How Complex Systems Fail: lessons from Boeing’s 737 MAX 8 crashes
Most of us are taught to think in Newtonian terms, where cause and effect are clear, proportional, and predictable. A small error leads to a small consequence; a large failure must have a large, identifiable cause. But in the world of complex systems, that logic often breaks down. Tiny oversights can trigger massive consequences. Understanding why requires a different mindset – one that can account for hidden interactions, systemic vulnerabilities, and organisational decision-making. In this thought-provoking presentation, forensic engineer Sean Brady examines the organisational causes behind the two Boeing 737 MAX 8 crashes, which led to the tragic deaths of 346 people. Using this case study, Sean explores how we should think about failure in complex systems, and what lessons we can draw to prevent future disasters.
Speaker
Sean Brady is a forensic engineer who specialises in investigating engineering failures—both technical and organisational. In 2020, he led the Brady Review, a comprehensive investigation into fatalities in Queensland’s mining industry. The review was tabled in Parliament and resulted in 11 key safety recommendations. In 2024, Sean conducted the technical and organisational review of the Callide C Power Station turbine generator failure. He is also a renowned speaker, writer, and podcaster, known for his compelling insights into why complex systems fail and how we can design them better.
Who Should Attend?
- Engineers and technical professionals
- Risk and safety managers
- Organisational leaders
- Students of engineering, systems thinking, or management
- Anyone curious about how small decisions lead to large failures
Event Supporter
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