HRO 9n Collision at Sea-The HRO Perspective2
This post continues my analysis of the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the Straits of Singapore from the perspective of High Reliability Organizing (HRO). In this post, I continue my analysis of what HRO might look like applied to actions that occurred before the CO’s order to change the configuration of rudder and engine control.
20 August 2017 (the day before the collision)
Navigation Brief
As noted in my prior post, an organization practicing High Reliability Organizing (HRO) might conduct a Navigation Pre-Brief before the Navigation Brief done by every ship in the Navy. A small group of the ship’s senior leaders conduct the Navigation Pre-Brief in the presence of the CO to show him their plan for entering port and, as a team, assess readiness, consider all appropriate risks, air disagreements and concerns, and consider changes to the plan. In HRO, airing, discussing, and resolving disagreement is not a weakness, but rather a source of strength. It is an important aspect of practicing Weick and Sutcliffe’s (2007) Preoccupation with Failure. Lack of disagreement or concern at briefings is NOT a good thing in HRO. In HRO, lack concern prior to an important event is itself considered a problem to be explored more deeply.
* Weick, K.E., Sutcliffe, K.M. (2007). Managing the unexpected: Assuring high performance in an age of complexity. Jossey-Bass.
After the Navigation Pre-Brief, the ship’s senior leaders conduct the Navigation Brief. Neither of the reports give any details about the topics addressed in the brief held by the JSM, but they are the same as the Pre-Brief: important events before setting the Sea and Anchor Detail (SAD), the time for stationing the SAD, the time of sunrise or sunset (if it will occur during the entry to/exit from port), navigation details of the transit in restricted waters, weather, tides, currents, time for meeting the boat bringing the harbor pilot to the ship, key watchstanders, and status of any equipment related to the transit to port. In HRO, there will be a review of a written Operational Risk Management (ORM) plan.
Another aspect of Preoccupation with Failure during a Navigation Brief is a focus on things that must go right or present great risk if they don’t. This might include communications that need to occur between key stations (Combat Information Center, Bridge, Navigation Team, After Steering, Line Handling areas, and Engineering) and actions to take if there is a casualty to ship control systems. HRO does not assume the important things “just happen.”
In HRO, briefs have two other features that can make a very large impact on their effectiveness: a watch bill and interactivity. Organizations practicing HRO do not begin event briefs unless there is a signed watch bill (assigning personal to all positions) and all personnel identified on the watch bill are present. This has nothing to do with what happened on the JSM. It is the standard (not a goal) for HRO. Making the watch bill a standard for beginning a brief reduces the possibility of “well-meant shortcoming” spiraling downward into “heedless or stupid blunder.” (John Paul Jones, 1775, September 14). First, senior leaders at the brief need the watch bill to ask evaluate the readiness and level of knowledge of specific watchstanders. Second, watchstanders cannot prepare for those questions unless *they* know the role they are assigned.
Interactivity means senior leaders ask the watchstanders questions to evaluate their understanding of the plan and what their responsibilities are for casualties or problems. The written ORM plan facilitates these questions. The questions take the form, “Officer of the Deck, what are you going to do if the Helmsman reports a loss of steering?” “Helmsman, what will you do if there is a loss of steering?” “Conning Officer, where is the shoal water?” “What visual navigation aids will you use?” “Officer of the Deck, what will you do if you disagree with a recommendation from the Navigator?” Preoccupation with Failure regarding a Navigation Brief includes foreseeable problems like: loss of steering, engine casualties, loss of electrical power, radio failures, and failures of radars or navigational equipment. No one wants to have a casualty in restricted waters, but the important thing in HRO is being prepared if there is.
21 August 2017 (the day of the collision)
From an HRO perspective, there is nothing to be gained by analyzing the order of the CO or the decisions of the Bridge watch team to implement it. To use a theatrical metaphor, the stage was set, the actors were in place, and they did what they did after the CO’s order to split the duties of the Helmsman with an additional watchstander. We know how things turned out (badly). While learning from mistakes is an integral part of Weick and Sutcliffe’s Reluctance to Simplify and Preoccupation with Failure (Weick and Sutcliffe, 2007), my focus is on the contribution of HRO *before* the CO’s order.
The conditions that existed on the Bridge just prior to the CO’s order (covered in great detail in previous posts) were:
The JSM was entering the Singapore Strait Traffic Separation Scheme (TSS), in the darkness, twice as fast as the MV ALNIC.
The Sea and Anchor Detail was not set.
The OOD had qualified 3 weeks prior, making her possibly the least experienced OOD on the ship.
All personnel on Bridge watch were qualified in accordance with the ship’s implementation of the U.S. Navy’s Personal Qualification Standard (PQS).
Several key watchstanders didn’t understand the controls and indications of the Integrated Bridge and Navigation System (IBNS).
There was no procedure for changing the configuration of the Ship Control Console (SCC) in the Engineered Operations Sequence System (EOSS) or one that was locally generated.
There were gaps in the IBNS technical manual.
My choice of language with respect to the qualifications of the Bridge watchstanders, “in accordance with the ship’s implementation” of the PQS, is important. No qualification system is perfect. People that are qualified for their duties using *any* system can have knowledge deficiencies or do the wrong thing.
In some parts of the U.S. Navy, the qualification system goes far beyond the Navy standard. Its key attributes are:
A list of qualification “practical factors” for each watch station that require performance of important capabilities or simulating them when demonstrating is impossible, which happens in major maintenance. Simulation is as rigorous as possible. It includes pointing to indications, explaining what they mean, touching switches, explaining what results from operating them and how an operator would observe that response. When simulation is required, a person is only “provisionally” qualified until the ship’s material condition supports performance. The performance requirements are seldom waived.
Strict control and formal documentation is maintained for the people qualified to certify that a trainee has the required knowledge and has demonstrated performance of practical factors.
Personnel coming from other commands or with extensive prior experience can have an abbreviated personal qualification. This justified and documented in writing.
Every qualification requires a written exam using questions from an approved test bank.
Nearly all qualifications require an oral examination by a designated authority. The questions from the exam are documented and the officer in charge of the qualification signs the record of questions with the grade.
Personnel that are qualified periodically undergo oral Level of Knowledge checks. These are also documented in writing.
Each qualification has proficiency requirements. If a person has not stood the watch in a prescribed period, their qualification lapses until an approved authority evaluates their level of knowledge and documents this assessment in writing.
All qualified personnel periodically re-qualify. At a minimum, re-qualification requires taking qualification tests again.
Not only is this qualification process rigorous, every aspect is documented and retained so that the process is auditable. Performance to a standard and retention of records make the qualification process both rigorous and formal. The ship does periodic process audits and regularly presents the records to outside agencies for their evaluation. The point of describing this implementation of the Navy’s PQS system is not to criticize the leadership of the JSM. It is to provide an HRO point of reference for qualifications. Some organizations could apply this process to all their qualifications. Others might be selective with its application depending on the impact a qualification has on outcomes important to the organization.
In part 3 of the HRO perspective in my next post, I will what describe what I think is really involved with Preoccupation with Failure, Reluctance to Simplify and Sensitivity to Operations.
