USS George Washington
What’s the best way to respond to an accident?
Have an blame oriented investigation and then fire someone.
At least that’s the standard US Navy method to ensure improved performance.
The USS George Washington had a fire. Thirty-seven sailors had minor injuries while fighting the fire and $70 million dollars in damage was done.
So what was the result of the Navy’s investigation? The Commanding Officer and Executive Officer (pictured above) were fired. Obviously they were the bad guys. Firing them will fix the problems aboard the USS George Washington, a nuclear powered aircraft carrier. And fix problems across the fleet (which has been run hard during the war on terror). At least that’s what it appears from the Navy’s PR.
What! This corrective action isn’t good enough. But don’t worry … The new CO will probably discipline additional crew members. And no doubt they will caution everyone in the fleet. And … What about another fleet-wide safety stand down? The Navy likes those at least once every few years.
What “caused” the fire?
The “scuttlebutt” (Navy term for rumors – in this case from a Navy PR person) is that someone was smoking where they shouldn’t have been smoking and started a fire. (The guilty smoker has not been identified.) That fire somehow caught 90 gallons of refrigerant compressor oil ablaze. The refrigerant compressor oil was stored outside the normal flammable storage lockers. Aided by the burning oil, the fire spread through electrical cableways and the ventilation system to more flammable material in supply rooms.
Why do we have to rely on “scuttlebutt” for our info? Because the Navy has not released the “investigation” results.
What kind of investigation was conducted? The Chief of Naval Operations directed a Manual of Judge Advocate General Investigation headed by the Commander, U.S. Pacific Fleet. This is not a standard accident investigation. nothing like NTSB or CSB investigations. Advanced root cause analysis is not performed. These investigations are disciplinary in nature. People involved better have their attorney handy. Discipline is the most frequent outcome.
Being a Navy veteran, this typical action continues to make me sad. Why can’t the Navy figure out how to properly investigate operating problems and perform advanced root cause analysis? These skills should be a standard part of every officer’s “tool box.” Admirals should be demanding that TapRooT® investigations be conducted of these major operational accidents. Instead, this fire investigation can be added to the list of poor investigations and failed corrective actions that don’t address the root cause of major operating accidents. Here’s a small sample of the types of accidents I’m taking about:
It’s time for the Navy to stop pointing fingers and start finding root causes.
Then real performance improvement can begin.
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You have very accurately characterized the Navy approach to all problems aboard ship. Conduct an investigation and then fire the Captain. This allows the “big Navy” to avoid having to address the real problems.
I would suspect the George Washington was designed with insufficient flammable stowage space, thus setting it up for an accident like we have here. Now that the Captain and XO have been assigned the blame we’ll move on. Is anyone going to track down the individual(s) who designed the ship with inadequate flamable stowage? More importantly, is this lesson being identified and rolled into the design of CVN 78?
Without a real root cause analysis, we are left to guess at the causes.
Read the redacted investigation reports today following their release. The findings of fact are weak:
1. It does not appear that any true investigation took place beyond gathering statements from persons involved. What’s missing are explanations of why the persons involved did what they did. It ignores the rationality principle.
2. Where specific questions were asked, the tone of questions implies a direction that investigators wanted to lead the findings toward.
3. There are creative leaps made as to critical findings such as smoking as the source of ignition and the culpability of a junior sailor who claimed to have reported his observation of smoke in an area near the presumed site of the fire.
This is the product of an investigation done ‘by the book’. Why anyone would want to make a career of working for an organization with so little commitment to safety and addressing systemic factors is beyond my comprehension.
Thanks for your comment …
I agree with the weakness of the process used and the findings.
The “by the book” problem they are having is because they don’t have a good book to go by!
Having been an Officer in the Navy for 7 years, I can tell you that the people involved are good people – Admirals to Seaman Recruits. However, being a good person doesn’t give you the knowledge you need to analyze accidents and change performance.
Unfortunately, the officer community in the US Navy is stuck in 1960′s thinking about accidents, accident investigations, and human performance improvement. Our goal shouldn’t be to over-criticize … After all, it hasn’t been that long ago that we saw the light!
Rather, our goal should be to get them to see the light and improve their root cause analysis practices and get the fleet trained in how to solve problems.
It’s so much easier to fire the guy at the top and really find the problem