• Lack of attention-to-detail
• Perceived sense of urgency
• Failure to maintain standards
• Failure to comply with procedures
• Limited experience/qualified but not proficient
• External influence and admin tasking
• Inadequate/Flawed ORM
• Flawed mission analysis and poor mission planning
• Leadership failure
• Poor communication and coordination for team evolutions
• Wrong choice of action
• Delayed necessary action
HFACS alone don’t suffice when looking at cause vs. effect. Current Safety Management System thinking (for the last 10+ years), has moved from looking at HFACS to looking deeper into threats and error precursors. On the surface these may seem like small differences, but to Human Factors Engineers they help illustrate a bigger picture. For example, two of the HFACS codes are "checklist not followed correctly" and "procedure not followed correctly.” These are NOT, in fact, causes or human factors, they are the outcomes caused by human factors (deliberate decisions, miscues, inadvertent omissions, etc.), in turn influenced by environmental factors, fatigue, lack of complete knowledge, etc. – they are what people did, not why they did it. Another tenet of this approach to operational safety is that there is enough rigor built into our systems (equipment, procedures, training, and supervision) to allow for some error.
This frame of reference was the catalyst for the Safety Office to go back to the former mishap reports and review every single one of them, looking for commonalities while applying a new lens to get a more accurate view of the mishaps.
During the review, the analysis team examined the documented human performance contributions of those mishaps, looked for common traits, and compared them to a set of solutions recommended by mishap boards.
The exhaustive analysis found there were six common traits
all ship mishaps:
1) Someone did not perform a specific required action or protocol
that they were trained, qualified, and certified to perform.
2) The ship, crew, or watch team had a previous near miss but took
no specific corrective measure.
3) Poor log keeping during the duration of the period examined
4) Substandard risk mitigation in operational and daily planning
5) Lack of watch team coordination
6) Ships were generally regarded as above average.
Importantly, no single error was the ‘cause’ of a mishap in our review. It is only when errors are allowed to persist and propagate that the threshold to a mishap is crossed. We noted that the recommendations of the investigative bodies pointed to better procedures, training, manning, equipment, or supervision protocols, but did not directly address the fact that if the current equipment (as found), procedures, supervisory measures, or training had been used, the mishap would not have happened. We will always hold ourselves and our Sailors accountable. It is tempting to think, however, that finding and punishing errors “solves” the underlying problem(s). Something else is needed much earlier to break the mishap chain that enabled the last error to push the team across the mishap threshold. Of particular note is that 1) failures to perform an action or follow protocol almost always happened in mission areas where the ship was certified to safely operate, 2) as number six points out, the majority of incidents occurred on ships known to have a good “operational reputation” -- were the “go-to” ship because outside commands and the crew believed they could get the job done, and 3) a similar near miss was uncovered. These show that inside and outside the ship, there was no recognition that the margin to safety had already eroded. The ship drifted into failure as a team because they and their assessors did not recognize and cope with those errors and other hazards, on the spot.
These concepts are key to understanding, developing and fielding our recent initiatives.
“These six common traits align with failures in executing the six watchstanding principles,” wrote Vice Adm. Brown in a Navy message to the Surface Fleet. “They indicate an organization drifting into failure. Recognizing these indicators requires objectively examining our teams’ performance in daily operations.”
When the Safety team examined the reports beyond HFACS codes, they noted explicit signs of organizational drift expressed in the common traits of mishap ships. This included signs that watchstanding was not fully embraced as a primary duty – one where everyone on watch was personally responsible for the safety of the ship.
Some of the programs put in place to recognize and arrest this drift and build team capacity were ineffective. Among other observations, we noted that bridge resource management (BRM) and operational risk management (ORM) were evaluated based on administrative program requirements, not how well they were applied during daily operations; the planning process itself was specifically assessed; and there was not a consistent force-wide examination of the effectiveness of post-mishap actions taken, or whether the changes were sustained over time. We were using compliance-based measures of effectiveness which are incompatible with a system that is based on effectively applying operational principles.
The truth is that the individual, daily decisions made by each member of the crew, influenced by the commanding officer’s guidance and example, create an environment that leads toward either success or failure of the organization. As a result, an increased awareness of how we execute basic blocking and tackling aboard ships, each day, is necessary to preventing the six traits from resurfacing and leading to future mishaps.
To improve safety and reduce operational risk, VADM Brown has directed the following actions:
- Surface Force Pacific and Atlantic will provide training to learning sites and Afloat Training Groups on the six common mishap traits and lessons learned/near misses. We must become a true learning organization, fostering a culture of learning, and create the structures and process that fully embrace this commitment.
- Learning sites and Afloat Training Groups will incorporate these six common mishap traits into curriculum and shipboard training evolutions. Ditto.
- Immediate Superiors in Command (ISICs) and Ships will support access from Bridge Resource Management Workshop (BRMW) execution and human traits engineers to develop and validate observable team human performance measures and means of implementation. One consistent trait in our mishaps was that objective indicators or measures of performance (to include ship readiness indicators) did not show that a ship was at risk, and often showed just the opposite. We owe the Force the observable criteria that define teams that will succeed, regardless of the mission assigned.
- All Inspections, Certifications, and Assist Visits (ICAV) providers will collaborate with Surface Force Pacific and Atlantic on data capture and aggregation initiatives. Previously, few ICAV executive summary reports were produced, and reports often contained only a list of discrepancies. ICAV reports should address root causes and trends for particular ships so COs and supporting commands can better prioritize actions that will prevent them from progressing to failure. Existing data, better captured and aggregated, will be used to assist COs and the Force to increase our margins to safety.
- Commanding Officers will use the six common traits to shape their wardroom discussions and evolution planning processes. We must self-assess, trend problems, follow through on corrective actions in the wake assessments, and use mishap, near-misses and lessons learned in our planning to keep mishaps from happening again. Tools are coming, but we can start right now.
As the CR notes, “Historically, leadership would typically go through three phases following a major mishap: order an operational pause or safety stand down; assemble a team to determine what happened and why; and develop a list of discrete actions for improvement. Causes were identified, meaningful actions taken, and there would be repeated near term success in instilling improved performance.”
When those phases were complete, it was easy to think we’re “done” since our plan of action and milestone actions were completed. The problem is that those improvements have proven to have only marginal effect over time in the absence of enduring and effective programs and processes that ensured lessons were not forgotten as personnel changed and priorities shifted. For this reason, all levels of command must continuously evaluate internal means and methods to recognize and account for human factors in a team setting.
Our “business as usual” approach does not work. Again, these traits can be used to help assess how we are doing business right now; every commanding officer and crew member can look around at their commands today and evaluate how they are doing, leveraging these traits, and employing the watchstanding principle to combat them. The Surface Force is committed to providing the tools and resources needed to improve safe shipboard operations, but it first starts with the decision to critically evaluate how your ship is doing and the commitment to eliminating traits that exist on mishap ships.
“Ultimately, we must increase awareness and not allow these traits to creep into our ships,” noted Brown in his message to the Fleet. “I charge you to think of training, qualifications, certifications, daily operations, maintenance, and high end warfare missions in these terms – as the means to avoid the common traits of a mishap. Nothing less will suffice.”
As the Force Safety office, we challenge commanding officers to engage with your crew on where your ship stands on the mishap traits, questioning the status quo of “normal” operations. This daily team performance is the foundation that is assumed to be rock solid going in to every special evolution. Most mishaps, however, occur during those things we do often: normal operations. This is a team sport. Mistakes are expected. It’s the team’s job to recognize those, and adjust constantly to keep the safety system strong – as a team.