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Tiny, Tiny Problems

April 6, 2011

Southwest Airlines Flight 812 developed a 6ft hole in the fuselage midflight from Phoenix to Sacramento. Photograph: Ho/Reuters

By John Munce, Deployment Executive, The Tatham Group

I could be the guy in 12D listening to my headphones when the roof comes off.  Pop go my ears. Down drops the oxygen mask.  Off we go to an emergency landing.  All this happens because of some tiny, tiny cracks in a sheet of aluminum.

How could this happen? The plane was an old stand-by, an industrial-strength, proven workhorse. The engineers knew cracks like this could occur.  The repeated stress of pressurizing and depressurizing the cabin can cause the small cracks.  Based on testing, they were not expected for 60,000 flights.  This plane is two thirds of the way there.  Shouldn’t happen.

The Boeing engineers were no fools.  They’ve worked to make a science of predicting when problems might occur and then work to create the fix before it’s needed.  Yet this surprised them.

That should be a cautionary tale for all of us who manage processes.  Most people are good at taking care of the big things: wings still on? Check. Engines work? Check.

Do we pay equal attention to the tiny, tiny problems?  Maybe not exactly equal.  We’ve got to check the engines every time we fly.  Even the now very cautious Boeing engineers say you should check for the tiny cracks about every 500 flights. How carefully should be attend to the little things?

An old boss used to say, “Any time you see something that’s not right, stop and take care of it then.”  His theory was better to clean a small spot than to have to scrub down a stinking mess.  I have to admit that the little things I stopped to fix weren’t the ones that got me in trouble over the years.

One time a colleague, Rose, decided to take care of what she thought was a simple, tiny problem.  She wanted to know why there were a few thousand dollars of losses from the secured credit cards.  This was on a portfolio of billions.  But it bugged her.  A secured card is tied to a savings account in the bank so that any losses on the credit can be immediately recouped from the savings account.  There should never be any losses on the P&L.

Why were there little losses?  Rose and a teammate poked and prodded and followed the threads in the system.  They discovered a flaw in the system logic that allowed some cards to go to losses. Simple fix. Problem solved.

The payoff was much bigger, though.  That same logic flaw applied to all cards.  The potential impact was huge. No one had ever thought to test this particular logic chain. Rose uncovered a big risk because she’d looked at a tiny, tiny problem. Those Boeing engineers wish they’d had some indicator to check the metal fatigue before tiny, tiny cracks became a big problem.

  • Great post John. I had a conversation yesterday where a team member brought up her fear that the leaders of the organization would stop once all of the big items of the project were implemented. She felt like she was working herself out of a job as they wouldn’t allow her to continue past the project phase to fix all of the tiny, tiny problems. The analogy made was that leaders tend to overhaul the engine every two to three years instead of investing in regular maintenance. How many times have we seen that? Your story reinforces the importance of ongoing monitoring and care.