Culture and high reliability organizations the case of the nuclear submarine

~ Joumal of M&JIIIFIIICIIt ,.... 1995, Vol21, No. 4, 639-656

Culture and High Reliability Organizations: The Case of the Nuclear Submarine

Paul E. Bierly III Monmouth University

J.-C. Spender Rutgers University

Perrow defined as 'high risk' those organizations that combine complexity and tight coupling with the potential for catastrophic failure. He concluded that accidents are 'normal' for such organizations because their managers face irreconcilable structural paradoxes. Centralization, the method of dealing with the tight coupling, must be combined with delegation, the method of dealing with the complexity. Weick, researching the complex and tightly coupled systems found in air trajfJC control and carrier flight-deck operations, saw these problems differently. He argued that strong organizational cultures provide a centralized and focused cognitive system within which delegated and loosely coupled systems can function effectively. High risk organizations thereby become transformed into high reliability organizations (HROs).

Drawing on their personal experiences, the paper's authorsfocus on one type of HRO, the nuclear submarine. We argue for a multi-leve/ model in which culture interacts with and supports formal structure and thereby produces high reliability. In effective organizations culture and formality co-exist. 'lhe nuclear submarine service is aúo the intersection of severa/ different cultures. Rickover created a new culture for the nuclear Navy which is clear/y a crucial source of reliability, but it is also in tension with the o/der naval and submarine traditions.

High Risk or High ReliabiUty?

Organization theorists have long recognized that in turbulent circumstances organizations need to be flexible (Burns & Stalker, 1961; Lawrence & Lorsch, 1967). Centralized mechanistic control systems, it seems, are not capable of responding sufficiently rapidly. Their bureaucracy inhibits learning and communication. Decentralization combined with a flexible or 'organic' structure is a more appropriate response. Organic organizations search for new answers by having everyone 'pitch in', relying on high leveis of individual and work-group commitment to the overarching goals rather than on

Dim:t aiJ c:onespondenc:e to: PauJ E. Bierly UI, Monmouth Unívcrsity, School of Busíness AdminístTation, West l..oag Branch, NJ 07764.

CopJript o 19'5 by JAIPrelalne. 1149-2163

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conformance to established bureaucratic procedures. Learning from both successes and failures is rapid. The organic, loosely coupled organization, flexible and responsive, dedicated to learning new solutions to new problems, has become the accepted wisdom (e.g., Drucker, 1992; Nonaka, 1991).

But such flexibility carries risks. Perrow broke new theoretical ground when he argued that an increasing number of technology-intensive and complex systems could not be entrusted to such loose or poorly defmed modes of governance (Perrow, 1984). The public and private risks of system failure, and of the catastrophe that failures might cause, are escalating beyond reason. The tight coupling of nuclear power plants, continuous process chemical plants and, most obvious of ali, space programs, calls for a different approach. Perrow, who worked on an analysis of the Three Mile Island accident, and many accidents between ships at sea, dubbed these 'high-risk systems' (p. 62). They have several defining characteristics: ( 1) the potential to create a catastrophe, loosely defmed as an event leading to loss of human or animallife, despoiling of the environment or some other situation that gives rise to the sense of 'dread' (p. 324); (2) complexity, defmed as having large numbers ofhighly interdependent subsystems with many possible combinations which are non-linear and poorly understood (p. 72); and (3) tightly coupled, meaning that perturbations are transmitted rapidly between subsystems with little attenuation (p. 89).

Perrow's general thesis is that our technological progress has outrun our administrative capabilities. We have a proliferation of high-risk systems, some of which need to be abandoned as too risky since their possible social costs far outweigh their likely benefits. Five widely publicized catastrophic system failures, Three Mile Island, Chernobyl, Bhopal, the Exxon V aldez and Challenger, added considerable support to bis thesis. Clearly Perrow was correct to point to the rising number of systems which should be classified as highrisk by bis criteria, though he offered few solutions beyond bis Luddite advice. There was, for instance, no guidance about how to restore the balance between technological and administrative progress.

Despite Perrow's warnings, it is equally clear that these high-risk systems seldom fail. They continue to operate without creating catastrophes. The space shuttle flew so reliably, that NASA sought to further optimize the design. Only then did disaster strike (Starbuck & Milliken, 1988). Roberts (1989, 1990, 1991), Rochlin (1989), Weick (1987, 1989) and others have written about air traffic control, electrical power distribution and naval carrier flight operations. Commercial aircraft near misses occur with some regularity, but collisions are becoming less frequent despite rapidly increasing air mileage. Power transformers do blow up, yet system wide failures and 'brown outs' are less frequent in spite of rising consumption. Despi te A T &T's periodic telecommunications problems, their world-wide systems operate with remarkable regularity. aass A accidents on carriers (those wbich cost over a million dollars or involve the loss oflife) bave declined from S 1 for every 100,000 flying hours in 1955 to 1.89 in 1989 (Roberts, 1991). Ali in ali, this evidence seems to contradict Perrow's forebodings and to suggest the presence of some powerful stabilizing structures overlooked in bis analysis.

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THE CASE OF THE NUCLEAR SUBMARINE 641

Failure

As part of bis theoretical framework for examining the mechanisms of high risk organizations, Perrow (1984, p. 70) proposed a hierarchy of failure. The scale is of steps from the smallest incident to the largest catastrophe. At the most elementallevel, within an isolated subsystem, a failure is merely an incident. As the effects of this failure propagate to other subsystems, an incident can develop into an accident involving damage. As the damage propagates it induces component failure. Finally as the component failures propagate they eventually cause system failure and, under some particular circumstances, catastrophe.

As an organization theorist in the structuralist tradition, Perrow argued that centralization is the only effective way of preventing failure in tightly coupled systems. They cannot be decentralized because the lower levei decision makers do not know enough about the inter-relationships between their actions and the consequent effects on other parts of the organization. However, the same conservative structurallogic led him to argue that decentralization is an effective way of preventing failure in complex systems. Here the problem is with the decision-making load. Centralizing ali the complexity would overwhelm the senior executives. The paradox, or rather the contradictions evident in Perrow's advice, occurred because he considered no other forros of organizational control. As a conservative theorist, he suggested only variations of the classic bureaucratic fonn of control.

Other theorists looked for other modes of govemance. Williamson distinguished bureaucracy from market based forros of control (Williamson, 1975). While Perrow focused on the formal structural relationships between roles, and on the way control follows the exercise of administrative authority, Williamson noted an alternative, that the actors' self-interest can be harnessed and channeled by an appropriate reward system. This provides a second mode of administrative control. Williamson further argued that though market based controls are normally best, they fail when the information people have about the consequences of entering into relationships is uncertain or 'impacted'. Thus Williamson described the employment contract as 'incomplete', with the employee committing to occupy a role without knowing precisely what he or she might have to do in the future. This deals with some of the uncertainty which Perrow regarded only as a source of risk.

Ouchi went on to suggest a third mode of administrative control (Ouchi, 1980). Under conditions of extreme uncertainty and complexity, the contractual relationships envisioned by Williamson are of little avail. Using the term 'clan', Ouchi argued that a third clan mode of control was predominantly social or cultural. Control is established over the organizational actors' system of beliefs and perceptions rather than over either their behavior or output. The notion of clan assumes individuais are acculturated into a system of controls and meanings. Ouchi argued that for this mode to persist, there nceds to be a relatively high levei of goal congruence among the individuais, a shared sense of duty to the collective purpose, and some shared general paradigm for making sense ofthe world (Ouchi, 1980, p. 471).

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In short, faced with the sort of high risk organizational problem which Perrow identifred, other theorists have identifred several ways in which managers might control individuais in order to reduce the probability of systemic failure. Perrow focused on the narrowly bureaucratic, and perceived a paradox between two classical structuralist responses to different aspects of the high-risk situation. Williamson focused on personal incentive systems and Ouchi extolled cultural controls.

There are at least two problems with a market or an individual incentive based approach. First, it becomes progressively more difficult to measure and evaluate individual performance as the organization becomes more complex. Second, but related, is that these incentives are not only directed towards task performance. They are also incentives to control opportunism and dysfunctionality as individuais, for instance, are tempted to 'free ride' on the work of their colleagues or take advantage of others' ignorance. These dysfunctionalities lead to subgoal displacement ofthe type noted by Roy (1952) and Selznick (1949). If the agency problems cannot be solved, so that personal incentives merely exacerbate opportunism, does this leave culture as the most appropriate mode of govemance for high-risk systems?

Culture

In recent years organizational culture has generated a huge literature. Schwartzman (1992, p. 33) provided a useful summary of three different approaches. One thread treats culture as an externai (national) variable, leading researchers to contrast organizational processes in different national contexts. This thread derives from the work of Tylor and the early anthropologists. A second thread treats culture as the non-formal aspects of organizational life. This goes back to the Hawthorne studies and the 'discovery' of the informal within the formal organization. The third thread comes from more recent anthropological developments and treats the organizational culture as evidence of the institutional system within which al1 the organization's processes, even the most formal, are embedded. In this approach culture is the underlying pattem of meaning articulated into both the formal and the informal aspects of the organization. This kind of culture is recreated and reconstituted by the organization's cultural activity.

By using the term clan, Ouchi clearly appealed to the third concept and suggested a levei of analysis above that of the formal, for the formal is subsidiary to the institutional. As Ouchi (1980) noted, it follows that the culture based approach required a different kind of understaDding by the people involved, both greater in quantity and qualitatively different from that required under the simpler bureaucratic or market modes of control (p. 471). W"llkins and Ouchi explored the conditions that encouraged the development of these higber levei cultural modcs of organizational oontrol (Wilkim &: Ouchi, 1983). They wcre: (I) long history and stable membcnhip; (2) absence of institutional altematives; (3) intcraction amona members. The result is control that is exerted at leveis above the immediate actions which are so preeisely controllccl under both the

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market and bureaucratic modes. In that sense, the cultural mode is inherently more flexible and, under circumstances that call for flexibility, more efficient. There is also some commonalty with Ashby's (1968) distinction between single and double-loop control.

Wilkins and Ouchi did not pay specific attention to the high-risk organizations on which Perrow focused. Weick (1987), on the other hand, did so and has argued that the cultural mode of control may be the crucial source of a.dministrative control in high risk organizations (Weick, 1987). He noted that high risk and high reliability organizations are not the same. Rather, high reliability organizations are those which choose to place reliability above profit, or indeed above any other organizational objective. His notion of failure was also different from Perrow's. While Perrow focused on failures in the technological and administrative system, tracing their propagation from incident to catastrophe, Weick focused on the people who attempt to operate within this system. He argued (1987, p. 112) that accidents occur because the human beings who manage and are integrated into these complex systems are insufficiently complex to sense and therefore anticipate the system's problems. On the other hand, the organization 's culture comprises a substantial body o f higher level collective knowledge ( or mind) which can support individuais when they are under pressure in high risk organizations. Similarly Wilkins and Ouchi (1983, p. 475) noted that the organization culture can provide decision makers with categories, routines and examples of good and poor solutions.

Orgaaizational Leaming

We see organizational culture as a body of shared knowledge built up through learning. Thus theories of culture are incomplete without a corresponding theory of collective learning. In most learning theories it is the individual that learns rather than the collective. Thus the corresponding learning theory needs to bridge between the individual and collective leveis. This bridge fails, as culture management fails, when communication is substituted for or confused with learning (Denison, 1990; Trice & Beyer, 1993). The collective learning which results in cultural change also presumes collective unlearning, that there is a cognitive and affective resistance to be overcome (Fiol & Lyles, 1985).

Most practicallearning is by trial and error, indeed this is the essence of empirical science. But bit and miss tria1s are clearly not feasible in high-risk organizations. Their complexity also makes it difficult to interpret results. Their tight coupling, and resulting tendency to propagate failures, makes even small failures potentially dangerous. Given the complexity of the system's internai relationships, and the resultant lack of understanding about how the various sub--systems actually inter-relate, especially under conditions of partia! failure, a purely 'scientifiC' approach to learning is clearly of limited value. Under more certain conditions, a system can be disaggregated into its parts and each part can be tested and understood separately. Then we can aggregate our knowledge about the parts to determine the behavior of the entire system. Perrow's central thesis is that we cannot do this for high-risk organizations.

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March, Sproull and Tamuz (1991) suggested an alternative to the scientific strategy for organizational learning. They argued that collectives which are internaliy di verse are able to apply that diversity to smali samples of criticai events and so experience them 'richly', probing their varied manifestations and interpretations more completely. Thus the paucity of datais balanced by the richness of the analysis. An additional result of this rich analysis of criticai events is that organizations often learn as much about themselves and their internai relationships as they learn about the criticai event itself. Thus a reconsideration of the Aloha Airlines incident, in which an airliner lost part of its outer skin yet landed safely, triggered a major change in the F AA 's approach to maintenance (March et al., 1991, p. 2). The Challenger inquiry changed NASA and the whole complex of subcontractors with which it did business (Starbuck & Milliken, 1988). Near-accidents can also set these learning processes in motion.

Weick made similar points, stressing the collective's variety and its ability to draw more data from events provided 'requisite variety' is maxim.ized. This occurs when each person behaves both as a valid dependable model for others, and as a dependable observer (1987, p. 117). Under such circumstances the individual is both an isolate and a member of the collective. The group process is the principal source of learning. "The ... group enacts equivocai raw talk, the talk is viewed retrospectively, sense is made of it, and then this sense is stored as knowledge in the retention process" (Weick, 1979, p. 134).

Weick also noted the development of a certain kind of trust within collectives, but one that was more precise than the commonplace or lay use of the term 'trust'. The isolate's cbronic suspicion that ali is not well is combined with an unquestioning respect for and trust in the other members of the collective. As the collective bonds form between such suspicious individuais, so a shared sense of social context and of the meanings to be attached to each individual's actions emerge. Thus the existence of a culture indicates shared knowledge about the collective and its context. But individuais are only aware of their culture when they maintain the isolated dissenter's criticai awareness. The dialectical tension between these positions is the dynamic behind the structuration o f human and organizational society as social systems express and are expressed in the routines of daily life (Giddens, 1984, p. 36).

The fundamental divergence between Perrow and W eick goes beyond the conventional notion of culture. lt revolves around the presence or absence of higher levei collective knowledge and its impact on the individuais operating the system. For Perrow ali knowledge was scientific, embodied in roles, rules and structural relationships. By definition, in high-risk situations the organization's scientific understanding is faulty, so centralization, wbich depends on total knowledge, conflicts with delegation, which is a way of dealing with faulty knowledge. Weick, and Wilkins and Ouchi, took a different view. For them, scientific knowledge coexists with higher levei collective or social knowledge. The modes of control interlace at different leveis. Centralization based at the collective levei ean coexist with deeentralization at the individual levei. This, Weick argued, is wby higiHisk organizations can be transformed into high reliability organizations. Despite bcing trained as a sociologist Perrow

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essentially ignored the people manning and completing the high-risk system, and the human tendencies which lead to socialization. Thus he also ignored their acculturation and the development of collective knowledge.

In the next section we apply the notions developed above, of different modes of control acting at different leveis and of different theories of leaming to the rather unusual context of the nuclear submarine.

The Submarine and lts Mission

We focus on life aboard a Los Angeles class attack submarine. This is a teardrop shaped vessel 33 feet across, 360 feet long and displacing just under 7000 tons. lt costs over a billion dollars and can travei at well over 30 knots when submerged under full power. Two thirds of the hull space is devoted to the nuclear plant which provides the power for the boat's propulsion, operation and survival. The attack submarine fights by despatching torpedoes (anti-ship), Harpoon (anti-ship) or cruise (anti-shore target) missiles (Sharpe, 1990). The ballistic missile submarine, of course, is a different class of ship and carries longdistance nuclear tipped rockets.

The front third of the submarine is where the 133 crew members tive and work. They occupy unbelievably cramped quarters. A sailor may, or may not, be able to call his bunk, one of three stacked one above the other in a 21 man berthing space, his own. He might have to 'hot bunk', for example, share it permanently with a sailor on another watch. The 2112 inch tray under this bunk is the sailor's only truly private space. The crew adjusts to an 18 hour workday, of which 6 are spent 'on watch', operating the submarine. The rest of the time is spent training, eating the generally excellent food, and some leisure activity. The boat may stay submerged many weeks, during which time the crew bond into a family, with all the closeness, respect, disrespect, and bickering typical of families ashore.

The organization of the submarine is strictly hierarchical with the Commanding Officer (CO) in absolute control. He is supported by 12 officers and 120 enlisted men. Aside from operating the ship continuously, life aboard centers around being extremely quiet. Since attack submarines have not yet engaged in 'for real' battle, they are used primarily to gather intelligence under 'near-real battle' conditions in which they share water with similar Russian nuclear submarines. They shadow each other closely and must avoid revealing their presence. Sound travels well under water, a loud sound can sometimes be heard several hundred miles away. Silence aboard is essential. At slow speed the entire submarine plant makes less noise than a small outboard engine (Dworetzky, 1987). The boat also guides itself by listening to other vessels and sources of noise. The person who drops a tool, slams a door or drops a toilet seat threatens the boat's entire mission.

The Subnuuiners' Cullure FU'St, a word on method. Ethnography or disciplined personal immersion

in the target culture is the primary method for doing research into culture and

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higher levei collective knowledge, even within modem organizations (EvansPritchard, 1951; Gregory, 1983; Rosen, 1991; Schwartzman, 1992). The researcher's first objective is to see the world from the point of view of the acculturated 'native' who is a member of the collective. This gives the researcher preliminary access to the organizational culture, as well as to the other modes of control and goings on within the situation. The second objective is to analyze the culture, to separate it from the context's other sources of meaning and action. The third objective is to report back the culture to an unsocialized audience. This requires the researcher to maintain a dissenting altemative position and fmd bridging concepts which are relevant both to the culture being researched and to the researcher's audience (Spender, 1989). Rosen argued that the goal of ethnography is to decode, translate and interpret the behaviors and attached meaning systems o f those occupying and creating the social system being studied (1991, p. 12). Having already entered the submarine culture through our own naval service, the authors were able to shortcut to the second objective.

The military culture reflects long tradition, the intensity of death and battle, and rigid bureaucratic mode of control (Morison, 1966). Yet its fighting units, operating many miles from the hubs of its bureaucratic power, have their own histories and develop their own localized subcultures. The submariners' culture naturally reflects the peculiarities of their mission and way of life. Their heroes tend to be cunning, vigilant and independent whereas Navy pilots' heroes are skillful fliers, brash and confident. Squadrons differ widely. The submariner's culture is markedly risk-averse. lt is also widely shared between different boats. This is partly the result of common training, partly due to constant movement of crew between boats.

Drawing on Van Gennep's classic analysis, Trice and Beyer (1993, p. 138) noted that there are three principal stages in the acculturation process: separation from the 'old' culture, transition as the new culture is leamed, and fmally incorporation into the new culture as a legitimate member. In Naval boot-camp one is stripped, literally, of one's old culture (Zurcher, 1967). The same applies to Officer Candidate School or the Naval Academy. The recruit is swom in, given an haircut and a uniform, told how to march and salute, and that he can forget bis past. Eventually through hard work and pressured interactions with bis peers, the recruit transitions to a new identity aligned with Navy values. The uniform, no longer an ill-fitting strait jacket, becomes a symbol of pride, commitment, achievement and loyalty. They are taught respect for their seniors. They approach the fmal transition of incorporation. Formal acceptance into the Naval culture, once the recruit qualifies in an entry levei position, is a moment of great significance, generally attended by intense partying and sore heads.

The military culture includes a sharp distinction between officers and 'enlisted' men. The officers are addressed differently, as Mr. Smith, Lieutcnant Smith or Sir. The officers do not share quarters with the rest of the crew. Junior offlCCrs denote their senior officers by position e.g. 'CO' (meaning Commanding OfflCCr) or 'NA V' (meaning Navigating Officer). This fonnality and separation is seldom relaxed. A well known exceptioo. is 'Crossing the Line' meaniDg the

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Equator, when the crew divides between 'shellbacks', those who have previously crossed the Line, and 'wogs', those who have not. During the ceremony the shellbacks 'haze' the wogs, regardless of rank. Sports competition may be another exception.

The military culture includes its own set of sanctions. Afloat the CO is absolute master of the ship, responsible for everything that happens or does not happen as it should. H e is also the local judiciary, acting within the US Military Code as prosecutor, jury and judge while dealing with minor crimes such as poor performance and petty theft. Major crimes are dealt with through court-martial ashore after confinement aboard (though there is no brig in a submarine). Aboard the accused is tried at 'Captain's Mast' where the CO determines and disposes. The punishment for those found guilty may be a fme, a loss of liberty privilege or even a reduction in rank, and the outcome is posted for all to see. The rites ofthe Captain's Mast also consolidate the CO's authority as well as the structure and continuity of the Naval culture. The rite of the guilty person's degradation also publicly acknowledges the existence of problems within the community. For instance a sailor's poor performance also signals the failure of bis immediate superiors (the sailor's leading petty officer and division offtcer) to manage the man in question.

The military culture entails its own language. Evered (1983) noted that the Naval recruit walks into a veritable blizzard of acronyms, new technical terms and administrative designations. Submariners have developed their own terminology. While this language is a highly communication efficient contextualized jargon, it also has symbolic and cultural dimensions which the recruit must master to become incorporated (DiTomaso, 1987). There is also an 'informal' language to be acquired and displayed. Trice and Beyer (1993, p. 148) noted that the obscenity of this informal talk may be more apparent than real. Similarly Zurcher(1965, 1967) argued that the terms become detached from their sexual origins, serving merely as the identifying argot of the group. Thus the conditions for the development of 'clan' control, which Wilkins and Ouchi (1983) identified, stable membership, absence of altematives and high interaction between individuais are met.

Submarine Leaming and Communi'cation

As we noted above, a theory of culture must embrace a theory of learning, and much of this learning takes place before the recruit boards the submarine. But learning is also an intensely serious activity for everyone aboard. At the technicallevel, crew members may spend up to 3 hours a day mastering both new activities within their immediate areas of expertise and others beyond their special duties. Cross-learning is vital for the operators of the submarine's tightly coupled complex systems. But as with all high-risk systems, there is little opportunity to 1earn by experimentation and induced failure. Submariners have to leam through: (1) extensive training; (2) frequent 'drills'; and (3) an efficient inter-boat network which leverages the learning from small samples of disasters, near-misses and mistakes of others. The networking and the diversity within the crew enables the 'rich' group-oriented learning process which Weick (1987)

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and March et al. (1991) noted. There is formalized networking between submarines. Crews are rotated frequently. Reports of accidents, equipment changes and other issues are circulated among the submarine fleet. Officers are required to read and sign that they have read these reports.

Much of training effort is towards establishing very specific communications behaviors. Two watchstanders, such as the OOD (the Officer of the Deck) and the sonar technician, will question each other intently, as co-professionals, throughout their watch. This free flow of questions and information facilitates and sediments group responses to problems, especially in the development of the temporary 'epistemic networks' through which new problemistic teams form to deal with speciftc situations (Rochlin, 1989). The communications are formalized so that they are precise, unambiguous, impersonal and efficient. Individuais are denied their own idiosyncratic communication style.

In peacetime the military, and submarines are no exception, spend most of their time running drills and taking part in exercises. Those involved take great pains to make these realistic, as in the recent accident in which a US surface ship targeted, frred and struck a Turkish destroyer with a ship-to-ship missile. For instance, in a frre exercise aboard the submarine, the participants may be required to wear blackened masks to impair their vision. People get hurt, and occasionally killed, during exercises. The exercises are also designed to explore the complexity of the interactions between the submarine's various systems, what happens to other systems when one goes down, bursts into flame, releases its contents and so forth. These exercises attempt to familiarize the crew with every possibility, to reduce the disorientation produced by surprises. They also remind the crew that there is an infinite amount to be learned about so complex asystem.

The communications behaviors this training produces are absolutely central to keeping the submarine operating, especially when things start to go wrong. Many of the systems aboard are controlled by mechanical valves which allow or prevent the flow of water, steam or other substances. During a maneuver, when a valve needs to be operated, the procedure is highly formalized: (1) the EOOW (Engineering Officer of the Watch) gives the order to open o r shut the valve; (2) the operator responsible repeats the order verbatim to teU the EOOW what he heard; (3) the operator turns the valve while being monitored by a senior petty offtcer; (4) the operator reports his action to the EOOW; and (5) the EOOW acknowledgcs the action and updates the valve position on his status board. This cautious and apparently redundant formality reinforccs the authority relations between the EOOW and the operator. But it is also helps to establish crisis-resistant patterns of communication and behavior. Under stress step 2 may be omitted but the interchange remains witbin the same action-oricnted framework which earlier training has created. The mutual questioning mentioned earlier, as watchstanders educate eadl other in training mode, is displaced by the military's strict operational system of giving orders and acc:epting them without hesitation or question.

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The Genesis of the Nuclear Submarine Culture The culture aboard a Naval vessel is always the outcome of an ongoing

tension between the strict centralized hierarchy of the Naval chain of command and the relative independence of the individual vessel at sea. In the days of sail this independence was almost complete, with ships cruising independently under general orders which were open to considerable interpretation by their Captains. In the eighteenth and nineteenth century, it became more common to have fleets o f several, even dozens, of heavily armed warships moving around together and engaging in staged inter-fleet battles (such as the battle of Jutland in World War I, or Midway in World War 11-though at Midway the US and Japanese fleets actually engaged with their aircraft rather than with their guns ). This required the navies to learn how to form battle groups. But these could not be formed or commanded without sophisticated signaling techniques, such as naval flag signaling and semaphore. These were eventually partially displaced by radio. These signaling techniques also reduced the individual ships' independence. Fleet maneuvers involved closely coupled choreographing of the movements of many ships. As Perrow would have predicted, occasionally ships would miss their cue to turn and trigger a collective marine traffic pileup, sometimes with tragic consequences. The navy captains resisted these constraints on their independence ( captured in the tale o f the British Admirai Horatio Nelson putting bis blinded eye to bis telescope to avoid obeying a flag signal from his admirai). Similarly the appearance of naval radio communication was fiercely resisted for many decades (Douglas, 1985). By the nature of their mission submariners tend to independence and since the inception of the service before World W ar I they have always ~n something of a 'private' or maverick Navy. The general absence of radio communications while submerged further diminishes the extent to which the submarine can be directly controlled by a shore or fleet based command structure.

The circumstances surrounding the development of the US Navy's fleet of nuclear submarines gave these tensions a new flavor. The US nuclear navy cannot be understood without reference to Admirai Hyman G. Rickover, its creator. The development program began with the construction, in 1950, of two land-based full power working 'mock-ups' of this entirely new kind of vessel. It progressed to the building and launch, in 1955, of the USS Nautilus (SSN-571), the world's fiTSt nuclear powered submarine, and the USS Seawolf(SSN-575}, which employed a different reactor tecbnology which was subsequently abandoned. lt then flowered into a massive defense construction program which oontrolled the building and manning of several hundred submarines and a dozen surface ships including the carriers Kennedy, Nimitz and Enterprise. This program is jointly controlled by Naval Reactors (NR}, a division of the Atomic Energy Commission (AEq and Nuclear Propulsion Code 390, later Code 1500 (NPD), a department of the US Navy Bureau of Ships (BuShips).

This program., which in many ways created an entirely new naval service, was created by Rickover, who succeeded in getting himself appointed the joint head of both NR and NPD, thereby creating a single NR/NPD office with

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Czar-like authority over the development of the naval nuclear fleet. lt gave him direct control over the design, construction and, most important, the manning of these vessels.

Rickover was a figure of mythic proportions, a genius o r demi-god to some, an enigma o r egomaniac to others. As one of five young naval engineers involved with the Manhattan atom bomb project, he was the frrst to foresee clearly the potential of nuclear powered warships. He also foresaw with uncanny precision the changes he would have to force the Navy to make to tum tbis hightechnology concept into a weapon which would forever change the realpolitik of nuclear deterrence. He skillfully gathered the political power necessary to create and rule bis joint offlce untill982, thereby serving the Navy for 63 years, the longest period on record. Due to retire initially in 1964. each President (including Carter, who was a graduate of the nuclear submarine service) extended bis service until Reagan, pressured by Navy Secretary Lehman, forced him to retire at the age of 81. Lehman (1989, p. 62) noted that he found it surprisingly difflcult to remove Rickover, even at tbis great age, because of bis 'certain mystical and untouchable aura'.

Rickover's determination, clarity of vision and great political skills with Congress resulted inrepeated fundingforNR/NPD, often over-rulingthe Navy itself (Lewis, 1980). NR/NPD's facilities are superb, its ofticers among the highest paid govemment employees. Rickover also controlled every detail personally. Obsessively, he sought quality in everything, especially in the men of the service. H e interviewed each_personally, and interviews with tbis irascible and powerful man formed the basis for some of the best known stories that perpetuated the service's culture. They conveyed Rickover's fundamental principies: commitment, trust, communication and performance under pressure. The interview was, of course, a striking rite de passage into the elite of the nuclear submarine service.

The interview was also a model for the kind of naval service Rickover had in mind, unpredictable, demanding and also enlightening. He wanted to be certain that every one of 'bis' ofticers was truly committed to 'bis' service, and under pressure could stand up for what he believed. For instance Rickover would tell the applicant that the job was too demanding for married men (bome out by the high divorce rate). An applicant engaged to be married would be forced to choose between bis marriage and the service. lf the young offlcer said he would abandon bis fiancée, Rickover would become enraged and accuse him of having no values (and probably reject bis application). 1f the ofTJ.Cer stood by bis fiancée, Rickover would drive home the extent of the samurai-like commitment nec:essary to the submariner's difflcult and unnatural way of life.

Occasionally Rickover would play practical jokes on applicants, locking them in a closet for an hour or so to see how they responded. These methods were widely criticized, but even these criticisms servecl to reinforce the uniqueness of the service. To be admitted to the nuke community was a source of great pride. Rickover himself was a maverick, both in the power and extent of bis vision, amei also in minor matters. While utterly committed to serve the Navy and the nation, he was no ~apccter of ~ tradition. He seldom wore

JOURNAL OF MANAGEMENT, VOL. 21, NO. 4, IWS

THE CASE OF THE NUCLEAR SUBMARINE 6Sl

bis uniform, he openly challenged superiors (Duffy, 1986). He signaled to bis officers that it is OK to stand up and say what you believe rather than blindly follow orders.

Thus Rickover was a profoundly visionary figure, intense, brilliant, doggedly persistent, devious, highly political and obsessive, and an extremely charismatic figure for a certain group of people. He also believed in continuity and resisted the N avy's normal rotation processes. When he fmally left NR, the hundred most senior people had been with the department for an average of fúteen years, and the twenty division heads averaged twenty years (Duncan, 1990, p. 284). Rickover's charisma had also been wholly institutionalized into the NR culture, to an extent far greater than he could have anticipated (p. 292).

The implications of the Rickover culture were far reaching. lt forced responsibility down to the operator level. Every reactor operator needed to be aware of what was going on and to make himself responsible for understanding the implications and possible consequences of any action. This intense local awareness by thoroughly trained professionals compensated for ignorance or error at higher leveis in the system. lt prevented mistakes, some of which might have had catastrophic consequences in such a high-risk closely coupled system. If crewmen blindly followed orders, unaware and uncaring of the consequences, disaster might well have resulted. At the time of the Three Mile Island accident in 1979, Rickover was in charge of some 152 reactors which had been operating over a period of almost thirty years. Yet no single accident leading to radioactive emission had occurred. In the TMI inquiry Rickover insisted that this extraordinary reliability was not due to the military context and personnel, rather that it was due to careful selection of highly intelligent and motivated people who were thoroughly trained and then held personally accountable. Rickover's passion for quality also made him a difficult customer for the defense contractors. H e was the ftrst to accuse them of the systematic frauds which were revealed many years later. The submarine and power system constructors may have added to the pressure on Reagan to get Rickover out of the system.

Rickover's (1979) insistence on each individual's ownership of the task, responsibility, attention to detail, high professionalism, moral integrity, and mutual respect created the cultural context necessary for high quality communications under high risk and high stress conditions. Communication and recommendations can flow upward from the crewmen to the officers as well as downward. Likewise communication about all kinds of mistakes, operational, technical or administrative, can flow rapidly through the system. Anyone making a mistake can feel free to report it immediately so that the watch officers can really understand what is happening to the system. Rickover believed that the real danger lay in concealing mistakes, for when this happens those in charge become disconnected and disoriented. This could be disastrous in the high-risk circumstances of a nuclear warship.

Thus the NR culture supports the formal structure of command aboard the submarine and provides a framework within which individuais at alllevels can monitor, advise, criticize and support each other under circumstances of high stress, when mistakes are made or when surprises, failures, or malfunctions


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occur. The culture is also the flexible organic entity which gives individual operators access to the vast body of higher-level knowledge and accumulated experience that supports the formal roles and operating procedures applied.

The Other Dimension of the Rickover Culture In the section above we illustrate the pivotal role that the nuke culture

plays in the submarine's professional system, for it maximizes group performance and gives it the crisis-absorbing capabilities fundamental to highreliability operation. We can see how submariners are carefully selected and trained to use the culture as a coping mechanism. This much is in line with Weick's (1987) analysis.

But the nuclear submarine turns out to be an even more complex system. It has dimensions which were overlooked in Weick's (1987, 1989) and Robert's (1989) analyses. Rickover built his operation with clear ideas about the Iimits to the use of culture as strategy for creating high reliability. Certain aspects are highly centralized. In the same way that radio communications altered the balance between ship and shore, so Rickover's control over the nuclear power plant and its operation altered the balance once again. Along with his radical approach to the selection and training of the NR's men, Rickover developed a radical approach to the control o f the power plant. Everything about the plant, its design, manufacture and operation is affected with his obsession with safety. The contractors who built the submarine were forced to work to tolerances and quality standards previously unimaginable among submarine builders. Indeed Rickover fought to make his contractors realize the nuclear submarine was more like an underwater ftghter aircraft than a mere evolutionary development in submarine design. He forced contractors to approach their task with the same demanding zero-defect engineering standards that builders of supersonic fighters had used for years. Rickover called this the new 'discipline of the technology', a general enough idea but one that took on special meaning when dealing with nuclear fission and radiation (Duncan, 1990, p. 279).

On board, control is channeled through standard operating procedures (SOPs). The reactor operators are trained to know every procedure for every situation. lndeed everyone knows every casualty and recovery procedure by heart. One objective of using SOPs is to reduce surprise. But Rickover also built the SOPs into a massive bureaucratic system to protect the reactor against accident at every stage, from design, through construction, operation and maintenance to refueling and de-com.missioning. The shore-controlled application of SOPs during ship-board operations (going by the book) reverses some of the oldest concepts of the relationship between naval men and their ship, and reveals some of the subtle differences between submariners and those in other branch.es of the Navy. In the early days of swface warfare, naval captains often went down with their ships, the ukimate symbolic act to illustrate the captain's absolutc responsibility to keep the ship safe. Even today running aground is an almost certain way of terminating a captain's oaval career. Yet among submariDers the tradition was always th.e contrary, the ship would always be sacrifa:ed to save the crew.



But the Rickover culture implied, at the extreme, that the crew would be sacrificed to keep the reactor intact and prevent a nuclear accident. Hemond (1989, p. 45) has implied that the loss of USS Thresher may well have been such an example. With some, even sharply limited, propulsive power available a doomed submarine can often plane its way to the surface and give the crew a brief chance to escape. The Russian nuclear submarine lost off the coast of Norway, a widely reported incident which NATO aircraft photographed, managed to reach the surface long enough for about a third of its crew to escape. But Rickover's concem for the reactor, and maybe also for the disastrous consequences, ecological, political and for NR/ NPD, of an uncontrolled reactor accident, meant that the crew were trained to shut the propulsion system down and thereby deprive the submarine of its power. In tbis sense the reactor's real controllers remained ashore. Unlike the stories of engineering ingenuity and making-do which are the stuff of surface bome navallife (reflected in Scotty's resourcefulness in countless Star Trek episodes), Rickover's submariners were trained to suppress their imagination and creative talents.

Rickover also worked against innovation by the submarine's designers. Ali forros of automation were avoided unless absolutely necessary because of the hazardous working situation. Simplicity, which gave the well trained operator a chance to intervene, was bis declared design objective. The resulting systems combined reliability and extremely conservative engineering with unambiguous evidence of the operator's actions. Even the choice of reactor and transmission, a pressurized water reactor (PWR) with geared direct drive, is similarly conservative. Other systems, with different coolants and indirect drive, were developed at the same time as the Nautilus's PWR and offered substantially improved performance and design flexibility. The USS Seawolf, the second nuclear submarine, used a sodium cooled plant and operated effectively for two years. Y et Rickover standardized on the more conservative design and refused to consider improvements. As a result both the Los Angeles class boats and the forthcoming Seawolf class are technically obsolete (Hemond, 1989). But, given the consequences o f the incrementai engineering development in the space shuttle program, and the resulting Challenger disaster (Starbuck & Milliken, 1988), Rickover may have known precisely what he was doing. Properly designed, maintained and operated, the PWR is an inherently safe and ultrastable thermodynamic system, and is also powerful enough to do the job. Since we have not had to prove the nuclear submarine fleet in battle against the technically superior, though probably less well handled Soviet boats, the precise strategic consequences of this reliability f performance trade-off remain unknown.

This paradox within Rickover's culture, the insistence on commitment and personal responsibility coupled with the bureaucratically centralized control of the reactor, created a prodigious managerial problem. Rickover's solution showed bis genius for the subtleties of the interaction between the new technology, its operating requirements and the resistances he would face from the rest of the Navy. He solved the problem of interfacing between a bureaueratically controlled power plant and the naval tradition of independence


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by achieving control over the entire submarine crew. Using the discipline of the technology as the lever, he persuaded the head of Naval Personnel that he had to select and train the entire crew. Thus the CO, the EO and all the submarine's other officers entered the service as engineers. Every stage of their extensive training was controlled by NR. In this way Rickover devised and implemented a remarkably creative solution to the possibility of cultural conflict between the 'nukes' aft, who ran the reactor, with the 'sailors' forward, who ran and fought with the submarine. Ali were acculturated into the same system of values, attitudes and behaviors which they then carried, metaphorically, from the aft end to the overall control of the ship. In particular, Rickover was eventually able to bypass the naval recruitment procedures entirely and hire from outside. Ali inductees were then trained ashore for a year in an intensive program run by NR, before they ever saw a submarine. While bis solution was clearly effective, it won him an enormous number of enemies within the rest of the Navy and beyond in the country at large. Eventually Rickover was defeated and driven into retreat as these enemies crushed bis moves to expand the nuclear surface fleet (Lewis, 1980, p. 88). But the submarine fleet is still run Rickover's way today.

The overall outcome of Rickover's comprehensive vision, which included the development of world-class technology, a subtle combination ofhigh quality engineering and the strong operations culture to make this technology reliable, and the changes to the Navy which would translate this technology into an effective weapon, is clearly historie. The accident record is almost flawless and the development and deployment of the world's most powerful weapon was extremely rapid. Ultimately though, most of the submarine fleet 's officers leave early in their careers, seeking work where their individuality can be expressed. The reasons typically given for resignation are the long hours, the lack of creativity and individuality, and the peculiar stress of operating within a system of dual allegiances to NR and to their own naval careers (Chatham, 1978). As a consequence many of the NR trained operators go to nuclear plants ashore. Indeed Weick noted that one reason why nuclear power plants have the fmest reliability record among our prominent high risk systems may be that their operators are often NR graduates (1987, p. 124).

Condasioas

Without doubt, the nuclear submarine meets Perrow's criteria for a highrisk system. Y et the safety record is un.matched. despite the large number o f plants, the added exigencies of being mobile instead of fixed in one location, of operating secretly rather than publicly, in a hazardous environment and often engaged in highly demanding exercises with both friendly and hostile surface ships, submarines and aircraft. In this paper we argue that Rickover developed a culturally intensive system which coped with this amazing conjunction of threats. The system is both technical and human, multi-layered with tremendous richness anel depth. lt was inculcated by severe selection and continuous training. The submarine itself is merely the sharp visible tip of this system. While



it seems an independent entity, it is merely one of the points of interaction where the tecbnical, the bureaucratic and the cultural systems interact to produce high reliability.

The nuclear submarine illustrates how culture, as a higher levei system of knowledge and experience, can interact with and support a bureaucracy to transform a high risk system into a high reliability system. On board, high centralization over the operation of the reactor system is combined with a high degree of delegation. The delegation is controlled culturally by a powerful system of selection, training and mutual monitoring, criticism and advice. The result is a pattern of extremely efficient communications which gives the system the ability to absorb damage and surprises, and so detiver high reliability.

There remains the question of whether this kind of high reliability system can be implemented outside the military. As we have noted, Rickover argued that it could. But he may have been playing politics. lt is interesting that the systems researched by Weick, Rochlin, Roberts and others are either military, such as naval carriers, or have a distinctly service-like nature, such as the air traffic and electricity distribution controllers. Many organizations persuade their members to submit to a higher level body of knowledge and experience. We would suggest that where the members are not fully conscious of this, there is the possibility of cultism. The fundamental tenets of the culture need to be extremely attractive for this to happen when the members are fully aware of their commitments. This is easy to understand in religious organizations. lt is less easy to understand in a commercial organization. The military is somewhere in the middle ground. As Duncan (1990, p. 288) noted, what held ali the strands of NR/ NPD together was the patriotic belief that it was of vital importance to the nation. Thus Rickover drew on an even higher order culture, that of the nation itself.

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JOURNAL OF MANAGBMENT, VOL. 21, NO. 4, 1995

Culture and high reliability organizations the case of the nuclear submarine

Engineering

Transcript of Culture and high reliability organizations the case of the nuclear submarine