DISASTERS DON'T JUST HAPPEN

[Music] [Music] uh i've called you all together this afternoon to review the results of our recent ordinance loadout during this loadout i observed many safety violations such violations caused the disasters on the oriskany the forestall and the enterprise disasters don't just happen [Music] this is enterprise one of the world's greatest aircraft carriers but one fine day on a crowded flight deck her greatness was compromised the tow bar of one of the aircraft head on making it impossible for the starter unit to be parked in its usual position in front of and on the left side of the [Music] aircraft also the starter hose had been shortened when repaired [Music] the result hot exhaust just 18 inches away from a warhead the exploding warhead ruptured the fuel tanks of nearby aircraft and ignited their fuel the fire spread to other aircraft setting off more bombs and rockets 15 aircraft were completely destroyed three more were badly damaged total damage more than 68 million dollars but worse 28 men were killed and more than 300 men were injured many of them seriously the world's largest aircraft carrier was out of commission for six weeks [Music] this one just happened on forestall with the aircraft in pack formation pointed at one another across the deck ordnance crew members were performing stray voltage tests and making electrical connections [Music] obviously the equipment was not working and some stray voltage was undetected while the aircraft was still in the loading area the rocket was plugged in before the aircraft was pointed free and clear the safety pin was pulled [Music] the rocket that was fired hit an aircraft across the deck causing explosions and fires that spread to the other aircraft in the pack 21 aircraft were destroyed and more than 40 aircraft were damaged 134 men lost their lives and almost 100 were seriously injured this one just happened on oriskany very often there's a tendency to treat some items as harmless like parachute flares [Music] when men are tired in a hurry not properly supervised anything can happen [Music] [Applause] [Music] the smoke and fire were sucked into the living compartments trapping and asphyxiating almost all of the men in these quarters this accident that just happened caused the death of 44 men most of them might have been saved emergency oxygen breathing apparatus have been more readily available [Music] disasters don't just happen they're caught one of the causes is that supervisors are under such pressure to get the launch off that they work along with their crews instead of supervising them supervisors must avoid any activity that will interfere with their supervisory role supervisors should be aware of general safety elements such as never allowing ordinance to accumulate more than necessary and always keeping to a minimum the area and the people exposed to ordinance supervisors must be aware of new equipment or changing conditions and help their men to become aware of them also they must keep abreast of all new safety procedures and must make sure their crew members are up to date it's a continuing job a supervisor must be alert if safety precautions are not followed the potential for accidents is increased when 20 millimeter aircraft guns are armed disarmed and maintained when carriage and release checks of launching systems are not made before loading when weapons loading and hoisting equipment aren't used [Music] when hot exhausts are situated around ordinance when unauthorized tools are used in assembling ordinance when ordinance loads are not properly placed or secured on elevator platforms when familiarity with dangerous ordnance leads to a disregard for safety precautions disasters don't just happen they're caused they're caused by untrained and fatigued personnel the information needed to prevent these major disasters from happening again is contained in the manual remember enterprise so remember forestall [Music] remember oriskany um it's a matter of record that disasters don't happen when crews are well trained and well supervised and when all safety procedures are strictly followed it's a matter of record that disasters don't just happen [Music] so so you