You may recall the deaths of two SEALs back in Jan 2024, off
Yemen, during a night boarding operation in poor weather with 6 ft seas. One man slipped while climbing a scaling
ladder and fell into the sea. The second
man dove in to assist the first man who was struggling to regain the ladder. The Navy’s report states that the deaths were
preventable and attributes the deaths to,
The Navy identified what they consider the root cause of the
tragedy to be:
In this instance, the root cause was not the SEAL’s lack of
familiarity with the flotation equipment.
That was a low level cause but nowhere near the true root cause.
Moving up the root cause chain a bit, the person who
selected/specified unfamiliar equipment for the unit was a cause but, again,
not the root cause.
Proceeding further up the root cause chain, the assignment by
leadership of a mission in questionable weather by inadequately trained personnel
was a higher level cause but, again, not the true root cause. This is similar to whoever assigned the
riverine boats a mission beyond their capabilities which resulted in the boats
and crews being seized by Iran.
The true(er) root cause, then, was high level Navy
leadership who were unaware (or uncaring) of the equipment and level of
training of the unit and proceeded to assign a mission anyway under very
questionable weather conditions.
The truly ultimate root cause was a Navy system that
encouraged lackadaisical training, a never say no culture, an ignorance of real
world conditions, and a lack of personal responsibility towards those under
their command. To be clear, I’m talking
about SecNav and Chief of Naval Operations who fostered a flawed culture. This flawed culture has been evident
repeatedly in collisions, groundings, waivers leading to fatalities, capsized
amphibious vehicles, a surrender rather than fight mentality, acquisition
failures and coverups, prioritizing social issues over combat readiness, and so
on. There can be no disputing the failed
culture of the Navy.
Aside from the root cause, there is another aspect to this
tragedy and that is personal responsibility.
Frankly, given the SEALs supposed creed of attention to detail, I’m
astounded that they would embark on a mission with unfamiliar equipment and
known shortcomings in their training. I
know they (and the Navy/military, in general) have a ‘can do’ attitude (arrogance,
when it comes down to it) that drives them to do foolish things but there comes
a point where personal responsibility comes into play. In addition to knowingly endangering
themselves, each SEAL knowingly allowed their fellow SEALs to begin a mission
that they knew their fellows were not adequately trained or prepared for and
that danger was compounded by the darkness and weather conditions. Even if they wish to ignore the danger to
themselves, each SEAL is obligated to be responsible for his fellow team
members if he sees them about to do something foolish. Each SEAL member failed their obligation to
their teammates.
I’m deeply disappointed in the SEALs individually and as a
group culture.
Some of you may be offended by this analysis but that
doesn’t change the reality.
_____________________________
The cause of the deaths was attributed to poor training, unfamiliarity with flotation gear, and possible improper maintenance of personal flotation devices.[1]It is also noteworthy that the men were heavily loaded with gear.
Each SEAL carried about 50 pounds of personal and mission equipment. Navy Special Warfare Operator 1st Class Nathan Gage Ingram, 27, dived into the sea to assist Chambers. Ingram is believed to have carried about 80 pounds of gear when he dived in.[1]Diving into high seas with 50-80 lbs of gear is not a formula for success.
The root cause of the incident was unfamiliarity with personal flotation gear and a lack of standard procedure for using, training with, or wearing it.
Other team members told investigators that while they knew the importance of their tactical flotation system — which includes two inflatable floats that attach to a belt and foam inserts that can be added — few had ever operated one in training and there is little instruction on how to wear it.[1]Contray to the Navy's claim, that is not the root cause and the statement clearly indicates that the Navy doesn’t have the faintest idea what the term ‘root cause’ means or how to conduct a root cause analysis. A root cause is the ultimate reason something occurs and, inevitably, produces a cascading chain of lesser causes leading to the event itself. Almost invariably, the true root cause of anything lies with flawed leadership at fairly high levels and, almost inevitably, organizations stop their root cause analysis at a low level, well before they get to the true, upper level (leadership) cause (I wonder why they stop, he asked sarcastically, knowing exactly why).
https://redstate.com/streiff/2024/10/12/investigation-reveals-drowning-of-two-navy-seals-during-a-boarding-operation-was-entirely-preventable-n2180468
Not offended. You nailed it.
ReplyDeleteI read somewhere that the sea state was too high but the area SpecOps commander was an Army ranger who okayed doing the mission anyway.
ReplyDeleteI don't know why ships can't use a small crane like boom to swing boarders onto nearby boats. Either with a rope ladder or may be rappeling rope. Much faster and safer.
I never liked the idea that a SpecOps guy can be trained to do everything well. SEALS spend too much time doing army commando missions rather than Naval missions. I once wrote an article about this:
https://www.g2mil.com/commandos.htm
Of course a Mark VI patrol boat is much better suited for such missions but our great naval force has none. This should be a basic mission for US Marines, nothing really SpecOps about boarding and searching boats. But the Marines have little interest in basic naval infantry missions.
You may enjoy this post: SEALs
DeleteI have read more than a couple SEAL memoirs that would validate G2mil's belief that they do "army commando" operations too much. Fact is, they have spent more time in the mountains of Afghanistan than anywhere near the ocean. Most I've read even specified they had no interest in old school Frogman operations at all.
ReplyDeleteIn recent SpecOps competitions the Army's Special Forces scuba unit regularly beat SEALS in actual seaborne ops.
This is a job the Coast Guard has done in the gulf for decades now. Not to short change the USCG, but shouldn't a SEAL team be at least as well trained as a CG boarding team?
You may recall this post: SEALs
DeleteThanks for the reminder! I had forgotten that article.
DeleteThere are many things that SEALs can do to help the NAVY...the branch it supposedly belongs to. But being just another "elite unit" isn't what the Navy needs. If they need elite infantry then that should be what elite Marine units like the old Marine Raiders.
Mission creep has often turned into Mission confusion. The SEALs are no different than any other part of the Navy dept. We build every ship that isn't a carrier to be a do everything destroyer, and the Marines want to sink ships. We need to start having the various pats of the Navy and associated services stay in their own lane.
SEALs are secret squirrels that do sabotage, recon, and other navy duties first. The Coast Guard does LE boarding. Marines kill people and break things that aren't at sea. The Navy doesn't "show the flag" they sink enemy flags.
"I had forgotten that article."
DeleteForgotten???? Most people spend an hour or two every evening reading through the archives so they don't forget the accumulated wisdom of the blog! A bowl of ice cream and a couple hours reading the blog is a great way to spend the evening!
A root cause is something that if removed stops the chain of events that led to an accident according to Navy SIB so we need something that can fix the problem by only its removal.
ReplyDeleteYou are right to point to leadership. There is little supervision of training, little leadership involvement in mission planning, a fame seeking culture among SEALS that prizes doing tough missions to brag about in Instagram, and leaders who fail to supervise and then fame to publicly excuse his failures by blaming it on performance enhancing drugs that he failed in his responsibility to monitor.
SIBs are made to provide 4 options: operator error, lack of training, lack of maintenance or lack of Supervision. Only operator error are not the fault of a commander.
"A root cause is something that if removed stops the chain of events that led to an accident"
DeleteNo, sorry, that's incorrect and explains why both you and Navy have it wrong and fail to identify the true root cause. Here's a definition of root cause from the American Society for Quality website:
"The root cause is the core issue—the highest-level cause—that sets in motion the entire cause-and-effect reaction that ultimately leads to the problem(s)."
Note the reference to "the highest-level cause". This is the ultimate, true root cause (hence, the term 'root' cause).
What you and the Navy are doing is identifying low level causes, almost at random. Again, from the ASQ website:
"Some RCA [root cause analysis] approaches are geared more toward identifying true root causes than others, some are more general problem-solving techniques, and others simply offer support for the core activity of root cause analysis."
What you and the Navy are doing is identifying some of the causes in the incident chain of events. As you note, removal of any one of the links in the chain may have prevented the immediate incident, HOWEVER, unless the true root cause is identified, the problem is guaranteed to recur. For example, removing the lack of training on the particular flotation device might have prevented the incident but since the root cause of the flawed culture would persist, the problem would just manifest itself again, in some other way. In other words, the flawed culture ensures that the lackadaisical attitudes and so forth would make themselves felt even if you remove one specific link. It's like playing whack-a-mole. You may 'beat down' one mistake but others will rear their heads due to the flawed culture. On the other hand, if you remove the flawed culture and replace it with a good culture, all the potential incident chain links will be removed. That's what a true root cause is and does!
The failure to recognize what root cause really means ensures that the Navy won't fix the problem. This is why we've seen an unending sequence of groundings, collisions, fires, sinkings, and fatalities ... all due to the SAME root cause.
This is not merely a semantic debate on my part. Truly understanding - and identifying - what a root cause is, is the ONLY way to implement real change and improvement.
Here's a timely example of a root cause that is identical to that which we just discussed in the post. This one is from an independent group tasked with reporting on the Secret Service failure in the Trump assassination attempt. The group's conclusion was that the entire SS leadership had to go due to the pervasive failed culture or the organization. Sound familiar? Here's the link to the article: Secret Service Root Cause
Delete