USS Greeneville Analysis

     Safety is the product of a team, not the individual. Staff needs to be able to question across authority boundaries in order to “see” the work of others. Silo mentality restricts the ability to work cooperatively among disciplines. Recurring patterns in human error can be addressed through enhancing teamwork where missing expertise can be completed, hidden assumptions identified. Fixation on the plan can be set straight by a fresh perspective. Division of responsibility and authority can cloud understanding. Double binds put workers in a lose-lose situation, which occurs when people are responsible for outcomes but lack authority. Tunnel vision confines individuals to accurate but possibly incomplete knowledge; improved communication through teamwork helps us see the big picture. Covert work practices can develop as ways to get work done outside written policies. Teamwork enhances safety when we rely on the expertise of other and learn from their experiences.

In the USS Greeneville/Ehime Maru collision, the following shortcomings in teamwork contributed to the fatal accident:

• The commanding officer had absolute accountability for the ship yet external control ultimately rested with the admiral who arranged the excursion.
• Missing expertise due to absence of qualified sonar operators .
• Broken soar monitor led to breakdown in vital information.
• Crewmembers were reluctant to question their commanding officer.