Missing the Iceberg – avoiding project failure through killing or redefining it in time webinar, 6 September 2022
•
0 likes•567 views
Missing the Iceberg – avoiding project failure through killing or redefining it in time webinar Tuesday 6 September 2022 APM Systems Thinking Specific Interest Group Presented by panel members: Hugh Buckley, Cesar Rendora, Tony Thornburn, Simon Tinling, Amanda Whittaker and Andrew Wright The link to the write up page and resources of this webinar: https://www.apm.org.uk/news/missing-the-iceberg-avoiding-project-failure-through-killing-or-redefining-it-in-time-webinar/ Content description: Most project professionals have found themselves on a project where success looks unlikely, yet nobody does anything about it. Why is this? Flagging up that a project is heading for failure is typically a career limiting move - the messenger bringing the bad news get blamed. This panel delivered webinar on Tuesday 6 September 2022 explored a simple approach to how we, as project professionals, can flag up the need for changes to projects (or even killing them), in a way that avoids being blamed personally. This approach can be used in any context where stakeholders don’t want to hear changes are vital. Getting commitment to reshaping or killing a failing project without the messenger being killed.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Missing the Iceberg – avoiding project failure through killing or redefining it in time webinar, 6 September 2022
Similar to Missing the Iceberg – avoiding project failure through killing or redefining it in time webinar, 6 September 2022 (20)
More from Association for Project Management
More from Association for Project Management (20)
Recently uploaded
Recently uploaded (20)
Missing the Iceberg – avoiding project failure through killing or redefining it in time webinar, 6 September 2022
- 1. We’re doomed. Doomed! Missing the Iceberg – avoiding project failure through killing or redefining it in time Or - How do we stop digging and get out the hole when our project or programme can’t succeed?
- 2. The People Amanda Whittaker – customer-focused business transformation expert Andrew Wright – founder member and APM Co-Chair of the APM Systems Thinking SIG. Managing Partner, Dynamic Technologies Ltd Cesar Rendora - Head of Engineering & Technical Assurance (Major Programmes & Projects) at Jacobs Simon Tinling - Head of Requirements & Inventory at Nuclear Waste Services Tony Thornburn, Chair Behçet’s UK (rare disease charity). Alliance Network Chair Central and South Genomic Medicine Service Alliance. Hugh Buckley - specialist in Project, Programme, Change and Business Transformation Management
- 5. Doing nothing is no longer an option VUCA Complexity Dynamic, interacting key decision factors Volatility High rate of uncontrolled change Ambiguity Lack of clarity about target outcomes Uncertainty Lack of clarity about present/future states
- 6. Can wasteful projects be killed/adjusted?
- 7. PROJECT
- 8. How – A proven approach
- 9. How – A Proven Approach 5. Prepare, socialise THEN present three to five thoroughly thought-through alternatives 2. What are the success criteria? 1. What’s the problem with the project? 3. How do they interlink? 4. Can we meet the needs?
- 10. 1. Review the ‘problem’ situation – what may prevent success? https://www.apm.org.uk/blog/using-systems-thinking-to-identify-the-right-problem/
- 11. 1. Review the ‘problem’ situation – what may prevent success?
- 12. 737 Max The Problem © Steve Lynes from Sandshurst, United Kingdom, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons
- 13. 2. Understanding the success criteria of all the stakeholders Profit Available Internal Funding External investment Working capital Business performance Sales Dividend Product/service price performance Business cost R&D Cost cutting CEO President CEO COO President CEO Delivery COO Sales D Delivery
- 14. The Iceberg Model EVENTS PATTERNS & TRENDS UNDERLYING STRUCTURES MENTAL MODELS
- 15. 737 Max success factors
- 16. 3. Understanding how different stakeholders’ success criteria are interconnected Profit Available Internal Funding External investment Working capital Business performance Sales Dividend Product/service price performance Business cost R&D Cost cutting CEO President CEO COO President CEO Delivery COO Sales D Delivery
- 17. 737 Max: How were ‘problem’ and ‘success criteria’ interlinked?
- 18. 4. Can the proposed solution can really meet the business need?
- 20. 5. Prepare, socialise and present 3-5 thoroughly thought-through alternatives
- 21. 5. Prepare, socialise and present 3-5 thoroughly thought-through alternatives
- 22. Apparent project success…BUT… fatal quality and safety flaws leading to tragic accidents Faulty Design assumptions - engineering concerns ignored Financial and timescale pressures - Boeing exerting too much influence over the FAA Culture of concealment - beliefs in safety overwhelmed by drive of revenues profits When could the 737 Max team have changed course? The deeper we look, the earlier the signs? EVENTS PATTERNS & TRENDS UNDERLYING STRUCTURES MENTAL MODELS 2001? 2016 2017 2019
- 23. What options might the 737 Max team have proposed when MCAS became safety critical? Delay the delivery to make MCAS multi-sensor/multi-channel (avoiding single point of failure)? Develop additional pilot training to ensure they knew of MCAS and how to deal with an in-flight failure? Reduce the power and authority of the MCAS solution and compensate for this with significant pilot retraining? Do nothing: Maintain project delivery to schedule, but with unmitigated safety and reputational risks?
- 24. The Approach: Recap 4. Understand whether the proposed solution can really meet the business need i.e. meet all the success criteria 3. Fully understand how solving the problem and success criteria are interlinked 2. Understand the success criteria of all the stakeholders 1. Review the ‘problem’ situation – why won’t it succeed? What are the success criteria? What’s the problem with the project? How do they interlink? Can we meet the needs? 5. Prepare, socialise THEN present three to five thoroughly thought-through alternatives
- 25. Selecting options: Key Points 1. Make the options logical and bomb-proof 2. Exclude contentious options “beyond the brief” 3. Don’t recommend an option
- 26. Contact details APM Systems Thinking SIG: https://www.apm.org.uk/community/systems-thinking-sig/ More about Systems Thinking “Systems thinking in project management" https://www.apm.org.uk/blog/using-systems-thinking-to- identify-the-right-problem/ COVID crisis full webinar (60 min): https://www.youtube.com/watch?v=XXTZMraBD5o Remote working short video (17 min): https://youtu.be/bepLRCCwC70 Remote working full webinar (60 min): https://www.youtube.com/watch?v=1QO1SEDZUSM&t=1054s Project success and fitness-for-purpose: “Project Success and Quality: Balancing the Iron Triangle” Wright A J and Lawlor-Wright T F, Routledge 2018
- 27. END And thank you for joining us
Editor's Notes
- Andrew Hello, everyone! It’s often difficult or impossible to change the course of a project or programme we feel is heading for failure without limiting your career. We’ve all experienced this and got together to share our thoughts on how to tackle this.
- Amanda - I’m Amanda and I’m ….. Andrew – I’m a long-term project and programme manager and consultant that has seen too many of other people’s projects fail because too little was done too late, and have suffered personally on my own projects for flagging problems up Cesar - – I am a chartered civil engineer and a practicing project professional. Experienced in the planning and delivery of major engineering projects both in the UK and overseas. Also, I have been a ST SIG committee member for two years now. Simon – I've spent most of my career working on complex equipment and infrastructure projects. I'm currently working to establish conditions for success (and avoidance of failure) at the front end of a large nuclear infrastructure project. Tony – ex-military, with some time as a Programme Manager in MoD Abbey Wood circa 2000, and then lecturer in Systems Engineering, Cranfield University. Now in the charity sector, dealing with the health services and the same issues that haunted me in defence acquisition are apparent elsewhere. Hugh - I spent my career setting up and running complex programmes around technology and infrastructure and most recently, Business Change and Transformation. And like others here, I've some very painful personal experiences from finding myself in these sorts of situations!
- Andrew Many projects are sponsored that can never succeed because the selected solution cannot solve the perceived problem. This causes change, delays, cost-overruns, each having environmental penalties, leaving P3M's to carry the blame. Perhaps the purpose wasn’t clear – the benefits and outcomes not set at the start? Alternatively, was the focus on solution specifications not business requirements? Was the durability of the solution ignored? Or was the focus so tightly on delivering on time and on budget the solution was so descoped it delivered no benefits As fighting climate change becomes ever more important, we can’t afford current levels of failure.
- Hugh When we started to look at what's really going on and the major factors relating to programme success or failure, we began to identify four domains that seem relevant...So in no particular order… Firstly, the expectations of Stakeholders (who may or may not include the end customers) Secondly, the Programme Delivery itself – by which we mean the selected approach or solution, the capability, and the delivery of all that to the time, cost, and quality measures that we're all so familiar with Thirdly, any contractual and commercial arrangements that are essential to make the programme successful And Finally, the needs and benefits of the Programme is attempting to satisy – in effect the justification for doing this in the first place. [Start video] These four domains all usually start off sufficiently aligned in the early stages of any programme – how else do you get the approval to proceed? So why do projects or programmes head into trouble – or even become “doomed”? As time progresses and things change, or new information emerges, or key assumptions are shown not to be valid, then one or more of these four domains is likely to diverge dramatically from where it started. And this typically, is what we see as projects and programmes head into trouble. Amanda ____ Comment from Hugh (7th June). The scenarios we initially explored which cause this divergence were: 1. Shift in expected Programme Delivery (capability, time, cost, quality etc). E.G. Invalid assumptions, new information, original solution choice no longer viable / optimal etc. 2. Shift in the external context / environment the Programme is operating in…E.G. Political, Economic, Social, Technological etc. 3. Shift in stakeholder expectations…E.G. Change in organizational structure, business operating model, business strategy / plan, senior personnel Also - Commerical domain is least likely to shift on its own and most likely to be problematic if either (a) poorly setup up initially (incentives driving the wrong behaviours, insufficiently flexible) or (b) is not changed to keep pace with other changes in the programme as a result of 1,2,3 above?
- Andy Things change as time passes: - Contexts change, - Requirements emerge - Uncertainties are resolved - Assumptions are refuted What seemed a good idea at the time now looks like a white elephant. Post COVID there is less funding available but more change needed - projects need to be much more successful! Killing/correcting non-viable projects early on i.e. those that will not deliver the target benefits, or have adverse environmental impacts, would offer huge benefits.
- Tony Ok, so how can P3M's validate whether a project can succeed, and if not, convince stakeholders of either: the changes necessary to make success possible, or the need to kill the project quickly? Cost-cutting almost always creates disproportionate benefits-cutting. Descoping to "save" sunk costs often results in little or no benefit; it should be canned altogether. Examples could be: The Garden Bridge and Irish Sea bridge which were successfully cancelled before total large expenditure Both HS2 and the GWR electrification have been descoped against rising costs, delivering less benefit for more cost Simon …. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++[Finish Here] NB: The MOD attempted to adopt this approach following the Strategic Defence Review (SDR)* in 1998, seeking to streamline the procurement process in order to minimise overspend and delays in MOD equipment programmes; the introduction of Smart Acquisition (Initial Gate and Main Gate) where a decision to 'go or no-go' was taken at Main Gate. https://researchbriefings.files.parliament.uk/documents/RP03-78/RP03-78.pdf [*The UK spends, on average, £9-10 billion on defence procurement each year. Following consistent criticism from the National Audit Office of inefficiencies within defence procurement spending, the Strategic Defence Review (SDR) in 1998 sought to streamline the procurement process in order to minimise overspend and delays in MOD equipment programmes.]
- Simon ….So whose responsibility is it to call out a failing project and convince stakeholders of the changes that may be needed? It has to be the people who know about it! Your project needs you! Corporate cultures vary dramatically, and departments and projects can have their own sub-cultures; all of which influences how empowered you are, and believe you are, to raise concerns, and how they will be received. Raising a concern in a culture that doesn’t empower you or provide what is often called "psychologically safety", can be seriously stressful and even career-limiting. None the less, it is our professional duty to act in the best interests of our employers and clients. It's unprofessional not to speak up. A well-known example is Roger Boisjoly , the American engineer who raised strenuous objections to the launch of the Space Shuttle Challenger months before the loss of the spacecraft and its crew in Jan 86. Boisjoly correctly predicted, based on earlier flight data, that the O-rings on the rocket boosters would fail if the shuttle launched in cold weather. Managers decided to launch the shuttle despite his warnings. He presented a single recommendation, leaving managers the simple choice of accepting or rejecting that recommendation. Tony over to you....
- Andy We’d like to present a simple approach, suitable for all industry sectors, that applies practical psychology, to raising the need for change. This 5-step approach avoids conflict between project stakeholders and project team and minimises loss of face by both, through deepening and sharing understanding of the situation and likely consequences in different scenarios. The Institute of Civil Engineers publication “A Systems Approach to Infrastructure Delivery” supports this approach
- Andy Here are those 5 steps. [CLICK] What’s the problem with the project? - Review the ‘problem’ situation – why do we think it won’t succeed [CLICK] What are the success criteria? Understand the success criteria of all the stakeholders [CLICK] How do they interlink? Fully understand how solving the problem and success criteria are interlinked [CLICK] Can we meet needs? Understand whether the proposed solution can really meet the business need i.e. meet all the success criteria [CLICK] Prepare, socialise and present three to five thoroughly thought-through alternatives They do not form a simple linear flow – some backtracking may be needed – but one thing is vital – do all the spade-work before step 5! Step 1 addresses the ‘what’ that is going wrong questions, and steps 2 to 5 address the reasons ‘why’ it hasn’t or isn’t being addressed.
- TT So the first step is understand the problem – Why do you as the responsible project manager need to do this? Well you've got to establish some facts, from which to argue your case. Systems thinking offers powerful tools and techniques to overcome group-think, optimism bias and confirmation bias. Review the Purpose of the project or programme – is/was this fully understood and agreed by everyone /what has changed? [C:LICK] All kinds of tools and models can be used, and the adage KISS (keep it simple..) is applicable. Often "a picture is worth a thousand words", and it is easily shared, comprehended and indeed modified. Actor Maps for example - Identify what and who is involved: internal and external, and the policy environment within. Do not assume all behaviour is driven externally. Culture in any enterprise is a powerful, and sometimes, divisive force Another way of presenting graphically, to illustrate to your boss/senior line-manager what is going on is by using animated Venn diagrams (as used earlier, and easily built in PowerPoint for example). [Click], [Click] A project is successful when the customer says it is (because it addresses the genuine need – provided the need was identified correctly in the first place of course!). There is no glory in delivering what you were asked to, on time and on budget, if it doesn’t work! And you'll probably end up carrying the can. So, one has to identify why do I have a concern? Be honest and objective. What are the criteria against which it will fail? Consider establishing your “Top Cover” to do the full analysis, if it’s needed. So a. Do I need top cover to investigate? b. Or maybe a mediator?
- Simon The next major issues is that Business needs have to be considered as an ecosystem – this isn't merely a 'Bottom Line issue' Has the problem really been identified and defined properly, or just a solution proposed? Have the boundaries of the problem really been probed? Who or what does it rely upon, without which one has no control? How does the problem interact with external factors? What are the barriers to understanding problem? Culture, resources. Authority/Influence. Fear Is it a complex or merely a complicated problem? In sum, looking at the success criteria and identifying the options for moving forward is fundamental. Let’s illustrate this with the 737 Max. Hugh... +++++++++++++++++++++++++++++++++++++++++++ 1.Ref NAO Initiating successful projects 1 Dec 2011 (Purpose, Affordability, Pre-commitment, Project set-up, Delivery and variation management)
- Simon The next major issues is that Business needs have to be considered as an ecosystem – this isn't merely a 'Bottom Line issue' Has the problem really been identified and defined properly, or just a solution proposed? [CLICK] Have the boundaries of the problem really been probed? [CLICK] Who or what does it rely upon, without which one has no control? [CLICK] How does the problem interact with external factors? [CLICK] What are the barriers to understanding problem? [CLICK] Culture, resources. Authority/Influence. Fear Is it merely a complicated problem or complex? [CLICK] In sum, looking at the success criteria and identifying the options for moving forward is fundamental. Let’s illustrate this with the 737 Max. Hugh... +++++++++++++++++++++++++++++++++++++++++++ 1.Ref NAO Initiating successful projects 1 Dec 2011 (Purpose, Affordability, Pre-commitment, Project set-up, Delivery and variation management)
- Hugh – The Boeing 737 Max was conceived as an evolution of the 737 and a competitive response to Airbus's hugely efficient A320neo. But it had a fundamental problem which ultimately resulted in 2 fatal crashes costing 246 lives, and $ billions for Boeing. The central problem was that the technical solution needed for this major development of the plane – MCAS - had itself to be evolved during the design process to the point that pilots – who weren’t due to be trained in it at all – didn't know what it was doing or how to override it. MCAS became a safety critical element with a single point of failure,but wasn’t designed as safety critical – the aircraft had become fundamentally unsafe. Making it safe would also violate other key business requirements – avoiding pilot retraining for example – as well as extending delivery times – with huge cost & reputational implications for Boeing. Going back to the 4 domains we discussed at the start, you could view this as a divergence between Programme delivery and the Needs & Benefits.... In effect, some assumptions the Programme started with turned out not to be valid. And this reality wasn’t ultimately accepted until after the second fatal crash. Amanda
- Amanda Step 2 – understand the success criteria of ALL the stakeholders Different roles have different, sometimes conflicting, success criteria. These need to be fully understood and validated at an individual level in the context of the programme. Recognising the key success criteria for all stakeholders is important to building a consensus between them for changing the project/programme.
- SIMON - Iceberg model – Voice Over The Iceberg model is used a lot in systems thinking as we seek to penetrate beneath surface appearances to where the real drivers of project success or failure may be found. [CLICK] Events – are simply what we can see on the surface [CLICK] Patterns of behaviour and trends that develop over time [CLICK] Underlying structures that influence and drive the patterns that we see [CLICK] And at the deepest level – the mental models and beliefs from which the structures are created
- Amanda In the case of the 737 Max, How might a clear understanding of success drivers and interaction of those success drivers have revealed the threat both to its passengers and to Boeing itself? E.g. Commercial success, Boeing reputation etc
- Hugh Step 3 – understand how success factors interact Why model how success criteria are linked? To identify and understand Conflicts of interest Supporting interests Modelling the interlinks helps us to understand where we have supporters and detractors the divergence of stakeholder success drivers areas of tension between stakeholders May even help reveal competing success criteria for some stakeholders - Personal vs professional interests e.g. bonuses versus Accountability! All of this helps us to engage or manage our stakeholders more effectively Other models may prove helpful as well. Applying the Iceberg model can also help reveal the different drivers in the situation Actor maps and causal loop diagrams help understand the relationships and dynamics in the situation Andy
- Andy Increasing the MCAS power meant the 737 Max had become unsafe, but ignoring this ticked everyone else’s boxes – their success criteria were satisfied; together they overrode safety concerns Boeing’s failure tragically demonstrated that ensuring balance across the key success criteria is vital (quality / safety / commercial / timeliness ) but Different stakeholders are likely to have more dominant drivers due to their role. So how are success criteria driving your “Titanic” project What needs to happen to bring different perspectives back into acceptable balance?
- Cesar – Step 4 – will the solution deliver what’s needed? We need to look through the windscreen at where we’re headed. Has the solution we’re delivering been verified as really meeting all the business needs? Can it meet the success criteria? Have the outputs been mapped to target outcomes? If we are to fail, we should Fail-fast – that may require studies, concept demonstrators, proof-of-concept, simulations, digital modelling before heavy expenditure, but if those haven’t been done effectively, there are key threats: Andy - The solution is solving yesterday’s problem, not tomorrow’s Amanda - It doesn’t fix the whole problem, just moves the problem elsewhere Tony - It’s overlooked some of the elements necessary for success Simon - Not all Key Requirements were defined at the outset and won’t be achieved as planned e.g. Resources , Training, End users? Hugh – Its not meeting the essential quality criteria – maybe its not even safe! Cesar – From the Customer perspective, if we deliver to current plans will they be satisfied (and pay!) ? We need to check out Options and scenarios, redoing if necessary some verification activities. Systems thinking tools can be very quick and cheap to do this If we can, engage trusted experts not involved to date to carry out critical reviewing - Red team reviews/rock throwing/testing – to bypass group-think [Click] It’s not quite a crystal ball, but …
- Simon – In allowing commercial success to dominate, aircraft safety was compromised. This caused two fatal accidents, damaging Boeing’s reputation It demanded regulatory scrutiny that resulted in grounding the entire fleet until its safety had been addressed (which turned up a couple more design flaws!) The initial focus was on commercial success [Click] However, this compromised aircraft safety [Click] Which in turn resulted in fatal crashes [Click] Damaging Boeing’s reputation [Click] and triggering Regulatory scrutiny [Click] Ultimately stealing the commercial success originally targeted. [Click] Had COVID not removed demand for aircraft temporarily, the Airbus offering could easily have scooped the pool, and only Boeing’s position as a key defence contractor would have made it too important to fail.
- Hugh - Having gone through the previous steps to understand the situation thoroughly, we get to Step 5 - Preparing the options to make sure the right one is selected Why invest all the effort in multiple evaluations when you know only one is the right one? Andy - The psychology of managing up is important – the stakeholders/bosses want to make the decision. If you make a single recommendation {CLICK}, their options are to accept it or make an ill-informed alternative decision of their own {CLICK}.
- Andy. If you present multiple options, their options are all laid out for them to make a fully-informed decision {CLICK}, clearly showing the impact of each option, and they are likely to choose 1 [CLICK] Hugh - What goes into the option evaluation? Cesar – All the relevant factors you can identify, including stakeholders’ success criteria e.g. Market movement, opportunity loss, cost, delays, viability, achievability Hugh - How many options? Tony - 3 – 5 depending on what makes sense in the circumstances Include the “do nothing” option is de rigeur, but needs truly fully evaluating (including whole-life/through-life costs) as it puts a spotlight on what is going wrong! Hugh - How much effort in evaluating the options? Amanda – Be Comprehensive, do a global business impact assessment but be context sensitive Scenario 1: The boss loves and trusts you and your judgement and is the final arbiter – light touch Scenario 2: The boss loves & trusts you & your judgement but has to convince others who don’t – deep dive Scenario 3: The boss doesn't love or trust you or your judgement and has to convince others too – deep dive Use ST Tools and techniques because "a picture paints a thousand words".
- HUGH - These key findings come from the US Congress investigation into the background to the accident [CLICK] Apparent project success – lucrative commercial launch amidst intense competition …BUT fatal quality and safety flaws revealed through two tragic accidents [CLICK] Faulty Design and Performance assumptions breaching Boeing’s own design rules. Engineering concerns and whistle-blowers ignored [CLICK] Tremendous financial and timescale pressures. Boeing exerting too much influence over the FAA in relation to certification. And even later, FAA were the last regulator to ground the plane. [CLICK] Culture of concealment. Beliefs in safety and quality gradually overwhelmed by beliefs in the preeminence of revenues and profits [CLICK] 2. SIMON - Iceberg model – Voice Over So when we look at the findings from the investigations, we can see how they relate to the Iceberg model that we discussed earlier. [CLICK] [CLICK] And then finally, thinking about when and how these various levels show up, we find that the deeper we look, the earlier the warning signs and the earlier the opportunities are to change course. [CLICK] So when might the 737 Max team have changed course and what alternative options could they have developed? NEXT SLIDE ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ BACKGROUND AND BRIEFING MATERIAL: Rough timeline (from Wiki) 2010 - intent had been to to do a completely new plane, but decision to proceed was postponed 2011 - Competition from Airbus A320neo forced Boeing into a re-engine 737 instead (neo was 15% reduction in fuel burn). Cost of re-engine version c.$2-3B vs $10-12B for a new plane 2015 - first test aircraft produced 2016 - first test flight 2017 – FAA certification and first planed entered service. Estimated $12-15m operating margin per plane delivered at a list price of $122m each (although sales were heavily discounted) 2019 – 2 plane crashes – Boeing deny any design issues and FAA slow to ground the planes 2020 – plane was allowed to flay again; Boeing paid $2.5B in a criminal settlement; plus $several-billion in other costs (not to mention share price impact) Background / References: Ref: House Committee on Transportation and Infrastructure final report: https://transportation.house.gov/imo/media/doc/2020.09.15%20FINAL%20737%20MAX%20Report%20for%20Public%20Release.pdf Exec Summary Pg12 – 5 central re-occurring themes affecting design, development, certification and FAA oversight. Tremendous Production and Financial pressures to meet goals / targets - extensive efforts to cut costs and maintain programme, some even jeopardising safety Faulty Design and Performance Assumptions – failed to classify MCAS as a safety critical system, MCAS able to activate on input from a single Angle of Attack sensor, its operation also breached Boeing’s own design guidelines, Culture of concealment – in relation to FAA, its customers, and pilots. Pilots not informed of existence of MCAS system, failed to disclose that the AOA Disagree alert was inop on vast majority of planes, despite being certified with it as a standard feature; concealed flight sim test data that revealed it took test pilots more than 10s to respond to un-commanded MCAS activation – described as “catastrophic”; Conflicted oversight structure between FAA & Boeing, jeopardising safety. E.G. Concerns raised by “Authorised Representatives (AR’s – Boeing employees representing FAA’s interests) as early as 2016 not investigated or responded to properly by Boeing, and not reported to the FAA. Boeing Influence over FAA’s oversight structure – FAA own technical experts over-ruled by FAA management at the behest of Boeing, affecting morale of FAA staff as well as integrity of the process and safety. FAA culture reportedly ‘overly concerned with achieving business cantered outcomes’. In summary: FAA failed to ensure safety of the traveling public Boeing Production pressures – costs, schedule and production pressures undermined safety Boeing failed to classify as a safety critical system, concealed critical information, and sought to diminish focus on MCAS to avoid increased costs and greater certification and training impact AOA Disagree Alert – Boeing concealed information from customers, pilots, FAA that AOA Disagree Alerts were inop, despite them being mandatory on all aircraft. FAA failed to hold Boeing to account 737 Max Training – economic incentives led company to lack of transparency with FAA, customers, pilots… compromising safety Boeing and FAA gambled with public safety in aftermath of the first crash, with the FAA failing to take actions to avert the second crash Scary fact…FAA’s own risk assessment in 2018 estimated that without a fix to MCAS, there would be potentially another 15 fatal crashes resulting in over 2900 deaths over the fleet’s lifetime – but it still permitted the plane to continue flying !
- As non-experts and Boeing outsiders, we can’t really know... but here are some speculative possibilities of options that might have been developed once it became apparent that the MCAS solution was safety critical. Referring back to our iceberg model, it's apparent that any presentation of these options would need to tackle the underlying mental models and structures that had allowed the project to get into this state, and (through the 'do nothing' option) call out the unmitigated safety and reputational risks that were later seen to materialise in catastrophic events.
- Andy We've gone through our 5-step process, which we have tested and proven to work. Review the ‘problem’ situation – why won’t it succeed? Understand the success criteria of all the stakeholders Fully understand how solving the problem and success criteria are interlinked Understand whether the proposed solution can really meet the business need i.e. meet all the success criteria 5. Prepare, socialise AND ONLY THEN present three to Five thoroughly thought-through alternatives We hope it will be useful and effective the next time you’re faced with managing an uncomfortable situation upwards
- Cesar We have some key points about the options you evaluate: Make the options logical and bomb-proof – no visible bias towards any option Exclude contentious options “beyond the brief” – if the management want to explore other options, help them Don’t recommend an option - leave it to the management to decide, Then it’s their skin in the decision, not yours Tailor option presentations to the individual stakeholders - their interests and perils
- Presented by: Andy Thanks for joining us today – I hope we’ve prompted many thoughts about handling managing up differently