Leading in a Culture of Checklists
By Lieutenant Joseph Graham, U.S. Coast Guard
In October 2007, the Associated Press reported that the USS Hampton's (SSN-767) commanding officer was relieved after required nuclear-reactor checks were not performed. The Navy made it clear that this incident did not, in itself, pose a threat. But the mere existence of a checklist for monitoring certain aspects of the nuclear plant reflects their importance to proper operation of the submarine.
Anyone who has spent time in the armed forces has quickly been introduced to some form of checklist or other detailed, step-by-step procedure. The military coordinates thousands of personnel, among whom many are in given situations for the first time in complicated, dangerous operations where there is no room for failure. Even tasks that appear routine, like completing maintenance, support these life-or-death missions and must be approached with an equal amount of thoroughness. Detailed procedures and the checklists that accompany them are crucial to provide consistency and efficiency in completing these tasks.
Routines and Backup Routines
Yet even with these measures in place, failures still exist in the system. The example of the Hampton is an extreme case, but numerous times in my relatively short career I have seen situations in which processes and checklists were not followed. Once, while I was deployed doing counter-narcotics patrols in the eastern Pacific, the cutter lowered her small boat into the water to conduct routine training exercises. About halfway into the scheduled drill, the boat ran out of fuel and had to radio back to the cutter for assistance.
The boat ran out of fuel because it was launched with only half a tank, even though a specific process existed to prevent this situation from happening. Each morning the boat engineer on duty completed a set of daily checks, including the fuel level. That checklist was delivered to the engineer officer of the watch, who signed it and routed it through the auxiliary division officer and the Engineer Department head. In addition to this, a separate small-boat engineer is part of the small-boat crew each time the craft goes into the water. That engineer also is required to perform an inspection, including checking the fuel level, immediately before lowering the boat.
With so many examples of processes not delivering results, there is more to fixing problems than listing everything that needs to be done. Before implementing some new checklist or process, several factors need to be considered.
Not Ends in Themselves
Does this scenario sound familiar?
Commander Smith: "Lieutenant Jones, are all the preparation complete for the admiral's retirement ceremony?"
Lieutenant Jones: "Yes, sir. I completed all the items on the checklist you gave me for the ceremony. We just finished setting up the chairs on the field."
Commander Smith: "The grass is six inches high. I hope you had the grass cut before you set the chairs up."
Lieutenant Jones: "Ah . . . no, sir. Cutting the grass was not on the checklist."
Planning for retirement ceremonies is a situation in which checklists are vital. All the lessons learned over years have a plan for rain, making sure there is enough parking, and making sure the access list is at the front gate to help a person doing the task for the first time. However, completing only the items on the list may not be sufficient. While it may be appropriate to add certain lessons learned, trying to cover every detail of every possible scenario is impossible.
Both the supervisor and the member checking off the list must keep in mind that a certain amount of critical thinking is necessary. Lists must be drafted thoughtfully, to incorporate the proper amount of flexibility to respond to situations. Those working off checklists must have a clear awareness of the true goal and what they need to do to reach it. All parties must understand that the objective extends beyond the written items, which offer only reminders in the bigger picture.
Checklists Work with Training
Because these lists can typically accomplish only one of the following three objectives, it is of critical importance to write them carefully for their intended purpose. They can:
- Provide reminders for knowledgeable personnel completing tasks such as filling out SF-702s forms used to ensure that physical security is maintained.
- Allow inexperienced personnel to accomplish complex tasks. For example, a pilot relies on a checklist to not forget steps in flight procedures. But if that same list is given to someone who has never been to flight school, he or she can still not fly the plane. On the other hand, directions on the inside of an artificial external defibrillator are written so that anyone can use the device. Depending on how a checklist is written, there may be insufficient information for inexperienced personnel to use it.
- Provide a means of recording important information such as that needed while testing any new piece of equipment.
In each circumstance, a certain level of training is necessary to make the list work. Unless it is specifically written for novice personnel, training must support the personnel making the decisions.
So training comes first, then lists to check off. Only on rare occasions should checklists replace training altogether. It is easy for a supervisor to assume that projects will be completed because each step is written down. However, without the proper background, the door to possible failures stays wide open.
Culture Is Key
As illustrated previously, simply completing each item on a list does not ensure completion of the task. Reminders are helpful but not foolproof, and having a supervisor oversee the details of every job is unrealistic and often counterproductive. The most effective way to ensure that jobs are properly completed is by cultivating professionalism. Taking a page from organizational behavior, by example and through constant reinforcement, leadership establishes cultural norms that mandate thorough job performance.
When shop chiefs inspect work and demand high-quality results, and when junior enlisted members are surrounded by senior enlisted who diligently complete their assignments, this behavior becomes ingrained in the group. This is one of the first leadership lessons we learn. However, when there is a problem in our organization, our immediate reaction is often to add a new policy or implement some new process to prevent the problem from happening again. Instead, the first step should be creating a high-performance culture, then adding any new process needed to reinforce and maintain it.
Checklist Maintenance
Checklists need to remain relevant. New policies, equipment, buildings, and even personalities change the way tasks are carried out. Lists and other job aids need to be consistently updated. All the experience brought to light in debriefs and after-action reports can be turned from mere discussions into tangible improvements by incorporating the information in checklists or other instructions. Because of this, the lists themselves need to be reviewed on a scheduled basis.
To simplify this maintenance, the name of the person assigned to it should be printed, along with contact information, at the bottom of the checklist. The process for submitting changes should also be obviously placed.
Books such as Atul Gawande's The Checklist Manifesto (Metropolitan Books, 2009), articles such as Dan and Chip Heath's "The Heroic Checklist" (Fast Company, March 2008) laud the use of the system, citing successes such as saving hundreds of lives after nurses started using checklists for certain procedures.
The military is well aware of their benefits, but despite potentially positive results, overreliance can restrict workers. They must always be built on clear goals, training, culture, and relevance.
They are an important management tool, even though problems cannot be solved by requiring people to follow more detailed lists. Before implementing yet another one, make sure strong leadership is in place down to the most junior members of the unit.
U. S. Coast Guard Auxiliary Aviation: Expandable Force Capability
By Ron Darcey
The U.S. Coast Guard's joint-force capability consists entirely of uniformed civilian volunteers serving in nearly every operational mission except law enforcement and combat. Most recognize the Coast Guard Auxiliary as a surface or float organization, but fewer are aware of the aviation element that, while comparatively small, acts as a vital strategic multiplier.
With an average of 150 aircraft nationally, Auxiliary Aviation (AuxAir) expands operations, increases force capability, and reinforces operational flexibility. Today, particularly after the service's transfer from the Department of Transportation to the Department of Homeland Security (DHS), the Auxiliary is being tasked with increasing mission responsibilities beyond the organization's traditional operations of recreational boating safety, education, and training.
Over the years, Auxiliary Aviation has matured into a well-trained organization, recognized and deployed as an important strategic and tactically capable asset flying small, private aircraft. It combines excellent handling, performance, and economy for a multitude of Coast Guard and DHS missions.
Unfortunately, many still do not understand the benefits that Auxiliary Aviation has available. In fact, many Coast Guard personnel are unaware that AuxAir even exists.
Recreational Boating Safety, Education, Search and Rescue
The Auxiliary was formed to provide recreational boating safety, small-vessel checks, boating education, search and rescue, and nationwide administrative support and reinforcement activities at Coast Guard facilities. Its role in boating safety is highly relevant in supporting the service in its enormous mission of monitoring a national average of 17 million registered pleasure craft navigating our shorelines, lakes, and waterways.
Search and rescue has always been an Auxiliary specialty, a mission performed exceptionally well during and especially after active-duty colleagues have ended the operation. Auxiliarists often continue the search and just as often successfully locate victims for rescue. Of considerable value, Auxiliarists, because they live and work in their area of responsibility, are intimate with the geography and climate where they patrol. They require no specialized area familiarization.
Coast Guard Auxiliary Aviation
With aviation capability being a primary extension of Coast Guard operations, airplanes flown by Auxiliary aviators complement that capability. Auxiliary Air was created by legislative action in September 1944, as Jesse F. England became the first AuxAir aviator. He was soon followed by eight pilots and aircraft at Glenrock Airport, Norfolk, Virginia, forming Flotilla 2, Fifth Coast Guard District. Over the years, other private pilots and observers have joined the air program that today includes more than 500 Auxiliary aviators.
Private, general-aviation aircraft are ideally suited for a wide range of operations in the traditional role and search and rescue, but are particularly valuable today for many tasks not previously considered part of the AuxAir mission. At between 1,000 and 2,000 feet, Auxiliary flight crews watch over bays, ports, harbors, bridges, and causeways; they stand guard over illegal immigrant interdiction; and they monitor large-vessel traffic transiting littoral waters and steaming through deep-water inland shipping channels.
Each Coast Guard district air station is responsible for deployment of its AuxAir component. Daily missions differ from district to district, as do mission assignments, relative to operational requirements and priorities. Most important is the use of AuxAir on lower-priority missions, which conserves Coast Guard aviation assets and allows air-station concentration on hazardous or specialized missions and training.
Auxiliary aircraft continue to operate as multi-mission-capable and are available to undertake a wide range of assignments such as target aircraft for the Coast Guard's rotary-wing air-intercept air-to-air training, flight-test operations, airborne-incident assessment, and operations in which general-aviation aircraft are valuable. AuxAir makes a viable supporting contribution to efforts against future terrorist attacks, and, in an era of high operating costs, it should be considered a significant and resilient, ready-responsive force multiplier.
AuxAir Mission Profile
The contribution made by small, general-aviation aircraft as observation platforms in World War II, Korea, and Vietnam remains important. The value of small planes should not be underestimated, especially when the focus is supporting the Coast Guard mission from the air. Of considerable benefit, Auxiliary aircraft, because of their variety of type, performance, and numbers and because they are readily available, are highly adaptable and versatile platforms for deployment in the operational environment. The typical Auxiliary aircraft provides flexibility for mission-specific tasks including integrated operations with Coast Guard air, surface, and Auxiliary float and land mobile units and, when required, state and federal agencies.
AuxAir's mission profile now includes a closer relationship to those small liaison airplanes of the past: observation, reconnaissance, aerial photography, and now DHS and Maritime Domain Awareness missions. AuxAir units are commonly situated along the nation's coastlines, ports, and harbors, on top of major tributaries and larger inland lakes.
Coast Guard District AuxAir Squadron 11N
Among the most prolific AuxAir programs in the country is Squadron 11N, responsible for a considerable area of responsibility including the greater San Francisco Bay and two deep-water shipping channels connecting the port facilities of Sacramento and Stockton to the Bay Area. Of considerable concern are the complex labyrinths of the immense San Joaquin Delta region and its 1,200 miles of navigable waterways, which are dangerous most of the year.
This important region contains a vast, fragile network of earthen dikes that always cause concern about potential breach and flood during winter storms. Littoral shipping and barge traffic along the coast of northern California are squadron missions that feature 30-to-50-mile offshore Maritime Domain Awareness and large-vessel photo missions.
Squadron aircraft are separated into single-engine for the San Francisco Bay and delta (they patrol along California's shoreline); and twins for long-range and offshore missions, logistics, crew training and VIP transportation. On any patrol, squadron aircraft easily range 300 to 400 miles.
Currently the squadron boasts a complement of ten aircraft flying from five airports based between San Francisco and Sacramento, and a roster of more than 130 aviators from seven Auxiliary flotillas. Having aircraft based at five widely spaced airports allows for a rapid response throughout the area of responsibility.
Entry into the squadron begins with an air program orientation that outlines the AuxAir mission, training, and qualifications. Pilot applicants first train as observers before beginning their training and qualification. This follows national requirements, but much is focused on the district's mission and especially flying safely in the complex and busy airspace over the San Francisco Bay. Each year pilots fly standardized Coast Guard flight and search-and-rescue check rides, and each year aircraft facilities undergo inspection by the squadron's maintenance team.
In early 2004, the squadron took a close look at its operational capability and how that could be expanded into a more viable force structure. This resulted in the Air Education Training Course, directed at expanding operational capability, refresher training, and ensuring that everyone does everything the same way. These courses are held each year at Coast Guard Air Station Sacramento to maintain standardization, facilitate multi-mission capability and air-surface-ground interface, and refine operational procedures.
Expandable Force Capability
Almost daily changes in security, safety, and especially maritime activities, increase our vulnerabilities offshore, in port and harbor, and inland. The Coast Guard is addressing these challenges. But ever-diminishing budgets, the service's Deepwater program, and modernization stretch the dollar. If these factors were not enough, the shrinking Arctic ice cap opens new maritime shipping routes that further impact our operational challenge. This becomes an issue in personnel and assets, in terms of present and future planning. The question is always: Should we react or respond
As the Coast Guard mission increases in operation and reach, so too will its need for personnel and assets. Using Auxiliary capability conserves and releases regular service personnel and units for more hazardous or specialized operations. This makes the Auxiliary an immediately available resource for acquisition of personnel and equipment at fraction of the cost.
Does this not suggest a broader, more expanded role for the Auxiliary? It would allow the organization's operational responsibilities to increase, while taking greater advantage of the service's personnel, capabilities, and available assets to complement the expanding mission requirement. Although Auxiliarists receive no salary-they are reimbursed for fuel and minimal maintenance-their satisfaction with serving alongside Coast Guard colleagues as "America's lifesavers" is compensation enough.
It seems only logical and operationally productive to expand the Auxiliary's role. With greater operational use of its average 35,000 members, 5,000 small boats, and 150 general-aviation aircraft, this integration of a diverse and responsive, cost-effective force multiplier clearly benefits both the Coast Guard and the nation.
Streamline Alert Signaling and Response
By Captain Fred Walley, U.S. Merchant Marine
A ship is in distress not only when she is overwhelmed by perils of the sea or other occurrences that deteriorate her seaworthiness, but also when attacks are perpetrated against her. The result is the same: threat to life, the environment, and property. Combating unlawful acts against civilian-manned ships at sea should be organized and comprehensive. One way to curb threats to the security of these commercial and noncombatant ships is to equip and expand the role of Maritime Rescue Coordination Centers (MRCC) so that they serve as watchdogs of the seas, and to reconfigure the Global Maritime Distress and Safety System (GMDSS).
The type of large deployment of naval resources to combat piracy in the Gulf of Aden is not the most efficient or cost-effective solution in the long term. Threats occur because of several factors, especially the lack of existing security apparatus, regionally organized, and globally coordinated to police shipping lanes and navigable coastal waters. They tend to be regionalized and have global consequences, and with no internationally organized, comprehensive deterrence and resolution approach, the intensity and severity have shifted from region to region.
With 40 percent of piracy incidents occurring in the Strait of Malacca in 2004, the cost of seaborne commerce increased, as did at-sea dangers in the region. This led to the initiative in Singapore, Malaysia, Indonesia, and Thailand to coordinate patrols and share intelligence and resources, thereby reducing the threat and taking control of the waters.
The Gulf of Guinea briefly topped the list of piracy-prone regions in 2007, until the Gulf of Aden beat that record in 2008. Other regions continue to experience lesser incidents, mostly inshore and while ships are in port. But experienced perpetrators could easily transfer their skills to offshore attacks against ships and maritime interests, thus raising the threat level.
We need to integrate the existing, successful systems for safety distress with security measures to create a permanent, coordinated effort to stem the security challenges that ships encounter at sea: armed robbery, seajacking, and other unlawful acts.
The Current GMDSS Configuration
Piracy and maritime terrorism, especially the former, have shown no sign of abating and have at times increased, despite the international community's requirement that all ships be fitted with a ship security and alert system (SSAS) by 2006 (International Convention for the Safety of Life at Sea, 1974, Regulation XI-2/6, December 2002 Amendment). But it is obvious, from the number of recent attacks, that the SSAS has not been effective. Whether the victim ships had properly functioning SSAS is an unknown factor, as is whether the units were activated during the attacks.
There is no doubt that with the overwhelming presence of naval forces in the Gulf of Aden, a ship can easily get response from the task force if its SSAS is activated. However, the alert has to be channeled via the ship owner or designated contact and flag state (or country of the ship's registry) before it reaches the task force. This is a bureaucratic hurdle. A quicker response is achieved if the ship requests assistance directly using GMDSS digital selective calling, radiotelephone, and other direct means. Unlike GMDSS, with SSAS the onus is placed on the ship owner and flag state. This makes the method flawed.
As the primary system for safety distress, GMDSS has proven vital in communicating with MRCCs in coordinating search and rescue. The system, which consists of optional modes in radiotelephony and satellite-based communications with some technological enhancements, has the potential of meeting the security challenges. In using GMDSS, the International Maritime Organization (IMO) operating guidance for masters of ships in distress or urgent situations proposed, in 1998, a standard procedure illustrated in the diagram shown above. The same procedure could be incorporated with security threat and incident alerting and response coordination.
Message-Routing Problems
The IMO's 1979 Convention on Maritime Search and Rescue established the MRCC. This system divided the oceans into areas to cover search and rescue. Each of them, with MRCCs and sub-centers, are well distributed by agreement between neighboring regional coastal nations. The MRCC system has been very successful at maintaining communication links with ships for search and rescue, which is equally essential for combating attacks against ships.
With frequent reports of piracy and armed robbery against ships in the 1990s, the IMO's Maritime Safety Committee proposed recommendations to governments for combating those problems, the role of rescue coordination centers in alerting security authorities, and reporting attacks (IMO, 1999, MSC/Circ. 622/Rev. 1). Predating the SSAS, these recommendations stated: "It is imperative that all attacks, or threat of attacks, are reported immediately by radio to the nearest RCC or coast radio station to alert the Coastal State/Port State."
The IMO also issued guidance to enhance maritime security, calling for a series of preparatory measures as part of the MRCCs operational contingency plans for responding to overt or covert signals from ships for assistance (2003, MSC/Circ. 967 and MSC/Circ. 1073). The challenge in implementing these measures is the requirement that local government security-force authorities respond to calls from the MRCC. Although ideal, this does not account for significant factors such as the following.
- The areas in which most attacks occur are territorial waters connected to states where individual governments lack the capacity in either resources or will to respond.
- These governments have internal political and administrative challenges with insurgencies, secessionists, uncontrolled rogues among the population, and rampant crime.
- Their lackluster performance on crime prevention and response on shore in general suggests ineffective response to attacks against ships offshore.
Except in areas where adequate resources exist to combat threats, having a dependable response requires that coastal states cooperate and share the burden. Such sharing can mimic the cooperation of nations currently combating piracy and hijackings off the coast of Somalia.
Establish a Three-Prong Primary System
These prongs should be linked to address the combined safety and security challenge to ships at sea.
- Create task forces to respond to attacks.
- Expand rescue-coordination centers to serve as primary shore-based contacts and regional sea-area watchdogs.
- Modify GMDSS and integrate security alerting and signaling devices.
The formation of voluntary regional task forces similar to CTF-150, the combined task force operating in the Gulf of Aden, can serve as the machinery to combat actual threats when necessary. These regional task forces (RTFs) will be prepared to respond to ships in need of assistance. They will receive alerts and coordinate with the regional MRCC.
To limit depletion of resources, the RTF will engage only in periodic patrols, as necessary to demonstrate presence in the coastal region and sea lane. The force could be a combination of the regional navy and coast guard, or any effective resource contributed by regional partners. The RTF will have the advantage of regional and local knowledge of the littoral area, as well as the intelligence to aid in pursuit of suspects.
The success of using regional task forces is evident in the reduction of attacks in the Malacca Strait, according to the International Maritime Bureau. With the cooperation of regional countries and support of the United States and others, attacks declined from a reported high of 38 in 2004 to only 2 in 2008.
The same strategy in the Gulf of Guinea brought together groups of neighboring coastal states from Liberia to equatorial Guinea, working with help from the U.S. Navy. This has stemmed incidents since 2007.
Expand the Role of MRCC
The MRCC can serve at the heart of preventing and combating attacks against ships and maritime interests. As a developed system for search and rescue, it has the capacity to receive alerts from ships, notify the RTF, alert adjacent MRCCs, and warn vessels in the vicinity. This capability can be further enhanced to coordinate response to all distressed situations that affect ships.
Doing so will avoid duplication of resources while creating a universal monitor and umbrella for ships at sea, irrespective of location and nationality. The newly required carriage and implementation of long-range identification and tracking could help to expand coverage of the sea area for MRCC monitoring. The essence of these rescue-coordination centers is expressed in IMO circular MSC/Circ. 892:
It is essential to enable shore-based facilities to respond without delay to any situation which constitutes, or has the potential to constitute, a danger to life. Time lost in the initial stages of an incident may be crucial to its eventual outcome. It cannot be gained.
The same approach applies to ship hiajackings. Once attackers get on board, the situation changes and it becomes difficult to reverse. If instead the ship can alert the nearest MRCC before she is seized, while also taking defensive actions, she may be able to hold out until the RTF arrives. This is obviously far more effective.
Rename the GMDSS
The SSAS should be part of a reconfigured GMDSS alert mechanism. Integrated, this can be part of an expanded GMDSS, with direct signaling of automatically selected MRCCs based on the location of the ship requesting assistance. The system should be renamed Global Maritime Danger Signaling System, and its primary purpose should be signaling potential and imminent danger to the safety and security of ships. It should be a means of exchanging information on threats to life, the environment, and property. The procedure for security message routing is suggested in the diagram to the left.
A comprehensive alerting and response system is vital to maintain safe seas and protect civilian-manned ships and seaborne commerce integral to the global economy and national security.