Technical design flaws, faulty assumptions about pilot responses, and management failures by both The Boeing Company (Boeing) and the Federal Aviation Administration (FAA) played instrumental and causative roles in the chain of errors that led to the crashes
The themes identified
What were these management failures? The report identifies several issues.
- There was enormous financial pressure on ensuring the Boeing 737 Max program could compete with the Airbus A320neo aircraft.
- There have been faults in design, particularly on the MCAS system which was n to identified as safety-critical.
- A Culture of Concealment was developed by Boeing, with the company withholding information from statuary agencies and clients.
- There was a conflict of interest between Boeing and the FAA both in terms of representation and “influence”. This led for example to too much delegation of oversight from the FAA to Boeing engineers.
It is evident that there is a vital organisation component
behind, and probably a great illustration of what happens when putting profit before safety.
It also shows how management decisions take unintentional routes when not well thought. For example, the report outlines how internal documents reported already in 2013 that plans existed to avoid increasing costs by minimising the impact of the MCAS system. As this would have required additional training for airlines, its impact was not disclosed fully (up to the point that references to this system where removed from the manuals for the pilots).
Internal engineering supervision failed within Boeing, privileging the “business objective” and “profitability” side.
Many of the interviews pointed out about a culture change underpinning Boeing operations, that moved to be focused on financial benefit rather than technical solutions and innovation as a setting. This is evident from the fact that the new aircraft had technical issues since the beginning, most of them hidden or downplayed by Boeing.
When things go wrong… scapegoating
The investigation in the aftermath of the accident showed the typical pattern of scape-coating that follows an event where a rippled culture change happened. Boeing tried to blame pilots, airline maintenance, a software provider etc.
Production ramp-up came with many safety concerns raised by several employees. But no actions followed through. Boeing introduced “Countdown clocks” into the MAX program, ensuring these were visible by employees. The workforce was exhausted to match the delivery plans, yet the program continued. Several supervisors were genuinely concerned about the fact that serious process breakdown that could happen is employees were continued to be pushed to their limits.
The report concludes with a mandate to Boeing to “restore its reputation as a company focused squarely on safety and quality”. They analysed that the company did both not things right nor the right things, showing failure in management and leadership.
What do we learn?
I share the view this report is essential reading for any HR and Company Executive. In a moment where ideas of agile working get diffused around the world as a way to better tackle efficiency and profits, what is the risk of giving up safety for lighter control and profits only?
This case shows the real effect of culture corrosion, where internal consistency moves the organisation into dangerous behaviours. Incentives entirely focused on production quotas and profit, have put in the second instance the relevance of safety and the engineering tradition of a recognised large corporation.
A clear example of how organisational awareness
and internal consistency
play a critical role in the way we manage our organisations. The action of every manager and leader has consequences, that we need to consider, thinking holistically and for the long term.