“….the current and former employees point to the single, fateful decision to change the system, which led to a series of design mistakes and regulatory oversights. As Boeing rushed to get the plane done, many of the employees say, they didn’t recognize the importance of the decision. They described a compartmentalized approach, each of them focusing on a small part of the plane. The process left them without a complete view of a critical and ultimately dangerous system.”
The link below to a New York Times article about the Boeing 737 MAX describes a fascinating story of poor design decisions, a lack of systems thinking, and functional organizations with pieces of ownership - yet seemingly with no one in charge of the complete system. In this case, the failures were rather serious.
Another interesting finding from this story was the lack of “challenge” to the baseline assumptions about a systems behavior. Since the fundamental decisions were not challenged, the design changes were made without a careful risk assessment. They lacked a “systems architect” who was overseeing the changes and their implications, and the impact to overall system performance. A perfect case study in engineering management failure with sad consequences.