How do you manage lessons learned so they don’t become forgotten lessons revisited only after an incident that they may have prevented?
While the Bonhomme Richard may be reminiscent of the George Washington, the GW fire was 12 years ago. Many of the junior enlisted crew members of the BHR had likely not yet joined the Navy in 2008, the junior officers had not yet been accepted to the academy. And even for those sailors and officers who were, how can a single incident stay relevant in the daily lives across years of service, turnover, deployments and assignments?
We are quick to point out the last similar incident report following a major event, but what is the count on non-relevant incident reports, procedural changes, and directives issued on all manner of subjects since 2008?
We typically got the word out in our fleet with early preliminary incident reports, to be followed by alerts, bulletins, and policy changes following the official investigation. And if deemed important enough those documents would get issued again years later. And perhaps they’d be read and understood, or perhaps they’d be skimmed and marked as read. But to suggest that the each of the hundred such notifications issued each year will themselves necessarily prevent the next similar incident several years down the road is, in my opinion and experience, highly unlikely.
I struggled with this constantly in the offshore drilling world. The most effective prevention of repeat incidents is by those who learned the lesson the hard way, those who were there at the time. I have the direct topical knowledge to prevent reoccurrences of incidents that I was onboard for, but even my relief is already one step removed from that. And my contemporaries on other vessels another step farther, especially if a different class of vessel with different equipment. We will surely never forget the Deepwater Horizon, those of us in the industry at the time. But for those joining the industry today, is that really and truly anything more than a slogan?
So what is the best way to manage this, for posterity? I am still searching for that answer.