SAFETY IN THE SURFACE NAVY: THE LEADERSHIP PERSPECTIVE

In the Indian Navy, as in most work organisations, it is a fundamental characteristic of regular daily work that the resources needed to do something are often too less. The most frequent lament and, sometimes a shortcoming is lack of time but, information, materials, equipment, fuel and manpower may also be in short supply. Nevertheless, we usually manage to attain acceptable levels by adjusting how we do things to meet the demands of the situation.¹ Most of the time, things turn out safe. Yet sometimes there are catastrophes. So, should we stop and wait till the time information, material supplies, equipment and manpower are optimal? If that were the view taken, the navy would never be able to get much work done! Every sailor knows that the ship might be the safest in harbour, but that is not where she is meant to be. Safety is to be achieved in the practical work environment where resources and time are often going to be short.

We must recognise that on a daily basis on ships, things go well because people make sensible adjustments according to the demands of the situation. When time or other resources are limited, this adjustment in performance, to match the prevalent conditions happens by a trade-off between efficiency and thoroughness.² People and organisations routinely make a choice between being effective and being thorough, since it rarely is possible to maximise efficiency and thoroughness at the same time. Yet a certain minimum level of both is mandatory, if work is to be accomplished successfully and safely. From this fact emanates the humbling realisation that safety has to be achieved in everyday situations where individuals may be tempted to forgo thoroughness despite existing rules and Standard Operating Procedures (SOP), in order to meet the demands of efficiency and other conflicting goals. What it means is that safety has to be achieved in actual work conditions and not in a utopian work environment, where mere formulation of rules and SOPs would have guaranteed safety. It does not certainly mean that SOPs and rules are not to be insisted upon or not enforced; it means that formulating only SOPs will never be enough.

While officers and sailors may instinctively know how to handle the work at hand, they may often lack a theoretical foundation of leadership principles for safety, to be applied for balancing the conflicting demands of daily work, of which safety is a critical and omnipresent requirement. For this, the understanding of ships as Complex Adaptive Systems (CAS) and the concept of efficiency versus thoroughness are important. The view of an organisation as a CAS is fundamentally different from the traditional view of organisations as rational, hierarchical structures. In hierarchical organisations such as the Armed Forces, the structure, rules and authority create stability, and any major adaptation is directed from the top of the organisation. In contrast, complex adaptive organisations, despite their formal structure, tend to self-organise in response to local conditions without any specific top-down directives. Therefore, if the navy is actually an organisation where top-down control has only limited application in ensuring safety, then there will surely be situations where tenets of military leadership, based on ‘command and control’ functions, are not able to completely meet the needs of safety leadership. This paper accordingly, endeavours to:

Navy as a Complex Adaptive System ⁴

Complex systems contain technical components, human elements and vast social networks. A ship or an airbase or the navy as a whole, is a typical example of a complex ‘socio-technical’ system consisting of several technical elements such as machinery, weapon systems and aircraft, as also many forms of social components, like management and planning teams at various headquarters and dockyards, crews on ships and elsewhere. Systems typically become complex by default when people are added to them.⁵ Complex organisations such as the navy have rich interaction at the ground level manpower, as also officers up the hierarchical chain, who have to respond to situations with the limited information each of them is presented with. Each one therefore, functions with an incomplete picture and under varying degrees of uncertainty. In complex systems, unwanted outcomes do not occur solely due to individual component failure, but most often from the unpredictable interactions between the components. For example, the way a sailor interacts with policies, procedures, goals, organisational culture, officers, other departmental sailors, environment, etc., influences his way of working. This means that when we are looking for strategies to solve human-centred safety problems, we need to apply complex systems thinking. We need to consider that complex organisations continuously ‘self-organise’ and adapt to local and unforeseeable conditions, as an inherent property.⁶ For example, on a frontline warship, as a consequence of the interactions of individuals, departments, external stakeholders and the work environment (which includes stresses and pressures of various kinds), new ship-level properties emerge. A safety culture, or a lack of it, is such an emergent property. Such properties are called emergent because they cannot be enforced solely by direct top-down orders.⁷ They emerge from within and are a result of inherently complex interactions of the components of the system. This is true not only for ‘safety culture’ but also for ‘team-spirit’ or the unquantifiable, but still discernible attribute of a ‘taut ship.’

Such emergent properties of complex systems cannot be traced back to individual components of systems. For example, it won’t serve any purpose to look for a specific sailor or an officer in his individual capacity and hold him blameworthy for a lax safety culture on the ship. Based upon our analytical thinking, hitherto we have tended to view our ships’ crews, who are frequently perceived to be taking short cuts and unnecessary risks, not wearing their gloves, rushing through their daily tasks etc., as the problem to be addressed. We attempted to solve our people’s behaviour! Rather than valuing the competence and common sense of the crew, we have tended to value compliance and control more insofar as safety is concerned.⁸ The fact is, unlike in machinery, you can’t just replace a sailor or an officer whenever anything goes wrong. You have to work with them and through them.

Safety Challenges in the Navy due to Complexity

As brought out, even a fairly ergonomically designed foxle of a ship, with all its fittings load tested and all SOPs and check lists in place, may still be an unsafe work space due to the complex human interaction between the foxle and bridge teams. Interactions between the components of a complex system may sometimes lead to certain other undesirable phenomena as well. Prominent amongst these phenomena are normalisation of deviance, organisational drift and systemic accidents.

Systemic Accidents. If left unchecked, normalisation of deviation and organisational drift, ultimately leads a unit towards an unsafe state from which even a small deviation can cascade into catastrophes, much like the proverbial last straw.¹¹ Often, the foundation for an accident is laid years before, as the organisation loses a sense of where its operating points are and how close is the accident boundary. The gap can close very suddenly. A single event may close the gap , but if one particular event does not occur, another one will. Therefore, only finding fault with those closest in time and space to the accident (which would normally be the ship’s crew), would not necessarily address the entire problem. Could the Betwa incident (in which this frigate toppled sideways in a drydock) be such a systemic accident?¹² Would the collapse of the under-construction dry dock in Naval Dockyard (Mumbai) be within this category?¹³ Or the sinking of the FDN (the IN’s floating dry dock) at Port Blair?¹⁴

Leadership for Safety in the Surface Navy

Although safety might be a stated priority, organisations do not exist merely to be safe. They exist to provide a service or an output, and to maximise that output. The navy exists to provide national defence and maritime security, not merely to stay safe itself. Yet we still have to be safety conscious to be able to provide national defence. We must recognise the fact that safety is not the default state of any organisation or ship. Safety has to be created by people in a thicket of multiple goals, divergent demands and complexity. Since safety needs efforts from everyone, and such efforts often must overcome competing demands on limited resources, it requires resolute leadership to make it happen.

Challenges for Leaders in Promoting Safety

Each Man Matters. The military leader’s position is difficult. He needs to respond to adversity, work in extreme environments, survive unforeseen challenges, be flexible in planning, and gain and retain the loyalty of those under his command. Further, while each individual of his team cannot ensure the complete success of the ship’s tasking, every unit member’s job includes some parts, which if executed improperly, could lead to catastrophic accidents. It gives a whole new perspective to the truism ‘each man matters.’

Sailors are Humans and Humans are Complex. Human behaviour is affected by many considerations including an individual’s intelligence, social and economic status, values, personality, and so on. Nevertheless, the primary mode to control or induce change in behaviour in any living being is the simple ‘rewards and punishments’ stimulus. In addition, regimentation, training, uniformity, strict discipline and rigid order, which are the hallmark of any world class military, and certainly of the Indian Navy, influence compliance among men. Yet, despite these, when it comes to safety, personnel continue to make decisions that lie outside the expectations of their superiors. Therefore, other organisational factors do influence behaviour besides just strict discipline, the lure of rewards or the fear of reprisal. Leadership for safety, therefore, is not simple and certainly cannot be merely transactional.

Resilience Paradox.¹⁵ Men and organisations who can perform with the best levels of resilience are those that are exposed to significant risks frequently and have therefore acquired the know-how to survive challenging conditions. Some of the most resilient units are also the ones where the greatest risks are taken (aircraft carriers, special forces, submarines, etc). Among other things, a conscious acceptance of the need to face reasonable risks and not opt to find a safe zone, would contribute to actually making the ship resilient. The Captain of a ship needs to manage this paradox. Therefore, the practice of operational risk management as being promoted by the Navy is critical in safety leadership.

Management of Higher Goals at the Lowest Field Levels. While the higher rungs of the naval organisation prescribe the goals and objectives, there are conflicts in the actual managing of these goals. These could happen in functional locations such as ships’ operations room, bridges, machinery rooms, etc. Here, goal conflicts are negotiated and resolved in the form of thousands of small and big daily decisions and trade offs, and not quite considering ideals and values of the larger organisation. Whether to increase speed in a high traffic density zone so as to make it on time for entry into the harbour, is the kind of a goal conflict faced frequently on ships, which impacts safety pointedly. These then are no longer decisions and trade offs made by the Navy as an organisation, but by individual operators or crews. This basically means that top driven orders to ensure safety and directives to regulate micro behaviour of the on-ground workers will have limited impact unless the crew members are adequately trained and empowered to take and manage risk.

Promote Safety as a Shared Guiding Principle. For loosening the reins of control, an essential prerequisite is a shared guiding principle according to which situational decisions are made by the front-line crew. For e.g. militaries are built on task orientation and an unwavering focus on offensive action, as their core guiding principles. Similarly, safety too must be one of those guiding principles. Promoting safety as a guiding principle requires that leaders constantly keep safety on the agenda. Talking about specific safety issues before every evolution and making allowances in time, manpower and other resources to ensure safety, would be a start point. Such whole ship interactions could include making risk management an integral part of every planning process on board, remind colleagues of its importance, and most importantly, show in the leaders’ own behaviour and decisions that safety issues are borne in his/her mind. Leaders must have the courage to set and enforce tough and sometimes-unpopular decisions to allocate safety resources, such as the right people and adequate materiel as well as provide quality training.

Acknowledge Goal Conflicts. It is a fact that most of the navy’s work involves ‘efficiency’ versus ‘thoroughness’ trade offs. It is a given that thoroughness requires time and effort. If an entire system is optimised to be efficient, which the navy is, it is difficult to turn around after an occasional failure and all of a sudden demand that the crew should have been thorough all along. This often is the outcome of many accident investigations, where, even though rules were not followed, the crew was judged to be well meaning and sincere in the work being done. Such situations leave the organisation often at loss of correctives to be implemented.

The inverse relationship between ‘efficiency’ and ‘thoroughness’ need not be at the cost of overall safety. First up, we need to acknowledge such goal conflicts exist in daily work and help people manage them better, not by implementing a new rule, but by helping people consider the trade off between thoroughness and efficiency, and giving them the courage to decide against common interpretations of what is and isn’t acceptable. The navy’s recent handling of the series of inadvertent operations of a fire fighting system is a case in point, where the check valves of the older fire fighting system were being kept closed by ships because of the frequent operation of the sprinkling in the magazines, which would often lead to damage to ammunition and to the pride of the ships and their Commanding Officers. When the newer generation fire fighting system too started to show similar signs of unexplained malfunctions and the ships seemed to be slipping into the expedient option of keeping the check valves closed rather than risk the ammunition getting wet, this dilemma was addressed in an open and transparent manner. The material shortcomings of the system are being progressively addressed both by procuring adequate quality spares and timely tests and repairs. Measures are being put in place to address training gaps. The issue is also being openly discussed in Fleets, Work Ups and CO/EXO Pre-Commission Training (PCT), so as to give the ships’ crews and the Commanding Officer the support that is needed for them to make the correct decision.

Optimise Local Efficiency. Even in the navy, each and every thing cannot be, and shouldn’t be, controlled by centralised orders from Commands and Fleet Headquarters. A certain latitude and local efficiency is essential for the survival of any organisation. The crew needs to take situational requirements into account and make judgments concerning how much effort, how much time and quantity of resources are allocated to different issues, including safety. Looked at this way, it intrinsically connects safety management to the general management of the ship. Safety cannot be treated in isolation of the core organisational processes. While activities need to be carried out safely, they too need to be done efficiently, and the safety tools and methods that the sailors use should not slow down work more than necessary. Safety is not an end in itself.

Facilitate Interaction and Build Connections. Connections and interaction are needed in order to guarantee organisational cohesiveness and for the system to act in a structured manner and yet be flexible enough to self-organise when it is needed.¹⁷ This goes beyond formal organisational structures. An environment that supports interaction is one in which people trust each other, know and respect each other’s competence and are willing to communicate and learn from each other. We in the navy understand this instinctively because we know that a happy ward room with good relations between officers of various departments, is a sine qua non of a taut ship. In practice, supporting interaction also means that the officers need to go onto the deck and work spaces, to talk and listen to sailors as they work, as well as with the senior sailors who are supervising. It can also mean discussing lessons from near-misses in other departments, or other ships, and likewise sharing ideas and information between different units/departments. What is more, it means networking both, inside one’s own organisation as well as outside, and with other important stakeholders, because it helps if these connections already exist before anything negative happens.

Nuanced, Calm and Focussed Leadership. Our work culture in the surface navy is all about “can do - come what may!” Without doubt, this is how it should be, because taut, operationally ready, available and deployed ships is what our Navy demands to meet the nation’s security needs. However, the spirit of “can do” must generally be considered with caveats. Each major accident chips away at operational readiness and availability of the ship and therefore seemingly defeats the Navy’s very purpose. Taking upon oneself unrelenting pressure to achieve more and specifically better than others, may have consequent costs being paid in terms of shortcuts in safety procedures, ultimately leading to non-availability of the ship for operations. Here the navy’s steeply pyramidal hierarchy and the resultant work-culture may, prima facie, be seen to be in conflict with the needs for a safe working culture. But it need not be so. As a start point, if officers as leaders, assign higher value to short-term results, the tendency to choose unsafe behaviour as a valid alternative is reinforced amongst the men on deck. Swayed by short sighted cost-benefit analysis, the crew might tend towards unsafe behaviour because the expected short-term utility outweighs the cost of slower pace, extra effort or personal discomfort. The Captain must keep a steady hand on the tiller and exhibit visible commitment to safety and ensure that his men and officers are committed to safety too. Leaders must have the integrity to hold themselves and their people accountable for violations of safety standards and to admit their own safety failures so that others too will do likewise. A safe ship is operationally available for all tasks that the navy may assign it. This is quite congruous with the requirements of career progression as well, if ever such a doubt existed.

Ask the Crew. Talk to the crew themselves when looking for measures for prevention and recurrence of a mishap. Ask them: what would help to get the right picture of the situation? Would any specific training, experience, knowledge, procedures or cooperation with others help? Could clearer guidance from above help make a better trade-off between conflicting goals?

Focus on the Blunt End. In risk-assessment, the focus is usually on the people at the sharp end, i.e. the people who are working at the time and in the place where the accident happens. People at the blunt end, meaning those who through their actions at an earlier time and in a different place, also affect the constraints and resources for the people at the sharp end. In our case it would be the support agencies such as Dockyards, Material Organisations, Headquarters, etc. We need to realise the fact that work at the blunt end often suffers from a lack of specific information, and the work environment is generic with meagre on-ground inputs. Like any other organisation, here too there are efficiency versus thoroughness trade offs. But these trade-offs have serious implications on safety because the appreciation of their effect on the downstream activities is distant and hazy. This is so especially when compared to the daily battles of labour problems, financial files, VIP visits and several other convoluted processes, which are far removed from actual needs of the end users. For the navy, focussing on the efficiency and thoroughness trade offs at the blunt end are as important as those at the sharp end and must be addressed in right earnest.

By contrasting safety leadership in a complex adaptive system with the hierarchical command and control set up of the navy, it is not intended to suggest that orders, SOPs and check lists be put to the wind. At the individual level, leaders will continue to insist scrupulous compliance of all check lists by their sailors and themselves as well. There is no better “aide-de-memoire” than written check lists when undertaking structured tasks. The traditional methods of ensuring safety, which include preventive actions, rewards and recognition, disciplinary action, training, inspections/ walk-arounds and scrupulous equipment maintenance must, no doubt, continue to be pursued. It is the leaders’ understanding of organisational safety, which requires a paradigm change because safety practices on ships today have come to be viewed by the crew as increasingly restrictive and aimed at restraining behaviour of the ground level workers. The officers’ understanding of safety concepts needs to transcend this skewed restrictive format of safety often applied onboard ships. People are not the problem to control, they are the solution. The key here is intervening in workplace conditions rather than worker behaviour.

But on the flip side one could certainly ask, what about people’s own responsibility? Instead of only looking for organisational reasons, should you not hold people accountable for the mistakes that they are involved in? The answer is, of course you need to consider the accountability of the crew. The point is that we have been taking this approach to safety for decades and yet accidents have not necessarily abated. It is the environment in which people work that plays a large role in producing the observed behaviour. What people do makes sense to them at the time, given the features of their work, their tools and tasks and surrounding situation. And, in all probability, it will make sense to others too in future if the underlying contributory factors are not addressed. Addressing those will reduce accidents.

Our current approach of incorporating strict rules and SOPs does indeed contribute to safety. However, its beneficial effects plateau after a certain stage. Beyond that plateau, stricter rules and SOPs only restrict efficient working of units. Taking safety beyond this plateau requires education of both on-ground workers and the decision-makers, on the frequent trade-offs between safety and efficiency that are needed to be made on a daily basis. Safety as a subject must be covered from the ab-initio stage and continue into the very senior levels. This education would provide us sound basis for making the correct risk decision and provide the understanding of what level of authority has the responsibility to make a risk decision. This will ensure that efficiency is prioritised at the cost of thoroughness only with the full knowledge and consent of the appropriate level of authority and not at a lower level, which is not accountable for what is at stake. The success or failure of frontline units continues to be attributed to the leaders who are expected to manage myriad environmental and organisational forces. Apprising leaders of correct aspects of safety in running frontline units is therefore critical if we are to earnestly pursue safety, without diluting combat effectiveness.

Endnotes

1. CNS Safety Message, 01002.

2. Eric Hollangel, The Etto Principle: Efficiency-Thoroughness Trade-Off: Why Things That Go Right Sometimes Go Wrong (Florida: CRC Press, 2014), 40.

3. Stephanie Duchek, “Organizational Resilience: A Capability-Based Conceptualization,” Springer Link, 14 January 2019. https://link.springer.com/article/10.1007/s40685-019-0085-7, accessed 06 June 2020.

4. Teemu Reimana et al., “Principles of Adaptive Management in Complex Safety–Critical Organizations,” Safety Science vol. 71 (2015), 80–92. https://isiarticles.com/bundles/Article/pre/pdf/50192.pdf, accessed 12 February 2020.

5. Amit Gupta and S. Anish, “Insights from Complexity Theory: Understanding Organizations Better,” https://tejas.iimb.ac.in/articles/12.php, accessed 12 February 2020.

6. Adam Johns, “Complicated & Complex Systems in Safety Management,” Safety differently, 21 August 2019. https://safetydifferently.com/complicated-complex-systems-in-safety-management/, accessed 12 February 2020.

7. Ibid.

8. Reimana et al., Op Cit., n.4.

9. This is an observation of this writer from witnessing 32 Work Up activities as a part of the Indian Naval Work Up Team, over two years. Most COs and EXOs expressed concern at the safety ethics of the crew and looked towards the Work Up teams to assist in changing crew behaviour.

10. D Vaughan, The Challenger Launch Decision (Chicago: University of Chicago, 1996), 250.

11. J Rasmussen, “The Role of Error in Organizing Behaviour,” Ergonomics vol. 33, no. 10 - 1 (1990), 1185-1190.

12. Randal Ford, “Complex Adaptive Leadership and Open-Processional Change Processes,” Leadership & Organization Development Journal vol. 31, no. 5 (2010, June), 420-435.

13. Ibid.

14. Teemu Reiman et al., “Principles of Adaptive Management in Complex Safety-Critical Organizations,” Safety Science vol. 71 (2015, January) 80-92. https://doi.org/10.1016/j.ssci.2014.07.021, accessed 10 June 2020.

15. Ibid.

16. Daniel Crosby, The Laws of Wealth: Psychology and the Secret to Investing Success (Great Britain: Harriman House Limited, 2016).

17. Toft, Dell et al., Models of Causation Safety: The Core Body of Knowledge for Generalist OHS Professionals (Australia: Safety Institute of Australia, 2012).

18. Atul Gawande, Check List Manifesto: How to Get Things Right (New York: Picador, 2014).

19. This is a persistent and passionate feedback from all crews Worked Up during the two years this writer was a part of the Indian Naval Work Up Team. As the Captain Work Up (Safety, Seamanship and Design), there was ample close interaction with the crew, officers and the Captains, allowing the forming of this conclusion.