case study on decision-making (abcd version of ooda loop)
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TRANSCRIPT
What Would You Have Done? The set-up: It’s Thursday night and two mechanics who
worked all day (from 0700-1700) plan to drive through rush-
hour traffic to party at a club that is at least two hours
away.
Question #1: Supposing this was your plan, what do you think of it?
Now assume that these Sailors work
directly for you. In fact, they are among
your best workers. They have been making
this road trip once a week for three months,
and nobody has said anything about it.
Question #2: As a supervisor, what do you think of their plan?
You decide to discuss their plan with
them. They assure you that one of them will
be the designated driver and that they’ll stop
to rest if necessary.
Question #3 and #4: Do these risk controls make you feel better about their
plan? Can you do anything to improve their
chance of success?
Here’s another factor. Work tempo at the
command has been high, and they have had
a total of just 15 hours of sleep during the
previous three days.
Questions #5 and #6: What do you think
of their plan now? Do you see any red
flags?
The event: They stay at the club until
0300, having a great time. They start to
drive back to base so that they can report to
work at 0700. Even though the driver hasn’t
been drinking, he feels sleepy. He pulls over
to rest at 0400. However, feeling pressured
to get back to work on time, they get back
on the road at 0445 without getting any
meaningful rest.
At some point, the driver falls asleep and
loses control. The car crashes. The driver
isn’t buckled up and is killed. The passenger
(who was wearing his seatbelt) survives with
injuries.
Question #7: How does the loss of two of your best workers affect your team?
You have just lost two of your best
performers, and it will take some time
before BUPERS details new personnel into
your command. As the supervisor, it’s not
just a workload and mission issue (others are
going to pick up the tasking, which increases
their risks) that you are going to have to deal
with. Work-center morale and family
concerns of the lost members are going to
complicate the situation that you must
address.
Questions #8, #9 and #10: What does it say about the culture of a command when
personnel think that they can party all night,
getting little or no sleep, and still be able to
do skilled, technical work the next day?
What risk does this pose to the command’s
mission? Do you think these Sailors
understood ORM?
They apparently felt bullet-proof. They
had done some planning and had had the
same routine for three months. The hazards
of driving while fatigued, driving impaired,
sometimes not wearing seatbelts and ending
up not fit for duty the next day were all
additional risks that weren’t adequately
controlled.
Their execution of their “plan” wasn’t as
routine as they had thought. Time Critical
Risk Management would have been
appropriate to use and should have come
into play for both the Sailors and their
supervisor.
Let’s assume that these Sailors weren’t
afraid to call their supervisor to confess that
they would be late.
Using the A-B-C-D mnemonic, they could
have:
● Assessed the plan at the point where
they were too tired to drive.
● Balanced Resources by getting a hotel
room or stopping in the car for a longer rest
period.
● Communicated with their supervisor
(another resource, via a cellphone call or
text) that they would be late and would
make up for the lost work.
● Debriefed, after the event, by
discussing how to better plan this event in
order to have controlled the known risks, so
that no last-minute phone calls would have
been necessary.
________________________________________________________________ DISCUSSION POINTS
● As a supervisor, what could you do in your span of control to improve these
Sailors’ risk management? What could leadership do in terms of effectively teaching
Sailors how to balance work and play, and how to make sensible plans as a result?
● Why was there not some kind of command “trip wire” for leadership to provide to
their Sailors under circumstances like these?
RESOURCES AND MITIGATION STRATEGIES ● Have a Leave or Special Liberty Chit stashed for just such an emergency, so that
personnel are covered (to some extent) if they are late. This doesn’t mean they’ll
evade any repercussions, but you are protecting them.
● Establish a phone tree so personnel know who to call when their plans aren’t
working.
● Identify rest areas or lodging that can be easily accessed.
● Modify work hours so that Sailors can drive during daylight. Offer earlier secure to
avoid rush-hour traffic, thereby reducing driving time, or a late report the next day.
It’s better to lose a few hours from people than to lose the people.
● Duty driver.
● Different liberty schedule.
BY DEREK NELSON, HEAD MEDIA DIVISION
_________________________________________________________________________
Supervisors: Use this page to guide safety discussions with your personnel
Send your feedback to: [email protected]