Lessons in complexity learned from Boeing Max 8 tragedies - Canadian Occupational Safety

Using Boeing’s 737 MAX as a case study, Brady detailed how a series of seemingly minor technical and organizational missteps—each a "grain of sand"—accumulated to create a condition ripe for disaster. He described the Maneuvering Characteristics Augmentation System (MCAS), initially designed to enhance flight safety, which instead became a pivotal factor in the crashes due to reliance on faulty sensors and inadequate pilot training.

"Imagine a hill of sand," Brady said, using a metaphor to clarify his point. "Each grain of sand is a decision, an action taken during the design and development of a system like the Boeing 737 MAX. Over time, these grains accumulate, building a hill. It only takes one additional grain, seemingly insignificant, to trigger an avalanche."

This analogy struck a chord with the audience, as they understood the need for safety professionals to not only focus on the apparent causes of incidents but also to understand and address the underlying systemic vulnerabilities that could precipitate a crisis.

"The real issue," Brady continued, "is not just the technological failures but also how organizational culture and processes contribute to these systemic risks. At Boeing, the shift from an engineering-driven to a cost-driven culture created a steeper hill, making the system more susceptible to failure."

The implications of Brady’s analysis extend beyond aerospace, touching every industry where complex systems play a critical role. His call to action for safety professionals is to foster an organizational culture that prioritizes a deep understanding of systemic interactions over a superficial treatment of individual failings.

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2024-05-06 05:30:24Z
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