Index

References are to chapters, not pages: P = Prologue; 1–15 = chapters; 2a, 3a, 10a, 12a = What If? interludes; EV1–EV4 = Exploded Views; E = Epilogue.

737 MAX (Boeing) — 5, 8, 12, 14

algedonic signal — 4
ALIS (F-35 logistics system) — 6, 12
Allen, David — 3a
Amazon — 1, 2, 8, 12a, 13, 14
andon cord — 4, 12, 12a, 14, 15
Anthropic — 3
Appleton, Maggie — 3
Ashby, W. Ross — P, 1, 2, 3, 4, 9, 11, 13, 15, E

backchannel — 1, 14, E, EV1
Backstage — 9, 13
Bainbridge, Lisanne — P, 3, 10, 10a, 12, 13, E, EV3
Bates, Alan — 7
Böckeler, Birgitta — 11
Beck, Kent — 5
beer game — 6
Beer, Stafford — P, 3, 4, 5, 14, 15, E, EV1
Bezos, Jeff — 2, 12a, 14
Brooks, Fred — 3
Buffer — 14

Chaillan, Nicolas — 14
Cloudflare — 8
Cognition — 3
Columbia (space shuttle) — 3, 8, 12
compound engineering — 13
Conant, Roger — P, 1, 2, 3, 9, 11, 13, 15, E
constraint (Goldratt) — 3
Cook, Richard — P, 5, 8, 12, E
curl — 6
Cybersyn, Project — 4

dark factory — 3
Dekker, Sidney — 8, E
Deming, W. Edwards — 5, E
Dickerson, Mikey — 6, 12

Ellsworth, Jeri — 14
error budget — 5, 12, 12a

Feynman, Richard — 9
Fournier, Camille — 13
Future Combat Systems — 13

Gall, John — 13, 15, E, EV4
Gall’s law — 13, 15, EV4
Gas Town — 3
Gawande, Atul — 12
Geldreich, Rich — 14
GitHub — 8, 11
Goedecke, Sean — P, 1, 2, 11, 14
golden path / paved road — 1, 9, 13
Goldratt, Eliyahu — 3
Goodhart, Charles — 3, 5
Goodhart’s law — 3, 5
Google — 2, 3, 6, 8, 9, 12, 12a, 13

harness engineering — 11, 13
Hashimoto, Mitchell — 13
Healthcare.gov — 6, 8, 12, 14
holdout scenarios — 11, EV3
Horizon (Post Office) — 7, 12, 14
Huang, Jeff — 3a, 15, E

intent specification — 11

jidoka — 12
Jump (the fifth word) — P, 3, 14, 15, E

Kessel Run — 3, 14

Larson, Will — 13
latent failure — 8
Legibility — P, 1, 2, 3, 5, 6, 8, 9, 11, 13, 14, 15, E
Lemkin, Jason — 12
Leveson, Nancy — P, 2, 2a, 8, 10, 11, E

Mackworth, Norman — 10, 10a
Mars Polar Lander — 2, 2a
Meadows, Donella — 13, E
mechanisms (Amazon) — 14
Medina, Eden — 4
Medium — 9, 14
Meta — 5
metasystem transition — P, 3, 15
metis — 1, 6, 7, 8, 9, 11, 14, EV1
METR — 6, 10
Model (the first word) — 2

Newton, Casey — 15
NHS National Programme for IT — 13
normal accidents — 8
NUMMI — 9, 12, 12a

Ohno, Taiichi — 12, E
Orosz, Gergely — 5
Osmani, Addy — 3
Overleaf — 4

Perrow, Charles — P, 8, E
Phoenix pay system — 6
Pronovost, Peter — 12, 12a

Rasmussen, Jens — 8, E
red bead experiment — 5
Remainder — P, 5, 10, 14, 15, E, EV1
Replit — 12
requisite variety — 4, 11
reward hacking — 2a
Robodebt — 7
root cause — 8

SCiO — 4
Scott, James C. — P, 1, E
second brain — 3a, 15
Segment — 13
Senge, Peter — 6
single-threaded leader — 14
software factory — 3, 10, 11, 12, 13, 14, EV3
Sonos — 13
spec-driven development — 11
Spotify — 2, 9, 13
Stenberg, Daniel — 6
Stop (the fourth word) — P, 12, 12a, 15
Strathern, Marilyn — 5
Stripe — 8, 13
StrongDM — 3, 5, 10, 11, 14
Suma — 4, 13, 14

Tesla — 3, 9
Therac-25 — 8, 10
Toyoda, Sakichi — 12, 12a
Toyota — P, 9, 12, 12a, 14
Turchin, Valentin — P, 3, 3a, E
two-pizza teams — 14

Valve — 14
viable system model — 4, 5, 14, 15
Vik, Tomas — 15

Walker, Jon (Suma) — 4
Westenberg, Joan — 3a, 15
Widrich, Leo — 14
Williams, Sir Wyn — 7

Yegge, Steve — 2, 3

Zappos — 9
Zettelkasten — 15