GM: The Ignition Switch and Organizational Silence
Featuring Mary Barra
Engineers at General Motors documented a faulty ignition switch in the mid-2000s. It could cut engine power and disable airbags in a crash, and they proposed fixes. The knowledge sat inside the company for years. The fixes were rejected, the defect stayed in production cars, and over a decade later people died and millions of vehicles were recalled. No single villain explains it.
For operators, this is a quieter and more uncomfortable case than the headline recall. It is about why information stops traveling up, why agreement in a meeting does not become action, and what it actually costs when no one owns a decision. The diagnosis of whose failure this really was, and what you would have to change to prevent it, is the part the app makes you sit with.