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2022 CONCLUSION | Human factor analysis

2022 CONCLUSION | Human factor analysis

by Starling Insights

Starling Insights Editorial Board

May 15, 2022


The US Navy has struggled with “preventable” accidents, to include onboard ship fires such as that which cost it the amphibious assault ship USS Bonhomme Richard in July 2020, while moored pier-side in San Diego.1 Last October, the Navy released a report into the causes — after investigating similar incidents that had occurred in the last dozen years.2

“Human factors analysis of root causes was performed to find common causes,” read the Command Investigation into the circumstances surrounding the fire.3 “Top causes were found to be procedural compliance, inadequate risk assessment, and lack of command or supervisory oversight.” The loss of the Bonhomme Richard was “completely preventable,” concluded Vice Chief of Naval Operations, Admiral William Lescher — the Navy’s second-highest ranking commissioned officer.

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