| One of the biggest systems-level failures in recent memory is the Boeing 737 MAX story. I read this article and your comment and then went looking for an autopsy, found this: "The Boeing 737 MAX: Lessons for Engineering Ethics (2020)" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351545/ It's an example of a workaround that should not have been tolerated: > "The Maneuvering Characteristics Augmentation System (MCAS) software was intended to compensate for changes in the size and placement of the engines on the MAX as compared to prior versions of the 737." Rather shockingly this wasn't even an engineering problem workaround; it does seem that it was solely designed to avoid an aeronautical reclassification of the aircraft that would have required pilots to undergo an expensive retraining program on flight simulators, which might have caused lost orders. This does look like a systems-level failure, but one at an organizatonal level: the system went from a state where engineering took priority, to a state where financialization took priority. In systems thinking, this could be called a state transition: a fluctuation takes place, and afterwards the system settles down to a new (apparently) stable state quite different from the old state: > "One factor in Boeing’s apparent reluctance to heed such warnings may be attributed to the seeming transformation of the company’s engineering and safety culture over time to a finance orientation beginning with Boeing’s merger with McDonnell–Douglas in 1997 (Tkacik 2019; Useem 2019). Critical changes after the merger included replacing many in Boeing’s top management, historically engineers, with business executives from McDonnell–Douglas and moving the corporate headquarters to Chicago, while leaving the engineering staff in Seattle (Useem 2019). According to Tkacik (2019), the new management even went so far as “maligning and marginalizing engineers as a class”." |