Complex Problems & Simple Solutions

Back in June last year my colleague Suzanne Crouch wrote a fascinating piece on how organisations frequently convince themselves that their big and expensive problems absolutely must require equally big and expensive solutions.  Once they are confident of this equation, they then skip past any significant Root Cause Analysis (RCA) and overlook many of the simple, easy to implement and less expensive solutions that become ‘hidden in plain sight’.  In fact, this very narrative is currently at the heart of many discussions around the management of the spread of the Coronavirus.

Reading Chris Clearfield and Andras Tilcsik’s really excellent 2018 book on systems failure ‘Meltdown’ (essential reading for any student of Problem Solving and Project Management) I was drawn to another great example of how simple solutions have had a truly remarkable impact on a complex problem. In the example they offer, the solution in question was initially dismissed out of hand by the very people whose lives it would ultimately protect.  Why?  It was deemed to be far too basic! 

Just over a half a century ago the airline industry had a reputation as a dangerous and accident-rife environment.  Much of this was thought to have been caused, in some part, by the deeply hierarchical nature of the typical flight crew of the time.  (A scenario that Matthew Syed also investigates at great length in his best-selling book ‘Black Box Thinking’).   In these “bad old days” of the aviation industry, the Captain of the plane was considered to be infallible, a god-like master of the cockpit. Back then, First Officers and Crew would not dare to challenge their Captains under any circumstances, no matter how dire the situation. A scenario also well documented in medical and military environments until very recently. 

In practice a kind of cognitive dissonance takes place in the mind of observers that plays out something like this “I’m not sure what’s going on here but everyone else seems satisfied, especially the most senior person in the room, so I’ll keep quiet”.

As complexity in the industry grew, the cracks showed in this established ‘Captain is King’ model.   This became undeniable when in 1990 an extensive report showed that although Captains only had the controls for 50 percent of commercial flight hours, nearly 75 percent of accidents took place during this time. This was not because Captains were worse pilots, quite the contrary. It was because when things started to go wrong, crew would be extremely unlikely to effectively communicate their concerns.  In other words, the human (and very dynamic) checks and balances required for flight safety were disabled. Conversely, when a First Officer was at the controls and the Captain supervised, they were fully optimised.  

All this changed with the simplest of initiatives.  Known as Crew Resource Management (CRM) it revolutionised the entire industry by putting the whole crew on a far more equal footing. For many in the industry CRM almost looked too simple to work, too obvious, too rudimentary.  But it did work…  

CRM focussed on a straightforward 5-Step process that enabled crew to raise concerns. It went something like this:

1.     Deliberately get the Captain’s attention (“Hey David”)

2.     Express your concern clearly (“I’m worried that a thunderstorm has moved over the airport”)

3.     State the impact of this (“If so, there’s going to be dangerous wind shear”)

4.     Propose a possible solution (“Let’s delay landing until the storm moves”)

5.     Get a firm response (“Does that sound good to you, David?”)

The impact of CRM? Crew and Cabin Crew felt empowered to raise minor concerns and dissent was re-framed as essential feedback. Gone were the shy, vague mentions of a possible dangerous situation that could be easily ignored or misunderstood as a casual observation.  This resulted in an immediate and dramatic reduction in the overall number of accidents. And there was a re-balancing of the remaining incidents to a ratio of 50/50 between Captain and First Officers.  Passengers and crew were safer and innumerable lives were saved. 

Incredibly CRM almost never happened as time and resource were ploughed into enormous, cumbersome safety systems that addressed symptoms and not causes.   Initially written off as a mere ‘Charm Offensive” and “Psychobabble” the results were undeniable and similar processes have spread throughout most, if not all complex and challenging industries.  Today equivalent programs can be witnessed in medicine, emergency services, oil and gas, technology, finance and many other sectors. 

This simple, almost ignored 5-step process has become, arguably, one of the most powerful safety initiatives ever designed. 

Effectively conducted Root Cause Analysis will reveal the small, often hidden, Cause and Effect relationships in any complex system.   It’s here where these beautiful simple solutions are found, very often hiding in plain sight.