Don’t Close the Door on the Most Basic Quality Principles

“The safest part of your journey has come to an end.”

For years I heard these words and thought to myself, “Okay, now I just need to get myself from the airport to my garage.” But lately, I’ve been thinking, “Really? Was I really that safe in the first place?”

It’s hard to tell if near misses in the airline industry are happening at a higher rate, or if the news media is just in its own self-imposed feeding frenzy. The FAA identified 19 serious near miss incidents in 2023, the most in seven years and likely due to a shortage of aircraft controllers. But reliable statistics on aircraft failures inflight are harder to find. Meanwhile, it’s hard to ignore stories about landing gear that fails to deploy, airplanes on fire midflight due to engine failure, or, more recently, the doors on a Boeing 737 Max 9 jet blowing out after takeoff due to missing bolts.

“I think there is a quality control problem,” said Jennifer Homendy, chair of the National Transportation Safety Board, about the Alaska Airlines flight that lost its door midflight. To which I have to say, “I know, right?”

The FAA’s immediate response to the Boeing incident was to recommend more inspections of the aircraft that might be subject to the same failure. While inspections might catch similar problems, inspections won’t prevent quality problems that might arise in the future from processes that are incapable of producing quality outcomes. That’s why we say in the world of lean thinking that “inspections are fundamentally unproductive.” Inspections will typically only catch a fraction of defects present, and they won’t fix a broken process.

Fortunately, airplane travel is indeed the safest way to get from point A to point B, with a 1 in 11 million chance of being involved in a fatal crash. In other words, you would have to take three flights every day for over 8,000 years to become a fatality in an airplane crash and let’s be honest, you don’t have that kind of time.

But when the chair of the NTSB suggests the airline industry has a “quality control problem,” it’s fair to demand that the industry ensure some of the most fundamental practices are not just acknowledged, but put into practice every day. Here are a few practices that might benefit a process known to produce missing bolts.

Fewer handoffs. We learn in driving school that most accidents happen at intersections. Handoffs are intersections of two labor-intensive processes. Labor intensive processes are already error-prone, and the likelihood of an error increases exponentially when one worker is handing off responsibility to another. It was found that the Boeing plant involves the construction of multiple sub-components that would come together in the production of a new aircraft. The door assembly was one of those sub-components. If inspection is to have any value at all, it is at the time that sub-components are joined together during assembly.

Better yet, perform a thorough value stream or swim-lane analysis to reveal all the handoffs in your process. Then redesign the process to eliminate or at least minimize them. Solve this problem for the last time.

Error Proofing. Known in some circles as poka-yoke, or by the less politically correct “idiot proofing,” the practice involves identification and elimination of error prone parts of a process to reduce the likelihood of failure. Envision a process that is incapable of producing an error, and you have the right mindset to start. In actual practice, the goal is to “make it easy to do the right thing,” and that takes the form of unambiguous job aides, visual controls, and forced functions. There are volumes of literature devoted to this practice and not enough room here to scratch the surface.

If the culture in your organization is essentially “do the best you can,” then you really need to take a closer look at these methods.

Mindfulness. According to a study conducted by the Harvard Business Review, it was found that more than half of American employers offer some type of mindfulness training to their workers. This is a great start, but how many employees are actually using it? The purpose of mindfulness is to be in the present moment, free of distractions, with full concentration on the task at hand. Multi-tasking is inconsistent with mindfulness because while computers may be able to multi-task efficiently, human beings cannot. We ultimately sub-optimize most of the activities we are trying to accomplish when we are either multi-tasking, or otherwise not fully present.

I learned about mindfulness from my sister, a practicing Buddhist, who has been studying Zen principles for over a decade. We discussed the process of putting bolts on an airplane door, and I asked her to run that scenario through the lens of mindfulness. “If I am putting in bolts,” she said matter-of-factly, “I am putting in bolts. I am completely in the moment with this task.” Her remarks may seem overly simplistic to the uninitiated. To demonstrate the point, ask yourself, have you dined in a restaurant, eating a wonderful entree, while wondering what’s for dessert? Have you talked on your cell phone while taking a walk through the park? Thinking back on what you might have missed, you might understand how you, too, might have completely missed a bolt.

It is also important that employee incentives are properly aligned. In response to the incident with their 737 Max 9 jet, Boeing has announced that their bonus incentive plan, which was previously based largely on financial performance, will instead be based on quality and safety metrics.

It will not be one intervention that eliminates errors. If an employee is performing a task mindfully, but the process contains handoffs or other error-prone steps, then failures will inevitably occur. Only a relentless quality team can ensure that when it comes to the bolts, they are in the right place, at the right time, and at the right tension. That will produce the kind of door you can open and close with infinite confidence.