Process improvement opportunities are everywhere. Even in the steps in the New York City subway.

That’s the case of a remarkable story reported by NBC:

[The] video shows person after person tripping on the seemingly innocuous step in the middle of the staircase. Some catch themselves instantly; others fall straight to their knees.

…

The dangerous step, it turns out, is a half-inch higher than the others. Stairway design guidelines call for risers to be a minimum of 6 inches and a maximum of 7 inches, according to MTA spokesman Kevin Ortiz. The allowable variance is 3/8 of an inch.

How is that a half-inch makes all the difference? Watch the video for yourself to see:

At first glance, it’s amazing to think that the MTA could make this kind of mistake. Surely every part of construction is checked and double checked. And certainly once a station is completed, officials doing a final inspection would notice a step that wasn’t quite right.

But if you watch the clip closely, it’s obvious why the problem wasn’t caught sooner. Every person who trips blames themselves. In fact, this may be the most fundamental challenge with any business process improvement effort: we tend to think that we are the problem and don’t look for problems in the system.

Long before you can improve workflow in your own organization, you have to find out what is not working right. And before you can address those issues in a meaningful way, you must try to demonstrate that the problem is not the people, but the system.

That’s the secret of process improvement: focus on the process, not the employees. People make mistakes. Are you setting them up to make more by giving them uneven steps?