Why don’t they just follow the procedure?

Posted by  Mark Schenk —October 21, 2007
Filed in Anecdotes

On 29-30 August, a USAF B-52 bomber mistakenly armed with six nuclear tipped cruise missiles, flew from Minot, North Dakota to Barksdale Air Force Base in Louisiana. The incident has sparked enormous media attention and it is the first time the US military has publicly commented on the whereabouts of nuclear weapons.

The Air Force deputy chief of staff for operations announced the results of a six-week inquiry into the incident yesterday, the results of which pretty much conclude that the procedures were correct but the personnel simply didn’t follow them. The incident was evidently not a one-off: “there has been an erosion of adherence to weapons-handling standards.” The airmen replaced the schedule with their own “informal” system, he said, though he didn’t say why they did that nor how long they had been doing it their own way. Apparently, up to 70 people will be disciplined over the incident; a wing will be removed from wartime status and the base commander has been relieved of his command.

My 20 year career in the Australian Air Force, and consulting back to Defence since, makes me pretty familiar with the rigorous documentation of policy and procedure in the military…. and with the way these procedures are often used. I remember the mantra “policies are for the guidance of wise men and the blind obedience of fools” and how this was embedded into many of the stories told in the bar and on the flight line. What was also evident was the enormous amount of experience, knowledge and understanding of context that enabled the tailoring of procedures to be done effectively and with due regard to the circumstances. The ‘people’ bit was always much more important than the ‘process’ bit.

If we wanted a procedure to be followed precisely there was a lot of work up front ensuring the necessary understanding (knowledge, context) was provided and a lot of resources monitoring compliance. As the drive for military ‘efficiency’ bit in the late part of my career the extent to which the basics were done dropped dramatically. In the Australian Defence Force this was exemplified by the annual audit of Defence accounts being qualified (a very bad thing) for years on end due to a decade of neglecting the simple act of stocktaking. It was like the organisation just started to assume it would get done ‘because everyone knows its important’ and yet it behaved in a way that gave no indication that it was, in fact, important. Hmmm, sound familiar?

So, in the case of the recent ‘nukes across the US’ incident, I would love the opportunity to do some narrative-based research (probably using anecdote circles) to find out what was really going on. Of course, if the objective was to determine blame we would not get much better information than provided by an investigation. But if the objective was to understand the context and behaviors relating to the incident the insights could be incredibly valuable. And with something important (and I guess nuclear safety would fall in that category) we should be using the full range of investigative/evaluation approaches available to us rather than relying solely on traditional, linear ones based on the scientific method and focused on who was at fault.

Mark Schenk About  Mark Schenk

Mark works globally with senior leadership teams to improve their ability to communicate clearly and memorably. He has been a Director of Anecdote since 2004 and helped the company grow into one of the world’s leading business storytelling consultancies. Connect with Mark on:


  1. Brian Sherwood Jones says:

    Spot on. This is a topic dear to my heart. The people who do incident analysis ostensibly for learning purposes adopted the legal ideas of cause and blame uncritically. Despite clear statements of (some of) what is needed by Sidney Dekker and others, they show no signs of changing. My hope is that investigations by companies could do better than adopt the approach taken by national agencies, but I don’t see how the latter are going to change any time soon.

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