The Essence of Problem Solving #7 — The Privately Co...

> TL;DR: A fighter jet ground crew member secretly had a duplicate nose-wheel lock key made to skip the tedious cockpit handover — and worked at "anomalous efficiency" for three years until a single forgotten lock caused a serious incident. The operator was fired; so was the manager who fired him. The essence of the problem was not human error but a management system in which rule-breaking was the rational choice — and in which three years of abnormal efficiency went completely unnoticed. The cure is fail-safe (Poka-Yoke) design, not a test of human nature. The Surface Symptom: A Serious Procedure Violation In fighter jet ground operations, one safety rule is absolute: the moment an aircraft lands and comes to a complete stop, the nose wheel must be locked immediately. The standard operating procedure (SOP) was excruciatingly elaborate — ground crew had to set up a ladder, climb up to the cockpit to take the key from the pilot, climb back down to lock the wheel, and after the task, climb back up to return the key. Faced with this tedious, time-consuming, physically draining repetition, one crew member decided to "improve efficiency": he secretly had a duplicate key made. He...