If you are in a business where there is an interface between humans and nature, the concept of taking deliberate action is pretty clear-cut. Electrical utilities, airlines and cruise lines, manufacturing plants, and hospitals are examples. In these kinds of organizations, you’ll be able to see immediately how acting deliberately would help reduce mistakes. The challenge will be when things are happening quickly, or need to happen quickly, as in a casualty in a power plant or emergency room procedures in a hospital. It’s even more important that actions be performed correctly then. You don’t have time to “undo” something that’s wrong.
If your business doesn’t have an obvious interface with nature and is more service or intellectual, take deliberate action still applies, but in a slightly different way. It applies at the moment someone signs a form, authorizes an action, or enters a keystroke.
We didn’t realize it at the time, but it turned out that take deliberate action had two tremendous benefits in addition to reducing errors. Rather, as a mechanism to reduce errors, it operated in two additional ways.
First, in team settings, when operators paused and vocalized and gestured, it allowed adjacent operators to step in and correct mistaken actions before they were taken. When I arrived at Santa Fe, many operators felt it was a point of prowess to operate as quickly as possible, and we had to overcome this. For example, the reactor operator in a pump shift may say, “Shifting number one reactor coolant pump to fast,” and he would be pulling the switch at the same time he said the word fast. Unfortunately, if he accidentally had his hand on the switch for pump number two, it would be too late to stop him, and the wrong pump would be shifted. In exercising caution and deliberateness, the pause prior to starting the pump would allow the operator sitting next to him to stop him or for him to recognize the error himself.
In addition, when we ran drills, we would station monitors whose job it was to intervene to prevent inappropriate action. The drill monitor would have full insight into the drill and would know which actions were allowable and which ones were not. If the operator was tempted to take an inappropriate action, either intentionally or not, the monitor would stop him. Unfortunately, with the operators moving quickly, the monitors frequently only recorded errors after they happened because they didn’t have a chance to intervene. This was especially true if the operator announced the correct action but became confused in the stress of trying to respond properly to a casualty and physically operated the wrong switch, breaker, or valve.
Later, when Santa Fe earned the highest grade on our reactor operations inspection that anyone had seen, the senior inspector told me this: “Your guys made the same mistakes—no, your guys tried to make the same number of mistakes—as everyone else. But the mistakes never happened because of deliberate action. Either they were corrected by the operator himself or by a teammate.”
He was describing a resilient organization, one where error propagation is stopped.
Eventually we would expand deliberate action to administrative paperwork. When documents were signed carelessly, we injected the concept of deliberate action into the act (mostly for officers) of signing papers and authorizing events.
• • •
Many people talk about teamwork but don’t develop mechanisms to actually implement it. Taking deliberate action is certainly one.
If your company is operating a power plant or is manufacturing tools, it’s easy to see how you could apply deliberate action. But what if you are trading bonds, operating a hospital, or engaged in a service industry?
I think deliberate action still applies. In more administrative actions, we applied take deliberate action to the moment of signing the form authorizing an action. We wanted that signature to be deliberate. Recently, the case of the robo-signing in bank foreclosures demonstrates an excellent counterexample, but even in normal cases, I’ve seen where large stacks of administrative paperwork are just signed off on without much thought. Applied broadly, that will eventually get you into trouble.
QUESTIONS TO CONSIDER
How do you react when an employee admits to doing something on autopilot, without deliberately thinking about the action or its consequences?
Do you think that by implementing a system of taking deliberate action you can eliminate errors in your company, or within certain departments in your company?
Will employees in your workplace revert to acting hastily and automatically in a real-life situation?
How effectively do you learn from mistakes?
“We Learn”
Have you tried to divest control without first making sure your organization is competent to handle more decision-making authority? I learned the hard way that control without competence is chaos.
February 13, 1999: Makalapa Housing Area, Pearl Harbor, Hawaii (136 days to deployment)
I was just getting back from a run around the Makalapa housing area where we lived in Pearl Harbor, letting my mind wander over my first month in command, when I had an insight. I was thinking about another problem we had shortly after the shore power incident. This time the problem occurred in the torpedo room. An inappropriate valve operation removed hydraulics from a torpedo handling mechanism, which resulted in its moving out of position. While deliberate action would have helped, the issue here was more one of technical competence. The guys doing the work just didn’t understand the necessary system interconnections and responses.
Unlike the problem with shore power, it was difficult to understand what actually happened with the torpedo room problem. This was a weapons department issue, and Lieutenant Dave Adams had the responsibility to figure it out. We gathered logs, procedures, and records. We interviewed the participants. Who gave what orders? What procedure were you following? Who was the required conventional weapons handling supervisor for this evolution? The answers were vague and evasive. Moreover, when Dave probed the level of knowledge with questions like “What happens if you turn this valve with this part of the system depressurized?” the guys didn’t do well.
After the problem occurred, I was unsure we were on the right path. I went to see Commodore Mark Kenny.
“I’m questioning my approach,” I began. “Things just don’t seem to be getting that much better fast enough. Just when I think we’ve got things going in the right direction, something like this happens.”
“Look, I’m not surprised. I figured things would get worse before they got better. Right now you’ve got the space to make the changes you are making. I’ll keep everyone else off your back. You only need to worry about me, and I think you’re on the right track,” the commodore assured me. I was glad because not everyone on the waterfront was rooting for us. There were twenty submarines stationed in Pearl Harbor, and though some of those captains were starting to come by to learn what we were doing, rumor was there was another group that would have been just as happy if our little experiment fell on its face.
We had been taking actions that pushed authority down the chain of command, that empowered the officers, chiefs, and crew, but the insight that came to me was that as authority is delegated, technical knowledge at all levels takes on a greater importance. There is an extra burden for technical competence.
If all you need to do is what you are told, then you don’t need to understand your craft. However, as your ability to make decisions increases, then you need intimate technical knowledge on which to base those decisions. The laws of nature govern a submarine, and those laws are uncaring. With physics, you don’t have problems; you only have the consequences of your actions. They become problems when we decide that what happened wasn’t what we wanted to happen.
This was going to be hard. We were going to have to train our guys to a higher level of technical competence if we wanted to give them more authority. Fundamentally, this is where I think I failed on the Will Rogers. I had tried to push authority and control, but the technical competence of the engineering department, who were accustomed to being given specific guidance, had atrophied. It
wasn’t up to the level sufficient for making the decisions I had been pushing to them. I had assumed the requisite level of technical competence and I hadn’t taken the necessary steps. Control without competence is chaos.
At times like this, I felt an impulse to just say screw it, it’s not worth it, let’s just go back to the leader-follower model. That will save me a lot of time and trouble in training. However, with Commodore Kenny’s support, I was determined to persist. I decided to double down on our efforts.
This thought process helped me with another project we’d been working on: codifying our core principles into a creed and set of command principles. To get to our creed, I wanted something so basic that it would be applicable to every member of the crew every day.
During discussions with the officers and chiefs, we discussed what we did. Their answers were too vague at first:
We supervise.
We enforce standards.
We schedule.
We prepare for war.
We tried getting more specific, but now their answers were too much so:
We operate systems of the submarine, preparing to engage in combat operations if called upon.
We walk around and observe system performance and people’s operations.
We make decisions about how to best employ Santa Fe.
We load torpedoes, determine enemy location, and program the torpedoes to attack the enemy.
We talked about this again. With the perspective of needing to increase technical competence in mind, we thought about the simple reality “we learn,” and that’s what we adopted. It was something that every member of the crew did every day. It seemed to be the basic element that unified all of our actions.
No matter what we were doing, we would figure out how to extract the maximum learning from that event. Our philosophy was that we just didn’t have time to add a bunch of lectures, but the submarine gave us hundreds of opportunities a day to learn. Once we started looking for those learning opportunities, we found them everywhere.
We ended up codifying the philosophy of “we learn” with a statement of our creed.
USS Santa Fe Creed
What do we do on a day-to-day basis?
We learn.
Why is “learning” a better word than “training”?
Training implies passivity; it is done to us. We are trained; we attend training. Learning is active; it is something we do.
What do we learn?
We learn how to prepare a submarine for success in combat.
Why would we need to go to combat?
We would go to combat if called upon by our country to defend the Constitution of the United States.
Why is that important?
The personal liberty, well-being, and economic prosperity we enjoy in the United States are unique throughout the history of mankind. Man’s life has generally been short, hard, and brutish. The democratic system we have and the importance of individual rights specified by the Constitution are the reasons for our emotional and physical prosperity. It’s an important document, worthy of being defended. You are not alone in deciding this, as many have died defending the Constitution before you.
Why submarines?
Submarines can accomplish unique missions no other platform can accomplish. The American submarine force has a tremendous heritage of defending democracy. For example, during World War II, the submarine force, while only making up 2 percent of the Navy, sank over 50 percent of all Japanese vessels sunk. This was a critical contribution to winning that war.
If all we do is learn, how does the work get done?
We do the work. But, we learn by doing—maintenance, evolutions, casualty drills, studying. So, when we are working, even doing field day, we are learning.
It seems like a trick; we’re still doing the same thing, we’re just calling it something different.
Yes and no. Yes, in that we will still keep the boat clean, drill, do maintenance, qualify, and the myriad other tasks that take up our time. No, in that how you look at things makes a difference. Instead of looking at a task as just a chore, look at it as an opportunity to learn more about the associated piece of equipment, the procedure, or if nothing else, about how to delegate or accomplish tasks.
How does the training program fit in?
The training program is a part of the learning process, but by no means all of it. Training is a subset of learning, which in turn is a subset of personal growth. We strive to grow each day.
Therefore, our vision of our command is a learning and competence factory.
The raw materials are the new personnel reporting aboard each week, new equipment, and tactics. The product is well-qualified, experienced sailors who, upon detaching from the command, carry their competence throughout the Navy. Each of you, then, is both a product of the factory (when you learn) and a machine in the factory (when you help others learn).
What do you expect me to do?
I expect you to learn to be a better submariner each day. I challenge you to look at each field day, maintenance action, drill, monitor watch, underway, and deployment as an opportunity to learn more, and by doing so, to grow as a person.
Mechanism: We Learn (Everywhere, All the Time)
I began to look at our training program in a new light. It wasn’t an administrative program, and it wasn’t a program to minimize errors. Instead, it was a key enabler that allowed us to pass decision-making authority to lower and lower levels on Santa Fe.
Want to have a training program that employees will want to go to? Here’s how it should work:
The purpose of training is to increase technical competence.
The result of increased technical competence is the ability to delegate increased decision making to the employees.
Increased decision making among your employees will naturally result in greater engagement, motivation, and initiative.
You will end up with significantly higher productivity, morale, and effectiveness.
Divest Control, Increase Competence
Here’s something to try at your next leadership meeting or corporate off-site.
Hand out a bunch of four-by-six cards and markers.
Start with this sentence completion: Our company would be more effective if [level] management could make decisions about [subject]. You specify the level of management but ask the group to fill in the subjects.
Once you have the set of cards, post them on the wall, and go on break. Let people mill around looking at what they’ve written.
Down-select to a couple subjects.
Ask this question: What, technically, do the people at this level of management need to know in order to make that decision?
Again, answer on the cards, post them, and go on break.
Now you’ll have a relevant list of topics for training, and you can directly connect the training topics to increased employee decision making and control—in a word, empowerment.
When you set up the training, don’t forget to communicate this thought process to the group. That way they’ll know why they are going to attend training and want to attend, knowing it’s their path to greater decision-making authority.
• • •
WE LEARN (EVERYWHERE, ALL THE TIME) is a mechanism for COMPETENCE.
I found “we learn” helped my internal mental balance and my perspective as well. In the past, I was both apprehensive and nervous prior to an inspection. I would be worried about how the ship would do and how our watch teams would perform. I would worry about the grades, the ship’s reputation, and the potential embarrassment to me professionally. Perhaps the near-death of my career as a result of my experience on the Will Rogers is what made me edgy.
In any event, with the idea of learning in mind, I found myself in a state of calmness, even eagerness, as I thought about all that my crew and I would learn in the three days with a team of experts on board. My crew sensed this in me and reflected this attitude as well. Inspection teams would invariably co
mment on the eagerness of my crew to learn, and I had no doubt their earnestness caused more than one borderline grade to go our way.
QUESTIONS TO CONSIDER
Are you aware of which areas in your business are marred by mistakes because the lower-level employees don’t have enough technical competence to make good decisions?
How could you implement a “we learn” policy among your junior and senior staff?
Would you consider writing a creed for your organization modeled after the one we wrote for Santa Fe?
Are people eager to go to training?
Under Way for San Diego
How do you get people to think “at the next level”? We discovered we had to change a fundamental practice that was inhibiting this.
February 22, 1999: Pearl Harbor, Hawaii (127 days to deployment)
“Captain, I intend to get under way. All departments report readiness, the tug is made up, we have permission from port operations.”
“Very well.”
Turn the Ship Around!: A True Story of Turning Followers into Leaders Page 13
