Bloody Ships
By
David K. Hurst
"There seems to be something wrong with our bloody ships today..."
remarked Admiral David Beatty to his Flag Captain. Beatty was commander of
the Battle Cruiser Fleet at Jutland, and his cool comment belied the scale
of the catastrophe. It was 4.26 pm on May 31, 1916 and from the upper
bridge of the battle-cruiser Lion he had just seen her sister ship, Queen
Mary, disappear in a shattering blast as both main magazines exploded.
Twenty minutes earlier another battle-cruiser, the Indefatigable, had
vanished in a sheet of smoke and flame and, although Beatty did not know
it at the time, the Lion herself had narrowly missed a similar fate only
by flooding her Q turret magazine with sea water.
At the Battle of Jutland, the greatest sea battle of all time, the
British Navy would lose three battle-cruisers carrying over three thousand
men in less than three hours. It was not bad luck, it was bad management:
the result of the Navy's inability to manage a complex system from design
through to execution. For the roots of the disaster lay in the design of
the ships over a decade earlier. Thus the problem was systemic and
Beatty's puzzled comment represents one of the more dramatic instances of
the bewildered reaction of a CEO to symptoms of systemic problems in the
field.
Battle-cruisers like the Lion were the pride of the Navy. Known
affectionately as the "big cats", they were armed almost as heavily as
battleships and could reach speeds of over 27 knots. In the pursuit of
speed and firepower, however, protection had to suffer and the
battle-cruisers had only thinly-armoured decks. Their speed, their
designers thought, would keep them out of trouble. Their thin armour and
emphasis on speed created an aura of risk-taking and, not unlike our
modern day astronauts, the sailors who served on them enjoyed high status.
The compromises designed into the battle-cruisers were compounded
by modifications made to them to accommodate the Navy's peacetime gunnery
practices. Managers usually try to optimize the variables that they can
measure most easily, and the Navy was no exception. They had developed a
cult of rapid fire, for rate of fire was easily measured and as a
"benchmark" it allowed intense gunnery competition among all ships and
squadrons in the fleet. In their efforts to feed the guns with charges
from the magazines, however, gun crews began to eliminate the anti-flash
baffles that slowed the process. At first they left the flash doors open
but over time, as word spread about the performance benefits of the
practice, some were removed completely. Protection is hard to test in
peacetime and no one realized that the battle-cruisers were now
dangerously vulnerable. If a shell were to penetrate the main turret
armour, the resulting explosion was likely to flash down the ammunition
hoist to the main cordite stores in the magazines below.
The third systemic factor which sealed the fate of the battle-cruisers at
Jutland was the way they were deployed. If speed was critical and deck
armour thin, then the battle-cruisers would do best in high-speed
encounters at relatively close range, where the flat trajectory of enemy
fire would encounter their thicker side armour. This was not to be the
case. It had been a century since the British Navy had fought its last
major sea battle at Trafalgar and Nelsonian initiative was not common
among the senior officers. The technology of naval warfare had changed
enormously and was largely untested in combat. There was horror of losing
a ship and this conservatism was abetted by the recent introduction of the
wireless and the organizational centralization that accompanied it. As a
result, the battle-cruisers were held in a long range gunnery duel in line
of battle, where their speed was of little help and their decks were
exposed to plunging projectiles fired on high trajectories. On May 31,
1916 the systems loop had closed and disaster was at hand. Perversely, in
their efforts to preserve the battle-cruisers from destruction, their
commanders had actually made them more vulnerable to catastrophe.
Lessons for Managers
"War stories" are of interest to managers because they help remind
us that failures in complex systems under stress are rarely the result of
random chance. The British Navy's experience with their battle-cruisers at
Jutland, like NASA's much more recent experience with the Challenger
disaster, underlines the importance of taking a systemic perspective of
organizations and their problems:
Don't maximize one measurement of performance at the expense of
others. An exclusive focus on financial performance in business
enterprises, for example, can blind an organization to current events of
critical importance. Measurements of customer satisfaction, innovation and
operating excellence can alert the organization to problems long before
they show up in the financials.
Don't benchmark variables just because they are easy to measure.
Aided by incentive schemes, an organization can easily end up being very
good at doing something that doesn't make much difference. The essential
criterion is whether the end customer defines the variable as being a
valuable component of the product or service. In the aftermath of Jutland,
for example, it was found that a significant proportion of the British
Navy's armour-piercing shells had failed to explode effectively.
Don't allow ad hoc tinkering with systems design without
considering the systemic implications of the changes. This can be tough to
do, but prototypes and simulations are worth it. The opinions of
dissenters need to be addressed, rather than dismissed. There had been
several vocal critics of the battle-cruisers long before war broke out.
They had feared that they would be used inappropriately in a general fleet
action, but their concerns had been ignored.
Mistakes are opportunities to learn. The German Navy had no
systemic failures in their ships during the battle, but this was the
product of learning rather than planning. At Dogger Bank sixteen months
earlier, the battle-cruiser Seydlitz had been hit by a shell (ironically
fired by the Lion) and had two turrets burned out. As a result, all the
German battle-cruisers had their flash protection strengthened before
Jutland. It is probably true, however, that the German navy would never
have allowed their gun crews to remove the flash doors in the way the
British did!
When things go wrong, look for systemic causes first before
blaming individual components. It is all too easy to mistake the symptoms
for the disease and in complex systems causes can be located far away in
space and time from their effects. The problem at Jutland was not just
with the "bloody ships" - it was with the bloody system. And the system
had one cruel twist left. It was to be played out twenty-five years later,
almost to the week. The captain of the Invincible, the third
battle-cruiser lost at Jutland, was Horace Hood. Scion of a famous naval
family, Hood had been intelligent, handsome and dashing: to the public he
epitomized the ideal British naval officer. It was his loss, perhaps more
than any other, that was felt most keenly by the nation. It seemed only
fitting that, in 1918, the largest, fastest battle-cruiser ever built
should be named after him. The Admiralty, however, may have learned little
from experience. On May 24th 1941, the Hood attempted to engage the mighty
battleship Bismark. Hopelessly outmatched, she was destroyed by a
shattering explosion after a brief encounter. The Admiralty said it was an
"unlucky shell". But the blast was really a distant, systemic echo of the
disaster at Jutland.
David Hurst (dhurst1036@aol.com)
Speaker, Consultant and Writer on Management
Author of "Crisis & Renewal: Meeting the Challenge of Organizational Change"
(HBS Press, 1995) See Books at http://www.mghr.com
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