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The Self-Designing High-Reliability Organization:
Aircraft Carrier Flight Operations at Sea

Part 4 of 4

Notes

  1. See, for example, Charles Perrow, Normal Accidents (New York: Basic Books, 1984).
  2. Examples that have attracted recent attention include Bhopal, Séveso, Three-Mile Island, and Chernobyl. All four meet Perrow's criteria for coupling, response time, and complexity. The essence of a "normal" accident is that the potentiality inheres in the design of the system and, despite attempts to fix "blame," is not primarily the result of individual misbehavior, malfeasance, or negligence.
  3. By comparison, civil air traffic controllers deliberately stay far away from the edge. Fixed rules such as maintaining five-mile intervals are designed to err broadly in the direction of safety. Moreover, the turnover rate for controllers is relatively low (barring extraordinary events such as the recent [1981] strike); even equipment changes are few and far between.
  4. From this point we refer to carrier personnel as "men," since as yet the Navy does not allow women to serve aboard combat vessels.
  5. We have followed both the USS Carl Vinson (CVN 70) and the USS Enterprise (CVN 65), under a total of four different captains, through their training and workup from Alameda and San Diego, California, and across the Pacific into the South China Sea. In addition, one of us (Roberts) has been able to observe the initial sea trials of the USS Theodore Roosevelt (CVN 71).
  6. In formal organizational terms, we refer to this as "decomposability." The basic notion was introduced by Herbert A. Simon in "The Architecture of Complexity," Proceedings of the American Philosophical Society, December 1962, pp. 467--82, reprinted in Herbert A. Simon, The Sciences of the Artificial (Cambridge, Mass.: The MIT Press, 1981).
  7. During our interviews, one senior officer on a flag staff suggested that the several different functional and hierarchical modes of organization might be viewed as a set of "overlays" that are superimposed upon the formal organization at different times, depending upon the task or circumstance at hand. Many of the officers must shift roles numerous times during the course of a single active day of flight operations.
  8. The few examples that come to mind are large construction projects, e.g., nuclear power plants, the Alaskan pipeline, etc. However, these usually have considerable oversight from a separate firm whose sole task is to coordinate and schedule the work properly.
  9. This point was brought home sharply by the effort to bring up the ZOG computer system on the USS Carl Vinson, which would have required that almost complete knowledge about all details of ship operations be known and entered if the system were to function as originally intended. In retrospect, this can be seen as a near-impossible requirement without the mounting of a considerable special effort to collect and organize the data.
  10. Furthermore, a strong captain is capable of altering both the character of a ship and the way it operates, if he so chooses.
  11. Given the size of modern jet aircraft and the number carried at full load, the matter of spotting is far from trivial. Inefficient spotting can greatly reduce the ability to move aircraft about quickly. Incorrect spotting can lead to serious interference with operations, or even to a "locked" deck, on which it becomes impossible to move aircraft at all. In a trial using the deck model in Flight Deck Control, one of us managed to lock the deck so thoroughly that an aircraft would have had to be pushed over the side to free the deck.
  12. Some nonfunctional variations are being reduced. For example, all LSO platforms will soon be located at the same level and position relative to the arresting gear wires. However, it is nearly impossible to upgrade all of the ships at once when new equipment is introduced; therefore, each is at a different stage of modification and upgrade at any given point in time.
  13. To some extent this situation is improving. Landing Signal Officers (LSOs), for example, now work with simulators. Although this is no substitute for experience when "eyeball" judgment is concerned, it helps.
  14. As one senior chief remarked to us: " You have to know it, but it rarely helps when you really need it."
  15. Roger Evered, "The Language of Organizations: The Case of the Navy," in Louis R. Pondy et al., eds., Organizational Symbolism (Greenwich, Conn.: JAI Press, 1983), pp. 125--44.
  16. A very few stay on one ship for many years, but such "plankowners" are rare in the modern Navy.
  17. For example, the first crew was unable to spot the deck effectively; Flight Deck Control had been laid out with the deck model at right angles to the flight deck axis, interfering with spatial visualization and obstructing the Aircraft Handling Officer's direct view of the deck from his only window.
  18. The recent grounding of the USS Enterprise on Bishop Rock off San Diego may have been at least partially due to her participation in a difficult exercise combining the elements of what were usually two exercises. The effect on ship's morale was very visible. See Karlene H. Roberts, "Bishop Rock Dead Ahead: The Grounding of USS Enterprise," submitted to U.S. Naval Institute Proceedings. [Editors' note: To the best of our knowledge, this paper did not appear in Proceedings.]
  19. Lewis Sorley, "Prevailing Criteria: A Critique," in Sam C. Sarkesian, ed., Combat Effectiveness (Beverly Hills, Calif.: Sage, 1980), pp. 57--93.
  20. L. R. Giguet, "Coordinating Army Personnel Agencies Using Living Systems Theory: An Example," U.S. Army TRADOC, 1979, as quoted by Sorley at pp. 76--7.
  21. The term "proficiency" is used in the special sense of Hubert L. Dreyfus and Stuart E. Dreyfus, Mind over Machine (New York: Free Press, 1986), who classify five steps of skill acquisition: novice, advanced beginner, competence, proficiency, and expertise. For most officers, mastery of a specific assignment means at most the acquisition of proficiency--the ability to identify situations and act upon them without having to systematically think through the procedural steps involved. The most advanced stage, expertise, involves moving past "problem solving" to "intuition" in decision making. Examples of relevance here include the flying skills of experienced pilots and the specific expertise of senior chief petty officers--in each case representing many years of continuous practice of a small range of specific skills.
  22. We have observed several mechanisms used by the Navy to prevent such loss, including incentives for reporting successful innovation and formal procedures for their dissemination. The most general mechanism, however, is the informal dissemination of information by the movement of personnel, and through those responsible for refresher and other forms of at-sea training. A most remarkable combination of trainers and active personnel is the recently formed Association of Air Bos'ns, which holds annual meetings where information is exchanged and formal papers are presented.
  23. Often, officers near the end of their tours, with new assignments in hand, are also trying to learn as much as they can about their future tasks and responsibilities.
  24. K. Weick, "The Role of Interpretation in High Reliability Systems," California Management Review, vol. 39, 1987, pp. 112--27.
  25. Roberts observes that similar rules would operate to similar advantage on the navigation bridge, which of necessity operates under more formal and traditional rules.
  26. Even when fitness report ratings are based solely on merit, they are necessarily subjective to some degree. It is inherently difficult to compare ratings taken on different ships, in different peer groups, by different superiors, even under the best of circumstances. But the general opinion among those we have interviewed is that direct abuses of the system are relatively rare. As with all hierarchical organizations, politics will begin to enter as one moves to higher rank, but it is thought to be a minor factor below the level of captain.
  27. We note that the kinds of redundancy required to assure continued effectiveness in combat--e.g., in situations where physical damage to ship or command chains is anticipated--are qualitatively different from redundancy directed primarily to assuring the performance of safety-critical tasks. Elements of the former, however, are often major contributors to the latter.
  28. Martin Landau, "Redundancy, Rationality and the Problem of Duplication and Overlap," Public Administration Review, November--December 1973, pp. 316--51.
  29. In this context, we note that the tempo and character of U.S. carrier operations are so qualitatively different from those of other navies--including the French, British, and prospective Russian--that the envelope itself can only be measured by our own expectations and capabilities.
  30. The engines are in different compartments and are hand-set by separate operating teams so that collective failures in setting can only occur at the command level, i.e., in the tower, where a number of other independent measures for cross-checking and redundancy are in place.
  31. During heavy flight operations there may be anywhere from six hundred to a thousand settings of the engines in a single day. A typical deployment will have eight to ten thousand arrested landings ("traps"), involving thirty to forty thousand settings over a six-to-eight-month period.
  32. Although the probabilities are low, the possibility does exist. A minor error may simply result in too much runout, cable damage, or some damage to the aircraft. But an engine set for too heavy a weight can pull a tailhook out, leading to aircraft loss; setting for too low an aircraft weight can result in its "trickling" over the end of the angled deck and into the sea. Experienced air bos'ns and chiefs estimate that perhaps six or seven such serious errors have occurred throughout the entire U.S. fleet over the past twenty years. Our estimate for the rate of uncorrected wrong settings with serious consequences is therefore about one in a million--roughly comparable to the probability of a mid-air collision in a domestic commercial airline flight. Setting errors that are corrected are "nonreportable" incidents and therefore not documented. We also note that on the USS Carl Vinson, a much newer ship with a still unbroken memory, no reportable incident of any kind could be recalled in the first seventy thousand traps since its commissioning.
  33. Allan W. Lerner, "There Is More Than One Way to Be Redundant," Administration & Society, November 1986, pp. 334--59.
  34. This was brought home to us during a general quarters drill in which the bridge took simulated casualties.
  35. During the period of observation, CDC was also the center for fighting the battle group, a task that will be increasingly supervised by the new Tactical Flag Command Centers (TFCC) as they are installed. Depending upon the physical arrangement of the ship, the CDC area contains the Combat Information Center (CIC), antiair warfare control consoles, and perhaps air operations and carrier air traffic control center (CATCC); other warfare modules, such as those for antisubmarine or antisurface warfare, may also be included or be in physically adjacent spaces.
  36. For example, control of fighter aircraft can be done from the carrier, from an E-2 [airborne early warning aircraft], or from one of several other ships in the group.
  37. Evered lists qualities of "responsiveness to authority," "being ready," "can do," and "not fazed by sudden contingencies" as among the more "obvious" character traits of naval officer culture. These are transmitted by training programs, ceremonies, and historical models. The latter is particularly important for the "can do" aspect of the officer culture.
  38. Not only are the ship and its air wing parted, but the wing itself is split into component squadrons that train under different functional commands.
  39. No definite name for this thousand-foot-plus, angled-deck, sixty to seventy-thousand-ton nuclear-powered carrier has been ascertained at this time. [Editors' note: The year after this article was published, what would have become the Soviet Union's first nuclear-powered carrier, Ulyanovsk, was laid down at the Nikolaev yard in the Crimea (but was never completed). Two conventionally powered carriers of a new class with approximately the dimensions mentioned were, however, fitting out in the Black Sea at the time: Tbilisi--later Leonid Brezhnev, now Admiral Flota Sovietskogo Soyuza Kuznetsov--and Riga (thereafter Varyag).]
  40. See Bruce W. Watson and Susan M. Watson, The Soviet Navy: Strengths and Liabilities (Boulder, Colo.: Westview, 1986).
  41. Although it is currently believed that arresting gear and catapults will be fitted--and the deck mock-up at Saki airfield in the Crimea is so equipped--ski-ramps for a total loading of sixty to seventy short-takeoff-and-landing aircraft appear more likely in the short term, with possible future retrofit of catapults into pre-existing deck slots at some future date. See, for example, Norman Polmar, Guide to the Soviet Navy, 4th ed. (Annapolis, Md.: Naval Institute Press, 1986), pp. 164--5.
  42. As a group, we doubt they will be able to approach the operating conditions and efficiency of U.S. carriers in this century, if at all, even if they master the associated naval and aircraft technologies.


     

    *The first U.S. Navy aircraft carrier, commissioned as CV 1 (after conversion from a collier) in 1922. Langley was sunk by the Japanese in 1942. [Return]
    †Naval Air Training and Operation Procedures Standardization.

    ‡Petty officers, the middle ranks of U.S. Navy enlisted personnel, specializing in a "rate" (such as Aviation Boatswain's Mate). "CPOs," or chief petty officers, occupy the three highest enlisted pay grades (aside from Master Chief Petty Officer of the Navy).

    §Located in the island structure, and on the flight deck, respectively.
     

    At the time of publication, Professor Rochlin was adjunct professor of energy and resources and a research political scientist at the Institute of Governmental Studies, University of California, Berkeley. At the time of publication, Professor La Porte was professor of political science and associate director of the Institute of Governmental Studies, University of California, Berkeley. At the time of publication, Professor Roberts, an organizational psychologist, was professor of business administration at the University of California, Berkeley.
     

    This article was originally published in the Autumn 1987 issue of Naval War College Review.  Reproduced by GovLeaders.org with the kind permission of the publisher.

Copyright ©1987 Naval War College Review.
 



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