Complex Problems and Simple Solutions

Back in June last year my colleague Suzanne Crouch wrote a fascinating piece on how many 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 typically skip past any meaningful Root Cause Analysis (RCA) and overlook many of the simple, easy to implement and less expensive solutions that become ‘hidden in plain sight’.
 
Reading Chris Clearfield and Andras Tilcsik’s 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 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?”)