Flying Blind: The 737 MAX Tragedy and the Fall of Boeing by Peter Robinson (Penguin Business, 2021) is also an enthralling history of a massive accountability sink. I learned a huge amount from Gill Kernickâs Catastrophe and Systematic Change: Learning from Grenfell (London Publishing Partnership, 2021) about another case study in which interlocking systems combined to create a tragedy that couldnât systematically be pinned on any single organisation, let alone an individual.
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My friends Chris Clearfield and AndrĂĄs Tilcsik literally wrote the book on complex failure and why itâs on the rise. Meltdown, their engaging, and at times terrifying, book explains the âshared DNA of nuclear accidents, Twitter disasters, oil spills, Wall Street failures, and even wrongdoing.â Like me, Chris and AndrĂĄs were influenced by sociologist Charles Perrow, who identified risk factors that make certain kinds of systems vulnerable to breakdowns.
My engineering background had made me a fan of Perrowâs groundbreaking book Normal Accidents, first published in 1984, which had a lasting influence on expertsâ thinking about safety and risk. Perrow focused on how systems, rather than individuals, produce consequential failures. The importance of that distinction cannot be underestimated. Understanding how systems produce failuresâand especially which kinds of systems are especially failure-proneâhelps take blame out of the equation. It also helps us to focus on reducing failure by changing the system rather than by changing or replacing an individual who works in a faulty system.
From a cybernetic point of view, itâs interesting as an example of how the systems and structures mattered so much more than the individuals involved. The development of the Friedman doctrine into the intellectual backing for the leveraged buyout boom and the private equity industry are best seen as a conflict between two comprehensive systems of interest, both of which might have regarded the other as a threat. The great unremarked class struggle that happened in the 1970s and 1980s was that between capitalism and managerialism.
The managers lost this struggle, pretty comprehensively. And as weâve seen, the combination of the blind spots in management and the blind spots in economics came together to produce an ideology which was bound to remove management capacity. And that created further blind spots, and further reduced the systemâs ability to cope with shocks. The story of how we got to where we are is a story of the attempts of the system to cope with this, and to search for short-term equilibrium.
Micheal Jacksonâs Creative Problem Solving (John Wiley, 1991) is probably the one read if you really fancy having a go at applying management cybernetics to a real-world consulting assignment, although many friends swear by The Fractal Organization by Patrick Hoverstadt (John Wiley, 2011). Of course, Eden Medinaâs Cybernetic Revolutionaries (MIT Press, 2011) is the definitive account of what really happened in Chile.
Among many works detailing the state of management science, Iâd recommend Management Studies in Crisis: Fraud, Deception and Meaningless Research by Dennis Tourish (Cambridge University Press, 2019) and Nothing Succeeds like Failure: The Sad History of American Business Schools by Steven Conn (Cornell University Press, 2019). It is a bit of an indictment of things that H. Thomas Johnson and Robert S. Kaplanâs Relevance Lost: The Rise and Fall of Management Accounting (Harvard Business School Press, 1987) is still itself every bit as relevant today as when it was published.