My team and I were recently doing one of our “Rapid Operational Assessments” where we go into an operation and for 72 hours we observe, poke around, ask questions, and evaluate the operations against the principles of a High Reliability Organization. 72 hours is not a lot of time, but our consultants have decades of operational and leadership experience so we can get a good read on the situation pretty quickly.
We have a well defined methodology for this assessment developed with attributes for what “good looks like” and although the team does not always agree 100% on every specific issue, we are usually within a pretty tight tolerance band of agreement on the “good to bad scale.”
In the Nuclear Navy, I was twice on a team called the Nuclear Propulsion Examining Board where we would do a similar operational audit on nuclear aircraft carriers and submarines. Generally speaking the US Nuclear Navy operates with excellence, but occasionally there would be a situation that required immediate leadership attention. At the end of the audit, the ship’s captain would get a briefing of what went well and what didn’t. Standard audit stuff. And I had 100% confidence, the commanding officer was going to brief his boss very quickly. Bad news travels fast in the Nuclear Navy. You don’t want to be the “senior person with a problem.”
One of the things we looked at on navy nuclear ships was instrument alignment data. Not to get too technical, but basically you want to know that the instrument your operators are monitoring is accurate. It’s sort of like going past one of those roadside radar speed indicators the police put out to get you to check your speed. When you see the radar gun display a flashing “72” and you are in a 55 mph zone, what do you do? You look down at your speedometer and do a quick “alignment check” of your speedometer. If your car’s speedometer reads “59”, well, now you have a couple of problems. Maybe your first reaction is to pump the brakes. Good. But, do you ever ask yourself what is the real speed? Could the radar gun be wrong? Or is it your speedometer? How do you know?
The only way to know for sure is to conduct a “Prime Standard Alignment”. A prime standard alignment is simply an alignment done with a standard that is “universally” accepted as accurate. We could really go down a deep rabbit hole talking about Newtonian physics and quantum mechanics, etc. etc. But, we won’t. Let’s just say you have to use a prime standard if you want to be sure your instrument is calibrated to a known standard.
So back to our visit with a client at their operational site. We conducted an organizational alignment check of sorts. We measured their leadership, culture, management system and feedback loops (our HRO Model elements) against our HRO standards based on decades of operational excellence in the Nuclear Navy. What did we find? Well, I will just say we found some gaps. Some pretty decent sized gaps.
So after we briefed the VP and Plant Manager on what we found and got on a plane and flew home, I expected a couple of phone calls. I expected the VP’s boss and then maybe even the COO or CEO to call. I expected an “immediate action plan” to take steps to close some of the gaps we pointed out. I expected perhaps a “can you come back and help” request because we need to get our arms around this…
But, nothing. The weekend came and went. Nothing. It took a few weeks of prodding, talking with the SVP, COO, and CEO to find out they had not been told anything about our visit by their “chain of command.” Wow. MY calibration was off. I was expecting the results of our visit to travel rapidly up the chain of command. It did not.
Then I started thinking maybe this operational unit leadership did not see the findings of our observation as nearly a big of an issue as we did. Maybe their instrument was reading “Average” when ours was reading “Below Average”. We have since visited other sites for this client and the reaction was much different. Information flowed quickly up the chain of command. The leadership took swift action to formulate a plan to correct the most critical issues. It makes you wonder “Is there a common leadership standard across this organization?”
I guess the lesson learned is that if you are a leader of an organization, you must make the “Prime Standards” clear and you should periodically measure your team against those Prime Standards. This is especially true for leaders of large organizations as we have observed that standards can drift over time (normalization of deviance) and unless you re-calibrate your leadership teams, they may think they are doing 55 mph but they are actually at 72 mph and about to have a wreck. Time to pump the brakes.
Bob Koonce
Founder, High Reliability Group LLC
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