Current Thought Articles

The USS Carl Vinson, CVN 70

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:49 GMT

This is a discussion with Thomas A. Mercer, RAdm, USN, (retired)

RAdm Mercer, as Captain of the aircraft carrier USS Carl Vinson (CVN 70), requested an evaluation by academics from the University of California, Berkeley, to improve his crew's performance. He also desired to have an MBA program available for his crew. The academics did offer some suggestions but the end result was the codification of RAdm. Mercer’s command philosophy and modern leadership techniques as the High Reliability Organization.

CVN 70 was the third of Nimitz class aircraft carrier, commissioned in March of 1982. The crew did an around the world cruise and reported to Alameda, California, a year later. This was unusual because they were not getting the normal support from their support command on the west coast before they departed. RAdm. Mercer reported one-third of the way into the cruise as the ship was transiting to the Indian Ocean (where the support from the west coast for spare parts and replacement aircraft engines dramatically improved).

The accident rates as far back as the 1950s and 1960s were 17 accidents per 100,000 flight hours. Accidents, embarked and shore-based, are down now to less than 1 accident per 100,000 flight hours. The entire carrier force is now nuclear powered, which brings more capability and professionalism, appreciation for training and culture of doing things "right" that was not so before.

The USS Nimitz was commissioned in 1975 while the fighting in Viet Nam was largely over in 1973. Throughout the Viet Nam war, most of the super carriers were conventionally powered starting with the USS Forrestal. The USS Enterprise was commissioned in 1961. All the carriers were "driven hard" because of the Viet Nam war. The USS Enterprise had a major fire off Hawaii, killed about 100 people, bombs cooked off (burned or exploded) after being hit by a rocket fired on the flight deck.

The USS Enterprise had 8 reactors. All Nimitz class carriers have just two large reactors. Safety and readiness is a full system approach. The primary component of safety are the people, it is a people system with a very low authority gradient. Anyone can, and should, question what is being done.

[Aside: VADM (ret) Gene Wilkinson, was the first CO of the USS Nautilus, the world's first nuclear powered warship. He passed away this year (2013). He originated the famous phrase (at least in the Navy) "underway on nuclear power" in January 1959.]

All nuclear trained officers, particularly the CO, are personally selected by the Director of Naval Nuclear Power. The first was ADM Rickover, the longest tenure of any four star flag officer in the US military. Nuclear operators are very technically competent. The CO sets the tone for the entire organization. Always on duty.

Low authority gradient, anyone can stop an operation and question what is being done and is encouraged to do so. In the USS Enterprise grounding off of Bishop Rock, California, no one questioned the CO because he had trained each person on the bridge. A carrier’s Executive Officer is also nuclear trained and aviator. All COs of nuclear aircraft carriers must be aviators; they have not driven ships their entire career. The CO must rely on all his post-command department heads (Air Boss, Navigator, Operations Officer, Reactor Officer), senior Medical Officer and Supply Officer.

The Navy's Chief Petty Officers (CPO), the senior enlisted officers, have become stronger and stronger during Tom's career. There is a lot of technical training and expertise, they make things happen on a daily basis with cross coordination with their counterparts throughout the ship. It has been said that the Navy is run by the CPOs. One of their most important roles is training the junior officers.

In aviation squadrons, all the junior officers have many collateral duties in addition to flying so the officers depend on the Chiefs to get the work done. Some of the most junior people are the plane Captains, the enlisted person in charge of individual aircraft maintenance. There have been many improvements in the carrier (the ship), too. We have moved to angled flight decks to allow simultaneous launch and recovery. Planes touch down 92% on final and 100% on landing, four arresting wires and other barriers and pilots would sometime amiss and hit, have glide slope indicators and Landing Signals Officer to guide the pilots in, steam catapults instead of hydraulic catapults, just enough night lighting to keep you from having to sit in ready room in night goggles for 30 min to be night acclimated for night flying, still try to keep lights from casting to submarines and others, we have automated carrier landing systems so you can make hands off landing, he had in his career, but not perfected.

Comment on responsibility toward the other person, to help and protect others on the ship. This is part of the sense of duty we discussed.

Overall level of training and the culture are key components. People know they are top line people doing important work for the Navy. The formal training has become more and more detailed and viable. The Navy has an all volunteer force now as opposed to the draft during the Viet Nam War when we did not always have the highest caliber people. Many people want to enlist or reenlist and we don't allow it because they don't meet our standards. People feel like their trainee is their responsibility and would be very embarrassed if anything that happened to them. Always looking out for their buddy on the flight deck and throughout the rank structure people always have the philosophy and attitude that they are training their relief as they move up in responsibility.

At an EMS conference 20 years ago, and EMS veteran with 40 years of experience remarked that he missed the camaraderie between EMS personnel and hospital staff. There was pride not only in the organization but also in the system. The other person's welfare is part of the training. In the Navy is this part of recruit training or is it emphasized later?

Yes, it is part of recruit training but it is also part of unit policies and cultivated unit pride to build camaraderie and professionalism. You see a problem and you own it until someone gives you help. You teach people that everyone's job is valuable, trying to make sure that no one messes up another person's work, feeling that we are all in this together, there are few special privileges. Every person has worth no matter how menial his or her job.

In healthcare people tend to look down on rookies and novices yet in the 1970s on the ambulance and in the fire department it was a source of pride by how much the rookie learned. How much the rookie learned reflected the quality and performance of the crew. In healthcare, the novice or rookie seems to be in the way. How do you encourage people to look after the new guys?

Some personalities of course do not fit in, but there are ways to shuffle them off to the side or weed them out quickly. The demands for people and advancement make it necessary to ensure the new people learn as much as possible. People are always new in something. We know they will have to step in in an emergency and have a role to play in keeping the aircraft carrier or submarine running. The quicker you can get the person trained and reliable, trained like you are, the better it makes your quality of life. Every person can save the boat.

Numerous groups want to bring High Reliability into their organization. It is easy to say but it is hard to do. You said that you always encounter opposition. You advised to move forward despite the opposition not in spite of the opposition. How do you work despite or with the opposition?

You do get the feeling that it is you against the world. People try to take it as a matter of pride and good discipline. A book came out five to six years ago, It's Your Ship, by Michael Abrashoff. He happened to be the junior skipper in the destroyer group. He prided himself on not cooperating with other COs, to try to one up them. This banter must be friendly and not get out of hand. In some systems this type of friendly competition can further each other’s performance and make people better. You raise the bar for others.

If you come in and change what they are doing there is resentment. Rather, tell them what is good, then, ask what else we can do? If it is not working, then in private discuss how we can do better. You are going to get resistance when you tell people they are not doing things the right way or need to improve so you have to be careful about appealing to their sense of pride and professionalism.

We are designing out the hazards of a system, which may lead up as to designing out the capacities of the individual. For example, the use of auto landing systems in aircraft is such a system. Will this result in an effort to drive out risk and human reliability. As part of an High Reliability Organization, you have to have systems that are designed to allow humans to adapt to changing conditions that could be lost if we rely on more automation.

A doctor he met at a conference at USC had the impression that the automated systems and air traffic controllers should be held accountable for accidents and that accountability had shifted away from pilots.

While the academics from Berkeley focused on flight decks the piece de resistance of what you did involved kitchen duty. Some loved it, some hated it, and for some that was the best they were going to do yet you instilled in them pride in their job. As you said, “If you can take care of the ship below decks the flight deck takes care of itself.” In hospitals, no one pays attention to the lower ranks. How do you instill pride in in the lower ranks and acceptance by the higher ranks?

Everyone does kitchen duty or compartment cleaning. When they report to the ship no matter what their technical training is (with only few exceptions), the first cruise in the summer at the naval academy is in the role of an enlisted man. Everyone in the organization has had to do their fair share of the "menial" work. Even the military academy must learn the job from the ground up.

In medical school and residency this is called “scut work” and everyone is assigned these duties. However, it has the reputation of being meaningless, that it has no useful purpose. As a novice in many organizations you get free pass to ask any questions you wanted. This is a golden opportunity to learn. Health care does not seem to value this period. Is it to learn how the system works or because you are the lowest on the totem pole?

You described a lot of technology that was implemented at the same time as you were involved with cultural dynamics and personal leadership. What kind of change accounted for what kind of improvements? Did things ever get less safe when you were introducing technology?

Transition to some of the technologies was often not as smooth as you might think. His predecessor on CVN70 had a lot of time to work with marine architecture people at MIT and Carnegie Mellon in 1981 and 1982. They had a Wang beta email system throughout the ship. It had a very colorful and interesting map display system on the bridge and other areas of the ship well before GPS. It had a high-speed printer for generating all the paperwork the ship needed and some expert systems to improve air operations (fuel management, etc.). They had tried to automate many of the pre-underway checklists. All ship instructions automated and electronic. The problem was that no one was used to using them, computers were not strong enough to handle the load, checklists not easily updated when things needed to be changed. It did well in REFTRA, but it did not do well in the Operational Readiness Exam that followed. Many of these systems were detriments to the tried-and-true ways of doing things. Now the aircraft handler that manages plane status, arming, and fuel, and maintenance has automated systems to support him, but the automated systems cannot do all the thinking and coordination needed.

Right now the LA water system is putting in system called Safe Start: mind on task, eyes on task, behavioral safety . The real problem is just keeping people motivated to do things they don't want to do. How do you motivate people to do those things they don't want to do?

Make those basic unpleasant things universal so people know they cannot escape them. On the carrier, it is a test of how well you internally communicate, how much do you let people off at these training events know that they are still part of the team? Need them to know that someone is looking out for them and to return to their real job

When people are sent off for training in tasks not relevant to their job, we must convey that they own the material. We must let them know they are not going off just to do something. People have to feel a sense of owning something or vision of how these things they don't want to do are important

It seems like the sustainability of the motivation falls back to leadership to make it clear to front line staff that what they are doing is of value to leadership. They will see the value as well this way.

What are we modeling when we say one thing and do another? The staff pays a lot of attention to the signals the leadership send.

Deferring to Expertise, Part I

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:48 GMT

Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO

Expert, expertise, local knowledge, knowledge of the circumstances - what do we mean when we defer to expertise? It is not so simple as it sounds. If you believe in it and use it then, yes, it works. But many people cannot make the leap of faith and believe we are allowing "freelancing" or letting the patients run the hospital. So ... what is it? What are the benefits? How do we do it safely?

Physicians have difficulty the concept of deference to expertise, as they believe it is their responsibility to manage all aspects of patient care. They also have the idea that this means people can do what they like. Physicians do not see it as local knowledge or specialty knowledge in a field other than medical care.

In the Navy, the ship captain defers to the harbor pilot coming into port, or a sea pilot to avoid bars, especially in foreign ports. This is the individual trained to do it, knows local conditions, weather, and currents. The navigator of ship and commanding officer are still totally responsible. The primary thing is that the harbor pilot has a background in working with tug boats to maneuver the ship, they keep radio contact with the guys in the tugboats. The other major thing in the Navy is relying on the Chiefs, the middle managers, to go and back and forth with their counterparts to make things happen because of their expertise. Junior officers are trained to expect the Chief to be the expert and to learn from him.

During the introduction of Crew Resource Management (CRM) in the Navy, there was strong resistance because it appeared to some aviators as a challenge to authority. What it really meant was a person, grounded in the knowledge, should feel capable of challenging the senior leaders. In the Columbia and Challenger shuttle disasters, many on the ground had the knowledge of the risks but they were not listened to.

In wildland firefighting, how do you bring people up to deference to expertise without having them make bad decisions? Juxtapose wildland fire with medicine for a more clear understanding of this in healthcare.

The main challenge in medicine is that physicians feel autonomous; they feel they have to be infallible. The system encourages this as the governance in the hospital is the physician and it is the physician who is ultimately accountable for patient care. This leads to rejection of suggestions and physicians appear to have a large ego. The commander of ship analogy is deleterious to patient care in medicine. This makes the physicians feel they have to be in control and they become emotionally defensive and protective from suggestions by fellow caregivers. Sensemaking makes a better approach as there are no objections, rather suggestions, to improve sensemaking. We must break down the need for autonomy and infallibility in physicians and encourage system responsibility for patient care.

From a military background, one individual has had forward observers call for fire but he was the one ultimately responsible for where that fire goes (this is for artillery). You have green, blue, and NATO forces and must control your ego when you interact. He is not sure how to do that or teach it. But you must be willing to do it. If someone calls for fire and then the firing officer says you are not clear and you must defer to those who know. You must be willing to listen to those who have more information. If someone came back and questions what you do/act, you have to trust them to accept their recommendation. This is not easy to do but good leaders have to be willing to step aside, look at how obtaining and processing information occurs and using all sources available. This is hard in intense situations where decisions need to be made quickly.

Biases, ego, and emotions are the critical three that get us down. But egos are a driver for us. How do you keep that in check? In wildland fire management, as an example, there is a local unit fighting a fire in the fire escapes the initial attack so they call in outside resources. He must order up the incident command team and the resources necessary. The local unit gives a briefing then steps back. The briefing is supposed to give newcomers the information to protect what is important to the public. He has seen groups go astray from this. For example, "we know how to put a fire out so we do not need local people." They do not ask to meet local expectations for the local people and government. Maybe it is not so much ego what it is not thought about. What does right look like? What does success look like?

A wildland fire opetrator looks at how the interactions look to local people. He brings in local firefighters who know the road system, terrain, fuel load that may or may not be conducive to fire, the drainage, and wind flows by time of day. By him briefing with the locals he knows where to dump the gray water. The environment is not yours, it matters how you take care of it. One local fellow made a map table on some plywood and two by fours that they could talk over. This developed a new way to build new understanding, using a map table that is waist high and became a "talking table" (what they called it). This drew people for conversations, seemed like an invitation for the local unit personnel.

Clearly everyone needs to know when command has shifted - make it well defined. You need protocols but also dialogue so people do not feel ignored or marginalized. The role of the prior commander needs to be clear from protocols. He still needs to be there because the prior commander may be giving all the orders to the front line. But the new guy coordinates with those up the line. You definitely don't want him to back off.

In K-12 education (kindergarten to high school) there are individuals, egos, and the team. We need to overcome the view that individual leadership is all knowing because this creates a silo approach to doing work. There is lack of collective expertise that has caused systems breakdown. How you create organizational expertise vs. siloed individual expertise? He is enlarging the circle of engagement, enlarging the structure of meetings to include more voices not previously involved, bringing student voices, and moving to team level of expertise. This helps to accelerate organizational change.

We independently use expertise in different manners. To teach endotracheal intubation to paramedics, one faculty member will bring together a medical expert from the hospital, a paramedic with field experience, and an educator who writes teaching objectives. He recognizes that each one has an expertise component.

Deferring to Expertise, Part II

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:46 GMT

Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO

We have two kinds of ego, positive and negative ego-centrism. The negative egocentrism is "I am not smart" or "I am not correct" and it takes time to train this out of people. We need to add positive egocentrism's such as introspection, courage, and transcendence (things part of ourselves that help each other). This helps people feel empowered to say "this is what I think." We need to listen to them with fresh voice because they are seeing things we have not seen before. One educator does not allow people to introduce themselves as "just a student." He does not allow the additive "just."

How does deference to expertise show up in education, in the classroom? Lots of criticism by outside experts, marginalizes those inside the process, teachers know how to teach, but how to defer to them? How do we showcase the skill sets a to improve development influence of the experts that already exist in the organization?

One school bus driver has a route where the kids hide rather than get on bus. His route is for the kids who are about to be dropped from the school system for behavior problems. No one wants to be seen getting on his bus. He does not have a problem with student’s behavior. The district rule is to call dispatch if they stop more than three minutes and call the police if they stop more than five minutes. He starts for one minute then moves the bus forward and stuff for one minute. This means he does not have to report in. But the kids know they will be late getting home or reporting to work. They learn to control each other in a positive way.

If you empower the little guy you may be surprised at what they bring. When someone with no power can give their opinion you learn more and that benefits the whole program.

Sometimes deferring to expertise works against you as you do not recognize your own expertise. Also, others don't develop it expertise. Too much deference can result in people learning not to take initiative. There is a dark and a bright side to expertise when you differ too much

It is a necessary balance, depending upon the amount of time you have, to draw out from people their own expertise but in the end you must put their words into proper terms and make a decision. Then interpret for all in the broader context

With deference to expertise you are not making a decision solely on the basis of your power and authority. You defer to a person on ground with knowledge and skill appropriate for the circumstances. But what happens when life or death situations occur? The authority gradient is so great the person with expertise may not be forthcoming.

One physician referred a child to the hospital with a distended abdomen. The receiving physician stated the x-rays showed nothing. After the child died the referring physician investigator further and found that no new x-rays were obtained. The physician group justified their actions by stating that nobody would have admitted a child anyway.

Transparency in making decisions helps everyone, those involved and novices, learn from the decision processes used.

The leader can make decisions and build barriers that people cannot speak through. In an educational system, one person had to have preapproval from the superintendent an area that the person was an expert in. This is because there is a rule. When a person makes their first decision you can go wrong and that will kill the future initiatives. There must be willingness in the leader to give up control and defer to expertise. You must do this to defer to expertise. After you have deferred expertise, made a decision, and have given responsibility to the junior officer been the leader still maintains accountability and should not shoot the messenger if it does not work out. Should there be a process up front of who we identify as an expert? It is also their perspective you want, not the knowledge alone.

In the world of tree planting (Silvaculture) there is also a dark side of deference to expertise. There is strong sentiment to earn your stripes before you speak about your experience. The veteran tree planters did not have reliable roadmaps for building their expertise, there were no books and they built their knowledge on experience. They continue to say you don't know about the culture. This is dangerous because it absolves people of their responsibility to build expertise (feel like they can just wait around for it to emerge like the old-timers did) and contribute to overall knowledge

How do we commit to resilience?

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:44 GMT

Notes from a panel of people experienced in HRO

One person was taught in the fire department to "work through the problem." In other words, keep working, don't give up, help will come to you but stay engaged which ties in with Weick's concept of enactment. Resilience is to maintain stability during all hazards. Think of a gyroscope, we are the gyroscopes of the organization.

When you are being knocked down, how do you get back up into the fight? This requires emotional self-assurance, self-understanding, and patience with self and people. You must speak the truth of what people want and what they want you to do. You must deal with the disappointment.

Cowboys have the phrase "get back into the saddle." In many ways, cattle drives in the American West were the original high reliability organizations. They moved cattle from Point A to point A overcoming the obstacles, they were vigilant for anything that could cause a stampede or loss of a cow, they were gentle in order to keep the cows calm, and they could not turn back.

There is the individual level and the organization level of resilience. The job of the leader is to stay on top of the chaos and to persevere. The leader must go back to the action plan and monitor its effectiveness. This keeps the momentum going forward to keep the organization from being gripped with actions that are counter to the organization's culture and direction. This requires regular meetings with staff.

Experts look for bad news. When things are going perfect you start looking for bad news. You are Resilient if you see bad news sneaking up on you that others do not see. Many leaders avoid conflict and bad news. Situations may force the conversation to get information about the scenario that is not going right.

To bring out resilience one person has the group plan to develop group solutions; they can change things in early stages. They closed the discussion with the statement that the solutions they come up with are not going to be the answers to the situation. The real problems will not be the problems out there and the solutions we develop will not be the ones we use. We look for indicators and establish trigger points.

In Costa Rica, one speaker was limited by the fire service in what she could do so she watched out for her colleagues to help them protect themselves. In the hospital, it is almost impossible when you are a participant to not make a mistake. She observed in the hospital and people will deny something happened even though she saw them do it.

A surgeon discussed how, in surgery, you enter and cannot back out. Things do not progress in a linear fashion so you must have multiple plans. Yet, in the hospital, most people, especially physicians, are viewed as being error-free who do not plan to fail.

A chemical professional does “premortems” for preparation and then do a postmortem later where you consider a failed output as well as the success.

In petrochemical, there are layers of protection- they do a “layer of protection” analysis. One of the last barriers in place is operations. How to be resilient in operations is important but it is their weakest place. You have a support, or oversight, manager on call. Resilience can be in design (in situ) and then when the event occurs.

Layers of protection analysis (LOPA) is also to plan ahead. In the chemical process safety field they have process analysis. The hazard is loss of containment and operations is one area of protection. When it gets out of the pipe we have to change our approach to emergency mode. Resilience is when the situation occurs and we do not have time to think. The plan is not going according to plan so resilience comes when the plan fails. We must identify it at an earlier stage.

Resilience is preparing for potential failure of our actions. The process of planning for failures is good but when the plan fails you become stressed. Mental preparation for these events can stop them from cortisol blocks that occur when events do not work out. You build up a mindset that you expect things to go wrong.

Highly successful teachers have a higher level of resilience to keep their class on track. Each student has different things going on and brings that to the classroom. Can you plan for resilience? This involves how kids learn and what happens to their ability to learn. There are limiting factors to learning, which educators need to know and to accommodate to.

Resilience is learned through training, from mentors, and by your practice. How willing are you to call colleagues for assistance, adapt to the changing situation, and collect additional information? You must learn to respond to your own brainstem and adapt. On the institutional level resilience can be planned by enlarging the repertoire of people.

There is a feeling of safety around us. You may need coaching in real time. There is a video of an autistic child being taught by the teacher. Watching the video can give feedback to the teacher if this is done in a supportive approach, especially with the child, parent, and teacher being filmed.

From a teaching faculty standpoint, this is not so much fear as it is trust.

From this group’s perspective, to be at the top of you game you must be self-reflective and want to improve. Not everyone is like this. One person described how he models this behavior as a leader and he has people model it out loud for the team.

Many HRO principles do not stand-alone. Of all of them, resilience is a combination of what happens when you bring the other four principles together.

Sensitivity to Operations II

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:43 GMT

Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO

Massive information flow can block the system. Correct information is necessary how do we not lose the weak signal? The question becomes, weak signals, too much filter filters weak signals. This is a delicate balance. What does the group think?

When you assemble the team, you must give them context and your intent. Give expectation, intent, information flow, cross talk in organization regardless of hierarchy, goals, and objectives. When discovery of things that don't seem right matters, this helps maintain the balance. People think they now need to pay attention so they can communicate this and make sure it has reasonable content. Say intelligent things.

Back to STO, when you have a team operating, information is generated somewhere else as part of mechanics of the organization functioning. Weak signals develop from other people around you as well as the system. On the aircraft carrier flight deck there are many things going on at once. The operations of the flight deck must be sensitive to changing operations around you as well as keeping track. Carrier landings, difference between day and night, deck pitching, these stress out the already difficult task of landing, brings up operations risk assessment that need to change when risk increases.

One person, as a company commander in Afghanistan, established a baseline expectation. You are monitoring the information that is flowing and everyone has the authority to make connections. The intelligence officer can pick it apart and review later but sometimes people are dismissive of that. Intelligence officers commonly are criticized for all their wrong calls, but they make connections during dynamic times. It is easy for people to be dismissive when the intelligence person tries to predict what the enemy will do. Having that transparency/breaking down barriers, intelligence plays a critical role. This goes back to expectations. The intelligence officer is trying to predict, maybe not exactly, but he is doing a good job.

We are hoping the workforce will act on the weak signal. In the fire service different fire companies are in charge of different aspects of one incident. In one situation related by this person, one hose team could not obtain information from another hose team in time so one team ran into the inferno and one captain was killed.

None of this is linear or singular. It is a dynamic process. It is hoped workers will take action on weak signals without direction. You have to trust people are going to support one another. It is a good thing when those on the front line can take action on their own and not have to wait for headquarters.

How do we give feedback during the operation when things are not working? Sometimes have divisions or companies take individual action when things are going badly and, not being able to communicate, take risks that only a few can see.

One department started an initiative or improvement program. Line staff must perform sensitivity to operations and their work honored by management. In the operating room they started an operation, put the patient to sleep, but the operation did not get started when they found out the equipment was not ready. You open a pump in and find out that the seal for the replacement is the wrong one. Walkout, tag out, de-energize, the craftsman who did it may not be available at the time of work on the pump. He or she may not be aware of the purpose of the ongoing operation.

Several examples of starting operations (surgery, pump repair in refinery) and find out something was lacking. Were people that prepared feeling part of the program? One discussant noted that everyone on an aircraft carrier can quickly explain how what they do supports flight operations (learned from CVN 70, Carl Vinson, visit). This is easier on carriers because they are closed systems. Ships use closed-circuit television to provide a view of the flight deck during flight operations. Shows people all sorts of information that helps them stay connected to flight operations.

On the aircraft carrier, closed circuit television helps keep everyone sensitive to operations. Everyone on a ship can be keyed to how they are connected two aircraft recovery. The challenge to HRO it is how can we make this applicable two chemical processes or hospitals.

When we discuss operations we are assuming we understand what the operations are for in the system and the organization. The fire service had problems when EMS was added 30 years ago. The majority of calls went from fire suppression to medical aid calls. Now there are new assignments coming to fire service, these include high-angle rescues, swiftwater rescue, and urban search and rescue. Fire service has yet to define what their responsibilities are. Practitioners disagree about what their operations really are. "Operations" can change over time. Practitioners need to be grounded in what your core competencies are.

There is a balance of how much information you to be effective need vs. spending too much effort sending information to upper echelon without information overflow. When people are head down, butt up they do not see what is happening with the primary containment.

Sensitivity to operations is information flow, real-time information flow. This is reliability of information flow across days and for threats.

STO, other operations should not drive us, the balance came up several times, need enough to keep from being negatively impacted, too much and you drown it information.

Information flows happen and different rates and you have to be sensitive to some things that only change slowly. STO should be compared to planning and strategy making (not always the key activities), need to be in contact with what is going on right now.

Weick states that in sensitivity to operations he was comparing sensitivity to operations it to sensitivity to planning. This was to get people out of the mindset of planning and missing what was going on " right now.” So, it was done to counter sensitivity to planning.

Sensitivity to Operations I

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:42 GMT

Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO

One physician advised a resident physician that, once she mastered a procedure she should teach it because in life she will be teaching her subordinates as she is performing the procedure. She came to him excited, she did not know all the things that went on while placing a tube into a patient's windpipe (endotracheal intubation). During the evolution of dynamic events we easily cone our attention to what we are doing, shutting out other activities as we concentrate. One of the first things we must teach a rookie is to be aware of all that is around him.

Sensitivity to operations is not customary for people, they have to learn how to do it, learn how to actively monitor. But we cannot do things on automatic.

In Naval operations the operator must manage the bubble in situational awareness, that is, what is happening all the time. As managers we may become automatic and loses awareness of what is happening. In Naval systems they use a system response, did the actions you take affect outcome?

Can we distinguish between situation awareness and sensitivity to operations on an organizational level? This is the key- Individual situation awareness in the larger organizational view. How do you reach that level? In part it is how you structure the organization but also security, lack of fear from speaking up, and appreciation of even negative information (what can hurt). It is a system, organizational, human dynamic that moves information up and down and laterally. This makes the organization acutely aware of where going, where came from, and where you are right now.

In a hospital, one physician will ask someone to contact an administrator-on-call or medical consultant. The person often responds with "what can they do?" His counter response is, "If I knew, I would do it myself." This is part of a complex system. It suppresses the drive to ask for assistance. Is this the antithesis of sensitivity to operations?

Query - what would you be asking administrator to do? A child critically ill, in deteriorating condition, needed transfer to the pediatric intensive care unit. The parents were Jehovah’s Witnesses and refused to grant permission to transfer unless he could guarantee no blood transfusion. By law the physician could have transfused if necessary a parent’s permission. Sometimes the wisest use of power is not to use it. The administrator calmed the family, explaining procedures. The parents then allowed transfer of the child. The physician had no idea how the administrator would fix the problem when he made the request. The administrator was very sensitive to the complexity of the situation.

In fire fighting work things can inhibit information flow – procedures, task completion, personalities. One chief said to the captain on an incident, " The only thing I want to see in your hands is a radio mic." He found that if they help the firefighter then the information flow stops. You need to have pockets of information to communicate with each other. In time compression and short looped decision-making you need information flow to stay on top of the situation and the organization.

For information flow, what kind of assistant do you have to escalate information flow? How do you create a system allows escalation information flow without overtaxing the system? Information cannot get to CEO for every issue. We cannot communicate linearly for everything. Sometimes you have to skip layers, but how do you manage this without breaking down the system? Need a workable system that works when you need it.

If I have a question, I have to be sensitive that the resources I am drawing are not available to the rest of the organization. In human factors they use individual, team, in top leadership for organizational performance. Your organization structure is connected, when things go wrong there is a disconnection and they lose the shared perception of what is going on. STO to has to occur at each level.

Social media can support the attitudes of high reliability. It is a tool that can give us authenticity and transparency. We value authenticity and transparency but we then shut them down. Charlene Li visited the USS Nimitz and ascribed a night landing. Landing at night is frightening. Every time you land you die a little death. This is transparency and authenticity. Think of information flows that go on simultaneously, a tool that gives us authenticity and transparency (even though many educators want to shut it down in their environments), strengthens the ideas of HR, mentioned Charlene Li and the experience she related as a blogger visiting Nimitz (wrote a book about it).

Transparency can be confusing. Information is fine but you do not want everything to pass through-you need some prejudice. Internally, for operational effectiveness, they are constrained in using information that is applicable yet you also want external flow see how you work. Transparency is useful externally so people trust you. Internally you have to limit/constrain information to correct terminology, need internal information flow that is appropriate and correct, two different dynamics.

Who knows to know what and when do they need to know it? We are poor at this in healthcare because they lack the culture of safety and tend not to share information when things are going wrong rapidly enough. It would help patients when we bring in additional assistance.

In a United Kingdom chemical plant they had an alert system of "nonconformance." They would meet and talk about it the next day. They found a corroding tank and cleaned it the next day when they found it had nearly leaked. They were sensitive to the situation, investigated it in a controlled manner, and responded appropriately to fix it. How do you filter information so that too much does not go too high, bogging things down? If people saw something not right they would write a note about nonconformance. The tall caustic tank manhole looked extra corroded, took cover off to look into it, found corroded elbow at the bottom of the tank, found that it was about to fail, now escalated to urgent thing to replace elbow. Had it failed it would have drained tank. They investigated in control manner to prevent catastrophe, work later on why the piece failed, this group had a system of escalating concern and risk.

Reluctance to Simplify

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:40 GMT

Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO

We must simplify to gain a grasp of things and also to teach but we must also accept that there is more in these events than we can understand. How do we balance simplifying so we can think and talk about it yet accepting the complexity of events?

In building fires, we would ventilate the building to let out heat and smoke. We did this be putting a hole in the roof. We learned that it pulled fire through the building. Rather than releasing heat and making the situation better, we made the situation worse. We simplified and later found the simplification caused damage.

In aviation the cockpit checklist has become a ritual for errorless tasks. Ritual in the checklist becomes a trap, though. The pilots went through the checklist and, though they called it out, they do not take the action necessary in an ice storm. They were tropical pilots and glossed over the ice storm checklist. This "error of habituation" led to their deaths.

In a nursing home they use consistent staffing to have the same nurse on the same resident. They become so habituated on the drug regimen they continued giving the old drug dose not the new, changed drug dosing. The nurse said, "I been doing this for two months so I knew what to do."

In situation awareness when the situation changes the people must alter the task. In confirmation bias we look for information that confirms our conclusion. It is challenging to recognize that bias in ourselves.

In shortcuts, experienced staff who have served as mentors do not want to give the shortcuts out first. They show the actual way to do it. One individual read about FBI training to find a counterfeit bill. They must first learn what the real bill looks like so the odd bill will stand out. In shift work when returning from a long period of time off, the first change is long and detailed. The next night they want to say, “Nothing has changed,” in order to make the procedure faster.

We are probably not simplifying, we are just slowing it down. Weick (personal communication) emphasized the "reluctance to" as simplification is not bad in itself. In responding to a fire you have seen this before and you have not seen this before. You are reluctant to simplify but you will do it.

There is intentional simplification and unintentional simplification. If you have intuitive impressions, are you backing them with facts? Fact-check your intuitive feelings. Intentional simplification may have ulterior motives. For example, the manager may want to increase productivity at the expense of safety.

You can put trigger points or milestones into your decision-making. "I think the situation is… So we can expect…" He gives milestones and triggers. If it is not going the way we expect and we must reevaluate. Do we hurt our culture in fire to make it task, task, task, but not why? Firefighters have so much experience with the norm that they do not question. When things are not normal is when our programs again to falter.

Practical advice is missing on "reluctance to simplify" and making a prediction does that. It is a "test" of your assumptions.

We have become satisfied with policies and procedures and want all to go well. Then someone comes and says we can do it differently but our people do not want to change.

Confirmation bias, also optimism bias, you start to see things that confirm your belief. Our ingrained nature is to be optimistic. You want to find you are successful and see it working.

On the flight deck of an aircraft carrier they start off in blue shirts (call plain pushers) to learn but senior people quickly watch for those who have better awareness of what is going on. Then they are selected towards the yellow shirt, which is a director. Before that they are paired up with someone who has more experience (even if it is only 5 to 6 months more).

In the chemical industry they struggle with compliance, which people believe can be met by doing the task rather than engagement when you understand the "why." In chemical process safety, they have task-oriented procedures to ensure consistency. The practices are usually not seen in current procedures. They make it into simple steps then shortcut with no bad consequence. They do not know if they are lucky or good in this change but it then becomes fixed. Chemical process safety does have a management change process where they can discuss these changes.

Is it easier to achieve reluctance to simplify in a group setting? We tend to make it a simple problem with a simple solution. How you shape and define the problem helps you understand the solution. But some times we have a solution in search for a problem. Simplifying the problem and the solution can be dangerous.

What is the problem? There is an ad hoc committee in the hospital for "never events." They want to simplify to come up with the most obvious proximal cause. If they were reluctant to simplify, they would continually ask questions to find the true root cause. The logistical problem of hospitals and hospital boards is they place excessive efforts in quality solely with credentialing the physician. They equate the quality of a hospital on how they judge a physician.

The Five Principles of Weick & Sutcliffe

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:38 GMT

What is preoccupation with failure?

For the Individual:

Karl Weick told me that when he and Kathleen identified preoccupation with failure they were looking at system mindfulness and system failure . He did not consider failure of the individual in this concept. Those of us who came from high-risk activities automatically thought preoccupation with failure applied to us as individuals.

On another occasion, an academic group discussed with Kathleen Sutcliffe the use of the word “preoccupation” in Preoccupation with Failure. While Dr. Sutcliffe insisted that the word "preoccupation" was significant and critical others criticized it because some managers felt it meant we should constantly be thinking about it. Organizations seem to have an image problem with this.

As a participant I think she had very good reasons to use preoccupation as, on an individual level during high-risk processes, I am preoccupied with my failure that could harm other people or me. Unfortunately, we do not always know our procedures are high risk and, besides, this becomes habit much to the consternation of others without these experiences.

The culture I developed in came from men who experienced live-or-die situations and I have experienced my own on more than a few occasions. I look back to the events seconds, minutes, or hours earlier to see how I could have avoided the situation I found myself in. I don’t want to do it again. I guess you could say I am preoccupied with failure.

A better way to describe it is looking for early heralds of failure. In the intensive care unit I taught caregivers to look for covert, compensated states of physiologic dysfunction. These early heralds were precursors to shock or respiratory failure. It is at this point our interventions are easiest, cheapest, and have the greatest effectiveness with the least risk. It is a routine activity for us to always look for the early signs of deterioration. This is preoccupation with failure.

As paramedics working in an area with high drug use and gang activity we were vigilant for early heralds, subtle nuance, or vague signs of problems developing. We would watch for the subtle eye movement or nuanced behavior that would tell us the call was turning the wrong way. We were vigilant in the same manner towards our patients, before paramedic school all we had was observation and a few treatment tools. This carried over to my work in healthcare where I taught my students to look for signs of subtle change despite the difficulty of clearly understanding what was happening.

Vigilance for early signs of failure also gives you boundaries within which you can feel safe. This produces the paradox of feeling secure because you look for the danger. To those without this insight we seem to be pessimistic, always looking for the dark side.

My question is, "Can we make preoccupation with failure a habit without creating pessimism?"

What is preoccupation with failure?

For the Organization:

Karl Weick told me that, in his estimation, preoccupation did not have an action component in it while in the world of operators it drives anticipation, action, and learning from action. He also stressed that preoccupation with failure presumes that the organization has good communication. Nothing really matters much if there is not good communication in the organization. Communication is another blog.

One complaint about preoccupation with failure is whether it takes away from other duties and whether it creates an image problem to the organization. Preoccupation with failure means searching for early failure points, which means looking for bad news. In, as one administrator told me, to discuss openly improvement is to imply we were doing poorly. At the worst, the individual preoccupied with failure is considered disloyal while at the best individual is criticized for "crying wolf," overreacting, or acting the Cassandra.

But if you look for bad news and you can correct it earlier then it is more amenable to intervention, the intervention has less risk, and you correct the problem before it becomes systemic. In the HRO, leaders in the organization consider "bad news" a "good sign" and seek bad news to improve the organization.

The organization will seek out hidden failure, that is, the failure people consider inevitable or part of the job. When there is open discussion of problems, those who have solved the problem can share their solutions with those who believed it was unsolvable. This requires not only open communication but also requires frank discussion of all outcomes. In this manner, the organization creates a common language and grammar.

I asked a US Army Sergeant, a veteran of the war in Iraq, how the Captain of his Company found out about important information, such as weaknesses in the Company or outside threats, when the men did not talk about it. He said the captain would come by and play cards with the men and eventually they begin talking to him. Management by Walking Around sounds nice but if the leader is on a pass-through it accomplishes little. It is simply "showing the flag." While this is also a leadership issue it is and organizational issue because it can act as a conduit for information flow between line workers, administrators, and executives.

For another discussion, are we preoccupied with failure in communication?

My question is, "How can an organization make looking for bad news a good thing?"

High Reliability

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:37 GMT

What is High Reliability?

While training to drive a rescue ambulance for the Los Angeles City Fire Department my instructors impressed upon me the importance of hurrying when you are told to do a job, including turning out of the fire station in 60 seconds from alarm. During my probationary period a new station commander transferred in. An alarm sounded and I ran to my rig, nearly colliding with my new captain who was holding a full cup coffee. He held out his arm to block me and said, "Davey, you cannot help anybody with a broken ankle." It took me the rest of the afternoon to appreciate his point; “doing your job" and "doing your job safely" are the same.

Throughout my career in EMS and healthcare I learned reliability, resilience, safety, effectiveness, and efficiency are different aspects of the same thing – operations. We are reliable –we maintain our performance despite changing circumstances. We are resilient – we bounce back from difficulties. We are safe – we prevent and minimize injury while doing our job. We are effective - we reach our goal. We are efficient – we don’t waste resources while reaching our goal. In operations we treat uncertainty and threat the same.

Making a distinction between safety, quality, and productivity comes at the risk of depreciating safety to improve productivity and quality. This may make sense for intellectual and administrative purposes based on outcomes but from an operational sense it does not. Though we may identify and manage error during operations for dynamic events differently than for stable situations, the focus is more on immediate consequences rather than classification of consequences in either event. The experience of commercial aviation shows that safety done right saves money. The error is operational but the outcome is interpreted for administrative purposes. It defies my logic to separate them during operations.

It is almost magical how an experienced individual can orchestrate a team to smoothly resolve a time-constrained threat. The outsider sees none of the changing balances and shifts in authority much as one cannot see the strokes of the brush or cuts in the stone of a great work of art. We see the result but we cannot identify from observation alone the methods used by the master.

In the ambulance and fire service in the 1970s what we call high reliability was considered routine work. In the first month or so when I was assigned to fire Station 66 three men were killed when a wall fell on them. There was discussion not about what they did wrong but how we could make better decisions next time. Bad things happen and it is our duty to learn from them.

When I entered healthcare I found people hesitant to make decisions. I found people did not want to talk about possible mistakes. I found people did not help each other in the way we did in ambulance work and the fire service. I began to focus on making decisions when we only had imperfect information and had time constraints. Also critical to engaging an unexpected problem was teaching people to identify and managing their fear, helping them identify what makes them calm under pressure to help them focus on working the problem and work and act under pressure. Later, Karlene Roberts characterized my work as high reliability.

My question is, "If there is an academic and management distinction between reliability, resilience, and safety, is there also an operational or functional distinction?"

Reference:
Roberts KH, Yu K, van Stralen D. “Patient Safety is an Organizational Systems Issue: Lessons from a Variety of Industries” in The Patient Safety Handbook, Second Edition ed. Youngberg BJ (Burlington, MA: Jones & Bartlett Learning, 2013).

Do Safety, Reliability, and Costs Compete?

Chris Hart, Vice Chairman of the National Transportation Safety Board, gives a wonderful talk about how collaboration in the commercial aviation industry in the middle 1990s created not only a safer means of travel but also reduced daily costs. These savings did not occur because of the decrease in air crashes but because of improved daily performance and productivity. This required people who did not work with each other to come together for collaboration. This included executives, managers, and line staff. This included unions, industry, and regulators.

Matt Boyne, a retired US Navy Aviator and now commercial pilot and business consultant, described to me his deployment on an aircraft carrier with a tour commanding the machine shop. He couldn’t tell if a damaged bushing was a safety, productivity, or a quality problem as it could take two years until someone was hurt, they had to remake it, or it damaged a plane. But it did not matter at the same dynamics applied to safety, productivity, and quality.

How we approach error and our error management determines our success at managing the unexpected. We do not process errors that cause safety, productivity, or quality problems in different parts of our brain.

However, when executives and managers use these as distinct entities we see competition and amongst the choices productivity too often wins over safety.

My question is, "What can we do in our organization to bring safety, productivity, and quality into alignment?"

Civilian Misconceptions of the Military

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:35 GMT

Comments by Randy Cadieux, Major, USMC, MS

There are many ideas and misconceptions about the United States military services and the way leadership is used to influence service members to accomplish the mission. High-Reliability Organizations (HROs) have existed for many years, and while the U.S. military components do not necessarily call themselves HROs, many military units may fall within the criteria which describe HRO’s. It may be helpful to study how the military implements many of its tools to accomplish high-risk missions under conditions of uncertainty while minimizing losses to personnel and equipment. Additionally, dispelling some of the misconceptions about military leadership and followership may remove some of the barriers which impede the transference of HRO behaviors to other sectors and industries.

HRO as a Military Model

Some may think that HRO is a military model. High Reliability Organizing by itself is not a military model. It is a set of principles which can enable exceptional performance and resilience under conditions of uncertainty. While many military units seem to fit the definitions of High Reliability Organizations, as described by Karl Weick and Kathleen Sutcliffe in Managing the Unexpected, the military has not developed a unified HRO model. Many of the attitudes and behaviors used in the military are similar to HRO behaviors and are aligned with the 5 Principles of. By examining many military units, it is apparent that they are comprised of service members who are preoccupied with failure, reluctant to simplify, sensitive to operations, adept at deferring to expertise, and committed to developing resilience within their units and during operations. Many service members enact these behaviors without even knowing the principles of HRO.

Command Structure in the Military

Some think that due to the hierarchical organizational structure of military units service members of lower ranks blindly obey commands from senior leaders at all costs. The military is a hierarchical structure with a command element. There are officers and enlisted personnel in place to make decisions and carry out orders, but effective leadership in the military includes being able to listen to trusted advisors. These are often subordinate personnel who possess a high degree of expertise in certain areas. Ultimately in a military unit, obedience to orders is required to maintain good order and discipline, but effective leaders will seek out the advice of their personnel who are experts in key areas. Additionally, commanders are put in place because they have proven themselves to be effective leaders and communicators who understand how to use effective communication skills and ethical leadership as they develop and deliver orders.

Questioning Orders

There is often a misconception that equates military service with blind obedience and the lack of a questioning attitude. Many movies have portrayed military commanders as tyrants who bark orders and have portrayed military troops as nothing more than followers who do as they are told. Ultimately in the military when a lawful order is given by a senior officer it must be followed. The good order and discipline of the services depend on this precept. However, many effective leaders encourage subordinate personnel to speak up to determine if there is something missing from their plans, such as a critical aspect of the plan which is required for mission success. This highlights the trusted advisor role that many subordinate service members fill for unit commanders. This relationship is known as Special Trust and Confidence in the Marine Corps. Additionally, in Navy and Marine Corps aviation one of the 7 Critical Skills of Crew Resource Management (CRM) is Assertiveness. This critical skill (or attribute) which is trained and encouraged among all ranks, is required to help a crew perform effectively and safely as a team. If a junior aircrew member notices a problem or a dangerous situation he or she is expected to bring it to the attention of the aircraft commander.

Learning to Follow Orders Before Being Able to Give Orders

Most military training begins with learning to follow orders. This is true in recruit training and officer training. At Marine Corps Officer Candidate School officer candidates follow orders of the drill instructors, but are given opportunities to be evaluated as leaders. Peer leadership evaluations are conducted to assess an officer candidate’s ability to provide leadership, guidance, and direction to his or her team members. Additionally, candidates are placed in leadership roles and are evaluated by the drill instructors for potential leadership abilities. Commissioned officers are expected to be able to give orders early in their career. Junior enlisted personnel are expected to be technically and tactically proficient, follow orders, and provide feedback to their chain of command. As they gain rank they are normally given the opportunity to lead subordinate personnel.

Designated Leadership versus Functional Leadership

In non-military working environments sometimes leaders will use terms such as “being the captain of the ship”, thinking that in the military the captain is in ultimate control and that nobody questions his or her authority. While the captain of a ship is in charge and on Navy and Marine Corps aircraft, the Aircraft Commander or Mission Commander is in charge, he or she will often allow input from other crewmembers. The Aircraft Commander is assigned in writing and is the crewmember responsible for the safe conduct of the mission. In CRM terms, this is known as designated leadership. Oftentimes designated leaders will defer to the expertise of other crew positions to assist with decisionmaking. For example, when KC-130 Transport Plane Commanders must make a decision related to a cargo load, they will normally seek input from the aircraft loadmasters, who are the subject matter experts on cargo handling and loading. In CRM terms, this is known as functional leadership.

Perception that Recruits are Abused

Oftentimes it may appear to some outside observers that recruits, midshipmen, cadets, and officer candidates are abused during their training. Recruit, midshipmen, cadet, and officer candidate training programs are not designed to abuse service members. They are a way to indoctrinate trainees into a system which requires one to conform to the requirements of the team. This is a cultural change which takes American men and women and develops them into soldiers, sailors, airmen, Marines, and Coastguardsmen. This does require some negative reinforcement at the early stages of training, and as the trainees improve at their tasks positive reinforcement increases. This has proven to be a highly effective way of indoctrinating civilians into military service. The process is overseen by numerous layers of command influence and oversight and the safety of the trainees is extremely important. The sense of accomplishment upon completing the training curriculum of recruit training, Officer Candidate School, or one of the service academies is immeasurable and this training regimen serves to forge a strong bond between peers and helps develop future leaders with a common background.

The Need for Service Members at All Ranks

One misconception regarding how the military treats its service members is that troops at the lowest ranks are considered expendable while senior ranking enlisted personnel and officers are not. This is simply not true. One of the reasons officers exist in the Marine Corps is to lead and support the Marines in the lower ranks. Without the individual Marine, the mission could not be accomplished. The strength of the Marine is with the team, and the strength of the team relies on its best asset (the individual Marine). Officers and staff non-commissioned officers are preoccupied with not only mission accomplishment, but also with the welfare of their Marines. In the Marine Corps there is no policy which states that enlisted Marines are more expendable than officers.

Being Placed Under Stress to Understand How to Handle Stress

Some people think that as a junior employee or trainee that they will not understand how to handle stress unless they have been placed under stress. Stress has its place in all levels of training, from officer to enlisted. A baseline exposure to stress in training is required. The increase in stress may be dependent on the type of follow-on training, and can vary. In aviation training student aviators must be exposed to stressful situations to help prepare them for potential emergency situations. Many of the technical aspects of military training include self-induced stress. This means that the trainees feel a certain sense of pressure due to the exposure to a new training environment or techniques. As training progresses, the level of stress is increased to help prepare student aviators for potential emergency situations which require rapid action and decisionmaking. This is not the application of stressful training simply for the sake of observing a trainee react, but the stress is a byproduct of the technical training. In U.S. Marine Corps and Navy aviation these levels of stress are optimized to help students achieve exceptional levels of performance.

Yelling and Intimidation as a Form of Contr ol

Many people think that all military leaders use yelling, anger, and intimidation as the only way to influence subordinate personnel. Yelling, anger, and intimidation may be used in some instances, especially during recruit training. During this process the recruits’ attitudes are shaped by the drill instructors to help them understand what it means to follow orders and execute operations under pressure. One of bases for this is that in combat military personnel must be able to function rapidly with minimal direction in some circumstances due to the uncertain nature of combat. After recruit training mentoring and small unit leadership is used to train personnel and guide them through their tasks. In some cases yelling is used as a tool to motivate, but this is not necessarily an everyday occurrence in every unit. In many technical fields of the military, such as in Marine Corps aviation it is necessary to get an aircraft crew to work together as a synchronous team and yelling is simply not an effective tool during most aviation operations. While the Marine Corps does not necessarily use the term just culture, there is an environment where mutual respect is shared between all members and the enforcement of this respect and fair treatment is driven throughout all levels within the organization.

Duty

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:33 GMT

[Note, this is Duty and not referring to Duties.]

Duty is the moral commitment that results in action. High Reliability is a choice. You choose to want to do well. Duty is willingly accepted, it is not an external motivation.

Duty is intangible but it keeps drawing you back into your job. Dharma is duty or character, an essential truth in Hinduism. People may work at a job for money (utilitarian employee) but Dharma, duty or pathway, is why people perform well on the job. With duty you evolve personally while you are evolving the organization. Duty is the global overview of the mission; where the organization needs to go.

The most direct quote regarding military duty is from Lord Nelson, “England expects that everyman will do his duty.” In an HRO they do their duty and then one step more. This brings relief to the team or organization when you do your duty. The Lord Nelson quote is also alignment – as with England. There is alignment between individual values and the country’s values.

Duty is an ethical relationship to others; you are your brothers’/sisters’ keeper. Duty is responsibility for the welfare of others. In Crew Resource Management (CRM ) if you see something abnormal you must bring it to the attention of the crew. There is an individual sense of agency in the organization. This is part of who you are and you are a part of the organization.

Duty is related to purpose – why you are doing it; not the what of your actions. Duty is why the organization exists; the values are real and they are used. Duty must be in relation to the mission and vision statements. “I am agreeing to do this as I like what the organization does. This is different from individual responsibilities; this is beyond the tasks of the organization.

Duty has emphasis that certain things are required but HRO has a voluntary piece to it. You are required to do duty and this seems opposite of what HRO is. In reliability they range widely to see and do things you might not have thought of. [We are beginning to differentiate duty as task responsibility from duty as sense of duty or character trait aligned with mission of organization.]

Duty is related to cause; what is the cause of an organization? You believe in the cause of the organization therefore you help it move forward. Alignment the culture of the organization between the person and the organization; then the sense of duty is profound. Alignment between organizational culture and the individual is through the belief/value system.

Duty may not be appropriate for civilian organizations. Individual responsibility to the organization as a whole is seen in the uniformed services. They understand that their action and inaction can harm or help the organization. Duty comes from that.

Duty of the individual – show up on the job; be responsible for yourself; you have responsibility for things in an HRO; all these are instilled and then branch out to make you prepared for the next big job when you can contribute (not getting by). Individual duties and higher level group duties exist. “In the presence of avoid, move forward,” Jim Denney. In High Reliability people move forward. Every individual believes it is their job even if others are also problem solving.

Make duty infectious – don’t tell them to do it but they want to do it on their own, it is infectious to others who will then do it. An infectious attitude toward the cause and purpose, then each person will flourish and want to participate. They will self-sacrifice and go beyond their ego. Infectious or contagious – these are good in an HRO. You set the reputation of the ship when you go into a foreign port for five days after being as sea for 75-80 days. When a 6,000 member crew can leave without a significant liberty incident then you see the infectious nature of duty.

Leadership and Command

drpyke@gmail.com (Tracy Pyke) — Mon, 09 Nov 2020 21:32:31 GMT

Some aspects of leadership can be taught but it is also in the hands on / day-to-day work. In the military, command is where the buck stops.* The Commander is responsible for overall performance of the organization and involves some politics as you look up and down the line. Leadership is how you inspire people. Command is from your experience coming up the line. You develop from good and bad examples.

*[For some of our foreign participants: The buck was a type of knife common on Mississippi River gambling boats. It was passed around in a card game to signify the dealer. Where the buck stops is who had responsibility for the deal. Cheating and whether you had a good or bad hand clearly originated from the dealer (at least, to the gamblers).]

Leadership is empowering people and is more personal while command is more impersonal.

In wildland fire they have a phrase “In command and in control” which can be malignant vs. “in command and out of control” which is healthy. This works well with people and places more emphasis on the social sciences. It is distributed decision making.

As parents we start out being in command, then in the teenage years we take on more leadership, finally, we only have leadership. Command is the health and well being of people while leadership is making people strong.

Command – the physical abilities of the people to use their hands and achieve, and tactical.

Leadership – the hearts and minds, their vision, inspires, and strategic.

Leadership in wildland fire – the authority to lead is established by law and includes accountability. The desire to lead, “Why do you lead?” Because that is where the challenge is. Commanders can delegate responsibility but not the accountability.

Command is a tool that allows the organization to make a structure. Then there are functional leaders within that structure. The pilot is a commander and the functional leader comes from that. The designated leader is the commander and appointed by authority to make decisions. The functional leader is the leader for the time-specific event.

The aircraft commander may not be the pilot depending on the mission of the airplane. The pilot puts the plane where it should be and the commander tells what to do.

Can someone be both commander and leader? In the Aegis Cruiser the Captain is down below working with the missiles while the other person is on the bridge and keeps the ship going. In the movie Crimson Tide there are both aspects of leadership and command. There is the legal command of who is in charge by law and then there is the one who takes leadership.

How does the role transition in command when the functional leader takes over from the commander?

In the KC 130 refueling aircraft the aircraft commander is always in charge as designated leader. If the mission is command and control then the senior officer is the aircraft commander and the pilot gets the plane to where it needs to be so senior officer can act toward command and control, this officer then can function as his role as commander.

But for aerial delivery the KC130 must go to the specific spot to deliver things to the ground. The loadmaster then decides about the aerial delivery. For paratroops it is the Jumpmaster and for equipment it is the Loadmaster.

Leadership is not a position; it is a means of influence. Command is a position. Does the commander have the skill sets of a leader? In the art of leadership they can maneuver in that environment and not micromanage.

In Wildland Fire there is a transition from followership to leadership. The good follower learns tactical implementation. As they grow and mature they gain a greater understanding of strategy. Wildland Fire has a great gasp of leadership but structure fire does not. Promotion in structural fire is by exam and politics.

A good leader had a clear vision of where they need to go and they inspire others to get there so people will rise to the occasion. If the leader in the command structure does not trust then the command structure breaks down.

The command structure allows for effective flow of information. Leaders can over ride the people and goes beyond their training and their ability to obey. Managers will micromanage as they are good at the command function but are poor leaders.

With leadership and command is there nature or nurture? In a recent bus accident a young girl calmed the other kids and organized there exit without an adult to assist. She is a leader.

What is the difference between “Breakdown in command” and “Breakdown in leadership”?

Humility – the leader needs to be humble and listen to others and ask for help.

Framing: L eadership is focus on the team while command is focus on the situation.