Watch the smoke rising from a candle just extinguished in still air. It will rise in a straight line, then begin to break up into lively eddies and vortexes. The straight line is a laminar flow. That second phase is turbulence. You'll see the same pattern emerge on the backside of rocks in flowing streams. It's also there during surgery when an artery bursts into a flood. 

Turbulence is everywhere, including throughout our own health care sector. Once a flow becomes turbulent, prediction breaks down. That’s why all turbulence is characterized as chaotic. And in chaotic conditions, small permutations can give rise to uncertain and consequential effects.

Although turbulence is a common phenomenon, it remains inexplicable. The renowned physicist Richard Feynman once described turbulence as "the most important unsolved problem in classical physics." Important because it has proven to be a particularly vexing question for scientists. But also important because turbulence can generate significant implications for everything within its grasp.

Brittle rings

On January 28, 1986, the flight of Space Shuttle Challenger began with a pattern that the nation had come to regard as routine. There was an eruption of fire and smoke as the rocket rose and began to carve a familiar laminar contrail across the sky. But on that day, small things jumped out of synch with the routine and transitioned into turbulence. Challenger's rocket boosters exploded, propelling the shuttle and its doomed occupants into destructive chaos. 

The low temperature had been 52 degrees on January 22, Challenger's originally scheduled launch date. Six days later, the temperature at Cape Canaveral at launch time was 30 degrees. A series of unpredictable events had cascaded to delay the flight to the much colder day.

A big television audience had been expected for this flight because its crew included school teacher Christa McAuliffe. The repeated delays had caused frustration and impatience at NASA. And this gave rise to a case of "Go Fever." Resolutely determined to avoid further delays, NASA pushed ahead. As Challenger launched, 17 percent of Americans were watching. Within one hour, 85 percent of the nation knew about the explosion.

It was Feynman who would dramatically demonstrate how a very small thing had transitioned into a turbulent tragedy. In a hearing related to the shuttle explosion, Feynman dropped rubber o rings into a glass of ice water to demonstrate how the low temperature at launch made them brittle and leaky. NASA had been alerted on multiple occasions to the potential problem.

On February 1, 2003, Space Shuttle Columbia transitioned from safe laminar predictability into deadly turbulence as it disintegrated on re entry over Texas. A tile of insulating foam had broken away during Columbia's launch and punched a fatal 6 inch hole in one of its wings. The loss of foam during shuttle launches had become routine enough to have earned a name at NASA: "foam shedding." The sociologist Diana Vaughan would later describe NASA's attitude of casual acceptance of deadly possibilities as the "normalization of deviance."

Fatal discord

A lightning storm passed over Montana's Mann Gulch on August 4, 1949, and set off a small fire. What followed has been described by the University of Michigan's Karl Weick as the disintegration of organizational roles, structure and sense making. 

Winds were described as "turbulent" as a C 47 transported 16 smokejumpers towards the fire. As a result, the pilot was forced to drop the smokejumpers and their gear from an altitude of 2,000 feet rather than the usual 1,200. Their radio, a vital piece of equipment in potentially chaotic conditions, was pulverized when its parachute failed to open.

Soon the smokejumpers found themselves confronted by 30 foot flames rushing towards them at 610 feet per minute. Panicked, they started to run up a steep incline towards what they hoped would be a safe ridge. Their crew chief, Wagner Dodge, yelled at them to drop their tools. They complied. At this point, according to Weick, without their tools they ceased being smokejumpers. Their roles extinguished, they then faced the challenge of making sense of the inexplicable. 

They watched Dodge light a fire in front of them. He then ordered them to lie down in the area his fire had burnt clear. Because this made no sense to them, they ignored him and continued to try to outrun the fire. Thirteen of them would die. 

When they jumped, the fire had been predicted to grow in size from 10 to 99 acres. The smokejumpers would have called it a "10:00 fire," by which they meant they would have it under control by 10:00 the next morning. In the end, it took 450 men five more days to contain the Mann Gulch fire as it swelled to 4,500 acres.

What the foregoing calamities share is a pattern consistent with the smoke rising from the extinguished candle: a predictable laminar flow of events followed by chaotic turbulence. This pattern is reminiscent of the story Nassim Taleb popularized in his book The Black Swan – a tale about a turkey that, for all of its life, experienced a predictable flow of events in which the farmer arrived every day with food and water until one day, the turkey's final day, the farmer arrived with an axe. 

It is in pools of chaotic turbulence that Taleb's "black swans" can be found paddling about. A black swan is a highly consequential event that comes as a surprise and then is explained in retrospect. A black swan can also be characterized as an "unknown unknown" – a term that first appeared in a 1982 New Yorker article regarding the metal fatigue that caused sensational and initially inexplicable crashes of Comet passenger aircraft in the 1950s.

Beyond resilience

Turbulence has its positive side. While a chaotic force like turbulence can't be predicted or controlled, it can be leveraged to advantage. For example, turbulence is designed into tennis balls and golf balls. The fuzzy surface of the tennis ball and the dimples of the golf ball create a boundary layer of turbulence, which isolates the balls from the friction that they would otherwise encounter in their flight. Vortex generators are often placed on aircraft wings to accomplish the same thing. 

Of course, one person's threatening turbulence may be another's golden opportunity. Early in the space race, NASA's rockets kept blowing up. This delayed U.S. progress enough to give the Soviets the time they needed to be the first to put a man in space.

There is another potential upside to turbulence. Taleb has suggested organizations can be regarded as fragile or robust. Fragile organizations can be shattered by turbulence. Robust organizations are resilient and are designed to withstand turbulence. But there is a third kind of organization, one Taleb characterizes as "antifragile," that is actually made stronger by turbulence. 

To become antifragile, organizations must cultivate "optionality." If you can't predict, then all you can do is keep your options open and try to generate more upside than downside. Optionality is arguably a variation on the wisdom once conveyed as a core principle to every Boy Scout: "Be prepared!" Still, an inability to predict raises a fundamental question, "Prepared for what?" Perhaps the best response to that question is to occupy a position of "ready awareness."

Preventing chaos

As a nation, Switzerland has been described by the Canadian American economist Alex Tabarrok as particularly antifragile. In every Swiss village there are multiple spring-fed water fountains. Together, they comprise a decentralized water network that, in case of disaster, is not subject to the consequences of a broken centralized system. Like its water fountains, the political system of Switzerland is also decentralized. If the central government fails, according to Tabarrok, "The Swiss might not even notice." 

At peace since 1815, Switzerland has nonetheless remained prepared to defend itself. To support its state of "ready awareness," all Swiss males are required to serve in the military (or pay a tax if they cannot serve). The Swiss have built hidden hydroelectric dams in the Alps, and for generations they have been tunneling into the mountains to create secret hideaways for people and supplies. These are augmented by hundreds of thousands of private and public fallout shelters. The largest of these shelters can hold up to 20,000 people. 

Also hidden away are libraries with books that can be used to get civilization restarted, if necessary. These repositories include the means to read obsolete data storage formats, such as floppy disks. And in well-guarded bank vaults and bunkers, the Swiss store their gold and their Bitcoins.

Today, anesthesiology may be medicine's most antifragile specialty. But it had once been particularly vulnerable to turbulence. In the 1940s, anesthesia related mortality exceeded 6 per 10,000 patients. While anesthesiologists constituted 3 percent of physicians, they accounted for 12 percent of medical liability insurance payouts. In a corrective response to these troubling statistics, anesthesiology became the first specialty to champion patient safety as a specific focus. 

In 1978, a Harvard study profiled the use of aviation inspired "critical incident analysis" to understand the causes of anesthesia related mortality. This study caused the American Society of Anesthesiologists in 1985 to form the Anesthesia Patient Safety Foundation (APSF), which spurred research and education as well as adoption of new technology to increase safety. The APSF also pioneered and promoted standardization and guidelines, which were unique at the time. As a result, there has been a 10- to 20-fold reduction in anesthesia mortality.

Lessons learned

When anticipating or confronting turbulence, there is a mix of things leaders can do as they pilot their organizations into an uncertain future:

Don't lead directly into turbulence. Wise pilots recognize the potential for turbulence in storm clouds and either fly around or above them.

Know your options. Despite efforts to anticipate and avoid it, turbulence can still envelop an organization quite unexpectedly. In such situations, stability becomes a priority, as does the shortest path out of the storm.

Consider the potential for a cascade of associated events. One encounter with turbulence may transition into another potentially threatening situation. Still, turbulence can generate positive situations as well. For example, a competitor may stumble, or new customer needs may emerge.

Preserve roles. One lesson from Mann Gulch is that role definition is important. Absent a sense of identity and purpose, individuals within an organization can become reactive, disorganized and dysfunctional when confronted by turbulence.

Maintain control. Another lesson from Mann Gulch is that an organization's operating integrity and control must be maintained. If these are compromised, the organization can begin to disintegrate as it leaves laminar predictability and moves into the chaos of turbulence.

Recognize that a smooth, "routine" laminar flow always holds the potential to shift into turbulence. The space shuttle disasters taught the danger of complacency reinforced by denial and group think. Floating along in the predictability of a laminar flow can lull an organization into a false sense of security. Create ready awareness. 

Finally, keep your destination in sight. Like a carnival ride, turbulence can spin an organization around so fast that people end up disoriented. An organization's destination should be embodied in its mission and vision. But mission and vision are not predictions. They are aspirations that should never be surrendered to turbulence. 

In 1949, Sir Robert Macintosh, M.D., the first holder of a chair in anesthesiology had declared: "There should be no deaths due to anesthesia." That vision persisted and helped pull the specialty through turbulence.

Shakespeare had his finger on the nature of chaotic turbulence in Troilus and Cressida, when Ulysses says, "Take but degree away, untune that string. And, hark, what discord follows!" The first obligation of a leadership team is to secure the organization's future. Fundamental to fulfilling that responsibility is navigating through turbulent conditions.

Dan Beckham is the president of The Beckham Company, a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to AHA Today. The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.

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