back. Thankfully, what happened today was only mildly embarrassing and didn't affect the game.

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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.


    • Same comment by @bruceweinberg

      Shouldn’t hand over the coin until team has called and ready for toss. Like handing scalpel to surgeon before timeout.

      Rewatching the video, it sure looks like the ref was allowing Namath to step forward to toss the coin… it seems unfair to blame Namath. System failure.

  1. Speaking of things that got out of hand (coins, first snaps) –

    AND then there’s the Groundhog Day fail by the new mayor of New York City. My wife being a veterinarian who knows how to hold all KINDS of critters immobilized (including me), I’m gonna betcha nobody taught Hizzonor how to hold a wriggly groundhog securely.

  2. Better yet would be to error proof the toss. In the NFC championship series, the coin itself had Seattle on one side and San Francisco on the other side. So there was no doubt who wins the toss and also no need to call it.


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