HRO 9m Collision at Sea-An HRO Perspective1

With the review of the “as was” sequence of events and supplemental information from the accident reports (postmortems) complete, this post begins the process of applying the principles of High Reliability Organizing (HRO). I will use my understanding of HRO to reimagine key aspects of the sequence of events. This will require several posts to keep the length of each near my target of 1400 words.

In this rendition of the sequence of events, I will describe some of the ways a crew practicing HRO might function. Since there is no manual for HRO, I will describe practices that I actually used or observed. My focus will be on the day before and the day of the collision. I do not plan to go into depth on the qualification process for Bridge watchstanders, technical manuals, and training. I will do my best not reimagine the sequence of events based on knowing how things turned out (not so easy). I will also not criticize any decisions made by the actors involved for reasons I have previously divulged.

I reviewed the basic principles of HRO in my Introduction to HRO post. In that post, I made two assertions based on my experience with HRO.

First, if you want to cultivate higher reliability in your organization, focus on the behaviors you expect (including senior leaders), what you actually want people to do. Then cultivate the thinking that supports those behaviors (Weick, 2006). You need both, but all the theory in the world won’t help you drive a car before having some experience actually doing so. Actions lead to better thinking about higher reliability and not the reverse. At least not at first.

Second, an organization must observe (watch what their people actually do, including senior leaders), assess (look for gaps between processes as designed and how they are practiced), and adapt their practices constantly to account for different levels of experience and different environments or situations (Christianson, Sutcliffe, Miller, & Iwashyna, 2011). Most organizations that seek higher reliability (emergency rooms in hospitals, surgical units, rescue squads, air traffic control, commercial aviation, nuclear power plants, and Navy vessels) don’t have the luxury of expecting that every day will be like the day before. In fact, that’s a really bad idea. They also don’t assume that people will just do what they’re told or what the procedures dictate. People are enormously creative at adapting their behavior in the face of conflicting goals. Senior leaders may not realize these conflicts exist, but their people can spot them immediately. This isn’t a bug in human nature, it’s a feature. However, it’s a feature that requires constant monitoring and updating of procedures and training.

* Weick, K. E. (2006). Faith, evidence, and action: Better guesses in an unknowable world. Organization Studies, 27(11), 1723-1736.

* Christianson, M. K., Sutcliffe, K. M., Miller, M. A., & Iwashyna, T. J. (2011). Becoming a high reliability organization. Critical Care, 15(6), 314-318.

In my reimagined view of the sequence of events as performed in HRO, I will classify the behaviors according to where I think they “fit” with respect to the five principles of HRO. I will use the abbreviation FSORE:

• Failure (Preoccupation with Failure)

• Simplification (Reluctance to Simplify)

• Operations (Sensitivity to Operations)

The above three can be considered skills of Anticipation.

• Resilience (Commitment to Resilience)

• Expertise (deference to)

These two can be thought of as skills of problem Containment.

20 August 2017 (the day before the collision)

As I have seen them performed, Navigation briefs are more like a series speeches than pre-event briefs. I am sure the Navy Surface Warrior COs reading this will have their own ideas and I certainly welcome them in LinkedIn comments or on this website. If done well, they can be very useful, but it is my belief that they don’t lend themselves to frank conversations about risk and contingency planning. This is why practicing HRO is aided by a smaller meeting before the Navigation Brief with the ship’s senior leadership that I call the Navigation Pre-Brief.

Navigation Pre-Brief (FSO)

The CO meets with the Executive Officer, the Senior Watch Officer, the Chief Engineer, and the Navigator. The purpose of the meeting is for the CO to review with a small group of his senior leaders what they will present at the Navigation Brief. This meeting is done before the Navigation Brief so the CO learns what his senior leaders think. It gives him the chance provide input, make comments, possibly argue, and ask questions before the brief when the stakes for public disagreement are much lower. In this smaller group, his senior leaders might be less inhibited from disagreeing with him depending on how the CO has behaved in the past. Two important ground rules (there can be many more) are: 1) surface all disagreements and 2) no shooting people or cutting them off over those disagreements. By “surface all disagreements,” I mean that any member of the group that disagrees with “the plan” states so and why. Another approach is for the person briefing their part of the plan to provide a respectful summary of the disagreement they had with another leader and why they chose a different course of action. In HRO, people learn to appreciate the respectful airing of disagreement as even more important than consensus.

I have a rationale for the attendees noted above. The XO is the second in command and can assist the CO in deciding where to adjust the plan and supervision. He is a CO-in-training so this is an opportunity for him to learn as wel. The Senior Watch Officer is responsible for assigning all personnel to key roles and how they function in those roles. He can explain his rationale for those assignments, especially people very junior. The Chief Engineer is responsible for the performance of the emergency procedures in After Steering as well as the damage control posture in the event of a problem. The Navigator is responsible for the navigation plan and watch team, including hazards and general conduct of the passage to the port. In organizations practicing HRO, there can be a monitor present to provide information to participants about *how* the meeting was conducted (not easy, but very important). This is very common in nuclear organizations. I often allowed a junior officer to attend these meetings when I was Operations Officer at a Naval shipyard and later Commanding Officer. We would discuss their assessment of the meeting afterward to reduce their reluctance to give me a frank reaction as well as potential resentment from the senior leaders present (humans are humans). I plan to write a future blog post on my approach to mentoring junior officers for HRO because this was just one aspect.

The agenda for this pre-meeting is:

• The schedule of events for several hours before setting the Sea and Anchor Detail (SAD), the time for stationing the SAD, the transit to Singapore through the Traffic Separation Scheme (just the highlights), the time of sunrise, and the weather forecast. There are many ways to break down the sequence of events, but this one allows a full discussion of how the parts fit together.

• The Operational Risk Management (ORM) plan associated with the transit. The Navy has a formal program and detailed procedures for this that can be found on the web. The most important thing is: what are the likely risks and how does the plan created address them? Part of the ORM is to review the experience level of key watchstanders and what to do about it (replace them with someone more experienced, provide more supervision, provide more assistance from people with greater experience, etc.). ORM should also include recent maintenance performed on key systems and last date of casualty drills.

• The supervision plan that does not include the CO (it could be a recommendation). Where will senior leaders be stationed during the transit and exactly what will they be watching? What decision criteria will they use to intervene with watchstanders, if necessary? On many ships, this is part of SAD assignments, but this gives senior leaders a mandate to consider whether it should be modified.

• A premortem (Klein, 2004). This is the opposite of a postmortem (Latin for “after the death” as well as a Peruvian death meal band, yikes!). A postmortem is performed after the patient has died or after an organizational accident. Postmortems are done to learn what went wrong after the failure. In contrast, a premortem is done to learn what could go wrong before the event. It suggests risks that might not be accounted for in the plan. You can learn all you need to know about how to do a premortem from a web search using the term “gary klein premortem.” HRO includes premortems to assess the plan not from a “we aim for success” perspective but rather a “we know we failed and here’s why” perspective. In my HRO experience, premortems make people uncomfortable so they need lots of practice. I am not sure why, but it could be that even in HRO people prefer to focus on achieving success and not examining failure before it happens. Failure is “icky.” Only losers talk about failure. This is not how HRO works, which is why one of Weick and Sutcliffe’s HRO principles is Preoccupation with Failure.

* Klein, G. A. (2004). The power of intuition: How to use your gut feelings to make better decisions at work. Currency.

• Final questions and a decision by the team (not the CO) about whether they need to meet again to address modifications to the plan before holding the Navigation Brief. The only time the CO overrules the team is if they decide that another meeting is NOT needed and he thinks differently and can explain why. This is the more conservative approach and it is his prerogative as THE senior leader to be more conservative. The CO explains his reasoning for another meeting so his senior leadership team learns about his approach to risk. A senior leader should be very cautious about being less conservative than his team. He wants them to point out what he’s missed, not mechanically defer to him.

In the next post, I will continue this analysis with the actual Navigation Brief.