Episode 2 – Sorting Through the Clustershambles
In this second episode, I define the term “maximum clustershambles” and explain the concept of the “Framework of Failure.” I will also introduce five major themes that run throughout the story and lay out how the series is organized.
Please share your views, insights, and opinions through the MAX8 Podcast Comments form. Episode 12 will be dedicated to feedback from listeners such as you.
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EPISODE HIGHLIGHTS:
(1:40) – What is a Maximum Clustershambles?
(4:01) – How is the MAX a Maximum Clustershambles?
(12:15) – Introducing the Framework of Failure.
(18:07) – Why My Podcast?
(19:22) – Five major themes of this podcast series.
(21:47) – How My Approach Can Be Helpful.
(22:55) – Summary of episodes.
(29:12) – Key terms.
KEY POINTS:Defining “Maximum Clustershambles.”
Clustershambles is a bad situation that involves many different smaller situations coming together to create one massive, insanely intense ordeal.
Maximum Clustershambles is more than that: a massive, protracted situation in which many clustershambles are baked into events in multiple places and at different times. An intractable problem where the same incident, accident, or disaster happens repeatedly and where resolution is elusive.
The Framework of Failure.
This framework provides a structured, comprehensive way to organize the elements of a failure story. The elements are divided into four sequential phases, and their connections are explored.
The Context of Failure: represents the business, technological, and workplace settings where a need or problem emerges and the seeds of failure and disaster are sown. Serves as the essential backstory.
The Structure of Failure: represents the observable defined arrangement of individuals and technology, creating a precise cause-and-effect mechanism that can potentially generate an accident or disaster. This is often the story of technical design, including how that design comes to be.
The Occurrence of Failure: the failure event itself - the sequence of specific events, decisions, and actions that constitute a disaster, accident, or mistake. Exists within a tightly bounded time frame, starting with a specific triggering event and ending with an accident.
The Response to Failure: People's various, often competing interpretations of the disaster story afterward, generally in groups with shared interests. Creates the historical narrative we remember and can involve intense conflict over blame, liability, and technological and regulatory change.
Major themes of this series.
The complicated and somewhat dysfunctional relationship between Boeing, the airlines, and the FAA – and the evolution of the 737 in airline fleets over fifty years – drove questionable business decision-making by all parties.
The evolution of airline operations and the introduction of innovative technologies and automation changed the nature of the cockpit, the pilot's role in it, and the relationship between them, creating unanticipated tensions and interactions.
The MAX program’s key business goals shaped the mindsets and daily behaviors of Boeing’s employees – the engineers, managers, and test pilots – in ways that took on an unhealthy life of their own.
The fragmentation of knowledge across Boeing and the FAA led to a dangerous form of organizational ignorance. People played their positions, but few asked tough questions, and no one seemed to have led.
The narrow use of established business methods and processes contributed to failure in the design of MCAS, particularly in risk assessment and certification. A view that meeting certification requirements would be "sufficient" for safety won out over a view that considers basic regulatory compliance a “dirt floor” of sorts, inadequate for creating safe products.
As a result, MCAS underwent a dangerous but mostly overlooked evolution over five years during the MAX’s development, from a modest software function used in a very rare high-altitude situation to a more powerful and less safe function that could occur during takeoff. Tied to this was an assumption about how pilots would react to an MCAS failure that proved to be fatal.
Key terms.
Causality - The active, direct relationship between cause and effect or cause and its consequences.
Complexity – A situation in which the interactions among elements are not only deeply intertwined but also difficult to observe and predict—appearing random and often leading to totally unexpected outcomes caused in unclear ways.
Socio-technical - the idea that in so much of what we do today as humans, there lies a rich dynamic, or relationship, between us and our technologies. These interactions become distinct and complex things all to themselves, often difficult to observe, understand, predict, and control.
Summary of episodes.
The series is organized around the four phases of the Framework of Failure, addressed in order.
Episodes Three and Four are about the Context of Failure. They include a brief history of commercial travel, the history of Boeing’s remarkable commercial jet business, a discussion of four industry forces that are central to the MAX story’s context, and the business backstory of the MAX8 program that led to the creation of MCAS.
Episodes Five and Six are about the Structure of Failure. Episode 5, titled “MCAS is Conceived,” introduces the technology and describes why it was created and how it was originally designed. Episode 6, titled “MCAS Drifts,” describes its dangerous evolution over the course of four years during the aircraft’s development.
Episodes Seven and Eight are about the Occurrence of Failure. They describe the two crashes in detail. Episode 7 addresses Lion Air, and Episode 8 addresses Ethiopian Airlines. This also includes the remarkable and disturbing clustershambles that unfolded between the two crashes.
Episodes Nine and Ten are about the Response to Failure. Episode 9, titled “What Was Said and Done,” reviews all the major categories of Response events systematically and concisely – “just the facts.” Episode 10, titled “What This All Means,” focuses on several distinct storylines to illustrate how reactions, interpretations, and subsequent actions have shaped, and continue to shape, the public’s understanding of what happened.
Episode Eleven combines all the pieces of the Framework of Failure to draw conclusions about causality based on the information at hand.
Episode Twelve offers the perspectives and conclusions provided by you, the listeners. The Framework is meant to be a tool to drive dialogue. So, please provide your comments on the BradIvie.com website: Click the “Podcast” tab at the top of the page to access all podcast episodes and the online form available here to submit comments or questions.
USEFUL EPISODE RESOURCES:
Kurzweil, Ray. 2024. The Singularity is Near: When We Merge with AI. Penguin Books.
Tavory, Iddo, and Stefan Timmermans. 2014. “Abductive analysis: theorizing qualitative research.” University of Chicago Press.
Vaughan, Diane. 1997/2016. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. University of Chicago Press.
THINGS YOU CAN DO:
Let me know your thoughts.
Please share your views, insights, and opinions. Episode 12 will be dedicated to feedback from listeners such as you.
You can contact me through the MAX8 Podcast Comments form. While I may not be able to respond to all comments, I will read each one carefully. I’m very interested in your thoughts.
Download my Framework of Failure description.
The Framework of Failure is summarized in a six-page PDF that can be downloaded. Access is at the bottom of the Home Page at BradIvie.com.
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Please sign up to receive periodic email communications from me, primarily announcements of new podcast episodes and (in the future) blog posts. The signup form is at the bottom of all web pages on BradIvie.com.
Share this episode with friends and colleagues.
This podcast is created for many audiences: business professionals, management consultations, aeronautics industry professionals, aviation enthusiasts, policymakers, and the general public. Please share this episode with those who you feel would be interested in this story and benefit from the information provided and the analytic approach taken. Or perhaps the video trailer for the series.
