Thought this should be a new thread.
It’s a cinch we don’t use fatigue studies as an example of "lessons learned.
I think the lesson learned is primarily “don’t let anything get in the way of expediency or profit.”
If you are referring to information fatigue, then I agree that we never learn that lesson. But always putting expediency or profit first I’m not sure I agree.
Often our lessons were disseminated after investigation and review, took time and money to implement, and implementation and spend was required. This is because at the time, in the immediate aftermath, there is a push to protect revenue (profit) by preventing similar occurrences on other vessels. But not managing that through the lifecycle has the opposite effect.
My point is that in time this fades away from the forefront. Each subsequent lesson that is learned adds to the pile. And in time this pile becomes too broad to be meaningfully absorbed by onboard leadership. This is not to say that the GW fire was specific enough that the lessons were lost 12 years later. Fire prevention, I can only assume, is a primary pillar on a navy vessel. The article from the original post seems to suggest maybe the lessons learned were never actually implemented in the first place:
In the past month, far too many have sought to minimize safety culture, claiming that the USS Bonhomme Richard conflagration was due to circumstances unique to the pier-side environment, and would not happen with a full crew aboard. That is a false comfort, as the U.S. Navy has already suffered a Bonhomme Richard -like fire at sea.
The fact that exactly the same firefighting and safety deficiencies still exist little more than decade after a fire sidelined an underway and strategically critical U.S. Navy platform is inexplicable.
One area of success I’ve seen is in a dedicated shoreside manager who’s sole job was to ensure lessons learned on each vessel were implemented on the other vessels in the class. Though maybe to your point, that position was most assuredly cut in this current industry downturn to save money.
This might be the most effective way.
In my experience most DPAs or PEs will have something cross their desk and just forward it to the ship, sometimes with a note to include in next safety meeting.
For example one day a safety bulletin on confined space entry will appear randomly in the email inbox aboard but the ship will be preparing for two weeks of coast-wise cargo ops. Can either tag it “safety” and move on, print it out and give it to the C/M or have the cadet run it through the three-hole punch and file it.
Then when it’s time to actually do some tank diving it’ll be forgotten.
The task of providing safety information in a timely and effective way should be shifted shore-side. For example the port engineer could be instructed to have the ship review tank entry procedures prior to actual inspections or review the SMS and recommend updates.