Operational Risk Management Part II

In last week’s blog post I explained that I think most of the mishaps that happen in the Navy are fundamentally a breakdown of operational risk management. In turn, that breakdown stems from an inability to adequately assess risk. Military personnel are highly trained, and much of the structure of the military is there to help reduce risk. That means that people can do stupid stuff for a long time, getting by on skill alone until finally the situation becomes too big and people are injured or killed. Until that point, however, people will be unable to truly assess the risk they are facing.

Like I said last week, I had a lot of things go wrong on my watch, and many of them were my fault. I wound up in many critiques and wrote two incident reports. There were several times where I was the majority of the ship’s critiques. I only really started to get better when I started to actively think a lot about the risk/reward of any given evolution. Risk is a little abstract to think about, so what I started doing, unconsciously at first, was to think about explaining my actions at a hypothetical critique.

This is a technique I recommend. Before you start an evolution, imagine that something has gone wrong and you have to explain your actions to a very critical board of people. That way, if you are cutting a corner that potentially increases risk, you have to have worked out your exact reasoning for why you did that. This kept me from doing a lot of the little stupid stuff. If my reason for skipping the maintenance brief was “well I just didn’t think we needed that,” then I had to think about how that would sound out loud in front of Naval Reactors and Squadron personnel. I don’t think supervisors should live in fear of what could go wrong, but it works as a thought exercise in evaluating the risk/reward for your actions. Usually we assume that everything will go right, so any action we take is justified in the end. But if you start with the assumption that something will go wrong, then suddenly you have to work to explain what you did.

Once a year a submarine has to do an emergency blow. An emergency blow is when high pressure air is used to push all the water out of the main ballast tanks, causing the submarine to surface in an emergency. In 2001, the USS Greeneville was conducting an emergency blow as part of a VIP tour. They surfaced into the Ehime Maru, killing nine people. It can be a very, very dangerous evolution due to the fast nature of an emergency blow and reduced situational awareness. When our annual emergency blow came up, I was selected as OOD (I was to drive the ship). The original plan was to conduct the emergency blow during our normal watch time, which was during daylight hours.

Unfortunately, our assigned time to pull into port changed, meaning we could no longer do the emergency blow as scheduled. At the last minute, the command decided to change the plan. The emergency blow was rescheduled for the middle of the night. I flat out refused to perform the emergency blow and the evolution was cancelled. I had imagined what I would say to an admiralty board in case I got somebody killed in the performance of the blow. Changing the time would have meant we no longer had the benefit of the sun, reducing our ability to see contacts through the periscope. Having the daytime watchstanders perform the evolution at night meant they would no longer be alert.

Fundamentally, I didn’t believe anything would have gone wrong in the evolution; the watchstanders were very good, and there weren’t any contacts visible on the radar or in the moonlight. But still, something could have gone wrong, and I could not have justified these risks to anybody. We did not need to perform the emergency blow right then; we would have another shot at an upcoming underway. If we had performed the evolution during the day, with full visibility and alert watchstanders, and still something had gone wrong, I could have fully justified that we took every precaution possible to ensure the evolution would have gone smoothly. If we had gone along with the plan to perform it in the middle of the night, we would have been increasing risk when the evolution was not necessary to perform right then.

The second major change is that I would empower more junior watchstanders to make more calculations with risk. Unfortunately, and it is an unsolvable problem, there is a tension in a peacetime vs. wartime Navy (or military). In wartime, a large amount of risk is necessary; ships and sailors must go into battle. In peacetime, there are no battles to fight, so a lot less risk is acceptable. But the Navy must still train for wartime, where being shy about risk is no longer acceptable. This creates a tension in how much risk a CO should encourage.

Unfortunately, the way I saw every one of my captains try to solve this tension was by telling junior personnel to encourage risk. Each captain wanted me and my cohorts to recommend and push for higher risk activities. This would put us in the high-risk (and hopefully high reward) mindset. Meanwhile, the captain would be the final arbiter of risk and, if our plans were too risky, he would veto them. This method was employed by my captain that got fired as well as by the “fixer” captain sent in to replace him.

There are two major problems with this method. One, it depends on the captain to be perfect at assessing risk. The chain of command exists for much the same reason that the triple-check of the tagout system exists: it is highly unlikely that me, my department head, the executive officer, and the captain will all make the same mistake. But these captain’s methods, where they wanted to be the arbiter of risk, meant that they were the sole arbiter of risk. If they made a mistake, there was no one to back them up, and others (the ones in the dangerous situations) paid the price.

The other problem is that it means that more junior personnel never get practice assessing risk. If your marching orders are to disregard the risk of an evolution, depending on others (the captain) to evaluate risk, then you’ll never get good at it. This would be especially problematic when one of these officers, in turn, becomes captain. After a whole career of never assessing risk, these officers would be ill-equipped when it was finally their job to be the one to assess risk.

I do think it is necessary and important to be willing to take on risk where there is a commensurate reward. The fundamental tension of a peacetime vs. wartime Navy will never go away, but you can think like you are in wartime even if you then act like you are in peacetime. Whenever there is a potential evolution (and it fits to do this), I think that multiple courses of actions (COAs) should be presented. These should come with an honest and complete evaluation of the risk and the potential higher rewards that come with with COA. Both high and low-risk COAs should be evaluated on their merits, and then the COA chosen with the lowest risk that achieves the necessary objective.

The military is a fundamentally dangerous job. Risk will never go away. The military does a great job, and should continue to do a great job, at training personnel to excel in their skillsets and to put measures in place to reduce risk as much as possible. I think the military’s “can-do” attitude, necessary in wartime, hampers the ability to conduct honest and accurate risk assessments in peacetime, leading to unnecessary injury and death. To solve that, every person participating in an evolution needs to think through where risks are being taken on for what reward. More junior personnel, especially supervisory personnel such as officers, should be required to evaluate risk honestly instead of pushing for more risk in the name of training for wartime. A focus on operational risk management won’t solve every problem, but I can tell you it helped me.