In 2018, an employee at the airline Condor Airways, was tasked with buying some plastic cups, plastic cups to contain in-flight hot beverages for the airline’s pilots. It might appear as if this is a fairly clear or obvious or simple decision space, or even perhaps slightly complicated if you want to push the whole plastic cup procurement process. Anyway, cups were procured, at a good price, probably the price of the lowest bidder for the cup supply contract. The only difference between these cups and the normal recommended cups was that they were slightly different dimensions. which, when you're sitting in a cubicle, not in an aircraft, and from that cubicle, you are trying to get the best deal for your company and possibly looking towards some form of procurement bonus, that's all you need to do. You have sourced some cups at a good price and everyone was happy. simple as that or obvious is that or clear as that. Everything in the world of plastic cup procurement is going swimmingly and what could possibly go wrong as a result of making that simple or clear or obvious decision.
On the 6th of February 2019, a Condor Airways Airbus A330-243, registration Golf Tango Charlie Charlie Foxtrot, took off from Frankfurt in Germany, heading for Cancun in Mexico. Aboard the aircraft were 11 crew and 326 passengers, holidaymakers, escaping from the wintry weather of the northern German plain aboard a European plane. And everything continued to go swimmingly until the captain of the flight attempted to drink some coffee from a plastic cup that had been procured through a clear and simple and obvious procurement process. The Airbus A330-243, like most large commercial aircraft, has the convenience, some might say luxury, of cup holders in the cockpit. These cup holders, like most things on aircraft, have been manufactured to very specific dimensions, and as such, the aircraft manufacturers recommend that any plastic cups being used in the cockpit should also conform to these very specific dimensions.
The economically procured plastic cups, however, were too small for the aircraft cockpit cup holders and so the pilots often just balanced them on a small fold-out table in front of them. As you may already be familiar with, Airbuses do not have conventional control yokes for manoeuvring the aircraft. Instead, they use a side stick, leaving room for a fold-out table, which is intended to be used as a place to put things such as the pilot’s logs or an iPad with navigation charts and procedures. Because economically procured plastic cups do not fit properly in the cup holders, it is also a natural place to put a cup of coffee.
In straight and level flight, in the cruise, this might be thought of as a fairly safe and steady place to rest a coffee cup on. It's not like the aircraft is going to be doing any aerobatics and the standard operating procedures of most airlines provide advisory bank angle limits. so as not to upset the self-loading freight down the back too much. At around twenty past four in the afternoon, as Golf Tango Charlie Charlie Foxtrot was approaching a waypoint 55 degrees North and 2 degrees West out over the Atlantic, the aircraft captain was filling in in the pilot’s log, or Plog as it is usually known, with the appropriate navigation information pertaining to passing that waypoint.
He had also just been provided with some hot coffee in an economically procured plastic cup, but he was resting the cup on his fold-out table, contrary to the manufacturer's advice. As he was filling out the Plog, he knocked over the economically procured coffee cup. Most of the coffee ended up in his lap but some spilt onto his Audio Communications Panel, known as the ACP1, situated on his right hand side behind the throttle quadrant. The spilt coffee quickly made its way into the aircraft communication electronics. You can see where this is heading, can’t you? And it’s probably not to Cancun.
As there were no jumbo-sized bags of rice to hand, all the captain and co-pilot could do was to hope for the best. That is never a particularly effective or comforting strategy when you are at the pointy end of an airliner at 35,000 feet over the Atlantic Ocean. And at 1700 hours, 40 minutes after the coffee spillage, the Audio Control Panel, ACP1, became very hot, then failed catastrophically, accompanied by a burning smell in the cockpit. Out of all the emergency situations that pilots might face, an in-flight fire is the most feared and dangerous. If an engine fails you usually have at least another one. If all your engines fail, the aeroplane is still a glider, just not a very efficient one.
At approximately 1720 hrs, an hour after the coffee spillage from the economically procured cup, the audio control panel, ACP2, on the co-pilot’s side also became hot, hot enough to start melting one of its buttons, and then it too failed catastrophically. A small amount of smoke was observed coming from the ACP1. At this point, the aircraft is still heading for Cancun and approaching 56 degrees north and 3 Degrees West Waypoint. That's where Golf Tango Charlie Charlie Foxtrot was high above the Atlantic Ocean but where are we now in our decision making process? Was buying those incompatible plastic cups a simple decision, clear and obvious, or was it complicated, complex or potentially chaotic?
In some popular complexity theories, an aircraft is an apparently complicated domain, where everything is known and all the causal connections are known. As any commercial pilot will tell you, that is not correct. Most aircraft are not perfectly good Flying Machines, they are more akin to a collection of aerodynamic components flying in loose formation. Every commercial aircraft has as an MEL, a Minimum Equipment List that is required for the aircraft to be considered airworthy. The Minimum Equipment List will vary, depending on the context that the aircraft is being used in. If it is just a quick whizz around the pattern then you need less equipment, less functional equipment than if you are flying a whole lot of holidaymakers across the Atlantic Ocean.
Rather than being a complicated system, an aircraft is more of a complex physical system, where each component influences other components and sometimes Influences those other components in unconventional and unplanned ways, with emergent behaviour, possibly in the form of smoke and fire, particularly in the aircraft electronics and the software used to run them. The complex physical system of an aircraft is usually a subsystem of the complex imaginal system that is a human being. This was described very clearly by Edwin Hutchins in the paper ‘How A Cockpit Remembers Its Speeds’, published in 1995, in Volume 19, Issue 3 of the journal ‘Cognitive Science’. This paper also provides a very good description of the disseminated self, the self beyond the self, a psychological perspective that we use extensively in the Human Edge.
I have spent a lot of my professional life in high consequence situations, including working as a commercial pilot, and making an uninformed decision in a high-consequence situation can kill you. Although you might not end up in physical or existential danger because of making uninformed decisions, naively making uninformed decisions can kill your business, kill your reputation, kill your relationships. Instead of trying to pigeonhole your decisions into some arbitrary decision-making framework, it is far more effective to understand the decision space that you are in. And how you are connecting your decision spaces and the flow of information and decisions between those decision spaces.
Claude Shannon, who originated much of modern information theory, observed that the nature of the flow of information between decision spaces Is not so much about what was communicated but what could have been communicated. And what could have been communicated is largely dependent on being aware of what other decision spaces your decision-making process is connected to. A lot of popular complexity and complication theory is based on constraints and constrained decision spaces rather than the more effective way of being informed by connections and connected decision spaces. Working with isolated and constrained decision spaces can easily end in an unfortunate communication meltdown, which is exactly what happened to Golf Tango Charlie Charlie Foxtrot.
Fortunately, the crew were able to control this unexpected outcome of the plastic cup procurement decision-making process. They reduced the level of surprise, or what Claude Shannon would have described as reducing the level of information entropy, by making a successful diversion to an airport in Ireland that shares the same name as the great information theorist. Although the electrical system was now below the MEL requirement, the hydraulic system was still nominal and the pilots managed to extend the flaps, dangle the Dunlops, and make a safe landing.
To paraphrase the great ecologist John Muir, everything in your life is connected to everything else in the universe, even something apparently as trivial and mundane as a plastic coffee cup. Trying to base your decision-making on constraints, particularly arbitrary and artificial constraints In theoretical decision-making processes, will not help you to make great decisions. To make great decisions, it is far more effective to understand the connections between decision-making spaces and the nature of the flow of information feeding forward and feeding back across those connections.