The flight attendant on United Airlines got my name wrong three times yesterday. She checked her passenger list when she asked for my food order, but the list was no longer laid out like a seating chart. It used to be that way -- the passenger names were organized into a grid that corresponded to the seat arrangement in the cabin -- but a recent change in the IT system changed the layout. And now the flight attendants struggled to match the names with the people in the seats.

This wasn't a big deal to the passengers, but it was clearly frustrating and a little embarrassing for the flight attendants. They wanted to provide high-quality, personal service (yes, I know, hard to believe, but at least on the United PS Service between JFK and SFO this is true), but they kept calling people by the wrong name.

Presumably, someone in the IT department made a change to the way that passenger names were printed on the manifest for a reason. However, without talking to the downstream customer -- the flight attendants -- the change created all kinds of waste.

The complexity of organizations and IT systems means that changes in one area usually have ripple effects farther down the value stream. If you don't talk to your internal customers before you make the changes, you're likely to create problems that undermine larger corporate goals (in this case, providing high service levels).

Obviously, I don't know what went into this change, but it seems as though the IT folks didn't look downstream before crossing.