Dropping the Hammer

I’ve had to drop the hammer very few times in my career. And honestly, those times were the easy ones, because they involved red lines nobody crosses: an airman putting hands on a spouse, sexual assault, sexual harassment. I’m not going to dive into those, because I wouldn’t advise anyone to do anything other than what the military already tells you to do. Get your First Sergeant, legal, and the agencies built for it involved: Security Forces or OSI, Family Advocacy, the SARC. You don’t freelance those.

This piece is about everything else. My stories come from the other side: times the hammer probably should have dropped on me, and didn’t, and what I learned from that.

I’ve said elsewhere that nobody screws up on purpose. That alone should take the edge off the first wave of anger when someone on your team fails. But it doesn’t answer the harder question: when someone does fail, what do you actually do about it?

The wrong patient

Before I joined the military, I worked in the radiology department of my local hospital. If you’ve ever been a patient, you know the drill: they ask your name, your date of birth, and if you’re wearing a wristband, they check it.

I had a habit of asking for the name, and that was good enough for me, because if we had two people with the same name, I’d see it on the schedule. One day I went out to the lobby and called a man’s name. He stood up. I said his name again and told him to come on back. I took his medical history, walked him to the CT scanner, we scanned him, and went on with our day.

An hour or so later, another patient in the lobby asked what was taking so long. I asked his name. It was the name of the man we’d just scanned.

We had scanned the wrong patient.

That was my fault. I didn’t check the wristband. I didn’t ask him to state his name; I said it for him, and he agreed. Luckily, I caught the other man while he was still in for another procedure, so I could bring him back and do the right scan.

I spent the next week waiting to get fired. This could have had dire consequences: a misdiagnosis, wasted care, and two or three effects down the line, someone could have died. I accepted whatever punishment was coming.

My boss sat me down, and I sat there waiting for the sentence. She just asked, “So, what did we learn?”

Check the wristband.

Then we just talked. She told me about mistakes she’d made in the past. She made herself human to me, and that got me to open up about why I’d made mine. Eventually I told her, “I’m shocked you’re not firing me.”

Her answer made a lot of sense. “If I fire you, I risk hiring someone else who hasn’t made this mistake yet, and they’ll make it in the future. I can guarantee you’ll never do this again. You learned your lesson.”

That was it. My punishment was the guilt I’d carried all week. And she was right: I never made that mistake again. Twenty years later, I still think about it.

She was also right according to the research. Amy Edmondson at Harvard studied error rates in hospital units and found something that looked backwards at first: the better-led units reported more errors. Not because they made more, but because people there felt safe enough to say so. In units where mistakes got punished, errors still happened. People just stopped reporting them.¹ Fire me, and the next person who scans the wrong patient keeps quiet about it.

The $500,000 ambulances

In contracting, it’s impossible not to make mistakes, and unfortunately we see ours in dollars and cents. There’s a difference, though, between a mistake made out of carelessness and one made because you’re in a situation you’ve never seen before.

At one fiscal year-end in England, we got a requirement for four ambulances. Logistics Readiness had wanted them for years. They had to meet UK specs and be customized. Two needed to go off-road for crash and recovery. The other two were for taking pregnant patients downtown, because our base hospital didn’t have that capability.

Too easy, I thought. Commercial item: find a contractor who’s an expert, streamline it, and get it done in the thirty days left in the fiscal year. I got the specs from Logistics Readiness. From then on, I worked with medical on the equipment that would go inside. Any change or question from the contractor, I pushed to medical.

My mistake: I never went back to Logistics Readiness. I didn’t realize they own vehicles. So nobody who understood the vehicle itself was watching what we bolted into it. The off-road ambulances ended up so top-heavy with equipment that they handled the off-road work fine but couldn’t handle UK roads. The patient movers were so heavy the shocks stopped working. Any patient in the back would have ping-ponged all over the place.

There was no money left to fix them. If I’d kept LRS in the loop, it wouldn’t have happened. It was a $500,000 mistake. They were useless. Luckily they got repurposed for flight line use, but if I’m honest, I wish they’d use the stupid things for bombing practice.

My intentions were good. I wanted the people who’d use those vehicles to have everything they needed, and I failed to keep the experts in the loop. Now I preach it from the rooftops, and you’ll see it over and over in KTHQ trainings: LRS owns vehicles.

My punishment? Nothing. It could have been a waste case. It could have at least been a slap on the wrist. I didn’t even get that. I internalized it, blamed myself (rightfully so), and moved on. I’m thankful I didn’t get punished, and I’d have understood if I had been.

What would the hammer have done?

So what would dropping the hammer on me have accomplished? It would have held me accountable. But I was already holding myself accountable, and I think most people do. What would the guillotine have added? I’d have been terrified of getting anything wrong. I’d have slowed every contract down trying to make it perfect on the first try. I’ve written hundreds, maybe thousands, of contracts. One was this bad. Is dropping the hammer worth that trade?

For some leaders, yes. For others, no. I don’t think there’s one right answer. I can only tell you I’m thankful it didn’t drop.

In my opinion, everyone gets a freebie in situations like these. If you work on nukes or airframes, there’s no room for deviating from the process, and every i gets dotted. But contracting works with money, and things go wrong, in and out of our control, all the time.

One thing I think we need to stop saying is the old line, “In our line of work, if you make a mistake, you go to jail.” No, you don’t. You correct it and move on. You go to jail for bribes, fraud, and kickbacks. Even the Antideficiency Act, the law contracting people fear most, defaults to administrative discipline for a violation and reserves criminal penalties for people who violate it knowingly and willfully. Honest mistakes don’t put you in a cell.

Sorting the mistake

So when your troop makes a mistake, figure out what kind it was. Was it a bad habit they keep repeating? A new approach that didn’t work? Or genuine recklessness? And decide carefully what reckless actually means. You can label any mistake reckless after the fact, but our career field is far too broad for anyone to know every outcome of every acquisition.

That sorting has a name. David Marx built the “just culture” model that hospitals and aviation now use, and it splits mistakes three ways: human error, where the right response is to console the person and fix the system; at-risk behavior, a shortcut or habit whose risk the person didn’t see, where you coach; and reckless behavior, consciously ignoring a risk you know is there, which is where sanctions belong.² Edmondson found the same split in companies. When she asks executives how many of their organization’s failures are truly blameworthy, they usually say only a few percent. When she asks how many get treated as blameworthy, they say most of them.³

My wristband habit was at-risk behavior: a shortcut that seemed fine until it wasn’t, and the boss coached instead of firing. The ambulances were a situation I’d never seen before. In that case, I could have awarded to a contractor who knew better and caught it for us. That didn’t happen. A million things can go wrong, in your control and out of it, and a lot of the time it comes down to a troop’s inability to predict the future. That’s not a fair standard to hold anyone to.

So I extend my troops the same courtesy that’s been extended to me.

When someone on your team makes the mistake you once made, which boss are you going to be?