Overhaul16: Undeniable Truth of Overhaul 21
Introduction
This is the fifth installment of the Undeniable Truths of Overhaul series. This post describes Undeniable Truth 21: Errors require corrective action, but don’t be stupid. The post begins with two views of human error (spoiler alert-one of them produces stupid corrective actions). It continues with the safeguards, controls, and training that reduce errors in normal Navy warship operations. It identifies the features of overhaul that make errors more likely, focusing on two specific cases: the mismatch of qualifications and training with the overhaul environment and higher supervisor workload. Several examples of stupid corrective actions are noted before describing four pillars of effective corrective action design. Pre-corrective actions are proposed as proactive measures to lower systemic risk before errors happen.
Two Views of Human Error
People reflexively blame individuals for errors, a form of the Fundamental Attribution Error. Research suggests that most errors result from systemic issues beyond individual control. The Bad Apples view is that errors are made by defective humans who
aren’t “paying attention,”
lose “situational awareness,”
become “complacent,”
fail to “follow procedures,” or
need more training (always preceded by blaming and shaming).
The Systemic view is that few errors result solely from personal shortcomings. In this view, errors result from conditions systematically connected to the work (Dekker & Leveson, 2014). As I note below, most are foreseeable (Ziezulewicz, 2022).
The Smooth Sailing of Normal Operations
Procedures and complex activities performed by warship crews outside the shipyard are:
repeated regularly,
performed by experienced personnel or with just a few inexperienced, closely monitored newbies,
require few valve manipulations,
short, and
use standard communications.
System response is easy to predict and observe.
Operations outside SY’s are constrained. Error and its consequences are limited by qualification processes designed for the environment, procedures, instrumentation, culture (e.g., “believe your indications”) and robust designs (sometimes, integrated bridge control and navigation displays have had issues).
The Shoals of Ship Overhaul
The overhaul environment is rife with error producing characteristics. It fundamentally changes operations, maintenance, cleanliness, emergency response, and work control (UT 20 High performance is different in overhaul). This must be so because you can’t repair a ship at an industrial scale using rules tailored to normal operations.
The overhaul environment opens multiple pathways for error and work stoppages:
System complexity added by unfamiliar temporary systems, new procedures, and multiple, interacting layers of control
System response, a hallmark of high reliability, is difficult to observe and predict
Qualifications are not adapted to the environment (learning on the fly)
Distracting and frustrating quality of life hardships
In the sections that follow, I emphasize two environmental mismatches: training and qualification and supervisory duties.
Training and Qualification in Overhaul
The crew’s rigorous training and qualification processes don’t match the demands of the overhaul environment. Outside the SY, Navy technical training conveys three broad types of knowledge:
technical (system design and theory), the what
performative (how to do things) with apprenticeship (observe, do under instruction, do with supervision, do), the how
narrative (stories from experienced operators that transmit and reinforce performative and cultural knowledge), the why
Technical knowledge is still conveyed in overhaul, but has little application because it centers on at-sea processes and systems that don’t apply. Everyone is learning about the shipyard environment at the same time, so apprenticeship training models and narrative knowledge don’t reinforce the technical knowledge.
Supervision in Overhaul
The demands of the overhaul environment adversely affect the crew’s supervisors (UT 12: The crew’s most limited resource). “Effective supervision” is one of many folk concepts of performance in the Navy. “Everyone” can articulate what supervisors lacked after errors, but few senior leaders define it before problems occur. The two most important impacts of overhaul on the crew’s supervisors are increased cognitive load and risk management.
The cognitive load (demand on limited mental resources) of the SY environment is problematic for the crew’s supervisors. Off-watch, they manage divisional work, training, qualifications, and personal issues (lots). Supervisors must do on-the-fly risk management for the work in their division as well as SY procedures they may have only skimmed (they have to sleep sometime) and don’t occur as scheduled (stuff happens). Training for SY procedures is crushingly boring and may not develop insight into risk, watchstander qualifications, communications, and supervisor leverage (see UT 20 High performance is different in overhaul).
On watch, supervisors have more demands for their attention than a schizophrenic at Mardi Gras. They must quickly respond to “Shop X needs this now” demands support requests (UT 13: Never delay the shipyard). To accomplish this, supervisors do rapid risk assessments in areas where they may have no expertise (e.g., electronics technicians supervising mechanical operations). Focusing on “Who is available?” instead of “Is this person capable?” isn’t poor risk management, it’s a survival strategy. Supervisors lack the tools to think differently in overhaul.
The crew’s supervisors are the default deconfliction managers in overhaul. Why should the SY coordinate their support demands when they can offload that responsibility to the crew? Distracted, harried, overwhelmed supervisors don’t supervise operations or manage error well.
”Stupid” Corrective Actions
Corrective actions are needed to improve performance after errors and problems, but they are often ineffective or, worse, stupid counterproductive. When post-problem corrective actions ignore systemic sources of error, add additional controls, and slow SY support, delays result.
Causal analysis and corrective action training are non-existent in the Navy. The result is SF leaders copying what they witnessed other leaders doing who weren’t trained either. Neither is good.
Stupid corrective actions, based on the bad apples theory of error are simple, fast, and what “everybody does.” They don’t require mentoring, adjustments to the environment, or better support for watchstanders. They also don’t teach people to think differently. Some examples:
Any corrective action without mentoring and training for managing overhaul risk
Stopping all work and testing (the stupidity should be obvious)
The tagout “death penalty”: an officer or Chief observing every tag hung.
Designing Effective Corrective Actions
Effective corrective action design isn’t difficult. The four pillars of effective corrective actions are that they are:
measured (i.e., not so cumbersome that they interfere excessively with work),
targeted (i.e., focused on the people who lacked training, knowledge, or understanding),
performance-improvement focused (otherwise it’s just punishment), and
limited (i.e., have an expiration or an observable end state)
I’ll elaborate on the last pillar only due to space constraints.
All corrective actions, particularly those that add additional requirements, need an expiration date. This isn’t superficial. It is essential to minimize interference with SY work, keep the overhaul on schedule, and develop personnel to reduce future errors. Problems happen, but the goal is to exit overhaul, not prolong it.
Assigning end dates to corrective actions will generate resistance from third parties. A CO or RO who says, “We’ll put these measures in place for three days” will be challenged. Rightfully so. This is just going through the motions.
Corrective action expirations need to be explained with style: “I’m adding these specific controls and additional measures to address these specific crew deficiencies. My leaders and I will monitor performance and evaluate the need to keep the corrective actions in place over the next X days (or shifts).”
Heresy alert: two creative antidotes to stupid or unimaginative corrective actions. First, consult the Chiefs before imposing them. In a supportive command climate, they’ll help with intelligent design. Second, seek the counsel of the Type Commander (only a phone call away) and SY Chief Test Engineers (CTE’s). Both have reputations to preserve and have invaluable insight into the four pillars. The common practice is to decide on corrective actions at the end of formal problem investigations without soliciting advice, but no rule requires it.
Pre-corrective actions
Pre-corrective actions are like pre-mortems (Klein, 2004). They are actions to reduce errors and thus the need for corrective actions. They include training on risk management, rigorous pre-evolution brief protocols, articulating operator responsibilities and supervisor behaviors, monitoring and training watchstanders, post-problem analysis and mentoring, and tuning training and qualifications for the overhaul environment. Time-consuming? Absolutely, but these actions take one-tenth as much time as critiques, corrective actions, and follow-up. I know because I used them.
Wrap Up
Post-problem corrective actions based on the belief that errors are made by bad apples are simple and satisfying, but they blind leaders to defects in the system. Sanction the miscreants and move on. In contrast, effective corrective actions address systemic flaws, are thoughtful, and follow the four pillars of effective design (measured, targeted, performance improvement-focused, and limited). Since post-event corrective actions can impede shipyard support, it is imperative for crew senior leaders to maximize their effectiveness.
Examples or descriptions of all the tools I mentioned (and others that I didn’t) are available upon request (don’t ask for a dump).
References
Dekker, S.A. & Leveson, N.G. (2014). The bad apple theory won't work: Response to ‘Challenging the systems approach: Why adverse event rates are not improving’ by Dr Levitt, BMJ Quality & Safety, (23), 1050-1051 Published Online First: 03 Oct 2014. doi: 10.1136/bmjqs-2014-003585 https://www.sidneydekker.com/wp-content/uploads/2016/02/BadAppleWontWork.pdf
Klein, G. A. (2004). The power of intuition: How to use your gut feelings to make better decisions at work. Currency.
Ziezulewicz, G. (2022). USS George Washington suicides investigation reveals systemic issues. Navy Times, Dec 20, 2022 https://www.navytimes.com/news/your-navy/2022/12/21/uss-george-washington-suicides-investigation-reveals-systemic-issues/
