On 20 September 2013 two Qantas Airbus aircraft with a combined passenger load of more than 600, nearly collided 12km in the air almost above Adelaide.
The Australian Transport Safety Bureau (ATSB) began an investigation that day. It said it would be finished by September 2014 - almost a year later. In November 2014 and already two months overdue, it updated the investigation status to be that the report would be made available to the public by January 2015.
On 5 March 2015, almost two and a half years after the incident, six months longer than the date it was first promised, and two months past the amended reporting date, ATSB Transport Safety Report Aviation Occurrence Investigation AO-2013-161 was published.
Meanwhile, hundreds of aircraft carrying thousands of passengers continued to fly the same routes each day in the control of the same systems and people and decision making doing the same things that failed on 20 September 2013 and nearly killed 600 people.
The more important the decision, the longer it should take.
Decision makers can be tempted to do the opposite: Important decisions must be made quickly. Urgently. Decisively. Get it done. Get it over with.
Not so for the ATSB. The risk that the undiagnosed errors in person and machine could be repeated with catastrophic results did not compel it to compromise its decision making process.
How long should a decision take? It should take as long as a good decision takes. How long do the Five Steps take?
The ATSB process was not initiated by a complainant. Decision makers resolving complaints are under pressure to decide quickly. Complaints policies impose response times. Complainants demand answers. Neither serves good decision making.
This is one of many examples where a clear Widget cuts through the complexity. Does speed, appeasing a demanding complainant, or meeting an artificial time constraint in a policy or self-imposed serve the Widget?
The ATSB had a clear Widget:
'The ATSB’s function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; fostering safety awareness, knowledge and action.'
As each self-imposed deadline for the report approached, the ATSB would have asked itself: 'Will publication on the promised date serve our Widget? Which is more important: the integrity of our deadlines or of our findings and recommendations about aviation safety?' Appropriately the answer was the latter. Let's update the information on our website and continue inquiring with excellence.
Time constraints - 'Complaints will be resolved in x days' - should only be added to decision making processes if they serve the decision maker's Widget. 'Your decisions take too long' is not sufficient reason alone to impose deadlines. Better to manage expectations. Under promise and over deliver. Next time ATSB - promise us a report in two years and delight us by publishing it in one and a half.
A deadline may be appropriate to improve the turnaround time for a broken toaster under warranty. Yet it may compromise the careful analysis needed to understand the failure of a complex system.
Such as why two 240 tonne aircraft with advanced navigation aids and under air traffic control converged at a closing speed of one and half times the speed of sound 38,000 feet above the earth.
Or why that person did that thing.