Safety Is A Matter of Principles

By Admiral James A. "Sandy" Winnefeld, U.S. Navy (Retired)

We can ill afford to pay this price in lives and aircraft lost and ships damaged. The lion’s share of these losses may be traced to a single principal causal factor: human error. Often the responses are to mandate additional training, new procedures, or some kind of technical fix—all of which are intended to eliminate or reduce potential repeats of the original errors. While these are necessary components, they either address “micro-causes” or even symptoms rather than “macro causes.” Indeed, almost completely absent from the discussion is what causes human errors in the first place, and thus what must be done going forward to ensure safe operations.

As one who operated aircraft, amphibious ships with embarked Marines and SEALs, and a nuclear-powered aircraft carrier, I believe the keys to keep forces safe and effective can be found in the timeless principles of operational excellence. The closest our Navy comes to articulating these principles is in its nuclear propulsion community, which has not suffered a reactor accident in more than 75 years of underway operations.* While other technically complex endeavors, such as the Space Shuttle Program, have suffered catastrophic accidents attributable to human error, the nuclear propulsion community has reduced the incidences of serious human error to a very low level. It is not a fluke.

What are these principles? And where and how do they apply? Within the answers to these questions rests the potential to decrease accident rates in our Navy and Marine Corps.

Principles Matter

Numerous definitions exist for the word principle. The one most applicable to safe operations is “a fundamental truth or proposition that serves as the foundation for a system of belief or behavior.” Principles also have been called basic assumptions, ethical standards, and ways of working. They are all of these things.

I believe the principles that govern operational excellence are the following:

• Integrity: The foundational principle for all operational excellence is integrity. It is the most important assumption we must be able to make about our entire organization: commanders, watchstanders, hands-on operators (such as aircrews), and those who maintain our equipment. Integrity means adhering to standards when nobody is watching and freely admitting mistakes when they are made. This results in an organization that effectively and quickly captures lessons learned and does not have to waste time on detective work when something goes wrong.

We are not and should not be a zero-defects military, but we also should not tolerate mistakes attributable to a lack of integrity. Leaders need to hold their people accountable when they do not measure up to the principle of integrity. Integrity also must work in the other direction. If people in an organization trust they will not be ruined when they make and admit mistakes, they are more likely to act with integrity. A constant culture of integrity leads to enhanced trust across an organization. If you know the person next to you is likely to tell the truth, you are more likely to do the same.

• Knowledge: A proper level of knowledge is a key enabler of the other principles. It means knowing your stuff. It permits people to select the right procedure and to make the correct decision when a situation is not covered by a procedure. Many operational cultures impart only the minimum knowledge required to operate their equipment, but this is not enough. Rather, knowing more than the minimum breeds confidence and the ability to handle unanticipated situations when they arise, making us both better teachers and more prolific innovators. The proper level of knowledge requires hard work to obtain. Moreover, knowledge is perishable and thus requires near-constant reinforcement.

• Procedural Compliance: The violation of proper procedures is the single biggest factor in human-error mishaps. We need to appreciate that most procedures were written in blood let or treasure lost. Procedural compliance means knowing where to find the proper procedure, trusting its authors, and sticking to it instead of taking shortcuts. It means thinking before we act, taking the time to use the book, conducting thorough watch reliefs, and taking the time to modify procedures that do not work.

• Formality: Improper communications and crew resource management have been primary causal factors in a host of mishaps. Formality demands establishment of a special kind of atmosphere among the humans involved in an operation and very precise communications. Formality requires clearly stated, standardized orders and, in most cases, verbatim repeat-backs all the time. Such a communications cadence grants the one giving an order confidence it was heard properly and, in the absence of correction, the person receiving the order confidence it was properly given. Formality prevents complacency, misunderstanding, and confusion.

• Forceful Backup: This means having properly qualified supervisors on station and paying attention during key evolutions. It means remaining alert for fatigue, complacency, and deviations from formality among the people operating the machine. It means leaders constantly anticipating what is coming next during an operation or evolution, including potential hazards and unexpected events, and forcing the team to think about what could happen. It also means fostering a command atmosphere in which anyone, even the youngest Sailor or Marine, can speak up forcefully when something seems wrong and know he or she will not be punished when things actually are right. Finally, forceful backup is enabled when key evolutions are briefed in detail before they occur, through quality, formalized processes, because few operations happen the way they are planned.

• Questioning Attitude: We must ask our Sailors to use their knowledge and experience to sense when something seems wrong and to relentlessly follow every possible path to closure. It requires mental discipline and a nagging unwillingness to walk past a potential problem and never being satisfied with an answer that is anything less than thorough. It means taking the time to interpret data—turning it into knowledge—rather than merely recording and reporting it. It means constantly asking what could be going wrong, double-checking key facts, and following warning signals to their source. It requires constantly cross-checking what one’s instruments are saying against what appears to be happening visually and challenging anything that does not make sense. It is about the foresight that must occupy our time during a watch when our brains are not otherwise tasked. The friend of a questioning attitude is mental discipline; its enemy is mental laziness.


Principles: Not Only Words

These mutually reinforcing operational excellence principles apply across our Navy and Marine Corps. They work equally effectively in the heat and noise of a propulsion plant, on a hushed bridge at night, in a lonely cockpit during a carrier landing, in the bedlam of a flight deck, in the darkness of a command center, in the coordinated violence of an artillery battery, amid the high-tension forces on a refueling rig . . . or anywhere else heavy equipment is operated or key decisions are taken.

These principles must live within us before real-time operations. It begins with commanding officers personally inculcating them into their subordinates—so everyone on the team knows them by heart and understands them—and then lives them. In the process, the principles become the “basic assumptions, ethical standards, and ways of working” that govern how an entire organization moves together.

These principles also are valuable after an operation, when analyzing and debriefing the event or reviewing an accident, incident, or close call caused by human error. Candidly exploring which principles were violated is a powerful way to bring clarity to what occurred and, in the process, reinforces the principles themselves. As I grew more experienced in command, I insisted that we do this. I quickly discovered that in almost every case, more than one principle was violated. This probably is true of our most recent tragic events. A high form of this art is tracking principles violated across a unit’s operational history in an effort to identify trends.

It is possible to operate our force safely while achieving an extraordinarily high level of combat readiness. To be sure, there are many other less esoteric aspects of achieving safe and effective operations, but it is hard to find any factor as important as these principles. We in the naval services would benefit from formally codifying them in the way we do business.

Admiral Winnefeld retired in 2015 after serving as the ninth Vice Chairman of the Joint Chiefs of Staff.

The foundational principle for all operational excellence is integrity. Integrity means adhering to standards when nobody is watching and freely admitting mistakes when they are made.


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