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High-Reliability 1
The Self-Designing High-Reliability Organization:
Aircraft Carrier Flight Operations at Sea
By
Gene I. Rochlin, Todd R. La Porte, and Karlene H. Roberts
The following article was
originally published in the Autumn 1987 issue of
Naval War
College
Review. Reprinted here with the kind permission of Naval War
College Review.
Part 1 of 4
"A hundred things I have no control over could go wrong and
wreck my career . . . but wherever I go from here, I'll never have a better job
than this. . . . This is the best job in the world."
-- Carrier commanding officer
Recent studies of large, formal organizations that perform complex, inherently
hazardous, and highly technical tasks under conditions of tight coupling and
severe time pressure have generally concluded that most will fail spectacularly
at some point, with attendant human and social costs of great severity.1 The
notion that accidents in these systems are "normal," that is, to be expected
given the conditions and risks of operation, appears to be as well grounded in
experience as in theory. 2 Yet there is a small group of organizations in
American society that appears to succeed under trying circumstances, performing
daily a number of highly complex technical tasks in which they cannot afford to
"fail." We are currently studying three unusually salient examples whereby
devotion to a zero rate of error is almost matched by performance--utility grid
management (Pacific Gas & Electric Company), air traffic control, and flight
operations aboard U.S. Navy aircraft carriers.
Of all activities studied by our research group, flight operations at sea is the
closest to the "edge of the envelope"--operating under the most extreme
conditions in the least stable environment, and with the greatest tension
between preserving safety and reliability and attaining maximum operational
efficiency. 3 Both electrical utilities and air traffic control emphasize the
importance of long training, careful selection, task and team stability, and
cumulative experience. Yet the Navy demonstrably performs very well with a young
and largely inexperienced crew, with a "management" staff of officers that turns
over half its complement each year, and in a working environment that must
rebuild itself from scratch approximately every eighteen months. Such
performance strongly challenges our theoretical under standing of the Navy as an
organization, its training and operational processes, and the problem of
high-reliability organizations generally.
It will come as no surprise to this audience that the Navy has certain
traditional ways of doing things that transcend specifics of missions, ships,
and technology. Much of what we have to report interprets that which is "known"
to naval carrier personnel, yet is seldom articulated or analyzed. 4 We have
been struck by the degree to which a set of highly unusual formal and informal
rules and relationships are taken for granted, implicitly and almost
unconsciously incorporated into the organizational structure of the operational
Navy.
Only those who have been privileged to participate in high-tempo flight
operations aboard a modern aircraft carrier at sea can appreciate the
complexity, strain, and inherent hazards that underlie seemingly routine
day-to-day operations. That naval personnel ultimately accept these conditions
as more or less routine is yet another example of how adaptable people are to
even the most difficult and stressful of circumstances.
We have now spent considerable time aboard several aircraft carriers in port and
at sea, though our team of non-Navy academics retains a certain distance that
allows us to recognize and report on the astonishing and unique organizational
structure and performance of carrier flight operations. 5 We do not presume that
our limited exposure to a few aspects of operations has given us a comprehensive
overview. Nevertheless, we have already been able to identify a set of causal
factors that we believe are of central importance to understanding how such
organizations operate.
In an era of constant budgetary pressure, the Navy shares with other
organizations the need to defend those factors most critical to maintaining
performance without, at the same time, sacrificing either operational
reliability or safety. Following many conversations with naval personnel of all
ranks, we are convinced that the rules and procedures that make up those factors
are reasonably well known internally, but are written down only in part and
generally not expressed in a form that can be readily conveyed outside the
confines of the Navy.
The purpose of this article is to report some of our more relevant findings and
observations to our gracious host, the Navy community; to describe air
operations through the eyes of informed, yet detached observers; and to use our
preliminary findings to reflect upon why carriers work as well as they do.
Self-Design and Self-Replication
"So you want to understand an aircraft carrier? Well, just imagine that it's a
busy day, and you shrink San Francisco Airport to only one short runway and one
ramp and gate. Make planes take off and land at the same time, at half the
present time interval, rock the runway from side to side, and require that
everyone who leaves in the morning returns that same day. Make sure the
equipment is so close to the edge of the envelope that it's fragile. Then turn
off the radar to avoid detection, impose strict controls on radios, fuel the
aircraft in place with their engines running, put an enemy in the air, and
scatter live bombs and rockets around. Now wet the whole thing down with salt
water and oil, and man it with 20-year-olds, half of whom have never seen an
airplane close-up. Oh, and by the way, try not to kill anyone."
-- Senior officer, Air Division
Today's aircraft carrier flight operations are as much a product of their
history and continuity of operation as of their design. The complexity of
operations aboard a large, modern carrier flying the latest aircraft is so great
that no one, on or off the ship, can know the content and sequence of every task
needed to make sure the aircraft fly safely, reliably, and on schedule. As with
many organizations of similar size and complexity, tasks are broken down
internally into smaller and more homogeneous units as well as task-oriented work
groups. 6 In the case of the Navy, the decomposition rules are often ad hoc and
circumstantial: some tasks are organized by technical function (navigation,
weapons), some by unit (squadron), some by activity (handler, tower), and some
by mission (combat, strike). Men may belong to and be evaluated by one unit
(e.g., one of the squadrons), yet be assigned to another (e.g., aircraft
maintenance).
In order to keep this network alive and coordinated, it must be kept connected
and integrated horizontally (e.g., across squadrons), vertically (from
maintenance and fuel up through operations), and across command structures
(battle group--ship--air wing). As in all large organizations, the responsible
officer or chief petty officer has to know what to do in each case, how to get
it done, whom to report to and why, and how to coordinate with all units that he
depends upon or that depend upon him. This is complicated in the Navy case by
the requirement for many personnel, particularly the more senior officers, to
interact on a regular basis with those from several separate organizational
hierarchies. Each has several different roles to play depending upon which of
the structures is in effect at any given time. 7
Furthermore, these organizational structures also shift in time to adapt to
varying circumstances. The evolution of the separate units (e.g., ship, air
wing, command structures) and their integration during workup into a fully
coordinated operational team, for example, have few, if any, applicable
counterparts in civilian organizations. 8 There is also no civilian counterpart
for the requirement to adapt to rapid shifts in role and authority in response
to changing tactical circumstances during deployment.
No armchair designer, even one with extensive carrier service, could sit down
and lay out all the relationships and interdependencies, let alone the
criticality and time sequence of all the individual tasks. Both tasks and
coordination have evolved through the incremental accumulation of experience to
the point where there probably is no single person in the Navy who is familiar
with them all. 9 Rather than going back to the Langley, * consider, for the
moment, the year 1946, when the fleet retained the best and newest of its
remaining carriers and had machines and crews finely tuned for the use of
propeller-driven, gasoline-fueled, Mach 0.5 aircraft on a straight deck.
Over the next few years the straight flight deck was to be replaced with the
angled deck, requiring a complete relearning of the procedures for launch and
recovery and for "spotting" aircraft on and below the deck. The introduction of
jet aircraft required another set of new procedures for launch, recovery, and
spotting, and for maintenance, safety, handling, engine storage and support,
aircraft servicing, and fueling. The introduction of the Fresnel-lens landing
system and air traffic control radar put the approach and landing under
centralized, positive, on-board control. As the years went by, the
launch/approach speed, weight, capability, and complexity of the aircraft
increased steadily, as did the capability and complexity of electronics of all
kinds. There were no books on the integration of this new "hardware" into
existing routines and no other place to practice it but at sea; it was all
learned on the job. Moreover, little of the process was written down, so that
the ship in operation is the only reliable "manual."
For a variety of reasons, no two aircraft carriers, even of the same class, are
quite alike. Even if nominally the same, as are the recent Nimitz-class ships,
each differs slightly in equipment and develops a unique personality during its
shakedown cruise and first workup and deployment. 10 While it is true that each
ship is made up of the same range of more or less standardized tasks at the
micro level, the question of how to do the job right involves an understanding
of the structure in which the job is embedded, and that is neither standardized
across ships nor, in fact, written down systematically and formally anywhere. If
they left the yards physically different, even such apparently simple matters as
spotting aircraft properly on the deck have to be learned through a process of
trial and error. 11
What is more, even the same formal assignment will vary according to time and
place. Carriers differ; missions differ; requirements differ from Atlantic to
Pacific, and from fleet to fleet; ships have different histories and traditions,
and different equipment; and commanding officers and admirals retain the
discretion to run their ships and groups in different ways and to emphasize
different aspects. Increased standardization of carriers, aircraft loadings,
missions, tasks, and organizational structure would be difficult to obtain, and
perhaps not even wise. 12 There is a great deal to learn in the Navy, and much
of it is only available on the spot.
Shore-based school training for officers and crew provides only basic
instruction. 13 It includes a great deal about what needs to be done and the
formal rules for doing it. Yet it only provides generalized guidelines and a
standardized framework to smooth the transition to the real job of performing
the same tasks on board as part of a complex system. NATOPS and other written
guidelines represent the book of historical errors. They provide boundaries to
prevent certain actions known to have adverse outcomes, but little guidance as
to how to promote optimal ones.
Operations manuals are full of details of specific tasks at the micro level but
rarely discuss integration into the whole. There are other written rules and
procedures, from training manuals through standard operating procedures (SOPs),
that describe and standardize the process of integration. None of them explain
how to make the whole system operate smoothly, let alone at the level of
performance that we have observed. 14 It is in the real-world environment of
workups and deployment, through the continual training and retraining of
officers and crew, that the information needed for safe and efficient operation
is developed, transmitted, and maintained. Without that continuity, and without
sufficient operational time at sea, both effectiveness and safety would suffer.
Moreover, the organization is not stable over time. Every forty months or so
there is an almost 100 percent turnover of crew, and all of the officers will
have rotated through and gone on to other duty. Yet the ship remains functional
at a high level. The Navy itself is, of course, the underlying structural
determinant. Uniforms, ranks, rules and regulations, codes of conduct, and
specialized languages provide a world of extensive codification of objects,
events, situations, and appropriate conduct; members who deviate too far from
the norm become "foreigners" within their own culture and soon find themselves
outside the group, figuratively if not literally. 15
Behavioral and cultural norms, SOPs, and regulations are necessary, but they are
far from sufficient to preserve operational structure and the character of the
service. Our research team noted three mechanisms that act to maintain and
transmit operational factors in the face of rapid turnover. First, and in some
ways most important, is the pool of chief petty officers, many of whom have long
service in their specialty and circulate around similar ships in the fleet. 16
Second, many of the officers and some of the crew will have at some time served
on other carriers, albeit in other jobs, and bring to the ship some of the
shared experience of the entire force. Third, the process of continual rotation
and replacement, even while on deployment, maintains a continuity that is broken
only during a major refit. These mechanisms are realized by an uninterrupted
process of on-board training and retraining that makes the ship one huge,
continuing school for its officers and men.
When operational continuity is broken or nonexistent, the effects are observable
and dramatic. One member of our research group had the opportunity to observe a
new Nimitz-class aircraft carrier as she emerged from the yard and remarked at
how many things had to be learned before she could even begin to commence
serious air operations. 17 Even for an older and more experienced ship coming
out of an ordinary refit, the workup towards deployment is a long and arduous
process. Many weeks are spent just qualifying the deck for taking and handling
individual aircraft, and many more at gradually increasing densities to perfect
aircraft handling as well as the coordination needed for tight launch and
recovery sequences. With safety and reliability as fixed boundary conditions,
every moment of precious operational time before deployment is devoted to
improving capability and efficiency.
The importance of adequate workup time--for flight operations to be conducted
safely at present levels of technical and operational complexity and at the
tempo required for demonstrating effectiveness--cannot be overemphasized. During
our research we followed one carrier in which the workup was shortened by "only"
two weeks, for reasons of economy. As a result, the ship was forced to complete
its training during the middle of a difficult and demanding mid-ocean exercise;
this placed an enormous strain on all hands. While the crew succeeded--the
referees adapted compensating evaluation procedures--risks to ship's personnel
and equipment were visibly higher. Moreover, officers and crew were openly
unhappy with their own performance, with an attendant and continuing impact on
morale. 18
Copyright
©1987 Naval War College Review.
