Heart of the problems with Boeing, Takata, & Toyota (part 5): Boeing’s continued knowledge mismanagement

This five-part series looks at what Boeing’s repeated aircraft disasters have in common with the Toyota and Takata automotive recall scandals, and proposes a solution.

Previous articles in this RealKM Magazine series explore the knowledge management (KM) failures of United States based aircraft manufacturer Boeing regarding their Boeing 737 MAX crashes, and makes recommendations for change.

But now, five years later, has Boeing improved its KM?

On 5 January 2024, Alaska Airlines Flight 1282, a Boeing 737 MAX 9 aircraft, took off from Portland, Oregon in the United States. At about 16,000 ft in the air, an exit door plug violently blew out, instantly depressurising the plane and leaving a large hole in the fuselage (Figure 1). Oxygen masks came down and passengers were in shock. Fortunately, no one was harmed. But this incident amongst many others stem from a continued failure of proper KM within the Boeing organisation.

As discussed in part 1 of this article series, the Boeing 737 MAX had already been linked to 346 deaths¹ in 2018-2019 due to a flawed flight control system called the Maneuvering Characteristics Augmentation System (MCAS)² forcing the Federal Aviation Administration (FAA) to order the temporary grounding of all 737 MAX jets. By the beginning of 2025, the beleaguered Boeing company had faced over $56 billion in losses³, government intervention and probing, an extremely shattered reputation, and significant job cuts.

Key areas of knowledge mismanagement

Tacit knowledge ignorance

Engineers within Boeing have been raising concerns for a long time about outsourcing risks and supplier quality issues. After the Alaska Airlines door plug incident, one employee even filed a complaint to the FAA, alleging that Boeing took shortcuts⁴ when manufacturing its 777 and 787 Dreamliner jets. He also mentioned that Boeing’s manufacturing records show that workers failed to properly reinstall bolts meant to hold the large door plug panel in place. The job was given to a third-party firm Spirit AeroSystems⁵ and was not looked after by Boeing’s leadership.

The KM lesson identified here is to take into account the intuition and expertise that frontline teams give you. They are holders of the tacit knowledge⁶ within the organisation and listening to them is your early-warning system. Instead, Boeing’s leadership decided to ignore the warnings. They have even gone as far as relocating their headquarters⁷ away from Seattle, where most of Boeing’s aircraft are manufactured, because they don’t see that it’s necessary to be involved in day-to-day operations.

Teams in silos

Boeing shows signs of departmental misalignment and communication problems (Figure 2). During FAA audits, Boeing was asked to provide key information on the workers that were responsible for the installation of the door plug, but was not able to provide that information. This is linked with the fact that for a long time their own employees within the organisation were not able to locate any documents related to the door plug⁸, even after looking “extensively.” Boeing also claimed that the workers who removed the door plug and bolts to fix the rivets did not file any paperwork, and then another team re-installed the plug without the bolts and without paperwork. This led to confusion and miscommunication between the workers, and no one was aware that the door plug had missing bolts that needed replacing.

The KM lesson here is to first identify and then break down silos within your organisation. This is often the biggest challenge in your KM strategy. Boeing’s leadership launched a knowledge sharing system called “Speak Up” but its implementation and operation were mismanaged. So, instead, employees and departments kept things to themselves and feared speaking up about what they knew⁹. Rather than cultivating effective knowledge sharing, Boeing inspired a culture of fear amongst employees. Staff chose to not speak up about the faults that they saw, with the fear of retaliation¹⁰ and getting fired taking precedence.

Rotten culture

The negative transformation of Boeing’s culture¹¹ represents a critical failure in KM that extends beyond mere operational issues. They had an engineering-first culture and a culture of safety for many years, but that gradually eroded in favour of profits (Figure 3). The employees and the leadership were blinded to the fact that the main crux of their job is to ensure the safety of all their future passengers.

The KM lesson here is that Boeing’s leadership effectively created knowledge barriers¹² by chasing financial performance over engineering excellence, creating an organisational culture that was misguided. The physical relocation of headquarters away from engineering centers, the prioritisation of shareholder value over safety concerns, and the devaluation of engineering expertise when engaging in decisions are all factors contributing to the crisis in Boeing.

This crisis represents a failure of what KM practitioners call “knowledge governance” – the organisational mechanisms that should ensure critical knowledge flows effectively between different organisational levels. The result is a rotten culture where money trumps safety.

Conclusion

Boeing’s knowledge mismanagement starkly illustrates the importance of integrating the tacit insights of frontline experts, breaking down communication silos, and fostering a culture that values the right things. By ignoring early warnings and stifling interdepartmental communication, Boeing created knowledge barriers that transformed critical operational issues into catastrophic failures. Aligning a clear KM strategy with your business strategy (Figure 4) turns uncertainty into actionable clarity, ensuring that when crises arise, your organisation is resilient and prepared to navigate them.

Bruce Boyes reminds us that this KM strategy can’t be a traditional KM strategy. As discussed in part 2 of this series, Boeing has had a highly-regarded KM strategy, but this strategy is actually part of the problem rather than a solution because it ignores aircraft complexity¹³. While traditional KM strategy approaches such as after-action reviews (AARs)¹⁴ and lessons learned processes can still have a place in aviation, they are ineffective tools in the face of complexity because they are too linear and too slow. What’s needed are iterative learning processes that operate in real time¹⁵ as discussed in part 4 of this series.

Article source: Adapted from Boeing’s Knowledge Mismanagement, prepared as part of the requirements for completion of course KM6304 Knowledge Management Strategies and Policies in the Nanyang Technological University Singapore Master of Science in Knowledge Management (KM).

Header image: NTSB investigators examine the door plug from Alaska Airlines flight 1282, a Boeing 737-9 MAX.​ Source: United States National Transportation Safety Board (NTSB).

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