The Internalization of Attention at 28,000 Feet: Revisiting the K2 2008 Disaster

The Challenge Of Reliable Performance

We consider the work that organizations undertake in terms of the types of interactions and coupling of the individual elements (Benjamin & Levinson, 1993; Galbraith & Merrill, 1996). Interactions between elements can be understood on a continuum from linear to non-linear. Linear interactions are associated with single, identifiable, points of failure and systems with identifiable, planned interfaces. In contrast, the presence of non-linear (complex) interactions means that outcomes may be unknown (or unknowable). Components of an environment may be multifaceted and can fail in more than one direction (Roberts, 1990a). This can lead to unpredictable and invisible deviations from a planned state, which managers could not reasonably anticipate and which might not so readily be guarded against (Maylor, Turner, & Murray-Webster, 2013; Philbin, 2008).

The unknown, however, does not necessarily lead to catastrophic failure, unless points of failure interact with each other. The nature of the coupling between elements is of central importance. Loose coupling implies that events are relatively independent, and buffers or slack can limit the effects of interconnectivity. Loose coupling provides ‘breathing space’ to contain incidents, preventing them from gradually destabilizing the whole. In tightly-coupled systems (Perrow, 1984; Roberts, 1990a, 1990b), however, interdependencies between elements mean that incidents can build upon themselves and escalate rapidly.

The combination of interactions and coupling may lead to a range of situations in which the points of failure can accumulate – or ‘snowball’ - into a full-blown crisis. As Bonabeau (2007, p. 63) argues, “the enormous complexity of large scale systems like communications networks means that even tiny glitches can cascade into catastrophic events.” Our point of departure for this work was to understand how managers may respond more effectively to complex situations such as these. By considering these two dimensions (interactions and coupling), we have a straightforward way of representing the nature of the environment managers find themselves facing.