Operational Risk Management Part I

Reading this week:

  • Neptune’s Inferno by James D. Hornnfischer

Recently (as I’m writing this), this USNI News article popped up in my news feed: “Investigation: Reckless Flying Caused Fatal T-45C Crash That Killed Two Naval Aviators.” In the incident, a student pilot was flying with an instructor. The instructor was performing and telling the student to perform advanced maneuvers that were not part of the plan. Both pilots misjudged the height and speed of the aircraft and crashed, killing both of them.

I’m not a pilot and I don’t have the skill to judge the technical aspects of the incident. But I was a nuke and a whole lot of things went wrong on my watch, many of them entirely or partially my fault. In the nuclear Navy, when things go wrong we hold a “critique.” A critique is an analysis of what exactly happened and the root causes of what happened (the other communities have similar systems but I haven’t experienced those first hand). Since I caused a lot of things to go wrong I went to a lot of critiques.

When things go wrong there are only really, fundamentally, a few root causes. Something could have broken. Sometimes things just break. You can probably dig down and analyze the cause of that failure, but sometimes mechanical and electrical devices just fail in ways that the watch team could not have predicted. Sometimes, people do go rogue. I had one mechanic who was getting fed up with the maintenance approval process (it was a busy day and his maintenance was low-priority for us so it kept getting pushed aside, but it was high priority for him because it was between him and going home) and so he just opened up the panel on the piece of equipment he wanted to work on and got to work. This is a big no-no and landed us in a critique.

But the vast majority of the time, when things go wrong, it is human error. Under the category of “human error” there are of course sub-categories. Sometimes, people just weren’t trained properly. Through no particular fault of their own they wind up in a situation they are not trained for and make a bad decision because of it. Sometimes there are hard decisions to make, and you can’t know everything, so you make a decision that turns out to be wrong. But the vast majority of cases that fall under “human error,” and therefore in the vast majority of cases that go wrong, it is my belief the fundamental root cause is poor operational risk management, or ORM.

ORM is the practice of balancing the risk associated with an action with the potential reward. Good practitioners of ORM will actively seek the ways to reduce risk, but it is also true that risk cannot be eliminated. Risk should be taken on, however, only in proportion to the commensurate reward. Flying planes, and especially warplanes, is an inherently dangerous thing to do. Aviation has a fantastic safety record and is one of the safest methods of transportation out there, but you’re still hurtling your body through space at high speed and high altitude. That is risky. The safest thing to do is to not fly. But not flying is not really an option; modern war requires aircraft and people to fly those aircraft, and the only way to get really good at flying airplanes is to practice flying airplanes. So you seek to reduce risk: you install safety equipment in the aircraft, you use simulators to practice where possible, you train the pilots to be familiar with the limitations of the aircraft and avoid exceeding them, and you only perform maneuvers that are as risky as necessary to successfully complete the training. In that way, the risk is reduced and becomes commensurate with the training value achieved from actually flying the airplane.

The most frequent way ORM falls apart is a bad evaluation of risk. If risk is evaluated poorly, then it will be impossible to tell when the risk being taken on has exceeded any potential value from the evolution. You can google a whole set of articles on why people are bad at evaluating risk, but in the Navy, I think the root cause is that most people are phenomenal at their jobs.

In the T-45C crash, neither pilot was a bad pilot. The Navy put a whole lot of time and money into training both of them and it showed. Again, I’m no pilot, so maybe they were actually terrible, but according to the article both pilots were conducting very advanced, unplanned maneuvers, passing the controls back and forth pretty continually and everything was going fine right until the end. The instructor was an experienced pilot but the student was still managing these maneuvers despite being a student. These two men were very good at flying airplanes, as far as I can tell. The upswing of being a very good pilot is that you can do a lot of dangerous things for a long time and have everything turn out just fine. Given how nonchalant he was, this could not have been the first time the instructor was conducting these sorts of maneuvers, and since he lived through every other time, then every other time must have turned out just fine. So, in my analysis, the instructor was unable to evaluate risk because every other time he did something stupid he managed to survive based on skill alone, which meant these activities no longer felt risky.

Given the Navy’s (and presumably the whole military’s) skill at training their personnel, this inability to properly assess risk of course extends to all communities. Last year, of course, both the USS Fitzgerald and the USS John S. McCain collided with merchant ships leading to the loss of life of 17 sailors. In the Navy’s investigation of the incident, they concluded that “the crew and leadership on board failed to plan for safety, to adhere to sound navigational practices, [and] to carry out basic watch practices.” What that translates to is that the crew did not implement the appropriate risk reduction procedures commensurate with the amount of risk they were taking on. In both the surface and submarine fleets, the way you mitigate risk in high-risk situations, such as operating near navigational hazards or near a large number of other ships is to station more watch standers who are able to better evaluate information as a team than one person is able to do alone. On both those ships, the situations that lead to the incidents, with inadequate watchstanders and inadequate safety precautions could not have been one time events.

Having been on a ship where things went wrong, and having been responsible for those things, I can tell you that suddenly a whole lot of people unfamiliar with the facts of the case have a lot of strong opinions on what you must have done wrong. I’m not here to do that in these incidents, and for all of them the Navy’s official reports compiled by the experts in these events are available to read. But what I am comfortable saying what I am saying because I’m not saying these people were bad watchstanders, I am saying I think they were probably very good. Both of those ships must have operated with inadequate watchstanders numerous times, and were able to do that because the watchstanders they did have on watch were highly trained and very good at driving ships. That means they, like the pilots, were able to do dangerous things and have nothing bad happen, which means they were ill-equipped to adequately assess the risk they were taking on and mitigate it.

I think some of the structural aspects of the Navy can contribute to this inability to assess risk. In 2016 two Riverine Command Boats attempted to transit from Kuwait to Bahrain. On the way they were seized by Iranian forces and held captive. In the Executive Summary of the incident report, the very first cause of the incident listed is that the command “demonstrated poor leadership by ordering the transit on short notice without due regard to mission planning and risk assessment. He severely underestimated the complexity and hazards associated with the transit.” In this case, what I suspect happened is that every other time the CO ordered this crew to perform a task, they pulled it off. Short notice, no notice, difficult conditions, you name it. So the CO lost his ability to adequately assess risk when it came to ordering this unit to perform a transit.

A similar thing happened to us. The first time we did a berth shift (when we moved the submarine from one pier to another), we took a week to prepare. It is, fundamentally, a pretty risky task, because you don’t have the reactor running and just have the diesel, which means the submarine has very little ability to get itself out of a bad situation and limited backup systems in case something goes wrong. But we did a lot of berth shifts and did them all perfectly and so before you knew it squadron was comfortable giving us two hours of warning to do a berth shift where previously we spent a week getting ready. We even did a berth shift with only one tug where normally you have two, vastly increasing the risk of the operation. We may have gotten a bit better at berth shifts, but at no point did the risk actually reduce, just our perception of the risk did.

In the case of the Riverine Squadron, this meant the CO was comfortable ordering the boat crew to make a high-risk transit with little warning time. This is especially dangerous because the CO is supposed to be the final arbiter of risk. If he is the one ordering the mission to go ahead, he has to have made a decision that the mission has an acceptable level of risk compared to the potential reward. I firmly believe that the officer in charge of the actual mission has a parallel responsibility to assess risk and must refuse to carry out the mission if in his opinion the risk vs. reward calculation is not worth it. But given that the order comes from the CO that fundamentally alters the officer’s ability to assess risk; the CO has many more years of experience and often has access to more information and his judgment should therefore be more reliable. But I think our CO here had seen this unit succeed many times, changing his assessment of the risk, and the feedback loop to the officer in charge meant that no one was able to assess the risk any more.

I’m going to keep harping on things that make it harder to assess risk, but I am trying to drive home the point that assessing risk is a fundamentally hard thing to do in the Navy precisely because we work so hard to reduce it. A major aspect of Navy maintenance procedures is to require several people to verify that something is safe. Before working on a piece of equipment, we’ll tag it out. What this means is that we’ll turn off and isolate every power source to a piece of equipment (including electrical, mechanical, and hydraulic power) and hang tags on those switches, valves, or isolations to make sure that no one turns them back on (similar to but not the same as civilian lockout-tagout). To tag out a piece of equipment one person has to determine what isolations are needed, another person has to verify them, and, before the tagout is hung, the supervisor also verifies it. For more complicated tagouts even more people can be involved but at the absolute minimum three people look at a tagout to make sure the worker won’t be harmed when he goes into a piece of equipment.

For something to go wrong then, all three of those people have to make the same mistake. Things, therefore, rarely go wrong. Two people can miss an isolation and have the third person catch it. In that case, nothing bad happens; the equipment doesn’t get worked on until the problem is fixed and the worker doesn’t get shocked or hurt by dangerous equipment (for nukes chuckling about the inevitable critique, yeah, but my point is no one was injured). Further, as I have been harping on, all three people in that process are usually pretty darn good at their jobs! That means mistakes are rarely made anyways, but it further drives down the possibility that all three people fail in the exact same way. But that, in turn, increases complacency. One guy, swamped with work, can maybe not do as thorough a job, knowing he’s got two other pretty smart people who will check the work and make sure nothing bad happens. The problem, of course, crops up when the other two people make the same assumption, or maybe one person makes an honest mistake and the other two don’t check it. No matter how good you are, everyone makes a mistake every once in a while.

Please stick around for part two, next week, where I solve the problem.

Roots Roots and More Roots


Reading this week:

  • The Tibetan Book of the Dead translated by Robert A.F. Thurman

This past week (feel like I gotta get a new start for these articles) I went to an Orange Fleshed Sweet Potato (OFSP) Workshop! Loyal readers (there are none) will note I have already been to a workshop on OFSP, but this one was bigger, better, and longer. OFSP Reloaded. Where the previous workshop was meant to be an introduction to both OFSP and orange maize, this workshop was focused on producing orange fleshed sweet potato with a particular bent towards seed production.

Overall the workshop went pretty well. The first day was all classroom stuff and focused heavily on nutrition. OFSP are, of course, high in Vitamin A. Vitamin A is one of four major nutritional deficiencies in Zambia, along with protein, iodine, and iron. Since people already grow and enjoy the white-fleshed varieties of sweet potatoes, it is a relatively easy “upgrade” to the orange kind. During the workshop we focused on overall nutrition, why it is necessary to eat a balanced meal, and, most importantly, techniques we can use to teach these concepts back in our villages. One of the best ways to do this is using the “Go, Grow, Glow” model. In this model, carbohydrate foods are “Go,” giving you energy. Protein foods are “Grow,” helping to build the body. Finally, “Glow” are foods with minerals and vitamins that help maintain overall health. By assigning foods to these categories and encouraging people to eat all three with every meal we help teach about a balanced diet.


Over and above the previous workshop we did more hands-on activities. We went through the entire process of planting vines for rapid vine multiplication and for root production. We also did some rudimentary soil testing that people could do on their own land for little money. First, by feeling the consistency of the soil the farmers can determine if it is sandy, clay, or loam soil (or a combination). Then, by adding either vinegar or bicarbonate (baking) soda to some soil and seeing if it fizzes, farmers can determine if the soil is basic or acidic and act accordingly.


Dramatic low-angle cooking shot.

We also spent a whole day cooking meals with orange fleshed sweet potatoes. Traditionally, sweet potatoes are mostly consumed for breakfast and are only boiled. That might be unpalatable for some people, and since it is a “breakfast food” people might not eat the potatoes for lunch or dinner. So we used OFSP to make meals like curry or stew. We were also focusing on processing sweet potatoes, so we made OFSP flour. This flour is easy to make (just dry the potatoes and then pound them) and can be mixed 50/50 with wheat flour. The mixed flour can then be used like 100% wheat flour in recipes for bread, fritters, or other baked goods. This allows people to get Vitamin A in more of their foods and is a cheaper alternative to pure wheat flour. We even made OFSP pancakes on the cooking day and they were pretty awesome.

Finally, and exciting for me, my host dad and I got to see a cassava processing center. This workshop took place in Mansa in Luapula Province, the location of the nation’s root and tuber research center. Besides the sweet potatoes, they also have improved cassava varieties. I was interested in bringing back some improved cassava to the village, and my host dad was interested in seeing the processing facility. They have a very nice facility there where they have machines to grate, press, fry, and mill the cassava in bulk. Cassava is a very popular food security crop here, but with some mechanization can be a very profitable crop as cassava flour gets a much higher price than maize flour. And it takes less resources than maize! The research center here has planting and harvesting machines that they will bring to your fields for only ~$260/Ha. I am told this is cheap, especially as it includes fertilizer and herbicide, though farmers have to provide their own planting material.


Cassava/Sweet Potato Chipper. For making chips.

On top of all THAT, they also grow a lot of cocoyam (taro) here in Luapula province, and I was able to secure some seed for that as well. So now my host dad and I will be bringing back three different root crops to our village and I am pretty excited. Diversifying crops leads to better food security, as well as potentially introducing new markets that farmers could use to make more money. Root crops are usually relatively easy to grow, drought resistant, and very hardy, and make ideal crops for food security. Two years ago I never would have thought I would be this excited for roots man.

On Development

Sweet potatoes

Reading this week:

  • The Undercover Economist Strikes Back by Tim Harford
  • The Death and Life of Great American Cities by Jane Jacobs

I wanted to share a few thoughts on development work. The methods and effect of development work is a popular topic among Peace Corps Volunteers as would be expected. Books like Dead Aid are pretty common reads among PCVs, and I pay close attention when people like Tim Harford or Tyler Cowen talk about development. The topic of development is consistently in vogue due to the number of international agencies out there and the billions of people targeted by the work.

I think the current trend is to bash development work. There are projects like What Went Wrong? to document where projects failed (to be fair to them, their eye is towards doing it better). Having read Dark Star Safari, Paul Theroux travels through Africa and takes a dim view of the effect of development work (again to be fair, he doesn’t bash their intentions, except for the proselytizing ones).

The biggest thing I’ve learned since being here is that it is hard to tell what’s going to stick. I’ve brought a counterpart to several workshops, including workshops on animal husbandry, mushroom growing, rice growing, orange-fleshed sweet potatoes, and beekeeping. Of these, so far the only project we’ve implemented is orange-fleshed sweet potatoes.

I think it is inevitable that most development projects are going to fail. I don’t blame anything like the culture or people becoming dependent on handouts, I just think of development work like a business. It might not be universally true, but most of the projects I’m around here to implement are really about introducing new businesses. A fish pond provides other benefits, but the end goal of digging a fish pond is to sell the fish and make money. If I teach a farmer about beekeeping the end goal is to harvest and sell honey and beeswax and make money. If we get farmers to plant a new crop, the end goal there is to have diversified the outputs of the farm to allow the farmer to sell more products and make more money. In that perspective, a lot of development work is about helping people start a new business.

Unfortunately, even under the best of conditions, most businesses fail. Businesses fail here for the same reasons that they fail back in America. A lot of these projects have a pretty high start-up cost in terms of money, time, and labor. Digging a fish pond is hard, and even if digging a pond out of dirt is “free,” it still takes weeks or months. People are already busy doing things like hoeing and weeding their fields by hand, and the time it takes to dig a fish pond is time the farmer could have spent doing other things. After the pond is dug, it takes money to buy the fingerlings to stock the pond. People also must have all these resources available before they even begin as there aren’t really any sources of credit available to villagers around here. Back in America, people who want to start a business can take out a business loan to get the capital to start. But a farmer here who wants to stock a reasonably-sized fish pond has to have at least 150 Kwatcha when they’re struggling to put together 20 Kwatcha every four months to send their kid to school.

Even if a farmer overcomes the startup costs, they may find that the new business just isn’t cost effective. A farmer could decide to undertake improved animal husbandry as a business and start raising goats. The farmer could very well find that raising the goats takes time away from growing maize (so he can’t grow as much) and that the cost of vaccines, supplemental feed, and paying for any damages that the goats cause if they escape is more expensive than anticipated. He could find the market price he counted on doesn’t materialize and goats sell for less than he expected, driving down profits from his goat business. So the farmer sells off his goats and gives up on animal husbandry. That has an effect on the rest of the community. Where I live, people wait for someone else to try something new. If that other person is successful, then they’ll undertake the risk and start that same project. If that person fails, then they won’t bother with it. My village grows a lot of onions because one person tried it and found it profitable. It was hard to get anyone to dig a fish pond because years ago they tried it and it failed. Now that my host dad has dug a fish pond, people are waiting to see if he makes money before they try it themselves.

Although it is hard to predict what projects exactly will be successful, I do think there are some things you can do to improve your chances. A lot of these have been detailed elsewhere. Just handing a village something like a tractor with no training on repair and no way to pay for gas is going to be pretty useless. You have to make sure there is actually a market for whatever you’re proposing people make or grow, and a way to get it to that market. Projects should focus on people’s ability to maintain it using the resources they have available.

Along those lines, one lesson I have learned is on the definition of “low cost.” Sometimes I Google for ideas for things like improved solar dryers and come across projects that comment on their “low cost.” But when these projects say that, they usually mean that they are less than $25 or something like that, maybe even $2. But around here, $2 is a term’s worth of school fees, which I mentioned a lot of people have trouble scraping together. So if you come in with your “low cost” project of $2, you could be asking someone to choose between your project or sending their kid to school. So while I understand the need to spend money to make money, “low cost” can still be very pricey.

But with all that, I do think development work is very possible and very important, even if it could be done better. I think the timelines on a lot of these projects are really too short to tell if you’re going to be successful. I have two years here in Zambia, but the agricultural cycle takes about a full year. That means I really only have two shots to introduce a new agricultural system. And if I introduce something in that second cycle then I’ll probably be gone before I can really tell if it works. Agricultural projects can take years to pay off; techniques such as conservation farming require 3-4 years of labor invested before the farmer really starts to see savings in labor and fertilizer. On the health front, if I teach about malaria or HIV, then really the metric there is if they get malaria of HIV for the rest of their lives, not just in the two years I’m around to watch.

But development does have an effect on people’s lives. In Dark Star Safari, Paul Theroux meets people he knew and taught or taught with as a Peace Corps Volunteer and then afterwards as a university professor. These are people that have successful careers and have raised families. People have a lot of teachers in their lives, and each affects them, but who’s to say Mr. Theroux there didn’t have some meaningful impact in improving at least some of his student’s lives? Even if most businesses we help people start eventually fail, some will succeed and give people a shot at making more money than they otherwise would, with follow-on benefits like being able to send their kids to school or invest in more businesses. If they don’t start any businesses, then all of them will fail.

I’m very much in favor of development work as a whole. I think there are a whole lot of ways to do it wrong, and I’m not even sure the Peace Corps method is the best method if you’re main goal is improving lives most effectively and cost-effectively (America gets other benefits from the Peace Corps, don’t forget). But I think it is going to be easy to point out the ways the development fails because the nature of development work means most development projects will fail. But some will succeed and it is hard to tell on what timeframe they’ll make an impact.



Reading this week:

  • Origamy by Rachel Armstrong

This post is about my sweet new cat, Inwanwa. Unfortunately, shortly after I wrote the post Cats, Munono (the eponymous cat) disappeared. I don’t know where he wound up but I hope it is someplace nice; maybe his newfound fame lead him off to Nollywood or similar climes.


Anyways, getting a cat was kind of an impulse decision. Peace Corps regs prohibits the Peace Corps Houses from having house pets. This is an allergy and health regulation, but at our house in Kasama stray cats manage to eke out a living on the grounds despite us reading the aforementioned Peace Corps regulations to them. Cats! At any rate, presumably due to the proclivities of these cats, the house got a kitten infestation.

The story of me and Inwanwa is probably something along the lines of the cutest Rom-Com ever, because the first time he saw me he hissed at me and refused to come near me. By the next time I had come to the house, however, someone had fed the kittens and so suddenly they were all about people. This sounds cute, because it was, but the cats had to go. No longer afraid of people, they would aggressively go after your food on the porch and sneak into the kitchen in the house and wreck havoc (but cute havoc) as kittens are wont to do. So they had to go.


My poor cat here, no one wanted him. I didn’t really want him either, because owning a cat is like, responsibility, but Munono was missing and I have a big ole soft spot for the unloved. So my fellow PCVs, sensing weakness, pressed me to adopt him and so I did. The morning when I left he was unceremoniously put into a cardboard box lined with panty liners and I carted him home. This must have been traumatic for the poor thing because carting him home involved waiting an hour for a minibus, a three hour minibus ride, and then being strapped to the back of my bike and biked home. The poor thing survived in good condition and was welcomed home with some ham.

I was worried he would hate me after that little ride but apparently not. So now I own a cat. I had decided to name him after his distinctive mustache, so he was dubbed “Inwanwa,” which is apparently Mambwe for “mustache.” I asked my host dad and he didn’t think there was a Mambwe word for “mustache” (not a popular hair style) but the dictionary says it is Inwanwa so there we go.


Since getting the cat my hobbies have largely been making cat toys (he prefers toilet paper rolls) and pounding rebar into my walls and damaging the brickwork to make him platforms he doesn’t use. But he is cute and he likes to take naps on my lap and also claw me a lot. He has taken to stalking chickens and so my biggest fear is that he becomes a chicken killer, which would be expensive for me. He doesn’t eat kapenta which means I have to feed him cat food and when he can’t get me to play by clawing at me he bats at the dogs’ tails, which is playing with fire little cat. They mostly ignore him. So yeah, standard issue cat.