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The Boeing 737 Max crashes represent a failure of systems engineering

The 737 is an excellent airplane with a long history of safe, efficient service. Boeing’s cockpit philosophy of direct pilot control and positive mechanical feedback represents excellent human factors1. In the latest generation, the 737 Max, Boeing added a new component to the flight control system which deviated from this philosophy, resulting in two fatal crashes. This is a case study in the failure of human factors engineering and systems engineering.

The 737 Max and MCAS

You’ve certainly heard of the 737 Max, the fatal crashes in October 2018 and March 2019, and the Maneuvering Characteristics Augmentation System (MCAS) which has been cited as the culprit. Even if you’re already familiar, I highly recommend these two thorough and fascinating articles:

  • Darryl Campbell at The Verge traces the market pressures and regulatory environment which led to the design of the Max, describes the cockpit activities leading up to each crash, and analyzes the information Boeing provided to pilots.
  • Gregory Travis at IEEE Spectrum provides a thorough analysis of the technical design failures from the perspective of a software engineer along with an appropriately glib analysis of the business and regulatory environment.

Typically I’d caution against armchair analysis of an aviation incident until the final crash investigation report is in. However, given the availability of information on the design of the 737 Max, I think the engineering failures are clear even as the crash investigations continue.

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Visiting an operational missile cruiser

I was recently offered an incredible opportunity to spend a day aboard an operational U.S. Navy ship, meeting the crew and observing their work as they conducted a live fire exercise. The experience blew me away1. I came away with new appreciation for our surface forces as well as observations relevant for defense acquisition policy and systems engineering.

Naval Base San Diego

Americans are more disconnected than ever before from their military. To help develop awareness of the Navy’s role, Naval Surface Force Pacific occasionally invites community leaders to visit the fleet in San Diego. I felt very fortunate to be included as one of eight participants in an impressive group including business leaders, community leaders, and a district court judge who created a successful veterans treatment court.

The day began with a tour of San Diego Bay and the many ships docked at Naval Base San Diego. Our guide was Captain Christopher Engdahl, Chief of Staff of the Naval Surface Force Pacific.

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System lexicons and why your project needs one

A system lexicon is a simple tool which can have a big impact on the success of the system. It aligns terminology among technical teams, the customer, subcontractors, support personnel, and end users. This creates shared understanding and improves consistency. Read on to learn how to implement this powerful tool on your program.

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An Engineering Touchstone to Enable Successful Designs

Successful systems are created by engineers who understand and design to the ultimate objectives of the project. When we lose sight of those objectives we start making design decisions based on the wrong criteria and thus create sub-optimal designs. Scope creep, group think, and simple convenience are frequent causes of this type of variation. An effective design assessment tool is a touchstone by which we can evaluate the effectiveness of ongoing design decisions and keep the focus on the optimal solution.

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Agile Government Contracts

Agile is a popular and growing software development approach. It promotes a focus on the product rather than the project plan. This model is very attractive for many reasons and teams are adopting it across the defense industry. However, traditional government contracts and project management are entirely plan-driven. Can you really be agile in a plan-driven world?

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The Role of the Human Systems Integrator

This article is required reading for anyone who needs to hire, wants to become, or is going to be working with an HSI expert. Understand what the job entails, the key skills required, and how it relates to the rest of the systems engineering effort.

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