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 ofdealing
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, thepaper'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 therebyproduces high reliability. In effective organizations culture
and formality co-exist. 'lhe nuclear submarine service is aúo the
intersection ofsevera/different cultures. Rickovercreateda new culture
for the nuclear Navy which is clear/y a crucial source ofreliability, but
it is also in tension with the o/der navalandsubmarine 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'pitchin', relyingonhigh leveis ofindividual
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
639

640 BIERLY AND SPENDER
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 ofhuman or animallife, despoiling ofthe environment
or some other situation that gives rise to the sense of 'dread' (p. 324); (2)
complexity, defmed as havinglarge numbers ofhighly interdependentsubsystems
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 Valdez and
Challenger, added considerablesupport to bisthesis. Clearly Perrow wascorrect
to point to the rising number of systems which should be classified as high-
risk 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. Despite AT&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 involvethe loss oflife) bave declined from S1for 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.
JOUR.NAL OF MANAGEMENT, VOL 21, NO. 4, 1995

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 ofthis 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 ofpreventing 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 ofextreme 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
ofduty to the collective purpose, and some shared general paradigm for making
sense ofthe world (Ouchi, 1980, p. 471).
JOUR.NAL OF MANAGEMENT, VOL. 21, NO. 4, 1995

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). Ifthe 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 ofanalysis above that oftheformal, for theformal issubsidiary
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
thesimplerbureaucraticor marketmodesofcontrol(p. 471). W"llkinsand 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 ofinstitutional 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
JOURNAL OF MANAGEMEHT, VOL 11, NO. .-, 1995

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 of
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 corres-
ponding theory ofcollective 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 learningwhich
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 oflimited 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 ofthe entire system. Perrow's central
thesis is that we cannot do this for high-risk organizations.
JOURNAL OF MANAGEMENT, VOL. 21, NO. 4, 1995

March, Sproull and Tamuz (1991) suggested an alternative to the scientific
strategy for organizational learning. They argued that collectives which are
internaliydiverse are able to apply thatdiversity to smali samples ofcriticai events
and so experience them 'richly', probing their varied manifestations and
interpretations more completely. Thus the paucity of datais balanced by the
richness ofthe analysis. An additional result ofthis rich analysis ofcriticai 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 FAA'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 ofit, 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
ofthe 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 of 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 Weick 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 ofdealing
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
JOUR.NAL OF MANAGBMENT, VOL. 21, NO. 4; 199S

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, ofcourse, is a different class ofship and carries long-
distance 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
JOUR.NALOF MANAGEMENT, VOL 21, NO. 4, 1995

646 BIERLYAND SPENDER
higher levei collective knowledge, even within modem organizations (Evans-
Pritchard, 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 ofthe collective. This gives the researcher
preliminary access to the organizational culture, as well as to the other modes
ofcontrol and goings on within the situation. The second objective is to analyze
theculture, to separateit from the context's othersources ofmeaningand 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
ofethnography is to decode, translate and interpret the behaviors and attached
meaning systems of those occupying and creatingthe social system beingstudied
(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 ofdeath 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 anill-fittingstraitjacket, becomesa 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 ofthe crew. Junior
offlCCrs denote their senior officers by positione.g. 'CO'(meaningCommanding
OfflCCr) or 'NAV' (meaning Navigating Officer). This fonnality and separation
is seldom relaxed. A well known exceptioo. is 'Crossing the Line' meaniDg the
JOURNAL OF M.ANAGEMENT. VOL. 21, NO. 4, 1995

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. He 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 ofthe Naval culture. The rite ofthe 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 ofexpertise and others beyond their
special duties. Cross-learning is vital for the operators ofthe submarine's tightly
coupled complex systems. But as with all high-risk systems, there is little
opportunity to 1earnby 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 learningfrom small samples ofdisasters,
near-misses and mistakes of others. The networking and the diversity within
the crew enables the 'rich' group-oriented learning process which Weick (1987)
JOURNAL OF MANAGEMENT, VOL. 21, NO. 4, 199S

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 communica-
tions behaviors. Two watchstanders, such as the OOD (the Officer ofthe 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 inthe 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 or shut the valve; (2) the operator responsible repeats the orderverbatim
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. Understressstep2may be omitted but the interchangeremains 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.
JOURNAL OF MANAGEMENT, VOL 21, NO. 4, 1995

The Genesis ofthe 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 independentlyunder
general orders which were opento considerable interpretation bytheir Captains.
In the eighteenth and nineteenth century, it became more common to have fleets
of several, even dozens, ofheavily 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 ofthe
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 of 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 War 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, oftwo
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 buildingand manning ofseveralhundred submarines and a dozen
surface ships including the carriers Kennedy, Nimitz and Enterprise. This
program isjointly controlled by Naval Reactors (NR}, a division ofthe Atomic
EnergyCommission(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
JOURNAL OF MANAGEMENT, VOL 21, NO. 4, 199S

BIERLY AND SPENDER
Czar-like authority over the development ofthe naval nuclear fleet. lt gave him
direct control over the design, construction and, most important, the manning
of these vessels.
Rickover was a figure ofmythic proportions, a genius or demi-god to some,
an enigma or egomaniac to others. As one offive young naval engineersinvolved
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 high-
technology concept into a weapon which would forever change the realpolitik
of nuclear deterrence. He skillfully gathered the political power necessary to
create and rule bisjoint 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
ofthe service. He 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 thejob was too demandingfor 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. lfthe young offlcersaid
he would abandon bis fiancée, Rickover would becomeenraged 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 ofthe service. To be admitted to the nuke community was a source
ofgreat 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 Navy'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.
Ifcrewmen blindly followed orders, unaware and uncaring ofthe 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 ofalmost thirty years. Yet no single accident leadingto 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. He was the ftrst to accuse them ofthe 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 makinga mistake canfeel free to reportit 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 mistakesare made or when surprises, failures, or malfunctions

6S2 BIERLYAND SPENDER
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 ofthe 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 high-
reliability 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 of 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
Rickoverfought 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 ukimatesymbolicact 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
amongsubmariDersthetraditionwas always th.econtrary, theship 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 ofits crew to escape.
But Rickover's concem for the reactor, and maybe also for the disastrous
consequences, ecological, political and for NR/ NPD, ofan 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 extremelyconservative 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. Yet Rickover standardized on the more conservative design and refused
to consider improvements. As a result both the Los Angeles class boats and
the forthcoming Seawolfclass are technically obsolete (Hemond, 1989). But,
given the consequences of 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 ultra-
stable 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 reliabilityfperformance 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
bureaueraticallycontrolled power plant and the naval tradition ofindependence

BIERLY AND SPENDER
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 creativesolutionto the possibility ofculturalconflict
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
ofvalues, attitudes and behaviors which theythen 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 ofworld-class technology, a subtlecombination 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 ofthe 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 high-
risk system. Yet the safety record is un.matched. despite the large number of
plants, the added exigencies of being mobile instead of fixed in one location,
ofoperatingsecretly ratherthan publicly,in a hazardousenvironmentand 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. Thesystemis both technical and human, multi-layered withtremendous
richness anel depth. lt was inculcated by severe selection and continuous
training. Thesubmarineitselfis merelythe sharp visibletip ofthis system. While

it seems an independent entity, it is merely one ofthe points ofinteraction 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 ofextremely 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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