It's All about the Bystanders

By Commander Holly Harrison, Lieutenant Commander Mike Sharp, and Senior Chief Albert Fernandez, U.S. Coast Guard

Good People, Bad Choices

Before we could answer that question, we had to understand the answer to another: Why do good people fail to prevent, halt, or report seemingly obvious misconduct, safety problems, or violations of procedure or policy? After reviewing the investigation reports, we held discussions with individuals who had failed to act or take appropriate action to gain their perspective. Next, our Leadership and Diversity Advisory Council encouraged members of the crew to share their thoughts and ideas on the matter. Finally, we conducted a literature review regarding “the bystander effect.” Through these efforts we discovered multiple reasons why individuals failed to act.

First, no one believes he or she is or will be a bystander. In each incident, the bystanders were on the sidelines and didn’t know it; they thought they were “in the game.” Our experience and research indicates that bystanders are a significant part of the problem, especially when the circumstances are perceived to be minor, subtle, or ambiguous. Junior members, many of whom have not yet developed the experience, skills, wisdom, or courage to know when and how to take action, are especially vulnerable to the bystander effect.

Second, many of those involved lacked situational awareness. In these cases individuals failed to recognize that something was wrong or could go wrong, or it never occurred to them that it was their responsibility to act. They may have accepted risky behavior as the norm, justified it as blowing off steam, or they may have had impaired judgment due to alcohol consumption. Finally, they may have adopted an “it’ll never happen to me/us” mindset.

We are confident that if a member of our crew saw a fire or violent crime in progress they would intervene immediately. However, many had a hard time recognizing small indicators and warning signs that they or their shipmates were on the verge of trouble. This is particularly problematic in issues of misconduct against other people, as those rarely occur in public. Bystanders are typically not present when the misconduct occurs, so the need for them to pick up and act on subtle precursors is even more important, as well as the need for timely reporting when discovered after the fact.

Third, members who recognized a problem but took no action may have assumed someone else was taking care of the issue or have misplaced loyalty, leading them to be more worried about getting a shipmate in trouble than preventing or halting the problem. The mindset of bystanders can also play a role, and these situations were characterized by an “it’s not my responsibility” mindset, often linked to junior members; a “why should I say anything, nothing will be done about it” attitude, especially if the person involved was senior in rank, a top performer, or perceived as well liked by the command; or the belief that it was a “he said, she said” situation in which reporting was considered more trouble than it was worth because nothing could be proven.

Additionally, members may have had a fear of consequences, including how peers and the command would react, or that they would get punished if taking action meant exposing they did something wrong. Who the bystander was may also play a part. Junior members may have relied on the senior person present or involved to take action, or they may have felt uncomfortable informing on a senior member. Women may have been concerned that addressing crude or inappropriate behavior with male counterparts could make it harder for them to fit in with the group. Finally, in some instances shipmates may not have known how to take appropriate action or whom to turn to for help.

Lastly, in situations where members took ineffective action, they may have mentioned the incident to a peer instead of a more appropriate or senior person, or they may have expressed their concern to someone but failed to ensure action was taken. Often that other person thought the one who informed them was taking action, resulting in inaction on both parts. In some instances, members were too polite or non-confrontational with the offender to appropriately stop the problem. Finally, members may have approached the situation with an “it’s done, what difference would it make to say anything now?” mindset.

A number of these factors are addressed by Team Coordination Training or Bridge Resource Management, which are used to prevent operational mishaps. Typically, though, neither delves deep enough into factors leading to bystander inaction and, more important, how to correct them. With regard to training on interpersonal relations, they focus on setting expectations, stopping the potential perpetrator directly, and taking responsive measures after the incident has occurred. Bystanders are clearly told to take action, but there is little detail beyond that.

From a command standpoint, this leads us to ask how we counter factors driving bystander inaction, engage our personnel, and give them the tools, courage, and support needed to take appropriate and timely action. Through our experience, we have determined that leaders must actively engage and provide effective training; work to identify subtle precursors and mitigate risk factors; and change the practice of dealing with an incident at the lowest possible level.

Intrusive leadership and Quality Training

When testifying before the Senate Armed Services Committee on sexual assault in the military, Admiral Papp stated that “Prevention is the first and best option” and that it is “first and foremost a leadership responsibility.” While he was addressing one specific concern, his statements hit at the heart of the bystander issue. We must do everything in our power to prevent mishaps and misconduct. This clearly is the responsibility of leadership, and leaders must be more involved. However, this is not as easy in practice as in theory.

As leaders we have a significant amount on our plates. Time is our most precious resource, and there is not nearly enough of it to do everything required. We prioritize, we triage, and we do the best we can with what we have. Keeping a 29-year-old cutter fully mission ready and a crew that rotates every two to three years qualified is a challenge, especially in a time of declining budgets where training opportunities are limited and crews must spend more time fixing and maintaining equipment they cannot afford to replace. If our annual command climate survey reveals no major issues, we move on to triage the next item on the list. We suspect most commands do not fully recognize the importance or understand the nature of the bystander problem, or believe it may be too hard to solve. Those who recognize and understand the problem likely struggle to carve time from an already overloaded schedule or may lack subject matter expertise to rectify it.

One common training method is General Mandated Training, which is often presented on the mess deck with a lecture or taken individually online via a PowerPoint and short quiz. Training complete, block checked. Or is it? Does this type of training work to gain the attention, understanding, and genuine buy-in required to foster bystander engagement? We have found the most effective method is to break into small groups or even one-on-one to provide customized training and two-way conversations with subject matter experts and mentors on a continual basis. Although ideal, this takes a significant amount of time.

On board the Northland we are pursuing a team approach using the command cadre, Leadership and Diversity Advisory Council, Chiefs Mess, and junior mentors. Sharing the load across a wider network provides us with an ability to absorb the additional time demand, and it offers a more diverse array of opinions and ideas. Each leader has a different way of communicating a message, and what resonates with one person will not resonate with another. Using a team approach will improve the odds we can reach, influence, and motivate every member of the crew. We are also identifying mature, respected leaders from our junior ranks and giving these peer mentors additional training in how to intervene and help. Given social and rank barriers, if personnel are uncomfortable or unwilling to go to someone senior, we hope they will feel more comfortable approaching a peer who will be trained and empowered to assist that person or take further action on their behalf.

We are also working with the Atlantic Area Command Master Chief to reassess the value of having a full time command master chief or senior chief on board a major cutter. Major cutter crews are experiencing ever increasing workloads and stresses. They also contain a large percentage both of our most vulnerable population regarding misconduct against other people and those more likely to be bystanders—our junior workforce, both officer and enlisted. A backlog of “A” schools means many junior enlisted remain in this pressure cooker for years. The Northland ’s collateral duty command senior chief will overlap with his relief until his retirement later this year. Once relieved of his current duties, he will serve as a full-time command chief with no other duties or distractions. Throughout this trial, we will capture lessons learned and best practices and document the potential value of this position for consideration by leadership for fleet-wide application.

Identify Precursors and Reduce High Risk Factors

In order to break this cycle of inaction and promote engagement, commands must study real-life incidents and bystander research to learn how to adapt their command climates, crew cultures, mentoring, and training. As leaders, we must understand and then teach our personnel that under the right circumstances good people with the best of intentions can still fail. We must teach them about the bystander effect, how and why it happens, why it is so important to combat, and how to defeat it. We also must identify and teach others to recognize subtle indicators that lead to high-risk environments or behavior so they can be stopped or mitigated early.

Our efforts have led us to identify a number of precursors and high-risk environments as well as some ways to limit their impact. For example, when someone states “I thought, assumed, figured or believed,” they do not know and they are guessing. The only way to be sure is to verify. Use of these trigger words should cause others to question the circumstances and seek verification. Considering gender relations, The Northland has 14 women in a crew of 106—roughly 13 percent. If we can increase the percentage to gain a critical mass, would it provide an environment where women are more likely to speak up when inappropriate conduct occurs? If so, what is the right mix of women on board a major cutter to break this barrier? We don’t know, however, we have requested that additional women be assigned so we can begin to answer these questions. To ensure the crew is engaged, during navigation and other briefs, we ask questions of participants to ensure they understand what has passed. The briefer praises those who pay attention as a way to reinforce and encourage participation.

Properly preparing the crew for liberty is critical to reduce the likelihood of risky behavior during time ashore. Prior to each port call, the command discusses with the entire crew expectations regarding conduct on liberty—especially concerning the use of alcohol—and holds a liberty risk board to identify high-risk individuals. All personnel are reminded to look after their shipmates and prevent problems before they occur. The command also sponsors morale events that appeal to a variety of interests to provide fun but safe liberty options. Officers and chiefs attend these events and ensure they end well, rather than bolting at the first sign of trouble.

Although alcohol is a significant contributor to liberty incidents and misconduct, most individuals do not understand how it affects them personally. If members understood how their mood, behavior, or personality changes under the influence of alcohol, would they change their drinking habits? Encouraging feedback from liberty buddies may help some realize the need to change their alcohol consumption. Finally, acts of misconduct against another are rarely group activities. When the size of the liberty party decreases at the end of the night, individuals—especially those under the influence—could be headed for trouble if left alone or with one other shipmate. For this reason, we have reconsidered our buddy-system policy to require a minimum of three or more people when mixed genders are present, rather than the normal practice of two. We also do not allow mixed-gender use of hotel rooms.

Rethinking the Lowest Level Approach

Time and again, when asked why individuals failed to take sufficient action or failed to report a problem, the phrase “handle it at the lowest level” was invoked. This mantra has been beaten into the very fabric of our culture to the point where anyone who does not handle something one-on-one or at the peer level is viewed as blowing it out of proportion. This phrase needs to be retired, as it prevented a majority of our bystanders from bringing incidents to the command’s attention. Delaying proper notification allowed problems to continue and escalate, or prevented the command from identifying a perpetrator due to time elapsed, and violated Coast Guard policy. While its original intent may have been to empower junior members to act, it now causes individuals to take the most meager of actions, and in many ways imposes a cultural barrier that prevents them from seeking help from higher authority. Instead, our culture needs to embrace handling things at the “appropriate” level. We need to teach our personnel what the appropriate level is for different types of situations. If they are still unsure what to do or feel uncomfortable approaching a senior person, peer mentors provide a bridge to overcome this cultural barrier and relay information to the appropriate level in a timely manner.

Recently Admiral Papp stated that in each of the 141 sexual assaults that occurred in the Coast Guard last year there were people who knew or should have known but did nothing to prevent or report them. Current efforts at individual units to address the bystander effect show promise for wider application. For example, since the 2010 enactment of a Bystander Intervention Training program, Naval Station Great Lakes has received 50 percent fewer reported assaults, demonstrating the significant potential value of addressing bystander inaction. 2 Will reducing the number of bystanders stop every incident? No. But if we can prevent even one assault, hazing, or operational mishap, we have a duty and a moral obligation as leaders and shipmates to do so.

Telling individuals to take action is not enough, and more of the same training is insufficient. We must aggressively foster a command climate where every member’s focus is prevention and it is ingrained in our culture and character. We must understand and defeat barriers to bystander engagement. Every member of the crew must personally recognize, believe, and fully embrace their duty to act and have the tools, training, culture, and command climate to support them. We hope that the Northland ’s story will shed light on ways to approach and solve some of the problems that are plaguing our armed forces and trigger others to study and address the issue of bystander inaction.

1. Admiral Robert Papp Jr., ALCOAST 37/12: Shipmates 19: Respect our Shipmates—Duty Demands Courage , U.S. Coast Guard, January 2012, .

2. “Program helps reduce sex assaults at Naval Station Great Lakes, officials say,” The Associated Press , 9 June 2013, .

The authors are the current commanding officer, executive officer, and command senior chief of the USCGC Northland , a 270-foot medium endurance cutter homeported in Portsmouth, Virginia. Collectively, they have served on board 16 cutters and have over 32 years of sea duty.


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