November 3, 2016 | Mark Paradies

Navy Root Cause Analysis Focused on Blame Vision, Crisis Vision, or Opportunity to Improve Vision?


In a short but interesting article in SEAPOWER, Vice Admiral Thomas J. Moore stated that Washington Navy Yard had just about completed the root cause analysis of the failure of the main turbine generators on the USS Ford (CVN 78). He said:

The issues you see on Ford are unique to those particular machines
and are not systemic to the power plant or to the Navy as a whole.

Additionally, he said:

“…it is absolutely imperative that,
from an accountability standpoint,
we work with Newport News to find out
where the responsibility lies.
They are already working with their
sub-vendors who developed these components
to go find where the responsibility
and accountability lie.
When we figure that out, contractually
we will take the necessary steps to make sure
the government is not paying for
something we shouldn’t be paying for.”

That seems like a “Blame Vision” statement.

That Blame Vision statement was followed up by statement straight from the Crisis Mangement Vision playbook. Admiral Moore emphasized that would get a date set for the commissioning of the ship that is behind schedule by saying:

“Right now, we want to get back into
the test program and you’ll see us do that here shortly.
As the test program proceeds, and we start to
develop momentum, we’ll give you a date.
We decided, ‘Let’s fix this, let’s get to the root cause,
let’s get back in the test program,’ and
when we do that, we’ll be sure to get a date out.
I expect that before the end of the year
we will be able to set a date for delivery.”

Press statements are hard to interpret. Perhaps the Blame and Crisis Visions were just the way the reporters heard the statements or the way I interpreted them. An Opportunity to Improve Vision statement would have been more along the lines of:

We are working hard to discover the root causes
of the failures of the main turbine generators
and we will be working with our suppliers to fix
the problems discovered and apply the
lessons learned to improve the reliability of the
USS Ford and subsequent carriers of this class,
as well as improving our contracting, design,
and construction practices to reduce the
likelihood of future failures in the construction
of new, cutting edge classes of warships.

Would you like to learn more about the Blame Vision, the Crisis Management Vision, and the Opportunity to Improve Vision and how they can shape your company’s performance improvement programs? The watch for the release of our new book:

TapRooT® Root Cause Analysis Leadership Lessons

It should be published early next year and we will make all the e-Newsletter readers are notified when the book is released.

To subscribe to the newsletter, provide your contact information at:

Root Cause Analysis
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *