We all know Army operations are never static. Removing a...

Imagine you are playing Jenga. The 54-wooden-block tower wobbles, seems to hold for a second and then collapses — not because of a player’s last move, but because multiple missing and restacked pieces quietly weakened the structure. Army readiness fails the same way: One visible act is the result of long-term ineffectively assessed hazards, eroded procedures, training shortcuts and a failure to consistently enforce standards. The Human Factors Analysis and Classification System 8.0 (HFACS 8.0) helps expose those hidden failures after a mishap. But more importantly, HFACS shines a light on these system inadequacies before they manifest into mishaps through inspections and risk assessments, which the Army Safety Management Information System (ASMIS 2.0) gives commanders through targeted feedback to prevent the next collapse. The following will explore how Jenga’s missing blocks and nonlinear failure dynamics translate into practical checks leaders can use to enhance readiness today.

Why Jenga works as a metaphor for operational readiness

The Jenga tower is your safety system, and each block is a risk control — policies, procedures, training, leadership actions and resource support. In a perfect tower, every risk control is fully implemented and consistently evaluated for effectiveness. Removing a couple of blocks to meet a mission demand creates a small weak point, yet the tower still stands. Herein lies the trap. Success breeds a false confidence that hides where the instability from shortcuts over days, weeks and months continues to intensify. Remove several more blocks and the structure becomes more fragile until a single tug triggers collapse. This insidious drift is known as "normalization of deviance," and leaders must be intentional in preventing it from taking root.

We all know Army operations are never static. Removing a block and restacking it mirrors the daily reality of the mission:

  • Resource support – Budget cuts reduce supplies, maintenance and personnel.
  • Training shortcuts – Personnel lacking experiential learning and feedback.
  • Ineffective standards – Outdated, absent or unclear standard operating procedures (SOPs), technical manuals (TMs) and policies.
  • Leadership acceptance of risk – Risk deviation from a standard is tolerated to meet mission requirements, resulting in a dangerous precedence.
  • Individual strain – Fatigue, inexperience and stress, resulting in a lack of attention to a task.

The missing blocks: system inadequacies (the roots of organizational weaknesses)

Look beneath the wobble. What appears as a single error or hazardous behavior is usually a stack of “missing blocks.” These are the hazardous conditions created long before a near miss or mishap occurs. Army Techniques Publication (ATP) 5-19 and Department of the Army Pamphlet (DA Pam) 385-40 define these root conditions as system inadequacies. The HFACS provides a powerful lens to identify these five critical mishap barriers:

  • Leadership and supervisory failures: Ineffective risk assessments and planning; ineffective supervisory oversight, weak standards enforcement, permissive command climate.
  • Training failures: Outdated program of instruction, unavailable or mismatched unit training shortcuts in execution.
  • Standards and procedural failures: Unclear, outdated or impractical policy or procedures.
  • Support and resource failures: Staffing shortages, funding cuts, broken/dead-lined equipment, inadequate infrastructure.
  • Individual inadequacies: Inexperience, stress, operationally and/or individually induced fatigue or complacency that result from a combination of the other four failures.

When units stack workarounds, such as temporary fixes and procedural shortcuts, they raise the tower’s center of gravity and increase instability. The system becomes taller and more fragile until one move triggers a collapse.

Non‑linear reality of human factors: Why the tower falls suddenly

Failures don’t add up; they multiply exponentially. Small, dispersed changes produce disproportionate outcomes. A budget cut with an increased OPTEMPO and personnel shortage at the base of the system forces a leadership decision to accept risk, which shortens training, which produces inexperienced or untrained crews. Then, a single unsafe act triggers a catastrophic outcome. The HFACS helps safety personnel and their commanders to look beyond the final error of the operator. Its purpose is to aid in tracing these hidden, non-linear pathways of error, back to the roots of the system inadequacies so you can make corrections to re-strengthen the system.

When your safety personnel conduct inspections or investigate mishaps, they should start with curiosity: What is allowing this hazard to exist? What was accepted, deferred or ignored? Why was something accepted, deferred or ignored? How can we plug the hole?

Why this matters for Army leaders and their safety personnel

For leaders, the Jenga metaphor proves four uncomfortable truths:

  1. Risk is never static; it is constantly evolving, even after completion of a deliberate risk assessment.
  2. Latent organizational failures are far more dangerous than individual errors.
  3. Small, ignored errors don’t just add up in plain sight; they covertly multiply.
  4. Every system appears stable right before it collapses.

If the problem is systemic, the solution must be systemic. This demands a shift from a defensive posture of reacting to lagging failures to proactively hunting instability and attacking it early. Your job is to see the wobble before it becomes visible and to reinforce the base. Do these consistently and the tower will move without falling:

  1. See the whole tower – assess leading indicators. Track leading indicators from inspections and reported hazards versus the lagging indicators of mishaps.
  • Schedule regular reviews of maintenance logs, training rosters, supply status and the ASMIS 2.0 Program Management module to assess system inadequacy/latent failure trends of hazards. Data from the ASMIS program management dashboard and the Joint Risk Assessment Tool (JRAT) will help prioritize corrective actions that address root causes before they manifest into mishaps.
  • Direct your safety personnel to use HFACS 8.0 to:
  • Determine the root system inadequacies/latent failures of hazards during workplace inspections, then document them in the ASMIS Inspections and/or Hazard Management modules.
  • Treat near misses as mishaps and hunt down the system inadequacies.
  • Direct your leadership team to use HFACS 8.0 to:
  • Augment ATP 5-19 while conducting pre-mission deliberate risk assessments and capture the leading indicators from risk assessments in JRAT.
  • Aid in the development of a Job/Activity Hazard Analysis and document the system inadequacy controls in the ASMIS 2.0 Supervisor’s Portal.
  1. Encourage reporting – treat near misses as intelligence, not embarrassment. Your Soldiers and civilian personnel are the first to feel the tower getting unsteady. They know which procedures are flawed, who is inexperienced and where resources are thin. Normalize and reward near‑miss and hazard reporting. Make it safe to say, “This feels wrong,” provide timely feedback and act on reports.
  2. Map the chain – hunt down and attack the system inadequacies. Direct your safety personnel to use HFACS categories as part of inspection checklists and hazard analysis. For every near miss and hazard discovered or reported, map them back to their root reasons for existence and review them over the prior 30, 60, 90 or 120 days.
  3. Fix the fix – prioritize systemic fixes. Replace workarounds with durable solutions, document temporary measures and set deadlines for permanent fixes. Require after-action reviews (AARs) with your leadership team and direct your safety personnel to feed findings into the corrective‑action plans captured in the ASMIS Hazard Management module.

Conclusion

Catastrophic failures are never the result of a single error. The five-year trends of the Army’s “Dirty Dozen” (https://safety.army.mil/MEDIA/Safety-Brief-Tools) demonstrate the same truth that most latent failures derive from supervisory and training inadequacies, which foster a normalization of deviance. The final lesson from Jenga is not about preventing movement, it's about having a profound respect for the STKY (stuff that kills you) and intelligently managing instability.

Our systems are never static. People quickly migrate to shortcuts, missions creep and variability is a constant. The true challenge for a leader is to understand how these shifts interact and where risk is silently accumulating. The objective is not to freeze operations but to manage variability so the subtle movements never collapse the tower.

Leaders who embrace the HFACS and ASMIS tools with disciplined inspections and leading-indicator metrics will find and fix missing blocks before the final pull. When leaders view their formations through this lens, recognizing the interconnected, non-linear nature of human factors, they build resilience. They step back from focusing on individuals who committed the last act to focusing on the tower as a whole and humbly striving to reinforce the entire structure. In the end, the goal isn’t to keep the tower from ever moving; it’s to ensure it never has to fall and all players in the game get to go home at the end of the mission.

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