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Poka Yoke Devices and Airlines

There is a news story circulating around about an airliner that missed its designated stop. The control tower tried unsuccessfully to contact the plane for 78 minutes. The plane ended up flying 150 miles past the airport before the pilots re-established contact and turned the plane around.

Could Poka Yoke Devices Prevent This?

Could Poka Yoke Devices Prevent This?

It seems strange to think that a mistake like that is even possible-especially with all of the modern technology that is available to create poka yoke devices.

What are Poka Yoke Devices?

Poka yoke devices are simply tools that prevent mistakes. For example, the little bar in your freezer’s icemaker-the one that keeps ice from spilling out over the bin-is a poka yoke device. In Lean manufacturing, you might see a symmetrical part that cannot be inserted backward. The poka yoke is built right into a design.

How Could Poka Yoke Devices Prevent this Airline Problem?

At this time, there is no official explanation for what happened in the cockpit of that wayward airliner. There are only two things that are certain right now.

  1. Overshooting an airport is an abnormal condition. A process failed.
  2. Pilots are human.

I feel for doctors and pilots and law enforcement. People in service professions are often caught in a lose-lose scenario. Because of the nature of their jobs, any mistakes that are made, whether the individual is at fault or not, tend to become very high profile and subject to much criticism and ‘Monday-morning quarterbacking’.

In fact, I remember a while back seeing an article about how the Transportation Security Administration was overly aggressive with a search at the airport; and on the same day that there was an article about how contraband was making it through security too easily. Talk about a challenging problem!

Two theories circulating about the crew of the aircraft are that they fell asleep, or that they were distracted by an argument. The pilots deny this, but similar events have happened to all of us. I fell asleep during college classes and I also have driven past an exit I wanted when I was distracted by a disagreement with my passenger. I, like the pilots, am human.

Perfection, especially in more critical processes, requires the assistance of poka yoke devices. For example, if the cockpit communication system notes elevated decibels for a set period of time (indicating an argument) or if it does not detect noise for a similar period (indicating sleep), or if it notices a ‘sleep breathing’ pattern, a call could be sent to the cabin crew to check in.

While the job you do or manage may not have hundreds of lives at stake, it is still important to your customers. Leaders should use poka yoke devices to protect their teams, and the people that the teams are serving. Make your processes strong enough that they don’t need human beings to be perfect. 


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  • Tim McMahon says:

    Well, it turns out they may have been distracted by use of personal computers. I wonder if discipline in following a standard protocol is needed. But to your point we are human people make mistakes. I frequently use an alarm on my phone to alert my of times for meeting or when I need to leave to pick up the kids. It is easy to lose track of time out in the shop floor so this is a poka yoke I use. Of course in the pilots situation a number of poka yoke could have been used. It is shame that the pilots nor the air traffic controllers reacted. I wonder if they will be empowered to help create a solution to prevent such a similiar situation in the future or just be made the vilains for making a mistake. One with serious consequences of course but a mistake now the less.

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