The Normalisation of Deviance.
Dianne Vaughan explains how systemic failure saw NASA launch an orbiter it knew was not safe on that day. The result the Challenger loss.
These changes occur an increment at a time.
Nobody thinks their particular corner cut makes the difference.
It begins with endless focus on reduction of cost. Drilled into them at the business school, out they flow with economic orthodoxy. They continue the relentless cost reduction, bonus culture and eventually that permeates everywhere.
Customers of the aircraft, consumers of airline product, managers, pilots and even engineers all hearing the same beat of the drum.
Bit by bit margins are reduced.
Boeing has far bigger systemic problems than the share price.