GM released the results of an internal investigation of ignition switch failures today. The CEO said that some GM employees looking at the problem believed the ignition switch flaw was only “a customer satisfaction issue, not a safety issue.” They did not understand that shutting off the car would disable critical safety features like airbags. They did not have the critical information need to change their framing of the problem. Shockingly, “Over time, the company learned that air bags could also be deactivated when the cars lost power.” It did take time, eleven years.
How could a sophisticated engineering organization not understand the relationship between the ignition switch and airbag power? Some tools and techniques that may help lead to a better outcome:
- Communication Plan: “Numerous individuals did not accept any responsibility to drive our organization to understandwhat was truly happening,” the CEO said. Project managers must demonstrate significant leadership responsibility.
- Project Management: As a practice is intended to facilitate cross-domain collaboration to surface and communicate important information in a timely manner.
- Risk Management: Was there insufficient risk analysis of one of the most important subsystems of an automobile?
- Behavioral Analysis: One can imagine that power to the airbag subsystem would be identified as needing a high level of resiliency given the absolute requirement to function in a worst-case scenario accident.
- Project Design: Employing system engineering tools such as interrelationship and interaction matrices during the design process and available as organization assets may have identified and communicated the ignition switch link and associated risk.
- Design Thinking: Apply divergent thinking to explore and validate the nature of a customer problem, have we asked the right questions? Are we solving the right problem? Are we delivering what our customers really need or require?
There are some painful similarities with the Challenger disaster. In this accident, the engineering staff correctly diagnosed the risk, made efforts to communicate the problem to senior management, but it was not handled effectively leading to another tragedy.