Alaska Air Flight 1282 was on a trip from Portland to Ontario, California, on January 5, 2024. Barely six minutes into the flight, passengers heard a loud bang and a whoosh as the door plug in the middle section of the aircraft blew out. An unused exit door in the mid-part of the aircraft’s main cabin detached and fell out of the sky. One of the passengers sitting close to the opening lost his shirt, which was ripped off by the sheer strength of the wind. Fortunately, he was not sucked out of the plane because of the seatbelt. There was total chaos in the cabin. The plane was able to land back, saving 174 passengers and six crew.

It was a Boeing 737 Max 9 jet. A preliminary investigation by the National Transportation Safety Board (NTSB) showed that four key bolts meant to hold the door plug in place were missing. This apparently happened at an outsourced factory where work was done to close an unused door frame. The Federal Aviation Authority (FAA) ultimately ordered a temporary global grounding of Boeing 737 Max 9 jets.

NTSB image showing the gap in the midsection of the fuselage of Alaska Air Flight 1282.

Prior to this incident, two Boeing 737 Max 8 jets crashed in Indonesia and Ethiopia in 2018 and 2019, killing 346 people on board. A U.S. House investigative report in 2020 concluded that these accidents were a horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA. How a company such as Boeing, with a reputation for safety and quality, has come to the present conundrum is intriguing.

According to a recent report, several factors over the years might have led to these disasters. It all started in 2001 with the relocation of Boeing headquarters to Chicago from Seattle, where most of the manufacturing was located. The objective was to have a “neutral nerve center.” In 2022, Boeing relocated again to Arlington to be near their defense and space businesses. This placed the management further apart from the production facilities in Seattle.

Another reason is a sharp focus on shareholder value, which started with the acquisition of McDonnell Douglas in 1997. A resolute cost culture was initiated, benefiting Boeing share prices, which did better than even big tech companies such as Apple and Meta. From 2000 to 2018, Boeing shares posted total annual returns of 29.5 percent, surpassing Microsoft (21.7 percent), Apple (19.6 percent), and Alphabet (18.0 percent).

The third reason cited was the ill-fated “Partnership for Success” program initiated in 2011. Through this program, Boeing outsourced the manufacturing to various suppliers to save costs. The outsourced companies were also asked to cut prices by 10 to 15 percent with the threat of being placed on a “no-fly” list. As a result, a large bulk of manufacturing was done out of Boeing’s direct oversight.

The fourth allegation about Boeing was that engineers with practical experience were kept out of the managerial roles, and important decisions were made by executives with little experience about the jets who were solely focused on the bottom line.

Relevance to medicine

How is this door plug blowout in a plane relevant to medicine? Patient safety has been at the forefront of medicine in the U.S. since the Institute of Medicine published “To Err is Human” in 1999. Medicine has also learned from the impeccable safety record of the airline industry, adopting several measures, such as pilots’ pre-flight checklists for operating rooms.

The current practice of medicine in the U.S. faces several pressures, including financial. The landscape of medical practice is rapidly changing with disappearing independent practices, and currently, 74 percent of all doctors are employed by a hospital, health system, or corporate entity. Medical practices and hospitals are also targeted by venture capital companies. Physicians and clinicians are removed from the driver’s seat, and important decisions regarding patient care, quality, and safety are made by others.

The problems of focusing solely on financial aspects and profits in the health care industry are manifold. It is easy to cut corners to increase profits, but quality and safety monitoring and implementation will be compromised. Staff reductions are an excellent way to increase the bottom line, but they will invariably affect the organization’s capacity to run various quality and safety programs that are not immediately revenue-generating. Changes in the quality and safety metrics can be very subtle and might not show up in the outcome results immediately. The remaining employees are likely to compensate for the deficiencies in the short term. The breaking point happens when they are not able to compensate anymore and major cracks will show up. Quality and safety culture in medicine needs constant nurturing, evaluation, reporting, redirection, and education. An operation geared solely to generate profits will miss this.

The leadership of the current health industry is populated by non-medical personnel. This could be a problem in the long-term, as Boeing has experienced. Boeing relied heavily on management personnel rather than experienced engineers to make decisions about production, safety issues, and daily management. A similar situation is brewing in the medical industry. Physicians are increasingly unsatisfied, burned out, and not being heard. They are rapidly losing control over the main operation of health care, i.e., treating the patient. They have no influence over the decisions taken about the day-to-day operations of the industry. Care systems are designed and run without their input. Appointing physician leaders to decision-making positions will obviate some of these issues. It is also imperative that those leaders consider quality and safety issues primarily rather than just financial viability.

Venture capitalists and large corporations must accept the reality that quality and safety are important in the health care industry and expensive in the short term. Without quality and safety, there will be no profit in the long term, so short-term expectations may have to be curtailed.

The relocation of the headquarters far from the factory floors in Seattle where the actual assembly took place was a fatal flaw in Boeing’s saga. This is in anathema to the Japanese business notion of Genchi Genbutsu. The literal meaning of the word is “go and see for yourself.” This is a vital concept of the kaizen philosophy aimed at continuous improvement. Going out and seeing and understanding the actual work of a process or system with one’s own eyes to make informed decisions is the philosophy behind this idea. The best way to improve is to observe the whole process, identify the deficits, and decide how it can be improved. Management can convey a commitment to improvement and appreciation for the work done by the employees by following Genchi Genbutsu. Gemba is where the action takes place. Executives are encouraged to conduct periodic “Gemba walks” to places where work is done instead of spending time in the offices or meetings. Gemba walks are the way the principle of Genchi Genbutsu could be observed. These two terms are closely related.

The Toyota Production System, meant to achieve quality and safety, espouses these two concepts. If Boeing executives had done regular Gemba walks and indulged in Genchi Genbutsu, the problems involving the Max 8 and 9 planes could possibly have been avoided, even though final investigation reports from the NTSB are still pending.

In the health care scenario, executives must routinely visit hospital floors, various departments, or outpatient clinics. This translates into regular Gemba walks by the executives and management who can apply the principle of Genchi Genbutsu.

P. Dileep Kumar is a board-certified practicing hospitalist specializing in internal medicine. Dr. Kumar is actively engaged with professional associations such as the American College of Physicians, Michigan State Medical Society, and the American Medical Association. He has held a variety of leadership roles and has authored more than 100 publications in various medical journals and a book on rabies (Biography of Disease Series). Additionally, he has presented more than 50 papers at various national and international medical conferences. Several of his papers are widely cited in the literature and referenced in various textbooks.