In the aftermath of the two fatal accidents of Boeing 737 Max jets, tentatively blamed on the over-automation of Boeing's flight systems, renewed attention to Boeing production facilities was perhaps inevitable. Evidence is now trickling out that workers in the troubled Boeing 737 Dreamliner plant in South Carolina were pushed to maintain an overly ambitious production schedule and fearful of losing their jobs if they raised concerns. This is a textbook case of how the absence of psychological safety — the assurance that one can speak up, offer ideas, point out problems, or deliver bad news without fear of retribution — can lead to disastrous results.

The accidents and the resulting media attention together create a real wake-up call for Boeing, which I expect will now embark on an examination of every aspect of its operations. What's required, however, is more than operational fixes. It is nothing less than a full organizational culture change. But how telling it is that it takes a cataclysmic event (two, actually) for executives to take culture seriously? And yet, sadly, this is the way a thoroughgoing change in the culture of an organization happens most often: AFTER a big, visible failure or tragic event.