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Psychological Safety: the Missing Piece in Good Design.


(The following blog post has been written using information and direct quotes held on public record.)



I want you to imagine that you have a well-established, rock solid business. You are a leader in your industry with a prestigious reputation. You have deep pockets for research and development and you have some of the brightest minds available. You need to create an innovative product that customers will buy.


"You would have every reason to be confident that you’re going to knock it out of the park."

And yet once the product is sold, within a short time you need to withdraw it from market and your exceptionally intelligent designers will be described as “clowns who are supervised by monkeys.”


It might be humorous if it wasn’t for the fact that I’m alluding to the Boeing Max aeroplane, of which two aircraft crashed, killing 346 people.


What went wrong technically?


A basic rule in human factors when designing equipment, machinery and products is to have an obvious way of reversing an action or event when things go wrong. In other words you need to know what to do to put things right; however it seems that the pilots had a lack of information about how to override an aspect of the plane's auto-pilot. The lack of information proved to be critical, when investigators found that the auto-pilot had malfunctioned because of what’s thought to have been faulty sensor readings.


Even if we ignore the potential of a poorly designed sensor system which relied on only one sensor, there was nothing in the design that made it obvious to the pilots about how to regain control of the plane. Furthermore no training was provided to prepare pilots to know what to do in that situation.


What were Boeing employees saying behind the scenes?


So now it’s time to step back and try and understand how Boeing got into such a mess. How do you get into a situation where Boeing employees say things like ‘this is a joke, this airplane’s ridiculous’, or even before the first crash: “Would you put your family on a Max…? I wouldn’t”.


Simulator Training


Lion Air was the airline that operated the first plane that crashed. Lion Air contacted Boeing before it put the plane to work, asking about pilot simulator training. It was discovered that a Boeing employee said to another employee the request was down to Lion’s “own stupidity” and called the airline “idiots.” Following the catastrophic events, Boeing have stated that before the grounded plane returns to the sky pilots will undertake simulator training.



Why didn’t Boeing Want Pilots Trained?


A Boeing employee who was developing computer-based training for the new plane suggested the pilot manual should have more detail on handling possible emergencies, but he was told that the company couldn’t add more information because doing so might lead to regulators digging deeper. The regulator might then insist on extensive training for pilots flying the new planes. Boeing’s thinking was that training would take time, be expensive and could put off airlines who were thinking about buying the plane, at a 100 million dollars a piece.


The same employee who wanted more detail in the manual said he thought training would be important. Responding to his concern that training should be provided, a senior Boeing official said that’s “Probably true, but it’s the box we’re painted into,with the senior official then adding it’s: “A bad excuse, but (it’s) what I’m being pressured into complying with.”






An investigation also showed an email trail where workers congratulated each other for using "Jedi mind tricks" to persuade regulators that simulator training wasn't necessary. In further emails, one worker said: ‘I honestly don’t trust many people at Boeing’


And another worker said after both crashes: "I still haven't been forgiven by god for the covering up I did last year. Can't do it one more time. The Pearly gates will be closed."


All this shows that ethical standards at Boeing had slipped way below what they should have been.


It all points to a lack of psychological safety, where people feel safe and comfortable airing their concerns and they’re confident they can make things better.

But there was a feeling of powerlessness. As one employee said:I don’t know how to fix these things … it’s systemic...Sometimes you have to let big things fail … maybe that’s what needs to happen”.


And as we know it did fail, but it really shouldn't have taken two deadly crashes to get Boeing's attention to put things right.



How do you promote psychological safety?


  • Don’t compromise your values

  • Let people know you will support them in doing the right thing

  • Ask people if they have concerns.

  • Celebrate diligent dissidents, or in other words people who do the right thing, even when it’s not easy.



Dr. Jared Dempsey is the Principal Psychologist at Kognivate.


This blog is for education purposes and may be freely shared with attribution.


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