Humans ≥ Failure

Third in my favorite videos from YouTuber Drachinfinel is “Failure is Like Onions” – the infamous (usually to naval historians) layers of problems which plagued the Mark 14 torpedo during the Second World War. In the case of these torpedoes, the first layer – depth issues, masked problematic magnetic detonator reliability, which sufficiently hid the inconsistent contact exploder. The biggest obstacle in discovering a problem is often understanding what that there is a problem, and when egos and professional influence are involved. As was the case with the US Navy’s Bureau of Ordnance (BuOrd) and Ralph Christie during the Second World War, it is often suggested that the biggest problem about history is that we never seem to learn from it.

Recently, the story of questionable standards of metallurgic inspection for steel used in submarine construction surfaced (pun deliberately and optimistically intended) and, that from 1985 to 22May2017, “Person 1 knowingly devised and executed a scheme with the intent to defraud the United States Navy, and to obtain money and property by means of materially false and fraudulent pretenses and representations.”

The information is available – as it always is – via source documents… and in getting pulled into this rabbit hole of information feels akin to summoning the spirit of former Congressman Andrew J. May and his questionable wartime profiteering irresponsible comments which may or may not have provided Japan vital pieces of the intelligence puzzle concerning the construction and capabilities of American submarines during the Second World War.

However, the issues with fraud, carelessness, and bureaucratic opportunism – while nothing new and nothing which shall be remedied any time soon – are not limited to the Navy. Between 7Jan2012 and 7Oct2014, testing data for 262 main rotor blades for the Army’s UH-60 Black Hawk fleet were altered and/or manipulated by two former supervisors at the Corpus Christi Army Depot (CCAD). This particular story simultaneously hits close to home (7 years ago to the date of this writing was my last flight as a crew chief) and really brings to mind the question of whether or not I really want to keep going along this path of disconcerting discoveries…

Issues of incompetence or negligence are definitely not limited to the Department of Defense. In the compilation/collection of similar stories for this post, I came across the Arkansas Department of Transportation’s “Hernando de Soto Bridge Emergency Repair and Inspection After Action Report,” dated 10Nov2021 – two days old as the time of writing.

The ARDOT report on the I-40 bridge spanning the Mississippi River adjacent to Memphis, TN yields interesting commentary on organizational obstacles to safe and effective operations and inspections:

The terminated inspector was directly responsible for inspecting that portion of the Bridge in 2016, 2017, 2019 and 2020.

Management’s failure to adequately act on reports by employees concerned with the terminated inspector’s job performance perpetuated a culture where team members did not feel they had the authority or support to question a lead inspector’s procedures or thoroughness.

The 1Nov2017 findings of the separate collisions of the USS Fitzgerald and USS John McCain also provide a glimpse into the accident chains which led to tragic losses of life which should have been preventable and, therefore, a non-issue… yet, here we are…

I could go on: the Challenger disaster of 28Jan1986… the Columbia disaster of 1Feb2003… and pretty much any highly visible failure of “high reliability organizations” (HROs)… but that has been done almost ad nauseum… and key to one simple but true maxim I mentioned earlier but am compelled to repeat/reemphasize it here:

The biggest problem about history is that we never seem to learn from it.

A reference used in the Wikipedia entry for HROs also resides in hardcopy on my continuously growing bookshelf: Managing the Unexpected: Assuring High Performance in an Age of Complexity by Karl Weick and Kathleen Sutcliffe. In this book, there are five “characteristics” of HROs which may define success or failure:

• Preoccupation with failure
• Reluctance to simplify interpretations
• Sensitivity to operations
• Commitment to resilience
• Deference to expertise

Interestingly enough, the recent emphasis on identity politics does not factor into these characteristics in any manner… but that is a controversial topic for a later post.

Throughout the last few days as I have mulled these cases over and wondered how best to capture my thoughts on the matters, one name kept coming back to mind:

Abraham Wald

To summarize his contributions to aircraft survivability: Wald understood that the issue with looking at how to increase the survivability of aircraft lie not in studying the aircraft which were damaged and managed to return to base during the Second World War, but to look for the damage in the wreckages of those which did not make it back.

…To not look at what has worked, but to look at what has failed and improve from those datum points.

In typing that, it seems so obvious of a statement, but in retrospect and in relation to the contemporary examples of fraud, two questions come to mind:

What else is in question?

What else should be in question?

We are far from perfect creatures, hence the theme of this post: greater than or equal to failure. There is always the capacity to be greater – to provide a service or contribution praiseworthy to our own legacy or to the credit of the organization or group to which we belong. In some cases, that implies an adherence to policy or procedures meticulously curated and implemented to ensure compliance and safety; in other cases, thinking outside of the cultural norms and established procedures is critical to the immediate situational needs or larger strategic context.

We seem to be losing something here, however. Perhaps it is the follow-on of accountability…or a fundamental erosion in the ethics of quality assurance? It might even be something as simple as a lack of ownership to a product, problem, or solution. I don’t know.

What I do know is how dangerous one small seed of doubt – whether it is from unmistakable fact/finding or the fabricated doubt which is increasingly associated with traditional and social media… that seed can grow into a malicious monster of an organism beyond the cultivation abilities of those who have sown it.

Skepticism can be both a curse and a blessing… What is important to remember and apply when it comes to what is being questioned and what should be questioned is the severity of what happens if specific and/or vital questions are not asked… or allowed to be asked – the essence of any risk mitigation process.

This brings me back to what I wrote about playground equipment a few months ago:

In the process of this shift, the generations of children were deprived of some of the best self-developmental tools: risk identification/management, accountability, and consequences.

We have to get better… in accountability, in personal/professional ethics, in our perceptions of quality and the relationship all of these have in the local realms as well as the global arena. After all…

For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the message was lost.
For want of a message the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.