By John Cordle
A common saying in safety organizations is to consider the “half-life of scared” as a measure of the decay of institutional urgency after an accident. In 2017 the U.S. Navy lost 17 sailors in two tragic collisions that prompted an assessment of how the Navy looked at fatigue, human-centered system design, and an overzealous “can-do” attitude. The United States Fleet Forces Comprehensive Review (CR) recommended 112 corrective actions. In the ensuing two to three years, the Navy checked off all those actions as complete and built a system to ensure that the changes were enduring – as recommended by the report. Recent events, however, specifically a series of Class “A” mishaps in the past year, call into question the effectiveness of those changes across the Navy enterprise.
It was my unique honor to take part in the investigations of two of these three events, where I interviewed over a dozen Sailors who came within a few feet or seconds of losing their lives in a violent manner. It was my job to analyze these situations for signs of stress and fatigue and decide if these contributed to the incidents. I will never forget their stories.
Unfortunately, the timing and classification of these reports are such that they are not all complete as of this writing. I cannot discuss the findings here, but I encourage the CNO to have his staff bring them to him – the complete reports, not just the summaries – and read the Human Factors sections closely. I would have done this as part of my job, but as of my retirement in May of this year, both Human Factors positions in the Surface Force are vacant and unlikely to be filled soon (if at all) due to the hiring freeze and other new government personnel policies.
This action essentially “unchecks” the block for one of the major CR recommendations, ironically titled Sustaining Change: “(8.3.4.1 – Establish Human Performance Expertise at all Type Commander Staffs).” This all comes at a time when our naval forces are engaged in sustained combat operations which can easily lead to the same challenges that manifested themselves in 2017 – fatigue, poor system design, manning shortages, and an overzealous “can-do” attitude.
In letters to the last two CNOs in this forum, one in 2019 and one in 2023, I recommended that the lessons of the CR, which was primarily focused on the Surface Fleet, be applied to the entire Navy. I recommend these two articles to the CNO for action as well – before it is too late. The red flags are there – fatigue, manning shortages, and the “can do” attitude – if we are willing to look and come to grips with them.
Last year, as I was enrolling a Sailor into a sleep study on the USS Ford Carrier Strike Group, he shared that he was sleeping in the berthing compartment on the USS Fitzgerald just above where seven of his shipmates perished in the collision. He helped save some of his friends and still lives with the trauma of that day.
He shared that he was thrilled to participate in a study whose origins lie in the events of 2017. We had a friendly conversation, and he closed by asking me to “Make sure that we are not forgotten.” I told him I would do my best,” hence this letter.
Organizational drift to failure is always a risk, and an important protection against it is constant, critical self-assessment. These three mishap reports – viewed holistically – are a perfect opportunity to do just that. The question should not be “have we completed all of the CR recommendations?” But “did they work?” Recent events indicate they might not have.
A peer recently said to me, “Near misses aren’t enough to drive real change – only more deaths will do that.” I hope that is not true. The other question should be, “Would the Navy response be different if one or more of those Sailors in the LCAC, the F/A-18, or onboard the USS Harry S Truman had lost their life?”
The CNO’s appointment comes at a critical time for shipbuilding, ship repair, and warfighting. But Admiral Caudle’s well-articulated commitment to focus on Sailors’ well-being and resilience will be critically important as we prepare for potential conflict in the future. It would be tragic for us to relearn the same lessons of 2017 less than a decade later, so this is my message to the new CNO – Please consider a holistic examination of recent near misses to evaluate the effectiveness of the CR corrective actions and their application to the entire Navy.
Captain John Cordle, PhD, is a retired Surface Warfare Officer who served as a Type Commander Personnel Officer and Chief of Staff, and twice Commanding Officer of Navy warships, USS Oscar Austin (DDG-79) and USS San Jacinto (CG-56). He is the recipient of the U. S. Navy League John Paul Jones Award for Inspirational Leadership. He has been recognized as the Naval Institute and Surface Navy Association Author of the Year.
Featured Image: The guided missile destroyer USS Fitzgerald sits in Dry Dock 4 at Fleet Activities Yokosuka, Japan, for repairs and damage assessments, July 13, 2017. (U.S. Navy photo by Petty Officer 2nd Class Christian Senyk)
