10 seconds to failure!

10 seconds can be the difference between success and downfall.

Recently, I really enjoyed watching this. The programme is packed with learning points for safety practitioners, leaders of industry and academia that can be unpacked for years to come. Here is a few of my initial take away points for my own and others reflection:

What can we learn?

Boeing should have grounded their aircraft after the first incident. I would suggest that they lost a lot once the general public found out that this hadn't occurred. Rather, Boeing chose to blame human error of non US pilots for the downing of the first aircraft rather than understand the point of failure. This is a key learning point that whilst human error may play a part, blame should not bias any investigation.

A change of leadership changed everything

After 30 years, Boeings leaders changed and one has to wonder if the tragic outcomes would have manifested if the leadership had remained. Nevertheless, on the surface this change of leadership appeared to be a critical factor to the cause of these two dreadful incidents that led to the fatalities of 346 people. Clearly, little by little the culture of the organisation changed an organisation that once had safety at it's core, one person described had 'fell apart'.

"It didn’t happen overnight, it happened one little piece at a time".

When watching the programme you can see the family feel that the organisation traditionally had and can hear the feelings of pride, happiness and belonging prior to the leadership change. One employee describes when something wasn't right, she knew she could bring it up and not fear any consequences. It appears that the traditional leaders understood the critical value of safety and in my opinion safety should be a team effort where all the employees (regardless of rank or position) be in it together, watching each others backs and helping one another.

What is interesting from watching is how Boeing purposefully moved it's operations from Seattle to Chicago. It appears that this move allowed separation from the technical people so that executive could make financial decisions without challenge.?

"Boeing quit listening to their staff"

Boeing withdrew their headquarters to a different part of the country in order to make changes and they did this as they believed and knew that they would get push back from their engineers. Organisations must have challenge as without it, there is no growth, no opportunity to think differently, no way of providing a means of expression or a voice of and to the people. Organisations are led from the top, but leaders are from within the ranks that can steer an organisation to success.

Leadership can come from everyone - it is not confined to senior people (Jupp, 2021).

Organisations must listen to their staff (Lloyd, 2020), (Carillo, 2020) as the staff are the greatest asset that they hold. I love Richard Branson's approach to business with a view to looking after their staff and the staff will look after the customer.

However, Boeing moved towards a just get things done attitude, with less staff and expecting more, cheaper and with speed being of the essence with a system where time is money and money is time. Prior to the Lion Air Flight 610 and Ethiopian Airlines Flight 302 crashes, the reputation of Boeing as a global entity for aircraft manufacture was second to none, however what took years to build was damaged in a second.

"Profits more important that human life"?

One person said that "the laser focus on safety that had been traditional, had been compromised". Prior to the leadership change, shortcuts were not taken and quality control was valued in order ensure a right first time approach with no Foreign Object Damage (FOD) being a potential for bringing an aircraft down. One person describes how aircraft 'fly by wire' which was interesting and logical way to think that one mistake in the reams of wiring that is contained within aircraft can cause a fire and ultimately bring a large object down into a largely populated area killing hundreds of people.

The pressures from Wall Street however, greatly steered this once global success to global doom. Decisions around the boardroom table can and does (as history has shown us), endanger the general public. The total cost is estimated to be $20 billion in fines, compensation and legal fees with indirect losses totalling $60+ billion from 1000+ cancelled orders.?Greed leads to loss and loss of human life shows how profits are lost where you take this approach. We live in a competitive world and we can see just how much that is true from Boeing's tarnished reputation whereby Airbus thrived and the pendulum swung in Airbus' favour. So we can see that you must do it right, build in the quality and safety and the rest will take care of itself. Not doing so, is at your own peril.

Leaders have to build an environment of incubating a learning environment, an environment of trust, a place of care and a place where relationships are key to driving safety forward.

I would suggest that parts of this programme, will make a great training resource for organisations around the globe to show the devastating affect of what can happen when there is a change from safety to profit. I for one, will certainly be reflecting on how these lessons can change the future and how I can apply the lessons to be learned.