Every episode of Mayday begins with a tragedy but ends with a procedure. Investigators don’t stop at stating that “someone made a mistake.” They break the system down into its core components: decisions, communication, documentation, technical design, organizational culture, time pressure, technological constraints. Only from this puzzle does the real cause emerge.

From an industrial perspective, this is a priceless lesson. While in manufacturing the stakes are usually not human lives, the consequences of errors can still be severe — financially, reputationally, and operationally. A single defective production batch can cost more than a department’s annual quality budget. One overlooked design flaw can return for years in the form of complaints and rework.

That is why in engineering environments — including at Qwerty — process analysis rarely ends with superficial conclusions. The key question is not “what happened?” but “why did the system allow it?” — and what needs to change to make a similar scenario impossible in the future.

1. The Swiss cheese model: disasters are the sum of small failures

Investigators often refer to Reason’s model, known as the “Swiss cheese theory.” Each layer of protection — procedures, technology, training, supervision, design — has its “holes.” A single gap doesn’t cause a disaster. The problem begins when several of them line up.

In manufacturing, the mechanism is the same. A complaint rarely results from a single operator error. It is usually the outcome of overlapping factors: deadline pressure, unclear documentation, outdated standards, insufficient training, unintuitive technical solutions.

At Qwerty, such cases are analyzed systemically rather than personally. Human error is a warning signal, not a verdict. Instead of asking “who is at fault?”, the real question becomes: which safeguards failed at the same time? Was the issue in the design? In communication? In the interpretation of requirements?

This is where Root Cause Analysis (RCA) becomes crucial. RCA is not about finding a quick answer but about asking “why?” repeatedly until you reach the point where the process stopped being resilient to error. That’s the difference between putting out a fire and rebuilding the fire safety system.

2. Routine can be more dangerous than lack of experience

The accident of British Airways Flight 5390 is a classic case that should be discussed in every quality training session. A mechanic installed the cockpit windshield using the wrong bolts — chosen “by eye” instead of according to documentation. Experience told him “this will fit.” During the flight, the windshield blew out.

In production environments, the phrase “I’ve been doing this for 20 years” can be a warning sign. Routine dulls alertness. Over time, people stop checking parameters, stop referring to updated specifications, stop questioning their own assumptions.

Standardization is not bureaucracy or a creativity killer. It is the foundation of stability. Clear workstation instructions, unambiguous parameters, visual standards and references — all of this exists so decisions are not based solely on memory or habit. The process must be stronger than human routine.

3. Communication culture: when silence generates losses

The collision of two Boeing 747s in Tenerife Airport showed how dangerous hierarchy can be. The first officer had doubts but did not challenge the captain’s decision. Authority proved stronger than procedure.

In response, aviation introduced Crew Resource Management (CRM) — a culture in which every crew member has not only the right but the obligation to raise concerns.

In manufacturing, the situation is often similar. An operator notices an irregularity but does not stop the process, fearing a supervisor’s reaction, loss of bonus, or delivery delays. Meanwhile, a few minutes of silence can generate thousands in losses.

At Qwerty, system predictability starts with transparent communication. Mechanisms such as Andon and clearly defined escalation paths are not “soft” management tools — they are hard quality safeguards. A company that wants to be stable must create an environment where raising concerns is a sign of professionalism, not disloyalty.

4. The automation trap: technology does not replace process understanding

The crash of Air France Flight 447 exposed the danger of excessive reliance on automation. When sensors provided faulty data, the autopilot disengaged. The crew, accustomed to system support, lost situational awareness in a scenario that required basic manual flying skills.

Modern manufacturing increasingly relies on automation and control systems — and rightly so. But every technology has limits. When non-standard situations occur, humans must understand the process, not just operate the interface.

From an engineering perspective — close to how our team works — solution design must include failure scenarios. Interfaces must remain readable under time pressure. Information must be unambiguous. Operators must know what a given alert means and what the consequences of each decision are.

Automation should support human competence, not replace it.

5. Poka-Yoke: design systems so errors become impossible

Many episodes of Mayday show that humans can make mistakes at the least expected moments. Fatigue, stress, routine — these factors are unavoidable. That’s why systems must be designed with human imperfection in mind.

In manufacturing, this is addressed by the concept of Poka-Yoke. If a part can be assembled incorrectly — someone eventually will. If two connectors look the same — one day they will be swapped.

Eliminating potential errors already at the design stage means fewer reworks, fewer complaints, and greater process predictability. For technology-driven companies, this is not a detail — it is a quality strategy.

Qwerty – standards that build advantage

Aviation does not accept “human error” as the final explanation. Every accident leads to updated procedures, design changes, and revised training. The system learns from its failures — and becomes safer.

In manufacturing, organizational maturity looks similar. A complaint or failure should lead to a standard update, not just a disciplinary talk. A procedure is not a checkbox document — it is a decision to operate responsibly and predictably.

For us, safety and quality are the result of systemic thinking: design, process, and communication must form a coherent mechanism resistant to time pressure and human error.

Because regardless of the industry, the rule is the same: disasters — whether in the air or on the factory floor — rarely start with a single mistake. They start with a system that has stopped being airtight.

And system integrity is always a conscious choice.