The findings were the usual collection of “pilot error,
inadequate oversight of training and operations and an unprofessional command
climate”. I won’t bore you with
the details because we’ve covered them many times – every time there’s an
incident, it’s always the same litany of problems and they never get fixed.
Here’s the part I want to focus on:
“The
many findings of the investigation reconfirm our need to constantly evaluate
risks, identify unsafe conditions, and ensure internal controls are being
followed,” reads the summary.
Commanding
General of III Marine Expeditionary Force Lt. Gen. H. Stacy Clardy wrote, when
signing off on the investigation, that “we must all learn from these failures
and not repeat them,” according to the summary. (1)
These statements make me want to vomit because of their meaninglessness. We’re not going to
learn from the incident. We’re not going
to make any true corrections. We’re just
going to repeat the mistakes in the next incident.
Hey, Marines, here’s a radical thought … your report says you should
constantly “evaluate risks, identify unsafe conditions, and ensure internal
controls are being followed”. How about, just for shits and giggles, instead of
waiting for the next incident and then repeating the same report results almost
verbatim, why don’t you investigate BEFORE an incident occurs? That’s right – before. Pick any unit and any operation and
investigate it as if an incident had occurred and I guarantee you’ll find all
the same failings. Do that and you can correct the problems BEFORE they become the next fatal incident.
Hey, Gen. Clardy, if you care so much, why don’t you
investigate your force now, before they die?
_________________________________
(1)USNI News website, “Marines: Lack of Training, Command
Problems Contributed to Fatal 2018 Crash off Japan”, Megan Eckstein,
23-Sep-2019,
https://news.usni.org/2019/09/23/marines-lack-of-training-command-problems-contributed-to-fatal-2018-crash-off-japan
I'd say refueling a fast-moving jet from a slow moving Turboprop is,itself, the unnecessary unsafe condition.
ReplyDeleteBut hey, You've driven a million times without a seatbelt before, no need to wear one (or get a better KC plane) now.
"During the course of the investigation, four squadron officers were fired: the commanding officer, Lt. Col. James Compton, in April; the executive officer, the operations officer and the aviation safety officer, according to the summary."
DeleteDoesnt sound to me that the turbo-prop tanker- and fast jet refueling was the core of the problem. This would have been done 1000's over times over the last 10 years alone and would be thoroughly tested before being passed down to the squadrons for operational use so that the speed differential is not a problem in itself.
It terms of proactive investigation it seems to me you run into the problem of independence and who is doing the examining. Is group X or why really ready to face unannounced observations and inspection by potential experts who have no dog in the fight and no care about the fall out of good or bad reporting?
ReplyDeleteThat's are hard thing for most organizations to accept or buy into, they should its just hard to to do.
The same people who conduct accident investigations could conduct proactive investigations. Pretty simple concept. I'm not sure what your hesitation is.
DeleteBecause I don't think sans a lot of work to be truly independent of cost or consequence or gain those investigations would have the same weight.
DeleteI mean say take the USS Fitzgerald, or any random plane crash the FAA and NTSB look into. At the outset the fact is a massive accident happened. The ideal that somebody is to blame is or some procedure or decisions were in error does not seem out of line.
Independence rears its head if you look at the FAA and NTSB. How often has the FAA been party to regulatory capture that was only obvious after an NTSB investigation. But the NTSB is by and large not allowed to go on random problem hunts.
An investigation might have detected the culture of risk pushing that lead to either the Challenger o ring explosion of the Deep Water BP oil well issue. But in either organization before a massive mistake would that investigation have occurred or had any traction?
"I don't think ... those investigations would have the same weight."
DeleteSame weight as what? The current investigations produce pages of faults and recommendations and NONE ARE ACTED ON, at least not to any significant extent. Thus, they have no weight, now. Why would a proactive investigation be any worse? For that matter, how could it be any worse?
The potential upside is the possibility to prevent a career ending incident for leadership. There's the motivation to accept and act on a proactive finding of 'fault'. Even the Navy acknowledges that they have fostered a culture of zero defects mentality. Well, what better way to ensure zero defects during/under one's command than to implement the proactive recommendations? Thus, there is every reason for leadership to accept the proactive findings and act on them.
Consider the various commanders who have been fired over some of the recent incidents. Don't you think they would have jumped at the chance to avoid the career ending incidents by accepting proactive findings?
I'm not naïve enough to believe that a proactive investigation would completely solve the Navy's problems. Indeed not, because the main problem is incompetent leadership and they aren't going to fire themselves. However, what they might do is recognize that certification waivers are a career ending incident waiting to happen and stop the practice, for example.
"Deep Water BP oil well issue"
DeleteThe oil and gas industry is not a good parallel. Incidents are investigated rigorously and recommendations are generally implemented aggressively.
The Deepwater Horizon disaster had several hundreds of hours of exhaustive hearings and the recommendations coming out have been implemented.
IRL, the biggest change in the offshore industry came after the Piper Alpha disaster in the North Sea. 167 people dead. Lord Cullen's inquiry into the disaster is a masterpiece. His recommendations completely changed how the offshore industry works world-wide (I missed being onboard by three weeks so I had a dog in that fight).
Deepwater Horizon happened because the rules were ignored. Despite rigorous training and regular testing of everyone involved. I doubt a proactive investigation would have caught it as it was incident specific rather than a chronic condition.
" I doubt a proactive investigation would have caught it as it was incident specific rather than a chronic condition."
DeleteYou make a good point. It's very difficult to prevent isolated acts of stupidity. But, hey, if we could root out the systemic issues then we would have made a huge dent in the frequency of incidents because most incidents are systemic in nature.
The mere act of being watched changes behaviour. People will do it by the book when observed, then back to normal when the inspectors are gone. It's almost like passing a safety audit is more important than preventing accidents.
Delete"The mere act of being watched changes behaviour."
DeleteThere is an element of truth to that but it will only change the local behavior and, even then, only to a certain extent.
For example, the McCain/Fitzgerald incidents, had they been investigated when they put to sea, prior to any collision, the officers might have been a bit more alert and bridge-CIC communications might have been a bit better but the underlying problems and failed/flawed culture would have been readily visible. The certification waivers, the undermanning, the lack of training (being watched won't enable you to perform a task you don't know how to do), the culture of ignoring problems, etc. would have all been blatantly on display.
Similarly, a pre-sortie investigation of the riverine boats that were seized by Iran would have revealed the chronic lack of equipment, the chronic poor state of maintenance, the immediate mechanical problems, the lack of training, the overambitious plan, etc. that all led to the actual incident.
And so on.
" But, hey, if we could root out the systemic issues then we would have made a huge dent in the frequency of incidents because most incidents are systemic in nature."
DeleteThat is the key. I wasn't disagreeing, I was merely pointing out the oil industry does it way better than the military.
Personal experience and I have the facts to defend it on a large scale. Offshore platforms cost as much as a super carrier.
It makes a big difference when you have a P&L to defend.
@George
DeleteFair enough - sorry if you think I picked on Deep Water. But your other case Lord Cullen's inquiry it again occurred after a major accident.
So the question than is how do implement in the USN (or the Pentagon) a culture that accepts honest and penetrating post accident investigations allowed to follow mistakes or the causes for error to their root no matter who gets hurt and followed the recommend solutions.
----
"Same weight as what? The current investigations produce pages of faults and recommendations and NONE ARE ACTED ON, at least not to any significant extent. Thus, they have no weight, now. Why would a proactive investigation be any worse? For that matter, how could it be any worse?"
Because there would be almost no pressure to rock the boat (if you allow the pun).
Take again the Avenger class. By all accounts the fact one ran aground is hardly surprising. They are not maintained and their crews are ill trained, and maintenance on shore to the extent it happens is outsourced. They get hardly any sea time. They are despised by the navy who hates them and a whole list of other useful ships. So proactively if you are in any way associated with the people who make decisions in the Pentagon are you going to write a scanting pre-screwup report?
What if the commander of say the Fitzgerald had stood his ship down and resigned because of its state? Would he have any reason to believe any credible review of the state of his ship would occur?
@Kath
DeleteAgree with you. The oil and gas industry was pretty horrible pre-Piper Alpha. I had already been involved for about ten years and it was pretty scary.
The really significant thing about the Cullen Inquiry was how seriously the recommendations were taken. Everything was implemented and it completely revolutionized offshore safety culture.
To the point where the accident rate dropped so far they were able to tame down the safety training. More people were dying during training than were dying offshore which is quite remarkable looking back at where we came from.
Deepwater Horizon was about people in authority who 100% knew better getting sloppy and complacent when pressured to make faster progress by higher. Always a bad combination and that ties directly to some of the Navy's woes.
"So the question than is how do implement in the USN (or the Pentagon) a culture that accepts honest and penetrating post accident investigations"
DeleteYou do it by linking it to self-interests. You explain that by removing sources of incidents, that increases the chance of zero defects while the given commander is in command and vulnerable to mistakes by subordinates. In today's naval culture, zero defects is the goal. Link investigations (preferably pre-incident investigations) to better chances of zero defects and you'll have commanders lining up to have investigations conducted on their commands. Of course, the caveat to pre-incident investigations is that there can't be any repercussions, just rewards.
" Would he have any reason to believe any credible review of the state of his ship would occur?"
DeleteOf course not. He'd be relieved of command on the spot. You're failing to grasp what a pre-incident investigation is. It's an investigation when no incident has occurred. In your example of a CO refusing to sail his ship, that's an incident. A pre-incident investigation would be of a ship that sailed normally. Take that - a non-incident - and then check for waived certifications, undermanning, lack of training, etc. Come on, this is a pretty simple concept!
It's a natural consequence of an over staffed officer corps and an up or out promotion system. ANY mistake that gets reported kills an officer's career forever.
ReplyDeleteDemanding perfection doesn't result in perfect officers, it results in fitness reports and inspections that are a tissue of lies.
Until the military drastically cuts back its senior officer corps there won't be any way for honest proactive investigations. The investigators will find all the risks and then cover them right up.
Proactive investigations are generally a good idea. They do however suffer from the same fault as accident investigation. Without follow through they are a waste of time and ink.
ReplyDeleteAbsolutely true. However, as I described in another comment, the potential is there for action because it would serve the self-interest of career protection. See my other comment, elsewhere for a better explanation.
DeleteSometimes accidents just happen, and sweeping reforms, or the relief of a half dozen commanders isnt necessary. While in theory I agree with your idea, my fear is that it would just create another command, another staff that would get mired in its own bureauacracy, and that staff would grow complacent, as operational commands seem to have become. The Navy (and the other services) has regs, procedures, etc for everything, and they just need to be more closely followed/enforced. Maybe due to career involvement, it would create champions of safety, better procedures, etc. Maybe it is a good idea, but it feels like the knee-jerk reaction that happens after a horrific car accident, or shooting, or industrial accident that always creates more legislation that is often a reproduction of existing laws.
ReplyDeleteHow about we go back to the beginning and root cause of this ... the folks who were involved in the accident did not follow procedures, period. Pre-requisite activities leading up to participating in more demanding events also did not occur. We know how to do these things safely, but when people blatantly disregard policy and procedure, this is what happens. It takes strong leaders to instill the proper morale fortitude to do the right thing regardless of someone watching over their shoulder or not. Naval Aviation is an unforgiving activity and inherently dangerous, but … If time tested procedures are adhered to and followed, fatal and disastrous events like this one become afterthoughts, not reality. I was taught from a very early age in my flying career to one, never go on a routine training mission, no such thing. Take every flight seriously and constantly weigh the pros and cons of what you do or do not do with your airplane. I was also taught to think backwards from an accident and see what the accident board would say if you say, knocked the tail off a tanker. Hindsight is 20-20 in this case, never should have happened.
ReplyDelete