[meadsjn]

I know about the Belknap and the Kennedy. A couple of guys came to my ship from the Belknap, and told their experiences. I followed the news of the investigations for the next few years.

That happened during maneuvering drills, at night, wherein one ship takes tactical command, and orders all the ships of the formation to maneuver from spot to spot, using coded commands from the Tactical Signal Manual. "Somone" on at least one ship misinterpreted one command, and the Kennedy and Belknap locked up side by side, with the JP5 from the JFK spilling down on the superstructure of the Belknap, feeding the flames. Ammo was cooking off and exploding in some of the magazines, and people in the berthing compartments were crawling beneath the smoke trying to find the exits.

Yes, people do make mistakes, and the investigations go on for years. But while the crazy stuff is happening, a whole lot of people are wide awake, doing their jobs, and doing their best to prevent the train wreck.

This investigation will also probably take a while.

[rlmorel]

I know. Don't get me wrong. I am in no way wishing for this to be caused by poor performance, lack of focus, or any of those things.

My point is...all it takes is a few people (even just two out of entire ship's company of hundreds of people who are doing their job correctly) to make small mistakes, at the wrong time, in the wrong place.

I admit to being somewhat obsessed with this subject, since it hits home for me, and really resonates not just because I was on a ship, or saw accidents while there...my job requires me nearly every day to evaluate things that did not work correctly, find out why, analyze workflow, systems, etc. because they can result in harm to people if they fail to work as they should. We do have failures, and the overwhelmingly vast majority of the time, nobody is harmed. But I live in a constant state of watchfulness and concern, antennae twitching, looking for signs to alert that there is something going on out of sight and mind that might manifest itself at the worst possible place and the worse possible time and cause harm. Those things you just don't foresee or predict.

When you see accidents after the fact, in retrospect, it all seems like a permanently paved road that could not be deviated from, that it was nearly pre-ordained. But it isn't like that. Things can almost always be avoided...if they are noticed and seen. I don't want to be these guys:

I post it with apologies to Gary Larson, as I told him in my head I would post no more of his cartoons because of his nice letter he wrote to the Internet community, but...this is just too on target. It is probably one of the most common human antecedents to catastrophe.