HRO 9 Collision at Sea-Comments on the First Five Posts

References (I kept the reference letters consistent with prior posts)

(a) Navy Report of the Collision https://www.doncio.navy.mil/FileHandler.ashx?id=12011.

(d) U.S. Navy Regulations, Chapter 8, https://www.secnav.navy.mil/doni/US%20Navy%20Regulations/Chapter%208%20-%20The%20Commanding%20Officer.pdf

A retired Surface Warfare Officer (SWO) CO and friend from my active duty days noted that incidents like the JSM-ALNIC collision are multilayered, both in terms of causality and analysis. The layers of deep interest, such as “why individuals made certain decisions, and to what level the consequences were considered, [are] often lost to history - either not explored in a Human Factors framework or hidden behind legal or other policy decisions.” He went on to note that “personal dynamics are a huge factor that are often ignored or minimized in the investigation process.”

Soule reply: For whatever reason, outsiders will never know what those personal factors were. In the final analysis, it might not matter for the future even if we did know them. My blog posts are an exploration of what we *can* learn from what we *do* know. Readers will be finding out what I think about that as I continue the series.

I agree that personal dynamics and leadership styles can play an important part in disasters. The Navy report makes an oblique reference to this in its Findings. It is interesting that there is a section titled “7.3 Leadership and Culture” (ref (a), p.60), but the word “culture” does not appear anywhere in the section except the title. That is an interesting omission if it was intentional.

Another experienced SWO noted that what stood out to him was “a truism about such catastrophes [is that] they are never products of a single event. They always arise from a series of compounding errors. One person can be the hero and break the chain of events that otherwise would lead to catastrophe …”

Soule reply: I agree that there is seldom “just one thing” that causes a system accident like a collision at sea. There are generally so many layers of defenses and safety processes that it takes many decisions and actions to breach them (see my post on James Reason’s model of accident causality). This is why I believe that the concept of “root cause” is a myth. I think a better goal than searching for “the one thing” in accident investigations is understanding the causes and what we can learn beyond blame, shame, and retrain (hat tip to Bill Rigot, another mentor). Looking for or labeling *one* cause as the most important (the “root cause”) runs the risk of being satisfied with “folk” labels like “loss of situational awareness” or “lack of supervision” that aren’t helpful for changing behavior.

One of my motivations for studying system events like collisions is exploring what can we learn from separate small failures become linked to produce the catastrophe (Weick, 1990). What is it about those events that causes them to become linked when in many other circumstances they don’t? Sometimes it is someone speaking up when things don’t “look” right, but not always. As a leader, do you really want to put yourself in a position where someone has to be a hero to prevent disaster? HRO doesn’t rely on heroic behavior. What are the variables humans can influence in risky situations if they can’t actually control them? What I seek to accomplish in this series of posts is draw attention to the small things that aren’t obvious or seldom considered (but have enormous consequences) about disasters and their implications for High Reliability Organizing (HRO).

* Weick, K. E. (1990). The vulnerable system: An analysis of the Tenerife air disaster. Journal of management, 16(3), 571-593.

The commenter (he made lots of good points) went on to say that “two of the ‘speaking truth to power’ remedies - speaking to the CO's boss, either with him or behind his back - are simply not available in this sort of shipboard environment, as the CO's boss is not onboard/readily available. In any event, when to station the S&A detail is entirely up to the CO - even if the CO's boss agreed with the complaint, no one is going to think highly of the subordinate who brought this sort of item to his/her attention.”

Soule comment: I agree that underway, there is no way to escalate an issue to the CO’s boss unless the Commodore is onboard. I think it is a bit strong to say that the decision for setting the S&A Detail at a particular time is “entirely” up to the CO or his standing orders. Here’s why.

One philosophy of risk that I have seen COs practice and tried to practice myself is that the CO doesn’t make high-stakes decisions like when to station the S&A detail at all. His role in risk management is to accept the recommendation of the XO and Senior Watch Officer unless he thinks it is unsafe or is so conservative that it will compromise mission accomplishment. Both of these represent teachable moments. Just because “the responsibility of the Commanding Officer for his or her ship is absolute” (ref(a), p.59 and ref (d)) doesn’t mean he has to make all the decisions. (I know the commenter was not suggesting this)

I had a conversation with a CO about decision making along these lines. I thought that it turned out very well even though, surprise, it was difficult for me to initiate. I told him that his department heads could not do their professional duty if he made most decisions and merely informed them. Department heads and the XO have a duty to tell the CO when they believe he has made an error based on their independent assessment of the situation. When the CO routinely makes high-stakes decisions, this puts both his senior leaders and himself in very difficult positions. They have to disagree with him and he has to be willing to change his mind publicly. Neither is easy. I told the CO that he could still make decisions (very polite of me, I know), but he needed to let us do our jobs and make them first.

The duty you have to tell your boss when you think he is making an error reminds me of Rickover’s observation about the meaning of service:

Service ceases to be professional if it has in any way been dictated by the client or the employer.

The role of the professional in society is to lend their special knowledge, their well trained intellect, and their dispassionate habit of visualizing problems in terms of what ever task is entrusted to them.

Professional independence is not a special privilege but rather an inner necessity for the true professional and a safeguard for their employers and the general public. Without it, they negate everything that makes them professional and become, at best, routine technicians or hired hands, and, at worst, hacks.

There are many circumstances and many bosses that make it difficult to disagree, but it is the mark of the professional to do it anyway. Of course, I had some bosses that made it very difficult to disagree with them. Early in my career, I ignored the issue because I didn’t know how to pursue it with them. As I gained experience and was involved in situations with very high stakes, I sometimes asked for a private session to discuss the issue directly. My opening remarks were something close to: “My job is to support you and carry out your orders. It is also my job to give you independent counsel and tell you when I think risk needs to be managed differently. I can’t do that well if you don’t consider my concerns. You may see the risk differently or have a better understanding of the situation, but if we don’t explore those things as professionals, I can’t develop better independent judgments about situations you see differently.” This is not to intimate that I know exactly how anyone should handle high-stakes disagreements with their boss. It is another mechanism of “speaking truth to power” that is worthy of consideration when the stakes are really high.

We know from the Navy report that the XO and the Operations Officer of the JSM actually did express their concerns about the timing of setting the S&A Detail, but the CO overruled them. We’ll never know from the report how they did this. My examples in this post are not intended to suggest how they should have done it. In the end, it doesn’t matter.

I made the point in one of the prior posts that providing independent, professional judgment to the CO or any superior is seldom discussed in organizations. That is a serious impediment to HRO because conflicts over risk management are inevitable and perhaps necessary for people to learn. Thanks for the great comments.