Brisbane – How complex systems fail: Lessons from Boeing’s 737 MAX 8 crashes
14 May @ 5:00 pm - 7:00 pm
Many of us think in Newtonian terms, meaning that when we examine systems, we tend to think there is a direct link between cause and effect – everything that happens has a definite, identifiable cause and a definite effect. And there is symmetry between cause and effect: the seriousness of the effect is related to the seriousness of the cause – big failures happen because of big causes, and small failures because of small ones.
But intuitively we know this doesn’t hold up for certain, so-called ‘complex’, systems. Instead, we can have sudden changes in these systems, which often appear dramatic, but which have tiny causes. How then should we think about failure or dramatic change in these types of systems?
This session explores this question by examining the organisational causes of the two Boeing 737 MAX crashes that resulted in the deaths of 346 people.
This session comprises a presentation delivered by Sean Brady (Managing Director and Forensic Engineer at Brady Heywood), followed by a facilitated Q&A.
Click here to register
About the speaker:
Sean Brady is a forensic engineer who investigates engineering failures from a technical and organisational perspective. In 2020, he completed the Brady Review, an investigation into the causes of fatalities in the Queensland mining industry. The review was tabled in parliament and made 11 recommendations to the regulator and mining companies on how to improve safety. In 2024, he completed the technical and organisational investigation into the catastrophic failure of a turbine generator at Callide C Power Station in Queensland, Australia. He also speaks, writes and podcasts on the causes of technical and organisational failure.