Not Learning from Previous Incidents: Horror Stories

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Not Learning from Previous Incidents: Horror Stories
🔥 I recently watched a review of the fire aboard the USS Bonhomme Richard on July 12, 2020. The fire occurred while the amphibious assault ship was undergoing maintenance at Naval Base San Diego. The fire resulted in more than $3 billion dollars in damage and ended up with the ship being decommissioned and sold for scrap metal. Even for non-military leaders there is an important crisis management lesson to learn from this tragic event.

You see, the handling of this fire is an example of a crisis going worse because lessons were not learned from previous ship fires. It is not unusual for disasters and crises to have been exacerbated because incident commanders repeat mistakes from the past. In addition to failure to learn from the past, inexperience also played into the mismanagement of the fire.

The following issues played into the fire's uncontrollable growth:
1. It was the first day that the Command Duty Officer (CDO) was in charge of the ship.
2. The fire risk aboard the Bonhomme was significantly higher during maintenance than when it is underway at sea.
A. 87% of the 187 fire attack stations were out of service (OOS) due to construction or lack of maintenance. The ones that were in service were indistinguishable from those not working.
B. Aqueous Film Forming Foam systems were (OOS).
C. The automatic fire sprinkler systems were OOS.
3. Smoke was noted early on but disregarded by a sailor on board the vessel.
4. Smoke was reported to the Officer of the Deck (OOD) 10 minutes later but no response was generated as of yet.
5. The OOD contacted Damage Control (DC) and the CDO. Only then was an attempt made to notify the crew of the fire however, the public address system (1MC) was also OOS in most of the ship.
6. The base fire department, Federal Fire Department (FFD) responds to the fire after a 9-1-1 call from outside the ship.
7. Upon interfacing with the CDO, FFD received no actionable information causing FFD to take independent action and waste much time, staffing, and resources.
8. San Diego City Fire (SDC) and other fire departments respond to the Bonhomme. Their attempts to attack the fire were thwarted because they had no common communications with FFD. The lack of interoperability led to less efficiency and effectiveness in the fire attack.
9. FFD and SDC fire hoses were incompatible with the shipboard firefighting system and no one had adaptors to overcome this set back. This is a direct lack of learning from the Oakland Hills Fire in which hundreds of homes were lost because Oakland's equipment was incompatible with the rest of the departments in California.
10. The Commanding Officer, the Executive Officer, and the CDO failed to integrate the fire departments.
11. There was ambiguity in who was in charge of the responding units; it was thought at one point that FFD was running the incident.
12. 90 minutes after the fire starts, the Fire Chiefs noted an increase in smoke production and rate.
13. An hour later, the Fire Chiefs pulled their people from the ship and a few minutes after all personnel had evacuated the ship, there was a huge explosion.
14. From that point on no more direct attacks were attempted and extinguishment efforts were relegated to fire boats and helicopters.
15. The fire continues for 4-5 days and causes over 3 billion dollars in damage resulting in destruction of the ship and the court martial of several officers.

Overall, the lack of effective decision making, effective use of resources, allowing fire systems to degrade, having incompatible fire systems, a lack of interoperability between fire departments, lack of training for Naval personnel, ineffective pre-fire planning, and fire prevention efforts, led to the devastation of one of America's premier warships.

Being leaders, we all must know the history of our particular organization (and our industry!) to understand our main risks, so we can avoid and effectively counter them in case of any new event.

⇨ What crisis management lessons not learned do you have to share?

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