To students of safety and accident prevention, the recent collisions involving the guided missile destroyers USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) seem strange. How can this happen with top shelf modern warships, equipped with state-of-the-art electronics, radar and GPS? Hint: look for human performance issues, and a culture of blame and punishment.

These are tragic accidents, with unnecessary loss of lives. The Navy’s immediate response was a 24-hour “safety stand down,” and a 60-day review of surface fleet operations, training, and certification. Perhaps more significantly, the Seventh Fleet commander Vice Admiral Aucoin was fired, due to a “loss of confidence in his ability to command.”

And this is where the problems start. To an outside observer, the Navy culture of “firing those responsible” seems very old fashioned. Not only do we waste money on repairing ship damage that should never have happened, we also voluntarily get rid of a large investment in recruiting and training with each officer let go.

A better answer is to analyze what happened in each case, find the root causes and put in place corrective actions to prevent the same accidents from happening again. The Navy investigation results are classified, but let me offer up two possible causes:

1. Guided missile destroyers are smaller, leaner and meaner than the conventional destroyers they replaced. They sail with a smaller crew and fewer officers. However, there is still the same amount of horizon to scan, so to say, so officers will have larger spans of responsibility and fewer opportunities to rest. Fatigue is a powerful influence on human performance.

2. The world is a dangerous place, and getting worse. A shrinking Navy is deployed on the same number of missions around the world, not allowing enough time in between for maintenance of ships and systems. Training and development of crews also suffers.

Our long experience in root cause analysis tells us that no matter how sophisticated systems or equipment are, they need maintenance to work properly. There is also always human factors involved. Human performance is fickle, and influenced by many factors such as fatigue, alertness, training, or layout of control panels. It is better to do a thorough RCA to identify causal factors and fix them, than to fire people up and down the chain of command and still have the same issues again later.

#TapRooT_RCA