HRO 9d Collision at Sea-Sequence of Events3, HRO Value Conflicts1
References
(a) Navy Report of the Collision https://www.doncio.navy.mil/FileHandler.ashx?id=12011.
Day Before the Collision-Value Conflicts (Part 1)
In my prior two posts analyzing the Sequence of Events (SOE), I identified three interesting things from the day before the collision. Anyway, I found them interesting. First, the Officer of the Deck and Conning Officer that were scheduled to be on watch when the USS JOHN S MCCAIN (JSM) entered the Singapore Strait Traffic Separation Scheme (TSS) were not present at the Navigation Brief (ref(a), p.60). Second, “the Commanding Officer decided not to station the Sea and Anchor detail” prior to entering the TSS (ref (a), sec 7.3, p.60). Third, the three most senior officers responsible to the CO for safe navigation and operations at sea asked him to change this decision (ref(a), p.60).
The lack of additional information diminishes what can be learned from these three facts. What did the OOD and Conning Officer think about the position into which the CO’s decision placed them? What took place during the conversations the three officers had with the CO? Did they report their concerns individually or as a group? What was the CO’s rationale for rejecting their recommendations and accepting the risk? This is real life. Sometimes, the person with “ultimate responsibility” is not going to agree with your recommendation and sometimes investigation reports don’t help us learn why. If you do want to learn a lot more about a situation that was similar, read Diane Vaughan’s The Challenger Launch Decision.
Depending on things to work out for the best in the face of risk you perceive to be serious is not a High Reliability Organizing (HRO) strategy. Deciding to write a formal letter challenging the CO’s decision is an option, but likely not career enhancing. I will not describe what these three officers should have done because no one can learn from such hindsight assessments. Deciding what risks are worth considering and how to manage them is not an ethical issue, it is a value conflict. This is particularly true when people raise objections to the plan. Organizations practicing HRO actually support and encourage airing these objections because their leaders believe that unanimity regarding risk management is itself risky.
The U.S. Navy has procedures for just about everything except challenging the judgment of the Commanding Officer (CO). Nearly every conflict can be escalated to a higher authority except conflicts with the CO underway. Other organizations have similar limitations in different forms.
What can you do when you feel very strongly that your assessment of risk is superior to to that of your direct superior or someone higher? The options suggested below are not exhaustive; they are strategies I have used in the past with varying degrees of success. None of them are easy or without personal cost, but then few important things in life are.
When considering the options that follow, there are two points to keep in mind. Point one, don’t put your boss or anyone senior to you in a corner or demand a decision that may cause them loss of self-respect. In real world “it’s me or you” conflicts, the person with the lower status and power almost always loses. Point two, attempt to phrase your objections not as challenges to authority and judgment (which send you right back to point one) but rather as questions or attempts to clarify your understanding about the risk and proposed risk mitigation plan (if one exists beyond “hope for the best”).
One option is to inform your boss that you are not comfortable with the decision to accept the risk. Another way to state this is that you don’t understand the risk mitigation plan and want to learn what you are missing that makes it justifiable to accept the risk. Reevaluating a risk in the form of a question is easier than when it is presented as a challenge. Acceptance is a valid risk management plan in many circumstances. Accepting a risk without being able to explain why is not. In the best case, you might obtain insight you were missing, inspire your boss to establish additional mitigations (stationing a modified Sea and Anchor Detail on the Bridge before entering the TSS in this case), or encourage your boss to speak to his boss even if the decision was your boss’s to make.
Another option is to ask your boss to let you bring your concerns to his or her superior with your boss present. This might get you removed from your boss’s Christmas card list, but it is a less direct challenge and not as sneaky as doing it secretly (I’ve done that more than once when I thought it was my last option). It also removes the ability of your boss to proceed with the plan without informing his superiors that people like you have raised objections. It also eliminates the ability of the superior to say “Nobody told me there were objections.” This excuse is used more frequently than you might think. For an example, see US Army 15-6 Report of Abuse of Prisoners in Iraq, page 40, paragraph 14, https://fas.org/irp/agency/dod/taguba.pdf
Another option is to take your concerns directly to your boss’s superior without the permission or the presence of your boss. I have done this before when I couldn’t get my boss to acknowledge my concern or he had convinced me based on personal demeanor that it would be futile to ask. Only you can decide if this approach is worth the risk.
Another option is to tell your boss that you believe managing the risk is beyond your skill level and you think someone else should get the assignment. While it may not feel rewarding to admit such inadequacy, it is much less confrontational than telling your boss that you don’t agree with his risk management plan. It is hard for a leader to order someone to do something that person has said he or she doesn’t feel they can handle. I used this strategy many times on behalf of the people in my department when I felt we were being asked to do something for which we were not ready. I told the organization asking for the action that we were not ready, what we would do to get ready, and when we would be ready. Before I did this, I told my boss what I planned to do and requested his support when the organization appealed to him, which they always did. You have to plan for this. My boss never overruled me.
The situation that existed on the JSM the day before the collision underscores an important aspect of HRO that isn’t a principle. It is so important that it supports them all. How does the organization manage value conflicts? Conflicts over important values like safety, operations, efficiency, and risk management are inevitable. To expect otherwise is a triumph of hope over experience. Organizations that value Highly Reliable Organizing develop means to do this. How the organization manages value conflicts has important ethical and safety implications that I will explore further in my next post.
