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One of Canada's New Navy Ships Stopped in Hawaii After Taking on Water- July 23/ 2024

That would require a open communication and learning environment, like when your ship catches fire, afterwards, you openly share the report so people can learn what went right and wrong and how to avoid catching fire in the first place.
Woah woah tabernac, that's not how we roll!

In all seriousness, making slow progress there, but at least have an easy to use reporting system in sharepoint so getting better, and starting to get folks in the habit of attaching the investigation reports, photos, videos etc to that same incident report on sharepoint so it's a one stop shop.

Doesn't mean things like the BOIs are there, or the lessons learned from the existing recent fire investigations are taken onboard (pretty much none of the FRE fire recommendations from 2021 were formally implemented), but still, some progress.

Honestly seems like we need a major incident with ships lost or people killed for things to get on the radar for a while, but prevention isn't sexy like missiles so quickly falls off the radar of the operators.
 
Honestly seems like we need a major incident with ships lost or people killed for things to get on the radar for a while, but prevention isn't sexy like missiles so quickly falls off the radar of the operators.

In other big organizations the most senior leaders will stand up, tell truth to power, and lead improvements.

Does that not happen in the Navy?
 
Woah woah tabernac, that's not how we roll!

In all seriousness, making slow progress there, but at least have an easy to use reporting system in sharepoint so getting better, and starting to get folks in the habit of attaching the investigation reports, photos, videos etc to that same incident report on sharepoint so it's a one stop shop.

Doesn't mean things like the BOIs are there, or the lessons learned from the existing recent fire investigations are taken onboard (pretty much none of the FRE fire recommendations from 2021 were formally implemented), but still, some progress.

Honestly seems like we need a major incident with ships lost or people killed for things to get on the radar for a while, but prevention isn't sexy like missiles so quickly falls off the radar of the operators.
At Seaspan, they have a "Flash report" Anytime an incident happens like a near miss accident, fire, anything leading to damaged equipment , injury minor or major. A report is made about what happened, how it happened and steps to avoid a repeat. That is sent within a week or so throughout the different sites as part of the learning/safety culture. Each one is no more than 2 pages with pictures.
 
At Seaspan, they have a "Flash report" Anytime an incident happens like a near miss accident, fire, anything leading to damaged equipment , injury minor or major. A report is made about what happened, how it happened and steps to avoid a repeat. That is sent within a week or so throughout the different sites as part of the learning/safety culture. Each one is no more than 2 pages with pictures.
Yeah, I saw that during rounds of the yard, it's a good system. The airforce has something similar on the flight safety side, and it's discussed at their o-groups.

In the RCN, rumours float around and a lot of half truths and falsehoods hit the mill. Usually the actual lessons learned aren't, and what's worse is things that are actively factually wrong turn into gospel and undermines the usage of our equipment and approved tactics.

Folks were (are?) thinking that they would get cooked like a lobster in damp bunker gear (so can't fight a fire in a space with water mist running), that AFFF sprinklers would kill the equipment (despite the IP56 rating), that cutting a hole in the steel structure using an exothermic torch to vent a fire is a good idea, and that being in a space when halon goes off will kill you.

The AFFF example lead to the loss of PRO, so it's not really trivial misunderstandings.

The exothermic torch things was particularly stupid, and was actually an SOP on paper in one ship for a bit with designated cut points (including on the strength deck, despite how important the name indicates it is). Fortunately we now have standard SOPs with a simple flow chart to follow along that we drill to, but some of that pops up once in a while.
 
Yeah, I saw that during rounds of the yard, it's a good system. The airforce has something similar on the flight safety side, and it's discussed at their o-groups.
Not just O-groups and morning briefs - everyone gets sent the report and reads it. Crews discuss it as part of lessons learned processes.

The main cultural change to overcome is not to assign blame.
 
Not just O-groups and morning briefs - everyone gets sent the report and reads it. Crews discuss it as part of lessons learned processes.

The main cultural change to overcome is not to assign blame.
For sure, although sometimes blame really should be assigned. There is a fine line between open investigations and lessons learned and straight up incompetence or blatant negligence.

It's a good system though, and would prefer it to the RCN approach to bury everything, learn nothing, and then if someone is blamed, do it unofficially and arbitrarily, based on who has friends in the BOI or investigation.
 
Not just O-groups and morning briefs - everyone gets sent the report and reads it. Crews discuss it as part of lessons learned processes.

The main cultural change to overcome is not to assign blame.
Blame is not assigned by the flight safety system. Information and statements gathered by the flight safety system are protected by law from being used for any other purpose than flight safety.

In cases where there is clear negligence or malfeasance, collateral investigations can and are routinely commenced and administrative/disciplinary action taken where warranted.

Safety in aviation is not a get out of jail free card…
 
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