Defense Media Network

Mishaps at Sea Involve “Organizational Drift into Failure”

An interview with Capt. Bud Couch, USN (Ret.)


Courtesy of Surface Navy Association Surface SITREP (

Kevin “Bud” Couch is a retired naval aviator, flying helicopters. He’s not a stranger on the bridge of a warship. He’s commanded a big-deck amphib. He also is Navy nuclear power trained.

Today he has an important job helping the surface fleet navigate safely.


Capt. Edward H. Lundquist, USN (Ret): What is the Afloat Bridge Resource Management Workshop, and how is it being employed in the Surface Force?

Kevin “Bud” Couch: “We’re providing our commanding officers with the opportunity to work with a successful post major command captain – who has been screened and hand-selected – to help that CO understand the fundamentals of day-to-day risk management all the way from theory to practice. We also bring aboard professional mariners who are drilling Navy Reservists in the Strategic Sealift program who share their knowledge, expertise, and what to expect from surface ship interactions, making sure they’ve got the-, they’re very comfortable with all the equipment on the bridge and how it worked, and what tools are there, and that they can use them very well. But, the target audience, as far as Admiral Brown is concerned, for the rest of the effort is the commanding officers themselves.


Would the Strategic Sealift officers be taking the whole wardroom through all this, or just the CO? How does that work?

The arrangement is one-ship and one CO advisor – we’re not calling them mentors, but CO advisors – and usually two Strategic Sealift officers. They go aboard the ship when it pulls out, and they come off when it comes back in, aiming for a three- to five-day event with those three folks aboard.


Would this be conducted when the ships is already scheduled to get underway?

We try to capture it early in the basic phase with Afloat Training Group. Nominally it’s matched up with the Maritime Skills Week, scheduled on a “not to interfere” basis.

To prepare for the BRMW we use our simulators ashore. We start with classroom time, and then a planning phase, a briefing phase, the execution and a debrief, for two full watch teams for both combat and the bridge, including both the commanding officer and the executive officer. So, it’s a structured week-long course approach to how are we are going to plan through debrief a high-traffic density area transit. And in the execution portion of the BRM scenario, there’s nobody acting as the captain – it IS the captain. There’s nobody acting as the executive officer except the executive officer. And then some COs at their discretion will have the XO play the CO. The actual teams we will use on the ship will train together. The watch standers themselves and the teams that they compose aboard the ship are the training audience. We don’t train the training team first – we don’t worry about the shipboard training team until after that’s all cemented in place.

Cmdr. Daniel Hollingshead, left, executive officer of the amphibious transport dock ship USS New York (LPD 21), and Capt. Pete Kennedy, commanding officer of New York, point at surface contacts on the bridge wing aboard New York, Oct. 30, 2019. New York is underway conducting a composite training unit exercise (COMPTUEX) as part of the Bataan Amphibious Ready Group and 26th Marine Expeditionary Unit. U.S. Navy photo by Seaman Katelyn McClain

Your Strategic Sealift Officers are people whose regular daytime job is some kind of professional mariner.

That’s correct. And they are reservists that we bring on board for various periods of time. They’re volunteers who bring their valuable depth of experience at sea and perspective of what civilian mariners expect to improve the interactions between our bridge teams and combat and those other professionals on their ships.


We have a lot of people on a Navy bridge, whereas a merchant ship might have two or three.

Right. We need our people to know how their watch teams are structured, what their alarms are set to, what communications they are expecting. It helps build an understanding as how to include those other ships as part of the equation.


Do you actually have other ships that you’re interacting with?

The answer is yes. We don’t schedule anybody to go out and make runs with them, but there are numerous interactions in the course of the week. There are always crossing or overtaking situations, or a situation where we have to determine if somebody’s got to yield or not, so those interactions just occur as a matter of course.

After the Comprehensive Review, we went back and we started reading all these mishap reports again, and we tried to back up one level to determine what is common among mishap ships – what are they like on a mishap day.

Is the course based on the ship type, such as a DDG or LPD, for example? Or do you tailor the training based on what you have determined that this particular CO needs?

We don’t tailor the event itself much at all. The basic interaction portion that the Strategic Sealift Officers are providing doesn’t depend a lot on the type of ship or what the installed equipment looks like. But we may tailor who we send as a CO advisor, because it may make sense to provide a post big deck amphibious ship CO to advise that major command amphibious ship commanding officer. It’s not about “which equipment do you have installed,” but it’s much more about “how do you go about getting to the right answer regardless of equipment installed.” It’s much more about the human factors, those team interactions and how good commanding officers identify our risks today and take care of them with the help of the entire crew.


Cmdr. Craig Trent, commanding officer of the Arleigh Burke-class guided-missile destroyer USS Porter (DDG 78) observes from the bridge while departing Plymouth, England, March 25, 2019. U.S. Navy photo by Mass Communication Specialist 2nd Class James R. Turner

You mean the means, methods, and practices to determine what that risk is?

Yes, and which are a significant risk and which ones are not as important.


I presume the incidents involving Fitzgerald and McCain is the driver. Are there other factors?

There are two imperatives. First, the comprehensive review conducted an analysis of common causal and contributing factors, as well as a quantitative analysis based on safety reports. The CR came up with a long list of recommendations. The submarine force has this what they colloquially call “gray beards,” a group of retired, post major command guys who work in their submarine training centers. After the Comprehensive Review, we went back and we started reading all these mishap reports again, and we tried to back up one level to determine what is common among mishap ships – what are they like on a mishap day. Based on that qualitative analysis, we came out with the Six Common Traits of the Mishap Ship. When we talk about these “common factors,” you start thinking of it almost like a “kill chain.” If you interrupt those factors from happening, or you mitigate them – not one but as many as you can – you significantly reduce the chance of an incident occurring. While they are common traits, they are not necessarily causal. Instead, our working theory is that most of our mishaps involve some form of organizational drift into failure. In other words, a series of individual decisions made by individual people that gradually lead you away from the standard: all for good reasons at the time, all great individual risk decisions, but in the collective, those making these incremental decisions don’t have all the information. Crews and staffs end up not knowing where they stand with respect to who’s doing and not doing stuff. The result was some form of organizational drift into failure, based on a series of decisions made by individuals, but not communicated. It’s a gradual, unrecognized movement by the entire crew, resulting in an unrecognized accumulation of risk, particularly when the risk situation has changed.

It’s not recklessness. In retrospect some people looked at Fitzgerald as a mishap waiting to happen. And that’s just not true, knowing the view of the crew and the view of the destroyer squadron, the view of the CTF-70, and the view of Seventh Fleet, and the view of Pacific Fleet, and the view of INDO-PACOM, and the view of Type Commander, and Afloat Training Group in Japan… they were an entirely competent ship. In fact, part of the calculus in sending them on this particular mission was that they were a “can do” ship, and that’s true. What was unrecognized was, potentially, how far away from the way that things are supposed to be—that organizational drift into failure—they had gotten. And that was the unrecognized part. And one the important common traits of mishap ships is that all are “above average.” So how do we go about recognizing that this “thing” may be occurring. And we spent some significant calories with our human factors engineers to try to figure out ways to pull that out. That’s why we’re sending some of the best of our post major commanders out there, and they all have to go through training from me on that topic and a couple others. And they don’t get to go there until they’re convinced that they can have an effect based on having been through this theory session first and then going out and putting it into practice by walking around the deckplates. And those “six common traits of mishap ships” are very useful in that regard, which is, “Hey, it’s I just got this short little list of things to kinda think about, you can start picking up clues along the way. That’s the index card in their pocket. We picked that up from the submarine force. We went out to sea, we validated these, we made sure they worked for the surface warriors and we came up with the smaller list. We’re also incorporating this list of organizational drift indicators into safety surveys, for example. So we’re trying to exploit all the available tools but it starts with making sure the commanding officer has the level of knowledge that’s required to start making some great risk decisions consistently.

Our crew endurance policy requires that every ship have in place both at sea and ashore a circadian rhythm watch bill. They have to have a supporting shipboard routine that allows folks to get both rest and be on watch without having to leave for meals or whatever.

What else do the CO advisors cover?

They look at the crew endurance policy, all the way from “how do we derive it, why is it important,” to “do you have it in place on your ship right now or where do you need help.”


Cmdr. Zoe Arantz from Durand, Mich., the commanding officer of the Arleigh Burke-class guided-missile destroyer USS Nitze (DDG 94), salutes on the ship’s bridge wing. Nitze was underway as part of Abraham Lincoln Carrier Strike Group deployment in support of maritime security cooperation efforts in the U.S. 5th, 6th and 7th Fleet areas of operation. U.S. Navy photo by Mass Communication Specialist Seaman Apprentice Madysson Anne Ritter

Are you talking about time on deployment? Or hours on watch? Or how do you determine that?

Our crew endurance policy requires that every ship have in place both at sea and ashore a circadian rhythm watch bill. They have to have a supporting shipboard routine that allows folks to get both rest and be on watch without having to leave for meals or whatever. They use the crew endurance guidelines in their risk calculations for both deliberate and immediate risk determinations before they jump off into the exercise. Part of what the CO advisors do is make sure that watch bills are in place, and through the course of the time on board that they’ve consistently demonstrated that they’re using those guidelines in their risk assessments. We also cover critiques and lessons learned. “Critiques” are a method of investigation that has been used in the nuclear power community in the Navy for years and years. It’s a relatively quick bottom-up rather than just top-down approach that involves the entire crew potentially involved in a normal evolution, a near-miss, or a mishap.


Is this part of the plan, brief, execute and debrief (PBED) process? The last step?

It’s a means of doing that more effectively, and the value for us is that it ties back to the watch standing principles we’ve said are our core foundational elements of how we do our work in the surface force. It allows us to find out what happened, how to describe why it didn’t go quite right in those terms – things like formality, forceful backup, level of knowledge – and then apply discrete solutions to each one of them.


The aviation community has been good about that for years, about having that honest critique back in the “ready room.” When you read the aviation safety publications, they’ll have aviators who will say, “Don’t do this. This happened to me.” The SWOs are not open about admitting those types of things.

Correct, but that’s changing. We have to develop that culture of openness and reporting, and what critiques do is allow you a structured means to get to that pretty quickly. It’s my opinion, having been in multiple communities, that the critiques are a way to get there.


How do you know this program is working? Is there a way to measure progress beyond, “well, we haven’t had any collisions today?”

So far, it’s largely anecdotal. But we have three separate efforts underway to get to the point where it’s not just anecdotal. Intuition is a part of it. But we’re working toward being able to be able to cue that intuition a little more carefully. Working with our human factors engineers, we’ve come up with the “organizational drift indicators” – those things we’ll use in our survey questions and potentially just walking around to think about. Second is the human factors engineers also have come up with what we’re calling “Operational Fundamentals.” Afloat Training Groups have always measured the outcome of their events, but these allow us to go in and look at the actual, observed behaviors of the team as they’re in the planning briefing, execution and debrief phases, that contribute or do not contribute to a successful outcome.


My contemporaries will remember refresher training, or REFTRA, where the trainers time how fast you could go to GQ and set “Zebra,” and make sure everybody’s at their abandon ship station with their life jacket and the distance and direction to the nearest land written on their hand. You could measure if the crew did it in the right amount of time. But that doesn’t necessarily mean the function was done in the best way possible, or would save lives when the ship went down. It just got done. Is that the kind of thing that you would be looking at?

Yes, that’s exactly it. How did you get there is what we are beginning to measure, as opposed to “did you meet the stopwatch time?”  It’s one step prior to that which is based on the demonstrated team interactions, so that not only did you meet it this time but you’re gonna meet it every time. Maybe you got lucky and you had a great outcome, or was there some solid basis for the way that the team does it.

USS Milius

Cmdr. Jonathan Hopkins, from Fallbrook, Calif., commanding officer of the Arleigh Burke-class guided-missile destroyer USS Milius (DDG 69), stands on the port bridge wing as Milius was underway in formation during Annual Exercise (ANNUALEX) 19. U.S. Navy photo by Mass Communication Specialist 2nd Class Taylor DiMartino

You can be an observer and see if there’s a lot of coercion and yelling and screaming to get something done, or if it’s just fundamentally happening because people know what they’re supposed to do, they understand why it’s important, and when it comes time to doing it they do it instinctively do it. And they do it because it’s the right thing to do.

Yes. And there’s a level of trust you build up in the team, there’s a level of expectations, and what we’re observing is the actions of people to demonstrate those. That team cohesiveness, the understanding of what they’re supposed to do–they’re understanding their roles. We can put it in terms like “level of knowledge, formality, and forcible backup,” and things that make sense in this other context of our sound shipboard operating principles. We will validate those and roll them out as part of several afloat training group assessments, and we’re introducing those with the CO advisors.

When we stood up the program, we had a long conversation about whether this might be seen as somehow undermining the role of the immediate superior in the chain of command. And we decided at the end of it, after lots and lots of input, that for practical and professional reasons, “No, it’s not”, and this dedicated time with the personal attention of this person, is simply not available within the standard DESRON, PHIBRON, or other relationship.

How do you pick these advisors?

We’re provided a list from PERS-41 that says, “here are all the existing post major commanders in the world today.” What we do is we attempt to sort them into a couple groups. Our goal is to have a CO advisor from the same home port as the ship, but not in their administrative or operational chain of command. Basically, it means that anybody west of the Mississippi is eligible to be a CO advisor for west coast ships. I contact the individual, have a conversation, and then I have a nomination that I provide to Admiral Brown. He’s the final approval or disapproval, generally based on some additional conversations he has with other major commanders or flag officers. We have no scientific method, it’s a nomination and acceptance by the commander.


Is there a benefit for an advisor who is able to help and is successful, or is there anything negative if they feel they can’t support this request?

There is no written consequence for not participating. We could have hired some civilians who previous served as post major commanders to do this. We could establish a timeline and say you can only do it for five years because your relevance may be gone at that point. But we’re also looking at “how do get buy-in from all these people, some of whom have gone on to be flag officers, and all of them are in pretty important jobs, to be part of this. Admiral Brown has a vision that this is what the future of our community looks like. When we present it in that fashion, there are very few folks who go, “Boy, I really don’t have time for that.” So our take rate is pretty high. The difficulty is trying to schedule it in sufficient time because everybody has an important job, otherwise they wouldn’t still be on active duty at that point. It’s a matter of carving out blocks of time that they’re going to be available and trying to work with them to keep those blocks as inviolate as possible so that when the ship actually comes up, they’re actually available. It’s that last tactical mile of matching them to a ship that’s far more difficult than getting the candidate.


I imagine it would be a rewarding experience.

There hasn’t been anybody who’s done it who’s come back and said, “I never want to do that again.” It’s not that long of an underway period. They’re all pretty pumped up when they come back because they get to tell their sea stories. I encourage them to do that because many folks learn through stories much better than they do reading instruction manuals.


Who doesn’t want to do that! Go to sea; drink coffee; not be responsible; and tell sea stories!

Pretty much, though we find that the advisors work really hard at it while they are there. They understand the importance to the Surface community. And, the thing you owe at the end of it is a note back to the boss saying “the event is complete and here are my recommendations to make adjustments to the program better.”


Not about the ship or the CO, but the program.

It’s all about making the program better. We have no formal documentation beyond that. There’s nothing that precludes one of these CO advisors from giving the boss a call to say, potentially, I had some concerns but… that’s not part of the deal.


Cmdr. Rod Jacobo, center, commanding officer of the the Harpers Ferry-class amphibious dock landing ship USS Oak Hill (LSD 51), gets the bearings of surface contacts on the bridge of the ship during a basic surface warfare exercise while participating in a surface warfare advanced tactical training (SWATT) in the Atlantic Ocean. SWATT is designed to increase war fighting proficiency, lethality and interoperability of participating units. U.S. Navy photo by Mass Communication Specialist 2nd Class Brenton Poyser

Have you seen – or do you anticipate – that after this week at sea, that the relationship continues? That the CO might pick up the phone and call the advisor, and say, “Remember what we talked about three months ago, and now I’m out here and I’m doing this, evolution, what would you think about this course of action I’m planning on carrying out?”

That’s an expectation of our CO’s advisors. Once they do go to sea, one of the leave-behinds is their contact information. And the take-rate varies depending on the commanding officer. The 05s are kind of open to that idea, maybe more so than the sitting major command guys. But it’s a very useful means of operational, tactical networking that is NOT about your career – it’s about being a great commanding officer. When we stood up the program, we had a long conversation about whether this might be seen as somehow undermining the role of the immediate superior in the chain of command. And we decided at the end of it, after lots and lots of input, that for practical and professional reasons, “No, it’s not”, and this dedicated time with the personal attention of this person, is simply not available within the standard DESRON, PHIBRON, or other relationship. And, it’s useful to have this independent view and this voice, to lend itself to much more open discussion about the “goods and others,” as we used to say in aviation, than potentially you might have with your boss.


There’s really no reason not to open up.

But to answer your question, I don’t know any of our CO advisors who have done it one or more times who haven’t had a follow-on conversation about some aspect of what they discussed.


Ideally, you would want the advised or the advisor to have a great relationship with each other that would go on forever.

And like most things, the first day aboard with this post major command captain walks in, it’s not like, “Here, let me tell you these six things I’m concerned about,” but it takes place over the course of a couple of days, particularly if the CO advisor’s thing is, “Hey, I was just noticing this thing. Have you noticed that, too, and what do you think?”

We’re not going down the road of any kind of a mentorship contract, and we’re not going down the road of career advice.


Is that understood upfront?



How many ships have this relationship right now?

When we started the BRMW it was just the SSOs, with a senior reserve officer aboard. It wasn’t quite the flavor we were looking for. But we now have about 60 ships that we’ve completed with the Full Monty, with the CO advisor.


What kind of feedback have you received?

We get feedback from two directions. I check with the commanding officers about the program and its value to them, because that’s the only thing that counts. And I get feedback from the CO advisors, and both groups have been very positive. So that’s good, but like many things we do in the Navy, if you ask somebody if they like their training that’s different from the question about whether it was effective. We’re still working on the answer to that question. So as we work through the comprehensive review action items, there’s something about this personal approach to how things actually work in day-to-day operations that may be the key to making significant progress. Given all this other infrastructure and things that we’re changing at the same time, we know that, at least, it’s part of the secret sauce.


Capt. Edward H. Lundquist, U.S. Navy (Ret.) is a senior-level communications professional with more than...