The United Flight 3411 Mess, Holding Individuals Accountable vs. Fixing the System [Updates]


I posted this on LinkedIn earlier today and am re-posting as a blog post to get your thoughts… and then, as I writing this, the news about the man being forcibly removed from United Airlines flight 3411 from Chicago to Louisville went viral.

Update: He's now identified as Dr. David Dao, a physician with a “troubled past” who previously had his medical license suspended in Kentucky. By pointing this out, I was accused of “victim shaming” on Tuesday, which was not my intent at all. There is no excuse for how Dr. Dao was treated. He didn't deserve to be treated that way. I can simultaneously hold the opinion that he was horribly mistreated AND that he maybe shouldn't still be practicing medicine because of his previous conviction and ethical lapses. It's not like he was a serial jay walker or behind on his taxes. I wouldn't care about that.

My original LinkedIn musings:

It's interesting how English words can mean something different depending on context.

I can “be accountable” (which means to explain my actions) or managers try to “hold people accountable” (which usually means to discipline them).

Speaking of that word, I can “be disciplined” (meaning, for example, that I watch what I eat and exercise daily). Or I could “be disciplined” meaning a manager telling me I'm in trouble for doing something.

Or are they “holding me accountable?”

Discipline and accountability should be internally-driven. I don't think we can impose that from the outside or “from above” in an organization.

What do you think?

Hear Mark read this post (subscribe to the podcast):

I was working from home and realized that 90% of my Facebook news feed was about this awful story:

United CEO apologizes after video of O'Hare passenger dragged from flight goes viral

Was that really an apology? Is United sorry for what happened or sorry that the story got out?

Video via CNN:

Video via Twitter:

From the Tribune:

“Once the flight was boarded, passengers were told four people needed to give up their seats for stand-by United employees that needed to be in Louisville for a Monday flight and the plane wouldn't depart until they had volunteers, Bridges said. United increased the offer to $800, but no one volunteered.”

And this article says:

“Then, she said, a manager came aboard the plane and said a computer would select four people to be taken off the flight. One couple was selected first and left the airplane, she said, before the man in the video was confronted.”

And then that happened.

Update: The four people selected were Dr. Dao, his wife, and his grandchildren. In the one video, you see a woman coming up the aisle after Dr. Dao was brutally dragged off. Was that his wife? I guess the other 3 people didn't get off voluntarily before they dragged him off?

He was not wearing leggings.

I bet many people will react and blame the front line employees of United or the front line police officers who responded (see edit at the end of post, it was airport security, not CPD).

I've been thinking about some of the underlying systemic causes and contributing causes. Everybody works in a system. It's too easy to just name, blame, and shame.

Some apparent or possible contributors:

  • Being way too overbooked too often (that's a business choice the airline makes)
  • Lack of training?
  • Short staffing at the gate?
  • Short staffing requiring the dead-heading of employees to move them to another city instead of carrying a paying passenger?
  • Extreme pressure to hit on-time departure numbers, etc.
  • Not offering high enough voluntary incentive (does airline policy limit the amount?)

Will the CEO, Oscar Munoz, blame and fire employees or take responsibility for the system?

Will they say they are “holding employees accountable” for their actions? Will people “be disciplined?”

What will really improve? Will they improve the system and prevent a future incident?

A friend who is a really good Lean thinker wrote:

“I think we can do a quick 5-whys and find about a dozen systemic process failures before we even mention the decision to physically drag this person off the airplane.”

I guess individuals can be held accountable for their behavior? Were they just following policy? I don't see how you can “hold fully accountable” individuals who didn't create the system they work in.

Update: Munoz later praised United employees for following standard procedures (and didn't look good for blaming the passenger's behavior for the incident). O'Hare police suspended one officer for his actions (was he the one who got physical with Dr. Dao?). 

What role does culture play? A friend commented,

“This would never happen on a Southwest flight, as their employees are empowered to do the right thing for the customer.”

Here was the official response, which was also criticized widely online for only apologizing for the overbooking, not the aftermath:

This is funny, via the Miami Herald:

“Last month, Munoz, a former railroad executive, was named U.S. Communicator of the Year by PRWeek.”

A suggestion for a better response:

And a suggestion from Wednesday's podcast guest:

As Bouthillet, a fire captain who does post-event reviews said in the podcast:

What will be the result of United's “detailed review?” Naming, blaming, and shaming employees (well, they might not name them)? Or systemic improvements that prevent future occurrences like this?

I hope that the CEO doesn't try to “solve” the problem from headquarters. They probably have their PR people activated. What about the process improvement people? Will somebody go and do some rational investigation and problem solving, as I wrote about here?

Over 10 years ago, I posted something about United hiring people for Lean and continuous improvement. Whatever happened with that?

Jeff Liker wrote about CEO Munoz being “a Lean leader” a few years back. I hope that's the case.

The news cycle will have moved on. We might not hear about the follow up.

I'll update this post as more is learned.

Update:  Officer Who Dragged Bloodied Passenger From United Flight Suspended

Apparently it was “Chicago airport police.”

“The officers who removed the man from the plane were Chicago Aviation Police personnel, not Chicago Police officers.

“The incident … was not in accordance with our standard operating procedure and the actions of the aviation security officer are obviously not condoned by our Department. The officer has been placed on leave effective today and pending a thorough review of the situation.”

It's probably more fair and just to suspend somebody for not following SOPs. Would they have been suspended without the “bad result” of bad publicity?

Update: United Airlines: Read CEO Oscar Munoz's leaked email to employees in full after passenger dragging incident”  — More on this via Reddit

Treating our customers and each other with respect and dignity is at the core of who we are, and we must always remember this no matter how challenging the situation.”

Really? Respect and dignity?

And, do employees really need to be reminded about dignity and respect. Do employees really forget about safety and doing the right thing? See related posts about GM CEO Mary Barra and Cleveland Clinic CEO Dr. Toby Cosgrove blaming their employees for forgetting what's important. Do employees forget or do their executives lose sight of this?

This can be fixed. It needs to be fixed at the top, through changes to policies and systems, not by blaming the front line workers and manager.

Update: New video shared via the New York Post shows Dr. Dao saying he'd rather go to jail and you'll have to “drag me down” to get him off the plane. But that hardly constitutes permission to get physical with him.

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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. I have never had anything but rudeness and problems with United. The last – of many – a Unites employee said and I quote “they treat us like $h1t so we treat customers the same way”
    While disturbed on the most basic human level I am not surprised.
    #worstairlineever #getmoralsandclueunited

  2. It doesn’t make any sense when United says Flight 3411 was overbooked, United’s statements makes it clear the flight was correctly booked. The problem was that United needed to get four staff members on that flight to crew another flight at the other end so they needed to bump four passengers not because the flight was overbooked. Seating for overbooked flights are resolved before the passengers are loaded not after they are loaded and seated. It’s one thing to tell a passenger, sorry we don’t have a seat for you and something else to tell a passenger, sorry you are worth shit, we have to remove you from your seat so we can give it to a different passenger worth a little bit more than plain shit.

  3. As a business traveller, I currently have flown roughly 3 Million actual miles and have flown 1.2 Million of them on United alone. (these are not mileage points, these are actual, statutory miles flown) I currently have 21 United flights booked, paid for and confirmed between now and the end of April. This is a long post but, PLEASE read it. In ALL of the interactions mentioned below, I am the only Person of Color involved.
    On Wednesday morning I began my sojourn (Medford, OR – San Francisco – Newark – Jacksonville). At 5:00am I checked in with United at the Medford, OR airport. I needed to check my bag all the way to JAX. Because of the input errors of the United ticket agent, the bag was checked only to Newark. I had purchased First Class upgrades so the first 2 flights were great. Unfortunately in Newark I had to leave Security, go to baggage claim, pick up the bag, re-check the bag, go through security again, change terminals and still make it to my gate in time for the Jacksonville flight, WHEW! and Done.
    As it turns out the JAX flight was seriously delayed. As I sat in the gate area I noticed various travelers going to the podium and asking for departure updates. The gate agent was pleasant, solicitous and fully communicative with them. When I went to ask, he was gruff, barely looked at me and his communication was noticeably dismissive. I thought to myself: “Maybe he is having a bad day” ( I know I certainly was) and I just let it go. When the flight was finally ready, I stood to be the first in line, as I usually do.
    At some point another business traveller came and just walked in and stood in front of me. I politely asked: “Sir, how could you just come and stand in front of me like that after clearly seeing me here?” Before he could reply, the gate agent (5 feet away) barked: DON’T TALK TO HIM… DON’T YOU TALK TO HIM…YOU! TALK TO ME!” I replied, that I was having a private conversation with a fellow passenger and asked him to butt out. At this point he repeated his commands more loudly and more aggressively, adding: This man is a “Global Services” customer.. He is very important to us and one of our most valued customers. DON’T YOU TALK TO HIM! (All of this is happening at a now crowded gate area) At this point my fellow passenger who had STILL not had an opportunity to respond to my question was clearly embarrassed and I was feeling extremely devalued (READ “like chopped liver”).
    I attempted my conversation again at which point (still yelling from the podium) the agent said: “If you keep ignoring me, I will have you thrown off this flight.” I ignored him again at which point he left the podium, approached me and demanded to see my boarding pass. I demurred. he said (in my face): “Show me your boarding pass RIGHT NOW or I will call a cop and have you removed from the airport!” Now, I am getting miffed, but I complied, dreading any further travel delay .
    The agent then walked to the jetway, went in and slammed the door. I finally got to finish my conversation with the passenger. I congratulated him on being “Global Services”. and he told me that he thought my original question to him had been “completely appropriate”.. FYI “Global Services” is a highly exclusive and secretive class of United customers. There has never been ANY published information on how to earn this status (thresholds of miles flown, dollars spent, years as a United FF, Mayflower Ancestry, etc.). Membership is by private invitation from United only.
    After five to ten minutes, the agent appears at the Jetway door (40-50 feet away), yells; “MR: LYTHCOTT!!!” He crooks his finger at me (as if he were calling a child or a dog) indicating that I should join him at the door. He escorted me to the doorway of the plane where the Captain and Flight Attendant were standing and looking quite nervous; their eyes rapidly scanning my face, my body and especially my hands. The gate agent ordered me to “Stop right there…do not approach the plane further.”
    The Captain very politely asked me to explain myself. I recounted the incident to him and while I was doing so, he became visibly more relaxed. As soon as I finished, the gate agent (presumably for the second time) recounted his version of the incident to the Captain which included two sequential errors and two outright lies.
    The Captain, now looking embarrassed, cut him off and pleaded:”Gentlemen, can we PLEASE just fly on down to JAX????” At this point I was escorted back out of the Jetway to the gate and the flight boarding commenced. My fellow passenger boarded first and I boarded second.
    To date I have received the following communications from United:
    Voicemail On Thursday: “Hi Mr. Lythcott this is Kimberly Kelly calling to United Airlines call the customer care calling back in regards to your request for a phone call um we are the unpleasant experience you had with our age it um yesterday traveling from to Jackson that so I’ll try your office in your home and if you can’t get a hold of you I’ll call you back in another time or again um please feel free to provide details via email and we can go ahead and start a um a file on the display experience thanks have a great day…”
    On Facebook:
    We have zero tolerance for discrimination, Michael. Please private message us more details so we can look into this. ^CC
    I have not spoken yet with them directly but they now have the full details of the incident with this POST. At no point so far have I received an apology for any of this – not even a perfunctory one. Bless you all and I will keep you informed.
    Like · Reply · 2 mins · Edited

  4. Thank you Mr Graham and Mr Lythcott
    How we perceive an event, our personal history and the specifics of the moment create our experience.
    If every person is viewed of equal value our every day experiences would shift dramatically. When a person or a group or a system acts or fails to act from fear of losing power, or personal safety or fear of tenuous financial security we all suffer.
    We need to care about each other and about choosing to support businesses and people who choose to do what is hard, messy and complicated and definitely takes time and effort–pause and listen and act from a place of love.
    The process matters.

  5. I do not have to ask your political leanings as they are quite apparent. Your comment that discipline and accountability should be internally driven ranks with the liberal notion that you can change your gender just by deciding you do not “feel” like the gender with which you were born. I am sick to death of persons who think the world revolves around them. I suppose your small place in this universe attitude went out with our forefathers. I am a disabled person who will be attending a city council meeting this afternoon at no ease for me because our council decided that this community of small single family residences should not keep individuals from exercising their property rights. They are now permitting a boat and six cars in the driveways and unlimited vehicles in yards on a 100 x 100 lot regardless of neighbors rights and health concerns and declining property values of the neighborhood. Arrogant, narcissists are turning the United States into a 3rd world trash heap. It is people like you who believe they are intelligent that influence idiots. The internet is an example of science run amuck.

    • Clearly discipline and accountability are from within. It takes sometimes years of life’s experience to gain them. And clearly Lee lacks all 3. Discipline can be coached, encouraged, promoted externally, but ultimately it is to every individual to be steadfast, disciplined, principled and willing to be accountable.

      Continuous and over emphasis on these character traits during development can also have counter affects, causing rebellion. The typical teenager that never grows up though his parents are of military grade or lack of parenting also.

  6. I think they should not sell more tickets than the airplane capacity. Because if you buy a ticket is because you want to get there

    • My understanding from an article this morning is that the flight was actually not “oversold.” But, they ended up needing to transport 4 employees and they didn’t anticipate that. They didn’t have seats reserved for these situation.

  7. Mark,
    I really like your article. It hits an area that still has a lot of development needed in leadership development. That is understanding how the system succeeds and how it fails. Of course, individual accountability is an important aspect especially when dealing with negligence but as we’ve learned through years of air crash investigations, pilot error isn’t always the sole cause. If the system in place continuously allows a threat to develop into an error with out installing any active defenses then a mishap will eventually occur. I think it fits with what you are saying as well as with this scenario. Overbooking in my opinion is fraud. It is selling something that you don’t have, plain and simple. Unfortunately my opinion is worth exactly what I paid for it. It has been allowed to continue until finally this widely publicized mishap occurred. The active defenses of travel vouchers weren’t enough and it went way out of control. Once again very good article on how the system failed and created the problem in the first place….Jamie

  8. Very thoughtful Blog, as a person who flies with regularity I was outraged for this passenger and agree United should have offered better incentives until there were volunteers -that said we just flew United and my husband was very ill returning to Cleveland Clinic for care and United went way beyond to help me get him there – really so everything is global and personal

  9. United made an error allowing too many people on board. The doctor passenger made error in judgment. His actions caused his insult and injuries. In my opinion the passenger let his emotions override his intelligence. Why shouldn’t he be accountable for his actions or inactions? I commend Munoz for standing behind his employees.

    • I’m hardly impressed with the passenger’s actions.

      Has it been proven yet that he is a doctor?

      It’s hard to predict how one might respond in a stressful situation and having an airport security officer physically assault you.

      • I’m not sure we can blame the passenger for his reaction to a horrible system.

        It sounded like he had to be somewhere quite possibly saving lives. He was probably already stressed at the delay and his need was driven by his code as a doctor.Being late may harm him professionally as well as financially and emotionally.

        So against that you have the airline who decide after you have boarded that you can get off. Why. well because they can’t plan and are reacting to a simple minor issue with absolutely 0 empathy.

        The system then allowed an acceleration to tactics for removing disruptive passengers, not ones you have just deeply offended, want a huge favour from and at great expense to themselves.

        So like any reasonable human being he asked ‘what’s in it for me?’

        Safety from violence came the respones.

        And then it got personal.

  10. In my opinion this case is color discrimination. United Airline won’t treat a white passenger like that. They asked him to give up his seat because he old and minority.

    • News reports say people in China are very upset about the video. They’re upset that he was treated that way because he’s Asian.

      I’m upset about it because no person should be treated that way.

      The airline claims that their computer “randomly” selected passengers. But I’d bet that they weren’t going to randomly select people with high status in their frequent flyer program.

      • It turns out the passenger is Dr. David Dao, a Vietnamese-American.

        As reported by TMZ and a few other outlets:


        I guess he was being “held accountable” for his bad behavior as doctor when he lost his license in Kentucky? But he’s now allowed to practice in Florida?

        This brings the discussion back to the problems in our healthcare system, drug abuse, etc.

        It doesn’t excuse the airline’s actions or those of the O’Hare security.

  11. Another article on this:

    United’s booting of passenger wasn’t just a PR disaster, it also made no money sense

    United could have sent its employees by taxi about an hour across Chicago from O’Hare airport to Midway airport and put them on a Southwest flight to Louisville, Kentucky, where they were needed Monday.

    The top fare for the Southwest flight between Chicago and Louisville is $243, so under the airlines’ agreement, four United employees could have flown for slightly more than $100 combined with the discount. Southwest offers three nonstop flights from Midway to Louisville on Sundays. The trip takes about an hour.

    Read more here:

  12. I think buying a ticket is a contract. Once breached , it’s a law suit. No matter what it says on the back of the ticket, the printing is collusion. If people would start filing law suits this would end And remove them from business! I don’t think you can sign away your basic human rights!

  13. Comment via LinkedIn:

    Ziad Khashram
    United Airline; When fixing a problem with another problem. People who are on “standby seats” are supposed to be the last people to show up. So the other people of confirmed seats, either came in too late, or their other flight was delayed. The volunteer payout is a nice process they have in place, but they assumed 800$ was enough. The Sad part with all this is that people will treat this with a bad publicity, and PR need to fix its brand image, very unlikely they will review the process after all the problem is “Bad press”. Looking forward hearing updates on this.

    • It wasn’t passengers arriving too late, it was the airline realizing they needed to “dead head” four employees. They realized this too late and had already board the plane full. Yes, this is an operations problem, not just a PR problem.

  14. I agree with the comments regarding misuse of term “oversold”. Rather, United needed to get crew to Louisville and should have come up with a plan other than inconveniencing passengers who had paid for their tickets. If offering cash and/or vouchers did not result in four volunteers, they should have routed the crew through other cities or found a crew closer to Louisville.
    However, the passenger should not have allowed his emotions to get the best of him, nor should United employees or airport police have overreacted. There are many lessons in this for all involved which begin with each individual, as well United and it’s higher ups, acknowledging their errors and honestly seeking to correct them.

  15. Hello,

    I am also a frequent flyer, thankfully not on United. I have found Alaska Airlines and Delta to have much better customer service. My wife was a flight attendant when we met. That said, I have compassion for being a passenger and for the flight crew.

    As a passenger, we often choose our flights with very specific reasons. Behind every passenger is a story . Some of us are business passengers who need to attend a business meeting, which if goes well or bad has serious career implications. Some are about to embark on a dream vacation. Some are going to visit a sick or dying family member. We can fill a book with the stories.

    Flights crews are simply doing what “crew scheduling” tells them to do. I would love to know why 4 crew needed to be on the same plane, seemingly last minute. When did “crew scheduling” know these crew needed to be on the flight? What was the load on the flight the moment they learned that was needed? Was the flight already over booked? Was their available capacity that if the gate agent knew in advance could have made different regarding the upgrade or wait list? What would be the impact to other passengers if these crew were not on board ? Would 100 others passengers on another flight be not be able to get to their destination? Did the customer service agent accommodate some frequent flyers who were booked on a later flight but got to the airport early and asked for their flight to be changed?

    In short, there was a non-random process used to board the plane. The question I have is what is United’s view of a “just” algorithm to determine who should be selected to be removed and more importantly, would the “reasonable person” agree that algorithm is just? If there is gap they will create “customer satisfaction” issues over and over again.

  16. They should say it this way:
    Thank You for flying The Unfriendly Skies of United.
    Maybe Next Time We Will Try to Be More Friendly.
    But don’t count on it.
    This was an inhumane way to treat a person.

  17. Mark, as you mention this is definitely a systemic failure and for the airline to highlight the suspension of the officer as a means to show that something has been addressed lacks any accountability to the poor system the CEO and his managers have created.

    When employees are not given much to any room to address company led failures the above situation occurs. United should just ask Wells Fargo how well that worked out for them.

    • Funny you should mention Wells Fargo, as they were in the news today… they are doing more to hold senior executives responsible for the system they created:

      Wells Fargo Slams Former Bosses’ High-Pressure Sales Tactics
      Board claws back $75 million more from former executives John Stumpf and Carrie Tolstedt

      The report also highlighted how the bank’s push to boost revenue and profit trickled down to thousands of employees who felt pressured to meet unrealistic sales goals. One Wells Fargo branch manager, for example, had a teenage daughter with 24 accounts, an adult daughter with 18, a husband with 21, a brother with 14 and a father with four.

      Here is my blog post about Wells from last September.

  18. Excellent article, Mark. As others have noted, it was not an overbooking situation and I appreciate finding that out. Participants in the system were subject to pressures and in the moment made some decisions which turned out to be terrible ones. I wonder how many times I have reacted the same way (as part of a bad system) but simply lucked out and didn’t make it to the news.

    • Great stuff.

      A highlight:

      Having determined that employees had complied with procedures, it would seem, supporting them would be the right thing to do.

      But they are being rewarded for compliance and this communication further reinforces a culture of do what you are told. In a more enlightened organization, with employees with greater decision making ability, we imagine the airline would have been more communicative, resourceful and effective.

  19. This doctor is a high stakes poker player who played the odds when he found out that he was selected to leave the flight. He knew he hit the jackpot when security was called. He played the race card knowing it had nothing to do with him being Asian. I hope United fights this scam artist. And yes no one should be treated like this, unless you play into their lawsuit which didn’t take long!


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