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Scandalous Product Failures

Updated: Dec 27, 2023

In 2014, I was consulting inside the offices of a well-known engineering firm, by chance the same week that the GM CEO was testifying to the US Congress about failures leading to 124 deaths and a multi-billion-dollar recall. At the time the key problems at GM appeared to be a failure in properly managing the engineering change process. However, the engineers at my client chose to follow GM's failed change practices, even when my team pointed to the similarities. In short, the engineers who were about the same age as many of my students, were more concerned about appeasing their CEO than in following what the GM CEO referred to as "Engineering 101" business processes. But over the next few years, in the course of teaching this scandal, I felt that GM's legal team was misdirected, and while their conclusion was not inaccurate, it also did not lead to authentic improvements at GM. This is discussed in the article below.

In 2019, in the midst of teaching the Ignition Switch recall, the second Boeing 737 Max crashed, and of course we discussed that. Similar to the GM case, I researched what information was known from the crash investigation and newspaper accounts and wrote the following article with respect to Boeing.

My premise is that our business and engineering methods based on decomposition and reductionism are fundamentally flawed, and the source of these scandals are systemic, and not due to individual actions. Humans are building systems in pieces, which are too complex for humans to understand in their entirety. These articles fit into my post on Systemic Complexity, and you can find lecture videos there.

Better Products Need Better Cultures (GM Ignition Switch)

Better Products Need Better Cultures
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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 cultural dysfunction.

  • Products are developed based on requirements, the completion of which are decomposed across many groups (for example, the Systems Engineering "Vee-model"). It is this decomposition which creates dysfunction and leads to scandal.

  • This article details how the decomposition approach led to the General Motors ignition switch recall. It further discusses how the legal team which investigated the scandal reinforced the “bad-actor” fallacy, and it provides a counter-narrative to the legal report.

Additional References:

Complexity Beyond Imagination (Boeing 737 Max)

Complexity Beyond Imagination
Download PDF • 539KB

Idea in Brief:

  • Modern products are increasingly intelligent, and their development increasingly complex. Such complexity is managed through documented requirements, but these are decomposed and assigned to subgroups, eventually leading to a lack of product clarity and organizational dysfunction.

  • The Systems Engineering methods used to manage complexity are not up to the challenge, and we need Systems Thinking. Product Lifecycles are more complex than we can imagine, and we need to reduce, rather than manage, complexity.

  • This paper investigates how complexity and dysfunction led to two crashes and the eventual grounding of the Boeing 737 Max aircraft and notes similarities in the case of the GM Ignition Switch Recall

Other Stuff

Digital Enterprise Society Podcast

Interview on this topic with Craig Brown of the DES. 141: Solving Complex Problems with Systems Thinking - Digital Enterprise Society.

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