Team of Teams: New Rules of Engagement for a Complex World

by Stanley McChrystal

The aviation industry was faced with two possible ways forward. They could continue to try to mitigate risk, attempting to control for ever more specific contingencies: the FAA could add United 173 as a case study in flight school; they could alter emergency checklists to include explicit reminders instructing a particular crew member to check the fuel gauge every five minutes. Such instructions would reduce the likelihood of fuel exhaustion the next time an indicator light failed. But they would do nothing to prevent overreaction and teamwork failure in the face of any of the other thousands of minor glitches that might occur. Worse, an overemphasis on fuel procedures might well create a new blind spot, just as the overemphasis on landing gear procedure had eclipsed fuel monitoring. Alternatively, they could focus on risk adaptation instead of mitigation, accept the inevitability of unexpected mechanical failures, and build flexible systems to combat these unknowns; they could build a better managerial boat to navigate the volatile seas of complexity. NASA believed that the dwindling ability of flight crews to adapt to unforeseen events stemmed from the captains’ attempts to control and plan for everything in a vehicle that had become too sophisticated for that to be possible. Champions of the iconic Mission Control room where hundreds of experts crowded into one space to facilitate real-time communication and adaptation (which we will investigate further in later chapter...