Better Products Need Better Cultures (GM Ignition Switch)

This page provides reference material for Decomposition Creates Dysfunction on Substack.

Lectures: See also Systemic Complexity, for video lectures on dysfunction at GM and Boeing, and a primer on The Beer Game.

Additional References:

• The Valukas Report (from the NHTSA Website)

• GM Airbag Non-Deployment Archives - The Center for Auto Safety

• GM Fires 15 Employees Over Recall Failures (WSJ), which discusses the failure to change part numbers, but not the cultural impacts as to why the failure may have occurred.

Following is my final draft of the Substack article above, including detailed references and annotations.

Decomposition Creates Dysfunction (GM - Substack version).pdf

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Idea in Brief:​

When products result in scandals, an immediate response is to find a bad actor to be blamed, but this fails to recognize how bad actions are the result of systemic dysfunction.

Specialization has allowed for advancements in technology, but in turn requires the decomposition of work into small pieces. The whole becomes less than the sum of its parts, leading to dysfunction and catastrophic failure.

This article views General Motor’s “Ignition Switch” scandal of 2014, through the lens of Systems Thinking and Prevention Focus. It develops a counternarrative to that which was in the news, looking at decision-making in not only the switch, but also in the software development team who chose to use that switch in airbag safety circuitry without informing the company that they were doing so.