Even the U.S. military

In 2019, ProPublica published a deeply researched series of stories called Disaster in the Pacific: Death and Neglect in the 7th Fleet about fatal military accidents at sea. As in all accidents, there are many contributing factors, as detailed in these stories. In this post I’m going to focus on one particular factor, as illustrated in the following story excerpts (emphasis mine)

The December 2018 flight was part of a week of hastily planned exercises that would test how prepared Fighter Attack Squadron 242 was for war with North Korea. But the entire squadron, not just Resilard, had been struggling for months to maintain their basic skills. Flying a fighter jet is a highly perishable skill, but training hours had been elusive. Repairs to jets were delayed. Pleadings up the chain of command for help and relief went ignored.

Everyone believes us to be under-resourced, under-manned,” the squadron’s commander wrote to his superiors months earlier.

Faulty Equipment, Lapsed Training, Repeated Warnings: How a Preventable Disaster Killed Six Marines by Robert Faturechi, Megan Rose and T. Christian Miller, December 30, 2019

The review offered a critique of the Navy’s drive to save money by installing new technology rather than investing in training for its sailors.

“There is a tendency of designers to add automation based on economic benefits (e.g., reducing manning, consolidating discrete controls, using networked systems to manage obsolescence),” the report said, “without considering the effect to operators who are trained and proficient in operating legacy equipment.”

Collision Course by T. Christian Miller, Megan Rose, Robert Faturechi and Agnes Chang, December 20, 2019

The fleet was short of sailors, and those it had were often poorly trained and worked to exhaustion. Its warships were falling apart, and a bruising, ceaseless pace of operations meant there was little chance to get necessary repairs done. The very top of the Navy was consumed with buying new, more sophisticated ships, even as its sailors struggled to master and hold together those they had. The Pentagon, half a world away, was signing off on requests for ships to carry out more and more missions.

The risks were obvious, and Aucoin repeatedly warned his superiors about them. During video conferences, he detailed his fleet’s pressing needs and the hazards of not addressing them. He compiled data showing that the unrelenting demands on his ships and sailors were unsustainable. He pleaded with his bosses to acknowledge the vulnerability of the 7th Fleet.

Years of Warnings, Then Death and Disaster by Robert Faturechi, Megan Rose and T. Christian Miller, February 7, 2019

Then there was the crew. In those eight months, nearly 40 percent of the Fitzgerald’s crew had turned over. The Navy replaced them with younger, less-seasoned sailors and officers, leaving the Fitzgerald with the highest percentage of new crew members of any destroyer in the fleet. But naval commanders had skimped even further, cutting into the number of sailors Benson needed to keep the ship running smoothly. The Fitzgerald had around 270 people total — short of the 303 sailors called for by the Navy.

Key positions were vacant, despite repeated requests from the Fitzgerald to Navy higher-ups. The senior enlisted quartermaster position — charged with training inexperienced sailors to steer the ship — had gone unfilled for more than two years. The technician in charge of the ship’s radar was on medical leave, with no replacement. The personnel shortages made it difficult to post watches on both the starboard and port sides of the ship, a once-common Navy practice.

When the ship set sail in February 2017, it was supposed to be for a short training mission for its green crew. Instead, the Navy never allowed the Fitzgerald to return to Yokosuka. North Korea was launching missiles on a regular basis. China was aggressively sending warships to pursue its territorial claims to disputed islands off its coast. Seventh Fleet commanders deployed the Fitzgerald like a pinch hitter, repeatedly assigning it new missions to complete.

Death and Valor on an American Warship Doomed by its Own Navy, by T. Christian Miller, Megan Rose and Robert Faturechi, February 6, 2019

The U.S. Department of Defense may be the best-resourced organization in all of human history, with a 2020 budget of $738 billion. And yet, despite this fact, we still see a lack of resources as a contributing factor in the fatal U.S. military accidents described above.

The brutal reality is that, just because an organization is well resourced, does not exempt it from production pressures! Instead, a heavily resourced organization will have a larger scope: it will be asked to do more. As described in one of these excerpts, the Navy was focused on procuring new ships, at the expense of the state of the existing ones.

Lawrence Hirschhorn made the observation that every system is stretched to operate at its capacity, which is known as the law of stretched systems. Being given more resources means that you will eventually be asked to do more.

Not even the mighty U.S. Department of Defense can escape the adaptive universe.

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