Last October, I put up the “teaser post.” About this time in 1993, Capt Phil Balisle (now Admiral) came into my office and informed me I would be detailed to lead a team for Commander, Atlantic Fleet, to validate all Atlantic Fleet units properly under stood the safe employment of the NATO Sea Sparrow systems aboard their ships. The Pacific Fleet would have a team visiting their vessels, and we would work from a common set of checksheets during the course of the follow up to the investigation of the incident. I was given, from Commander Naval Air Forces, Atlantic, LCDR Don Diehl, from the Guided Missile School at Dam Neck, FTCS Goss, and from my own command, FTC Dann, and told to get to work.

The requirement levied upon us was to go to each ship, except those in such operational status that they could not show us the system, as was the case for the USS O’BANNON (DD-989), and ensure the men standing the watches were school/PQS/OJT on paper qualified, and, by practical demonstration, knowledgeable in actual operations of a simulated engagement in a training scenario.

Having already having spent some energy over the prior two years standardizing Combat Systems Assessments (CSAs) with the West Coast CSA Team, some ground work was already done, so the agreement on the plan for the standard inspection clicked quickly.

I read the report from, I believe Admiral Cebrowski, and the executive summary had some chilling words (I believe I recall them accurately):

Unfortunately, the system (NATO Sea Sparrow) worked exactly as designed.

That set the tone for where the deficiency was that turned that night into one so many would like to have gotten a “do over” card for: The people screwed up. All too often, that is the case in the course of operations. Equipment: “CHECK!” People: “Hold on, we have a problem.”

In the first few days of my assignment to this tasking, I attended a meeting set up by Commander, Air Forces, Atlantic (AIRLANT), where a large group of aviators were to determine just how many switch operations, cover lifts, or button pushes were required to get each of the weapons off any aircraft in the inventory. I think one pilot briefed than in an A-6E, it took 82 separate things to launch a Harpoon Anti-Ship Missile. So, there was sat, all morning, and after lunch, started up again. Finally, one aviator sitting at the table in front of me (I was the “shoe” in the room, so I took a cheap seat along the wall), out of frustration, made this salient comment:

If that man thinks he has permission to shoot, it doesn’t matter how many things he has to do, he’s going to launch that weapon.

The heads, mostly fighting to stay awake after hours of laboriously presented technical details, nodded in agreement. The meeting, didn’t last too much longer, for the primary point had been made by that statement. Unfortunately, as I came to understand more of the details of that night, this aviator was more correct than I would know at the time…..

More later…