Last week marked the twelve year anniversary of the Texas City Refinery Disaster where 15 workers died. I study this tragedy because it is so rich with lessons. I would rather study positive success stories but I guess my natural inclination is to gravitate to these disasters to learn as much as I can from them and share what I learn in the work we do. Lately I have been reading and hearing a lot about Human Factors and Human Performance when discussing safety in high risk operations. It seems that companies who are on an “Operational Excellence Journey” believe that the Holy Grail will be found in “Human Performance”. So I started asking dumb questions like “What is Human Performance, anyway?” I am not sure there is an exact definition (this seems to be a common thing in Operational Excellence). But, one explanation I get is “Human Performance is an operating philosophy which acknowledges that people make mistakes.” I am not kidding. This is Human Performance in a nutshell.

Okay, so the US Navy locked me up for most of 20 years in a steel tube called a Nuclear Submarine so maybe I missed something, but why is this idea (which seems so obvious) going to be the next revolution in safety? I don’t know about you but I think I learned humans make mistakes (To err is human…) in like 3rd grade. And I know I really learned it during my first maintenance period on a submarine.

In 1994 I was on my first submarine, USS NARWHAL (SSN 671), which was an old, one of a kind, boat built in the height of the Cold War. See below a picture of USS NARWHAL submerged in the Cooper River during Hurricane Hugo that is signed by baseball legend Brooks Robinson – I am pretty sure this is one of a kind, but I digress…

So there we were, deployed to the Mediterranean Sea, and while there we got word that USS SAND LANCE (SSN 660) had almost sunk at the pier in Charleston, South Carolina. It’s a long story but essentially divers and sailors on the boat miscommunicated where to put a flange on the hull of the submarine. Consequently, sea water flooded into the ship when sailors inside the ship started to take the piping apart to do maintenance. As the seawater flooded in and the sub started to settle to the muddy bottom, one sailor dove down under the several feet of water now in the submarine to tighten the piping back up to stop the flooding. Fortunately, no one died but there was plenty of damage to motors and equipment as you can imagine.

A few days later we were in a Quality Assurance training session on my submarine discussing this event. Part of the fleet’s response was to have everyone do training on the lessons learned. Now, we didn’t have many details since we were at sea and away from Charleston. One of our very tired sailors who had been woken up for this training complained about how stupid these USS SAND LANCE sailors were to do this and because of their stupidity, we have to do extra training. Everyone started to nod their heads and join in. But, then a Master Chief Petty Officer with 25 years on the boats stood up and said, “Boys, those sailors are us. We are them. They ain’t no more stupid than we are. Somebody failed to “Sailor-proof” that maintenance.”

Later on I asked the Master Chief what he meant. He said “Ensign Koonce, we all make mistakes. Sailors are human. So, our job as leaders is to make sure that we don’t set these kids up for failure.” That kind of stuck with me over the years. Every operation and maintenance procedure I reviewed or gave approval for was always evaluated first and foremost on how “Sailor-proof” it was. And when things went wrong, we tried to evaluate the situation on how we could have made it more “Sailor-proof” and not just blame the sailor.

Now, before anyone gets their underwear in a bunch about this term “sailor-proof”, this applies to naval officers, too. If you want an example of how not to “Captain-proof” an operation, research the 2001 USS GREENEVILLE (SSN 772) collision with Ehime Maru where nine Japanese fishing students, crew, and teachers tragically died off Pearl Harbor, Hawaii. I was in Pearl Harbor at the time and knew the skipper of GREENEVILLE. He was an impressive guy. He was competent and experienced. If this could happen to him, it could happen to any of us. So throughout my time in Command of USS KEY WEST (SSN 722) I tried very hard not to create any situations that were not “Captain-proof”. I knew I was going to make mistakes. Always have, always will.

So what is my point with all this? Well, I guess I am saying that this Human Performance thing is really just the same thing I learned in 1994 as a young naval officer. Humans make mistakes and if you are a leader in a high risk, high hazard operation, you have to “Human-proof” your operations and maintenance. That’s easier said than done. I certainly know that. The hard part (which is not so hard if you take the time with the right people to do it) is to recognize where the human errors could happen (anywhere) and where in the process would they cause the most damage or risk of injury. That’s where you put in place “safeguards” or “barriers” to prevent or at least reduce the risk.

In our work on High Reliability Organizations, we believe the final and best “safeguard” is a culture where the work force has a Questioning Attitude and Team Backup mentality. Those are two critical elements of the Navy Nuclear culture as we describe in our book and our workshops.

So as you grasp for the Holy Grail of Human Performance, don’t be surprised when your work force reacts with a “Duh, no kidding?” response. Talking about Human Performance is easy. Living it and leading it day to day in a refinery, hospital, off-shore drilling platform, factory, or nuclear submarine is the hard part. That’s why it must be ingrained in your culture at all levels. The Quest for the Holy Grail is challenging, but it’s worth it to keep your operations running and your people safe.

Bob Koonce served for over 20 years in the U.S. Submarine Force and retired from active duty in 2011 after commanding USS KEY WEST (SSN 722), a nuclear submarine based in Pearl Harbor, Hawaii. Bob frequently speaks and writes on Operational Excellence and High Reliability Organizations based on the leadership and culture of the U.S. Nuclear Navy. He is co-author of Extreme Operational Excellence: Applying the US Nuclear Submarine Culture to Your Organization available now on Amazon. You can learn more by visiting

Join us in Houston on May 9th for a High Reliability Organization Workshop where we will “dive deep” into the concepts of High Reliability Organizations and the US Nuclear Navy Culture.