change management | November 01, 2019

What the Boeing 737 Tells Us About Complexity: Award-Winning Author Chris Clearfield for The Globe and Mail

Earlier this year, Boeing’s 737 Max aircraft was involved in two fatal crashes caused by a malfunctioning sensor. Now, as the company testifies before U.S. Congress, Chris Clearfield considers how Boeing made such a critical error, why it was overlooked by regulators, and what it all says about our ability to manage complexity.  

Boeing’s 737 Max contained what would turn out to be a deadly flaw: a feature called the Maneuvering Characteristics Augmentation System (MCAS) that overpowered pilot commands and pitched the nose of the plane down. How did the thousands of experienced engineers on Boeing’s team make such an egregious mistake? According to Chris Clearfield, it was the underlying challenge of complexity that steered them awry. Clearfield is something of an expert on complexity. Along with Andras Tilcsik, he co-authored Meltdown: Why Our Systems Fail and What We Can Do About It, a National Business Book Award-winner that investigates why the increasing complexity of our systems create conditions ripe for failure.


The failures of complex systems are driven by interactions between parts, rather than the failure of a single element. The MCAS tests showed that in the case of a malfunction, the pilot could simply flip a switch and override the sensor. But the tests were unrealistic, Clearfield notes, because they happened under idealized conditions. “When the problem occurred in the real world [...] the cockpit became awash with conflicting warnings: altitude disagreement, airspeed disagreement and a shaking control stick that indicated that an aerodynamic stall was imminent.” To disable the system, a crew would have to recognize the common factor in “a cacophony of seemingly unrelated warnings.”


“Boeing’s approach to testing points to another lesson in managing complexity: the need to consult with outsiders. As complexity increases in any business, so does the cost of missing things. And outsiders—especially when they point out uncomfortable flaws in our thinking—become more and more valuable.”


Read the full article here.


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