634: Human Error in Volatile Situations

Ira Glass

In November 1979, at the Nuclear Defense Command Headquarters inside Cheyenne Mountain in Colorado, computer screens suddenly showed that Soviets had launched nuclear missiles, hundreds of them, a full-scale attack on the United States. The military response was fast and dramatic. Crews responsible for launching our missiles were put on highest alert. Fighter jets took off.

Before the president was asked to decide whether to retaliate, one person, a watch commander, thought something was not right and threw on the brakes. It was later discovered that a technician had accidentally put a training exercise into the computer simulating a full-scale attack. This kind of mistake, the technician who put the training exercise into the computer, is squarely in the category of human error.

And human error mistakes are especially terrifying because you never can fully do away with them. We are just prone to error. Fortunately, most of us work jobs where the mistakes we make do not result in millions of people dead or anybody dead.

But if you work for the US military, even when we're not at war, you can be surrounded at your job by gear whose whole purpose is to kill people. And so you can make mistakes on a scale the rest of us can't. Today on our program, we have two stories like that.

In both of these stories, the slip-ups that people make are so small. They're mistakes that, at most jobs, would mean nothing, mistakes maybe you've made yourself. One involves missiles. One involves ships.

From WBEZ Chicago, it's This American Life. I'm Ira Glass. Stay with us. And we begin with act one.

Ira Glass

Act One, The Wrong Tool For The Job. It's really easy for America's nuclear weapons to seem very abstract, right? We know they're out there. But it's like-- I don't know. In our minds, I think we picture like they're sitting somewhere. The power's turned off. They're parked in some missile silos, or airplane hangars, or something.

And they're there, dark until some terrible situation. And then somebody enters secret codes. And then the power goes on, and they rise from the Earth like something out of a Michael Bay movie.

But, of course, reality is not like that at all. In real life, the country's nuclear weapons are thousands of high-tech, very complicated machines. And the lights are not out. Things are happening.

They need to be cleaned and taken care of and monitored by tons of people day and night, all the time. And things can go wrong. Joe Richman has this example.

Joe Richman

Back in September 1980, September 18, Jeff Plumb climbed into his pickup and headed toward the nuclear missile silo near a tiny town in Arkansas called Damascus. He was a 19-year-old missile technician, a new trainee, riding with another guy, David Powell, who was showing Plumb the ropes.

Joe Richman

Plumb was a city kid from near Detroit. He remembers sitting in the truck that day watching the farms and fields fly by until eventually the truck slowed, pulled into a gravel road in the middle of nowhere, passed through some woods, and came to a fence. There wasn't much to see, a concrete slab with a handful of radio antennas sticking up out of the ground. Under that concrete slab, though, was a 146-foot silo, like an inverted 14-story building.

To get in was a sequence of gates, phones, secret codes, several super secure metal and concrete doors. And then at the bottom of the stairs, you could go two directions. Down one hall was the complex's three-story underground command center with all the communications equipment and computers and staff. A second hallway led to the missile silo.

Joe Richman

The missile in the silo that day, the one Jeff Plumb was describing, was called the Titan II. At the time, the Titan II was the most powerful nuclear weapon in the American arsenal. One of them, just one, could unleash the same power as all the bombs dropped in World War II, including the atomic bombs, times three-- all the bombs in World War II times three.

But besides being America's most powerful nuclear missiles, the Titan IIs were also some of the oldest. One especially dangerous and aging part of the Titan II missile was its fuel system. By 1980, most nuclear weapons had switched to solid fuel.

But when the Titan II was developed in the 1960s, nuclear weapons used liquid fuel. Liquid fuel meant that we took a nuclear warhead, and we put it on top of two gigantic tanks and filled those tanks with incredibly volatile liquids. One tank was rocket fuel. The other was something called oxidizer. Greg Devlin also worked on the Titan II missiles.

Joe Richman

But even if you didn't mix these fuels, they were extremely dangerous. The oxidizer on its own was a Class A poison, the most toxic category for any chemical. It could ignite spontaneously if it touched leather, paper, cloth, wood. The fuel could ignite if it touched rust, or even if it didn't touch anything. If there were enough fumes and you waved your hand too fast, it could explode.

Joe Richman

The teams that handled this hazardous stuff were called propellant transfer systems teams, or PTS teams. Surprisingly young guys-- 18, 19, 20 years old-- they were known for partying hard, speeding, driving motorcycles. Sometimes they would do this thing where they would put missile fuel in a bucket. Then they would take a ping pong ball, fill it with oxidizer, and toss it in the bucket and watch it blow up, like Mad Max beer pong.

These were the teams that David Powell was training Jeff Plumb to be a part of. Here's Plumb.

Joe Richman

So we're in the silo. Jeff Plumb and his trainer David Powell are ready to get to work on a job that was routine maintenance. One of the missile's fuel tanks was low on pressure. So the job was just to take off something called the dust cap, kind of like a gas cap but on a nuclear missile. Then they'd have to pump in more liquid, and voila. That was it. Except before they could start--

Joe Richman

The hydraulic platform went up and down the side of the missile, like a platform for window washers on a highrise. And it was broken. It's worth knowing these fuel tech jobs, PTS jobs, had actually gotten to be more and more of a grind around this time because the missiles were aging.

Joe Richman

So there was more work to do without more people to do it, which meant PTS guys like Powell and Plumb were increasingly overworked and burned out, hustling from one missile to another to patch them up, regularly pulling 12- and 14-hour days. And now Plumb and Powell had to wait to do this routine maintenance job in the afternoon of a long day.

Joe Richman

Finally, they got word the hydraulic platform was up and running. So boom, green light. Plumb and Powell suited up in protective gear. Picture the guys who kidnapped E.T. And they head down the hall towards the missile silo, ready for action.

Joe Richman

After hours of waiting, Plumb and Powell had left this crucial tool, the torque wrench, in their truck all the way up on the surface. It was kind of like forgetting your cell phone in your house, if your house had a bunch of enormous concrete and metal doors and required a secret code to get in. It was a pain in the ass on a long, irritating day.

Jeff Plumb says personally he didn't know what to do. He was just learning. And the procedures, they were so meticulously laid out. You had to follow these detailed checklists. You needed the right tools.

Joe Richman

So Plumb's like, what do we do? And he looked at David Powell. And Powell said, don't worry. For what they were about to do, there was actually another tool, not the official one. But he'd used it before, so forget the torque wrench. It'll be fine.

Joe Richman

Plumb looked at this wrench, like a three-foot Willy Wonka type wrench. And he wasn't so sure about it. And this giant socket wrench, besides being kind of the wrong tool, a huge, cumbersome wrong tool, it wasn't in the best shape. The two pieces of the wrench were supposed to click together, but they didn't.

Joe Richman

Here's what they did. One guy held the socket over this thing they had to remove, the dust cap. The second guy held the huge handle of the ratchet and turned. Sure enough, the cap screwed right off. It worked, no problem. Great. So Plumb hands the socket off to Powell.

Joe Richman

Just to make sure you're picturing this, Plumb and Powell were working way up in the silo, like window washers on the side of a nuclear missile, on a platform. Attached to the platform was this rubber bumper that was supposed to fit right up against the missile, so there was no gap for things to fall through. But as the Titan II facilities had aged, the rubber bumper didn't fit quite right. And so there was a small gap, a socket-sized gap.

Joe Richman

There's a hierarchy of not good. And this kind of not good might be at the top. This kind of not good was deadly, skin-melting, highly explosive rocket fuel spraying out of a 100-foot tall intercontinental ballistic missile. On top of that missile sat the most powerful nuclear warhead in the United States of America.

Joe Richman

On the other end of the radio was the missile complex's command center, a three-story underground bunker filled with monitoring equipment, control panels, and a team staffing all of it. On that team was a guy named Allan Childers. Unlike the PTS teams, Childers was an officer. And he didn't just know a few specifics or mechanics of the Titan II. Allan Childers knew the missile inside and out.

He'd spent six months studying it, reading a manual called the Dash-1 which laid out every piece of how the massive weapon worked. He and his crew spent most of their time using detailed checklists, going over all the missile systems one by one. Childers was standing behind a control panel when the call from Powell and Plumb came in.

Joe Richman

Just moments later, Plumb and Powell had made their way from the silo back to the command center. When they got there, they found a huge scramble, everyone besides them trying to figure out what the problem was.

Joe Richman

To be clear, faced with the fuel gushing out of the missile and now the command center firing questions at them, Dave Powell made a choice. It was the kind of choice you make when you're afraid of getting in trouble. He played dumb. He told them there was smoke in the silo, but nothing about the hole they had punched in the missile.

Jeff Plumb made his own version of that decision, which was to keep quiet and follow Powell's lead. That created a crucial knowledge gap in the room. On the other side of that gap, Allan Childers and the rest of the command staff were left to scramble desperately, frantic to figure out what was wrong.

All of that mattered because, if all the fuel leaked out, it's not like the missile would just sit there empty. The Titan II's fuel tanks were pressurized, like a tire. And if enough fuel leaked out, it would go flat. Or in the missile's case, it would collapse under its own weight. Enough oxidizer and fuel to carry a 330,000-pound missile across the ocean would smash together underneath a nuclear warhead.

Joe Richman

There were so many questions. How fast was the fuel leaking? When could the missile collapse? Could the silo contain the explosion? Could an explosion set off the nuclear warhead? Minute by minute by minute, Plumb stood silent, unsure what to do.

Joe Richman

With Plumb and Powell holding out, Allan Childers and the team in the command center was slowly running out of options.

Joe Richman

Eventually, a guy from the command center team, Rodney Holder, turned to Plumb and Powell.

Joe Richman

As news of what had happened traveled up the Air Force chain of command, everyone at the missile site was instructed to wait. To wait, of course, mind you, inside a nuclear missile complex teetering on the brink of a massive explosion. Just sit tight. Quite a bit of time went by like that, couple of hours actually.

One of the main questions was whether to keep the missile teams underground, try to somehow, somehow fix the leak. Or is it bound to blow up, and you should get everyone out, run like hell, and hope the nuclear warhead doesn't go off? Or maybe a surprising question, is the command center actually the safest place for them?

Joe Richman

Eventually, it was a colonel named John Moser back at the Air Force base in Little Rock who made the decision. He knew the command center was designed to survive a nuclear attack, like a direct hit from a Russian nuclear missile. But how could he be sure? Nothing like this had ever happened before. They were off the map.

Joe Richman

Allan Childers, back in the underground command center, disagreed with Moser's decision. He argued.

Joe Richman

Allan Childers made this case. He knew the Titan II missile inside and out. He knew the dangers, what could happen. He was staring at the United States on the brink of maybe setting off its most powerful nuclear missile right in the heart of the country.

He clung to any hope to do something, anything to claw the situation back. But Childers wasn't in charge. And eventually orders came down, and Allan Childers and everyone else in the Damascus missile complex evacuated.

With the benefit of hindsight, we can say that from this point forward, at every point in this story when the Air Force made a decision, it arguably made the wrong decision. Here, the Air Force ordered them to abandon post. The order was to evacuate through the complex's escape hatch, which had never been used before. It was a narrow tunnel that led to a ladder, which took them several stories back up to the surface. Greg Devlin was above ground with a bunch of backup teams from the Little Rock Air Force Base.

Joe Richman

And then with everyone on the surface, it seems the Air Force realized what Allan Childers had been arguing all along. That the best shot at diffusing this crisis, the only way to know what was up in the silo, was to have people inside. So you guessed it. They ordered two people to go back in.

Again here, the Air Force zigged when it should have zagged. The order was not to go in the open escape hatch which everyone had just come out of. Instead, they told the folks on-site they should break in through the front doors of the missile complex.

With precious time ticking away, don't go through the back door, which is sitting wide open. No, break through the front door of one of the US military's most secure facilities. Or front doors is more like it-- huge, concrete, and secure metal doors-- using only these tools-- a crowbar, a hammer, a long screwdriver, a bolt cutter, and a hydraulic hand pump.

It's worth also mentioning had Allan Childers stayed in the command center like he wanted to, he could have opened all those doors with a push of a button. People on the site were frustrated and confused. But they followed orders and started burrowing back into the missile complex.

Joe Richman

Devlin and his partner strapped on oxygen tanks to wade through clouds of lethal rocket fuel. They broke through several doors. And then after 30 minutes, a second two-person team went in to relieve them-- and not just any team.

One of this duo was David Livingston. Livingston was a member of the PTS team. He was also David Powell's roommate, Powell who dropped the socket that started the whole thing. Livingston was actually Powell's best friend. They made it all the way to the blast lock door where there was a meter, a meter that took readings of fuel present in the air in the silo.

Joe Richman

This is Colonel John Moser again, who was 50 miles away at the Little Rock Air Force Base calling the shots. The moment of the explosion, he was talking to people on the site, and the line went dead.

Joe Richman

While John Moser was at the Little Rock Air Force Base waiting for everything around him to be swept off the Earth by a nuclear explosion, Allan Childers was back at the Damascus missile site.

Joe Richman

Again, Greg Devlin, one of the guys on the first team to go back in and who was watching as the second team worked.

Joe Richman

The morning after, everyone was trying to sort out what had happened-- the press, Air Force, local law enforcement, the public. Simply put, the fuel exploded. The nuke didn't go off. The Air Force was keeping tight-lipped, refusing to confirm whether there had even been a nuclear warhead on site.

For the survivors, the injuries were extensive. Greg Devlin had burns on his face, neck, and back. His skin was burned off his left hand. Others had extensive burns and broken bones. One airman, David Livingston, was dead. Remember Livingston was David Powell's roommate and best friend.

Livingston was on the second team to go back in. And he was standing just outside the silo when it blew. All that meant Powell had kind of dropped the socket into some huge Rube Goldberg machine of bad luck and indirectly killed his best friend.

At the missile site, the damage was staggering, a monument to just how dangerous the situation had been. The missile silo's door, a 1.5 million-pound slab of concrete and steel, had blown off, spun like a Frisbee, and landed more than 500 feet away. And then there was the biggest question. Where was the nuclear warhead?

Joe Richman

As for the question of whether the nuclear warhead could have gone off, the military would later say no, impossible. There were too many safety measures in place. But lots of people who were familiar with nuclear weapons, who know them well, who worked on the Titan II, they say it absolutely could have. If the warhead had gone off, it's estimated the fallout could have reached more than 400 miles and killed people in Arkansas, Missouri, Kentucky, Illinois, and Indiana.

After Damascus, the Air Force officially blamed the incident on human error-- so Jeff Plumb and David Powell, who dropped the socket. That never sat well with many of the people who were there who worked at Damascus, including Jeff Plumb.

Joe Richman

Plumb says the Air Force knew that. They knew then, and they know now. That even when the stakes are nuclear weapons, human error is a factor. After Damascus, workers were required to tie tools to their bodies. One solution to the problem of human error, the lanyard.

We should say we asked David Powell to talk about all this, but he didn't want to talk about it. We did learn that he only recently told his wife and family. He'd kept it secret for years and years. Jeff Plumb says he thinks Powell really struggled with it, just like he did too.

After the incident, Jeff Plumb had an episode where he snapped, lost it, and started throwing beer bottles against the wall in a room at the Air Force base. It was bad. The Air Force demoted him, and things went downhill from there. He was eventually discharged from the Air Force. Even now years later, he finds the accident hard to talk about.

Joe Richman

One of the remarkable things about Damascus is actually how unremarkable it was, how many accidents there have been like this one. When it comes to nuclear weapons, it's so easy to assume that everything is all taken care of, oversight is airtight, precautions and protocols are in place. The stakes are so serious.

But the 70-year history of our nuclear weapons is littered with accidents like what happened in Arkansas. An accident like Damascus could never happen again because our missiles no longer use liquid fuels. So that risk is gone.

But there are other risks. There are new ones-- enemies hacking into missile systems over the internet, low morale and other personnel issues among the people who maintain and operate our nuclear arsenal, and aging facilities and technology. I talked to half a dozen experts who are familiar with our nuclear weapons, from places like Yale, Berkeley, Harvard, and former military officials.

They worry about mishaps and accidents that most of us never consider with weapons most of us never think about. All of them pointed out the accident at Damascus, no one saw that coming. There were supposed to be safeguards to prevent that from ever happening. One military expert said, the kind of accident we should worry about is the kind that seems impossible, like what happened in Damascus. Again, Greg Devlin.

Joe Richman

A single dropped tool setting off the explosion of a nuclear missile. Greg Devlin says he would have put the chance of that at zero.

Ira Glass

Joe Richman is the founder of Radio Diaries. To make their podcast your next new podcast, you can find it at radiodiaries.org or wherever you get your podcasts. Eric Molinsky helped report this story.

A special thanks to Eric Schlosser, who was a huge help to us and whose book on nuclear arms safety Command and Control covers this and other accidents like it. Eric pointed out to us that while the United States no longer uses liquid-fueled nuclear weapons, they are still in use in North Korea.

Coming up, from mistakes in the past to mistakes in the present. That's in a minute from Chicago Public Radio when our program continues.

It's This American Life. I'm Ira Glass. Each week on our program, we choose a theme and bring you different kinds of stories on that theme. Today's program, Human Error in Volatile Situations. We've arrived at act two of our program.

Ira Glass

Act Two, Erring Like a Sailor. In August, a Navy destroyer, the USS John McCain, collided with an oil tanker. 10 sailors died. This is just two months after another destroyer, the USS Fitzgerald, crashed into a container ship, killing seven sailors.

After the McCain crash, rumors swirled around that somebody, Russia or China or North Korea, hacked into the ship's navigation systems, caused the crashes. People said maybe hackers projected a fake GPS signal, so the ships didn't really know where they were. Maybe the hacking rumors got so much traction because it just felt better to believe the collisions were caused by an enemy, rather than the truth.

After an investigation, it became clear we crashed the ships ourselves. It was human error. Months ago, one of our producers, Stephanie Foo, started looking into these accidents and learned something about the Navy, an underlying reality about daily life for sailors the Navy has said played a role in these accidents. And it honestly really surprised us. Here's Stephanie.

Stephanie Foo

Ty is a sailor who served on a destroyer in the Pacific for four years, the USS John McCain. He moved to another Navy job in 2016. He was friends with four of the 10 men who died on the McCain and really close to one guy in particular, Jacob Drake. Because Ty's still in the Navy, he asked that we use a different name for him. And we had an actor, Scott Shepherd, replace his voice.

Stephanie Foo

Jacob Drake was 21 when he died. At first, Ty wondered if the hacking rumors were true. But a few months ago, at one of the sailor's funerals, a group of guys who were on the McCain during the collision started talking.

And Ty learned what happened up on the bridge that morning at 5:24 AM. The sailors who were supposed to steer the ship didn't really know how to steer this particular destroyer and made a series of mistakes that caused the ship to drift portside right as it was approaching one of the most crowded waterways in the world, the Strait of Malacca. It turned left into the the nose of an oil tanker.

The tanker punctured a hole in the USS McCain's hull, which flooded the berthing and drowned his sleeping friends. When Ty found out the reason for the crash--

Stephanie Foo

The USS McCain was just one of six major accidents within the Navy's 7th Fleet this year. The Fitzgerald is also in the 7th Fleet. The most recent incident was the day before Thanksgiving when a Navy plane trying to land on an aircraft carrier crashed in the Pacific Ocean. Three men were killed.

Most years, there are just a handful of deaths on Navy ships, three or fewer. This year, there were 17. About a month after Ty went to that funeral, the Navy released a report that detailed the causes of both the Fitzgerald and McCain collisions. The report verified the story Ty had heard.

It also described the panic of the sailors and how they struggled to save each other, pulling each other up ladders, using the Jaws of Life to extract trapped sailors from their crushed racks. The report includes scratchy, hand-drawn pictures of what the sailors saw as they tried to exit their racks, how the water was up to their necks. It describes how afterward, when divers went into the berthings to retrieve the bodies, one body was found underneath a television and another inside a bathroom.

The report also concluded that a long list of errors led up to each crash. The crew wasn't properly trained. They used their radars incorrectly. Then there were the sailors who were on watch. On the Fitzgerald, they looked out only one side of the ship, while ignoring the other.

All these mistakes left some people wondering, why were the crews so unbelievably sloppy? Rick Hoffman is a retired Navy captain and an expert on Navy collisions. He spent five years of his career analyzing case studies of crashes to teach young officers about them.

He pointed out in both the McCain and the Fitzgerald crashes, no one set off the collision alarm to warn the rest of the crew. No one shouted, hey, there's a 700-foot ship heading our way. It shocked him.

Stephanie Foo

I found some people who felt like they knew the answer to that mystery. Months before the Navy report on the crashes came out, I was on Reddit, where there's a community of people in the Navy. And I came across a long, impassioned discussion about the cause of the crashes.

It began with a single comment, quote, "I wonder if the watch were sleep deprived." And then posters just responded in droves-- about 1,000 posts of sailors and vets telling story after story about how little sleep they'd gotten during their time in the Navy. Many people talked about averaging three to four hours of sleep per night, every night.

And that years afterward, long after they'd left the military, they still had trouble sleeping more than four hours a night, which sometimes led to issues with depression. Someone remembered being so tired that they reported the moon as an enemy contact. One guy talked about cracking his head against a panel as he passed out from exhaustion onto it.

The commenters believed that these recent accidents weren't just caused by human error. It was human error as a result of sleep deprivation. It seemed crazy that giant, billion dollar ships could crash, that people could die because of something as simple as sleep.

So I started calling people in the Navy or who are connected to the Navy, talking to them about this. And over four months of reporting, the picture I got was staggering. Sleep deprivation seemed widespread. And there was this phrase people kept saying that sums up the Navy's attitude toward sleep.

Stephanie Foo

Here's a bunch of Navy personnel.

Stephanie Foo

In November, when the Navy released its public report about the McCain and Fitzgerald accidents, it confirmed that fatigue was one of the causes. Mike Love is one of the sailors who posted on the Reddit thread. And as soon as he heard about the Fitzgerald crash, he thought--

Stephanie Foo

Mike served from 2004 to 2008. This is a rare thing, but he explained that he would sometimes work 24-hour days-- so work a whole entire 24 hours, and then go straight on to the next 24 hours. And he told me a story that really sticks out in his memory. He was stationed aboard a dock landing ship which-- well, all you need to know is that it's a bigass ship.

And it was in the waters around Kuwait about 10 years ago. One night, he was doing rounds in a smaller boat, a patrol boat with five people in it. And they were circling the bigass ship. The guy who was driving the patrol boat looked tired. So Mike offered to take over.

Stephanie Foo

So he was driving around the bigger ship. And all of a sudden--

Stephanie Foo

Heading full speed towards it. He swerved away with just seconds to spare.

Stephanie Foo

His shipmates started freaking out. And even then, Mike still couldn't keep his eyes open.

Stephanie Foo

This story was like a lot of stories on the Reddit thread-- fatigue-induced close calls. And as Mike was telling me about this, he started describing what it felt like to be so sleep deprived. And just the way he talked about it, I realized, oh, you know this feeling really well. Like he'd been down that road so many times he'd come to recognize landmarks on the way.

Stephanie Foo

Scientists have studied this. National Institutes of Health studies have given cognition tests to sleepy and drunk people. And they showed that being awake for 23 hours is equivalent to being well over the limit for driving drunk.

Reaction times for people awake that long were 200% worse than people who are well-rested. Their hand-eye coordination was 30% worse. On some tests, they made twice as many mistakes.

Stephanie Foo

David Larter is a Navy vet, now a journalist for Defense News. And he's been thinking about the sleep issue and reporting on it for years. A few months ago, Larter was on an NPR program, 1A, with a retired admiral, Terry McKnight, who took a very old school Navy tack on all this. He said basically sailors have to deliver no matter what. You're an adult. You figure out when to sleep.

Stephanie Foo

Larter told me that the Admiral's comment made him furious. He brought it up twice in our interview, fuming each time.

Stephanie Foo

People have told me that a lack of sleep is a problem in all branches of the military. But the Navy is the worst-- the workweeks of 100 hours or more, sleeping just a couple hours for days on end. I spoke to the Navy's lead researcher on sleep deprivation and its effects on sailors, Nita Shattuck, to see exactly how pervasive this was. Did I just find some isolated incidents, or was this everywhere?

Dr. Shattuck's gone out with sailors in deployment and equipped them with essentially very expensive Fitbits to see how much sleep they get. She told me that, on average, sailors get a little less than six hours of sleep a night, close to five hours a night when they're on deployment. She said it's a huge problem, maybe bigger than the Navy would like to admit.

The official report on the McCain and Fitzgerald accidents lists a bunch of reasons for the accidents, training and leadership failures, and only devotes two sentences to fatigue. Shattuck thinks it's probably more significant than that.

Stephanie Foo

The timing being both accidents happened during the graveyard shift, 1:30 AM and 5:24 AM. I asked the Navy for details about how they knew the crews on the McCain and Fitzgerald were fatigued, how fatigued they were, and whether they could share the crew's schedules from the days before the accidents. They said they could not share that.

But they did let me speak with Rear Admiral Jesse Wilson. He's the leader of the Atlantic surface fleet. And he said, for instance on the Fitzgerald, it was clear the crew was overworked the day of the accident.

Stephanie Foo

Dr. Shattuck, the Navy sleep researcher, says one of the most problematic issues, and the thing that makes the Navy worse than all of the other branches, is that many sailors are on schedules that make them go to sleep at a different time every day-- which means one day bedtime might be 5:00 PM. The next, it might be 8:00 AM. Our bodies aren't built to do that, so sailors are constantly jet lagged.

So why has the Navy allowed it to happen? Well, in part out of necessity. The Navy is understaffed. It's been steadily shrinking for decades. And even though we have about the same operational demands as we have since the '90s, the number of ships available to do that work has decreased by half.

And on those ships, 14,000 jobs are unfilled, about 10%. The Navy has the money to make those hires. But they're having trouble recruiting people. That means the sailors we do have are much busier. They go out on longer deployments. And they wind up working longer hours.

Earlier this fall, Navy veteran and US senator John McCain expressed his concern about this at an armed services hearing about the collisions. McCain's father and grandfather, by the way, were both Navy admirals and both named John McCain. They're the ones the destroyer USS John McCain is named for. The senator said this to the chief of naval operations, Admiral John Richardson.

Stephanie Foo

It's worth noting that all of the accidents this year have been in the 7th Fleet, the busiest fleet in the Navy. They're in the Pacific and responsible for patrolling the waters around North Korea, Japan, and the South China Sea, all very tense, very high action areas right now.

In the wake of the McCain and Fitzgerald deaths, the Navy took steps to fix the problem of fatigue. In October, the Navy announced that it was going to start doing what Dr. Shattuck, the Navy sleep researcher, had been advocating for years. Make it mandatory that sailors sleep at generally the same time every day. The Navy calls it implementing circadian rhythms. All large ships, like destroyers, should have implemented the new schedules this month. Some smaller ships are expected to implement the policy this spring.

I found a sailor on an assault ship that's been under circadian rhythms his entire deployment. So according to the Navy, he should be getting enough sleep. But he told me that in practice, even though he gets to go to bed at the same time every day, he still works 16 hours each day and has just eight hours off.

The only way he could possibly get a full eight hours of sleep is if he skipped showering, reading, or relaxing for a single minute and instead collapsed directly on his rack and started sleeping right after duty. But of course, that's impossible. When he lies down, he says, he isn't able to fall asleep immediately and often thinks about work for a couple hours before he can drift off. He told me, quote, "If you're a human being in this system, you are OK with disrespecting your well-being every day."

Brad Martin believes circadian rhythms are not going to fix the fatigue and accident problems in the 7th Fleet. He's a retired Navy surface warfare captain. He held four commands during his 30 years in the service. Now he's a senior policy researcher at the RAND Corporation.

Stephanie Foo

He doesn't think the Navy can solve the problem without hiring and training people to fill the 14,000 vacancies it has on its ships.

Stephanie Foo

In the Navy, sleep is the canary in the coal mine. Martin told me it's a warning of much deeper, systemic problems. When the Navy puts on a three carrier show of strength off the Korean peninsula, or sends a destroyer to the South China Sea, the whole point is to project an image of American power. But the reality is the Navy is trying to do too much with too little. And behind those dangerous, powerful machines are sailors trying to stay awake at the controls.

Ira Glass

Stephanie Foo is one of the producers of our show.

[MUSIC - "AN HONEST MISTAKE" BY THE BRAVERY]

Our program was produced today by Dana Chivvis. Our team includes Elna Baker, Elise Bergerson, Susan Burton, Ben Calhoun, Zoe Chace, Sean Cole, Hilary Elkins, Stephanie Foo, Chana Joffe-Walt, Michelle Harris, David Kestenbaum, Seth Lind, Jonathan Menjivar, B.A. Parker, Robyn Semien, Alissa Shipp, Lilly Sullivan, Christopher Swetala, Matt Tierney, and Diane Wu. Our senior producer is Brian Reed.

[ACKNOWLEDGEMENTS]

Our website, thisamericanlife.org. This American Life is delivered to public radio stations by PRX, the Public Radio Exchange. Thanks as always to our program's co-founder, Mr. Torey Malatia. You know his Christmas present for me this year? I don't know. It just-- it just seemed a little hostile.

Ira Glass

I'm Ira Glass. Back next week with more stories of This American Life.