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634: Human Error in Volatile Situations

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Prologue

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.

Act One: 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.

Jeff Plumb

David Powell was certified. He had done it over and over and over. For me, it was fairly new. It was the first time I was in training with David.

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.

Jeff Plumb

I was in awe when I would walk into the silo. When you open up the silo door, and you walk in there and look at this-- and sometimes the lighting in there was just right to where it just loomed in the dark like it was a bullet in a chamber ready to go, you know. And it had this dark black warhead on top, pure destruction at the fingertips of a couple of men.

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.

Greg Devlin

And if they ever meet-- typically, they were meant to meet inside the motor, and then it propels it where it's going. But if they ever meet anywhere before that, you'll instantly have an explosion and a fire. So yes, it is a bomb sitting on a bomb.

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.

Greg Devlin

So between burns, explosions, fire, between inhalation-- if you got it on your skin, it would turn to acid. We actually had a greater fear of the fuels on board than the warhead itself.

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.

Jeff Plumb

We could do anything. That was our mindset. We were invincible, and nothing was going to stop us. You know, at 19, it just-- I didn't have any fear of things at that point in my life.

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--

Jeff Plumb

They had a problem with not being able to get the hydraulic platform to come down.

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.

Jeff Plumb

Materials were outdated, dilapidated, deformed. Valves leaked. Pumps failed. There was a lot of things wrong with the missile silo.

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.

Jeff Plumb

We were very anxious to get this job completed. It was a Friday night. We were young, wanting to get back to hang out with our friends and drink beer, you know. So I remember laying around up in the control center, just hanging out with these guys for hours.

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.

Jeff Plumb

And as we were going down the long cable way, we realized we didn't have the torque wrench.

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.

Jeff Plumb

The checklist was the Bible, you might want to say. And Air Force regulations required us to go through that checklist and follow everything step by step.

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.

Jeff Plumb

So we grabbed this ratchet-- like you would pull out of your toolbox, but quite larger. If you can picture it, it was a monstrous thing because it was about three feet long. It had about a three-foot long handle. And the socket weighed anywheres from five to eight pounds. It was a big socket. So it was a large piece of steel.

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.

Jeff Plumb

So we had a problem at that point. And so we improvised.

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.

Jeff Plumb

And I remember saying to him, you've got this, right? You got-- you're OK? You got this? And he said, yeah, I got it. Let go of it. And so I remember releasing it.

And I remember seeing it kind of just fall. And it hit the platform, the socket did. And it bounced, and it went between the platform and the missile.

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.

Jeff Plumb

It was like it bounced, and it landed perfectly in the gap, you know. It was almost like-- it was like somebody playing Tiddlywinks or something. You know how you would-- or one of those old drinking games where you bounce something and land it into the hole perfect. You know, it was just it bounced, and it was gone.

I literally watched it fall. We had dropped tools numerous times. It wasn't the first time that we ever dropped a tool and watched it fall. It was common. It just happened that when this socket fell, it went down 70 feet, 80 feet, whatever it was there, and it bounced off the thrust ring that the missile sat on, just this big giant round ring.

And when it fell, it picked up maximum speed and hit the top of that thrust ring and just ricocheted into the side of the missile. I heard it hit-- boom. And the next thing you know, I just seen fuel spraying out.

I just looked at it down there. I just looked in awe. I just-- I couldn't believe what just happened. The only thing I remember saying to David was, this is not good. This is not good.

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.

Jeff Plumb

You know, we didn't know how to respond. We looked at it for-- I don't know-- at least a minute trying to figure out what we were going to do about it. And then he contacted the team chief and told him that we had a cloud of vapor emitting from the missile.

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.

Allan Childers

So the first thing we heard was that there was smoke in the launch duct. And of course, the commander's going, what do you mean? What's going on? And then I heard him say, what do you mean smoke in the launch-- and he was going to say duct. But I don't think he ever got the word duct out.

As soon as that happened, the lights started coming on. And it's a klaxon alarm. And it's just waaa real loud. And all of the lights came on. So you're trained to punch the alarm off once it gets your attention, which it did, you turn the alarm off.

Well, the alarm would turn off. But it would immediately come back on again as another light came on, and another light came on. And so these indicator lights were oxidizer in the launch duct, fuel vapors in the launch duct, fire in the launch duct. Horns and klaxons were going off, sirens. Pretty much every light on the instrument panel, they were lit up.

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.

Jeff Plumb

They were trying to figure out how to deal with all these problems. They were resetting klaxons. And they didn't know what was going on. It was chaos. Because they didn't know.

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.

Jeff Plumb

I just-- in my own mind, I pictured poking a hole in a pop can. And so all this pressure now is turning to a negative PSI-- which internally in my mind, I thought it's going to collapse. This tank is going to collapse in on itself.

It's sucking itself in. I was scared. I was really concerned that this thing could blow up any moment. So my concern was to get out of there. I didn't know the safety of that 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.

Jeff Plumb

So I just-- I kind of kept my mouth shut. You know, I didn't answer. David was the one answering the questions.

Allan Childers

So they never told us what had happened.

Joe Richman

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

Allan Childers

We ran all of what we called our red tab checklist, our hazard checklist. And it didn't stop anything from happening. All the indicator lights stayed on. That's when the commander turned back to the team and said, what do you think it is? These indicators don't make any sense.

And this was a half-hour into it. They said, we don't know. We don't know what's going on out there. All we saw was the smoke in the launch duct.

Joe Richman

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

Allan Childers

And Rodney asked them again, what happened? What do you guys know that we don't know? And Airman Powell started crying. And that's when the commander went-- he said, you need to tell us what is going on out there. We cannot figure it out.

And that's when, as he was crying, he basically said, I dropped a socket off the end of the wrench. And it punched a hole in the side of the missile. And the commander just-- I could still picture his face. It just turned white.

And he said, you need to tell the command post what you did because they're going to have questions. And I don't want to be relaying it. So he handed him the phone. He brought him over to the console. He said, I'm going to put Airman Powell on. We have a serious emergency. We just found out what's going on, and I want him to talk to you.

And he put him on, and he told him. I don't know how he got it out because he was crying so much, you know. I just remember everybody standing there watching, just dumbfounded.

We're talking about a socket that was bigger than your fist punching a hole in the side of a missile. You couldn't patch it if you wanted to. And by then, so much had drained out you couldn't even open up the door and lean inside without it eating up your suit.

So you couldn't do anything about it by then. And then the commander got back on the phone. And we were basically told to stand by. And we stood by.

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?

Allan Childers

The launch control center, the control room, was supposed to survive a nuclear explosion.

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

For you giving the order, was it a clear call? Or was it-- were you conflicted? Were you unsure?

John Moser

I was not unsure. I was a straight up, clear order to evacuate because I didn't want people to be injured. We had no idea what was going to happen. We've never had an explosion or a potential explosion like this. It's never happened before. And I gave the order to evacuate.

Allan Childers

And I tried to talk him out of that.

Joe Richman

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

Allan Childers

I didn't think it'd blow up. And if it did blow up, I thought that the door and the complex would contain the explosion. It was underground. It had this cap on it.

I had two blast doors protecting me that were the size of bank vault doors. And I was sitting in a facility that was designed to survive a detonation from a Russian nuclear weapon. So I thought we're safer down here than if we go up above.

Joe Richman

I guess I would think most people would be happy to get an order to say, get out of there.

Allan Childers

I felt devastated. Yeah, I was devastated that I had to leave. Even to this day, it bothers me that I had to leave. Never in the history of an active missile complex had you left the missile with a warhead on it, walked away from the site with the site still running.

On principle, I didn't like it. The logic of it made no sense to me. I could not believe that we were leaving that complex. As in desperate shape as that site was, to leave that and not be able to tell people what was occurring out there in that launch duct-- even if we couldn't do anything, I felt like there was probably somebody was going to come up with something that we could do. And we would not be there to do it.

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.

Greg Devlin

It was really-- it was just really eerie that night. You know, you saw smoke coming out of the vents over here. You could get whiffs of fuel, hydrazine, which has like a fish type of an odor to it. So you could smell that. So it was a very hazy, eerie-looking scenario.

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.

Greg Devlin

The first two guys to go in were myself and Rex Hukle. We suited up.

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.

Greg Devlin

And at 18,000 parts per million, it's explosion ready. It's ready to explode. That's redlined. That's pegged out. So when he called back and said, this thing's about to blow.

And the command center said, come back now. So him and Dave Livingston traversed back up the flights of steps. They got just above ground. And within 30 seconds, an explosion happened.

John Moser

It was about 3 o'clock in the morning. And I was standing up listening to a conversation. And all of a sudden, I lost communications.

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.

John Moser

All you've ever read is when you have a nuclear explosion, you lose communications for some time. And we lost the communications. And I just had no idea if the blast wave was going to eventually hit Little Rock Air Force Base. I had no idea.

I had no idea what was going to happen. But I thought we lost the whole works out there, everybody. And you know, I'm not a really religious guy. But I had to-- I almost dropped on my knees to say a quick prayer.

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.

Allan Childers

It's so hard to describe an explosion like that. The only thing you see is this huge-- I mean nighttime turned into day. It was unbelievable. Because it was so bright all of a sudden.

And I literally turned to one of the guys. And I was feeling my chest. And I said, it couldn't be a nuclear explosion because we're still here. And that's what dawned on me. We were still there.

Greg Devlin

Man. Oh my gosh. I was standing at the fence. And I was facing the silo when it exploded.

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.

Greg Devlin

It was just a bang, the loud sound, and the concussion of wind. It was just-- it was like bang. It was like being in front of a-- picture yourself as nothing's there, but you just got hit by a Mack truck.

And all of a sudden, rocks started falling. It was like rain falling. And it was all this gravel from the complex. And metal started falling out of the sky. And everybody started to run.

The chunks of concrete that were landing everywhere were as-- I mean everywhere-- were as big as coffee tables. The real big ones were as big as pickup trucks and school buses and stuff like that. Those were everywhere. You could hear them hitting the ground around me. Man, it was like boom, boom, boom.

I got up immediately. I took off running. I got five steps away, and a chunk of concrete hit the ground behind me as big as a-- bigger than a school bus. The trees were on fire. The grass was on fire. The only light we had was fires. And you could see the shadows of just about everything because there was so much fire around there. It was like being in this forest fire without a forest being around you.

And then for just a second or two, it was this one point in time where there was no sound at all. It was like a total calm peace, kind of like the end of the world, for 10 seconds. And then you heard all the screaming and crying and guys yelling, oh my god, I'm hurt.

Announcer

This is the CBS Evening News with Walter Cronkite.

Walter Cronkite

Good evening. Modern age terror swept an area of rural Arkansas today when fuel exploded around a nuclear warhead in a missile silo. The incident began when officials say a workman dropped a wrench.

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?

Greg Devlin

The warhead ended up about a quarter mile away, intact, in a ditch. To me, that's amazing.

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.

Jeff Plumb

It wasn't uncommon for that to happen. Every guy that worked in those silos I know dropped a wrench or a tool at some point in his career-- every guy. And if they tell you they didn't, they're lying. Because there was no way to get around that. It just happened that one went the wrong way.

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.

Jeff Plumb

I'll tell the story. And I'll begin to tell the story to someone, and then you just get caught up in it. You tell that story over-- I've told it I don't know how many times, you know, and relived it a few times. And I think I really have-- I think I've had enough, you know.

Yeah, just thinking back on it, it just wasn't a very good time in my life at that point. So I think I really don't want to tell the story anymore. So yeah, this will be the last time. Yeah. This will be the last time.

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.

Greg Devlin

One dropped socket that A, should have let's just say not dropped; but B, should have never got past a platform; C, shouldn't have hit the thrust mount; D, shouldn't have hit the missile. If it hit, it shouldn't have punctured a hole in it. I mean there are so many things that shouldn't have happened, but one dropped socket wiped out an entire nuclear missile system. One dropped socket, nine-pound socket, took it all out. There's no one that thought that scenario out.

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.

Act Two: Erring Like a Sailor

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.

Ty

He was basically like a little chihuahua. This guy was probably 5'4" or 5'5". And then whenever we'd be roughhousing, and he'd punch me in the shoulder. And then I'd grab him around his shoulders, pick him up, and then put my other arm underneath his knees and just sandwich him up in the air. So that was how we got to be really, really good friends.

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--

Ty

I was [BLEEP] pissed. Operator error is what cost me four really good friends and 10 brothers total. It's a total waste. Like I don't know how else to describe that. We're taught from boot camp on attention to detail. That's what gets me the most because literally how small it was.

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.

Rick Hoffman

There was no indication that the bridge was even aware that they were about to have a collision. They didn't sound the collision alarm. They didn't notify the crew. They didn't tell the captain. And that's mind-boggling. That's mind-boggling.

These people are looking out the window. So you've got a sailor back there on a headset communicating with the bridge what he sees. And why that kid wasn't screaming is a mystery to me.

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.

Woman 1

You sleep when you're dead.

Woman 2

It's like a sleep when you're dead stigma.

Man 1

You're going to sleep when you're dead.

Stephanie Foo

Here's a bunch of Navy personnel.

Woman 1

You criticize somebody by telling them they're a rack hound, which means they sleep all the time.

Man 1

You know, what are you? Some kind of a weeny? You only been up for two days? Come on. What's wrong with you?

Man 2

Suck it up. You going to [BLEEP] cry about it? Yeah. Wake up. Drink another cup of coffee.

Man 1

So yeah, I mean that's the attitude.

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--

Mike Love

It wasn't even-- to me, it was like, well, obviously that's what had happened. It's that you're having a kid that's-- I don't know-- 19, 20 years old that you've been working 20 hours a day-- you're going to stand him out in the dark and tell him to look for stuff. Like what do you think is going to happen? He's going to [BLEEP] fall asleep.

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.

Mike Love

And I was like, man, you're looking pretty tired, you know. Do you mind if I step in? He was like, thank you. I appreciate it. It's been a long day. I was like, yeah, I feel you.

And as I was thinking about this, I was just kind of remembering, I wonder how long I had been awake. And I remember questioning this. Yeah, that was-- I mean yeah, that would've been going on 72 hours right there.

Stephanie Foo

Jesus. 72 hours.

Mike Love

Yeah. And I put my headphones in. And I'll never forget. It was playing Killswitch Engage. And I was trying to keep myself up, you know, some heavy metal-- ba, ba, ba.

I remember the officer saying something into my ear. And he was like, yeah, you know, you don't need to swing it so close for the patrols. We can take a little time. And I look up. I was like, OK, OK.

Stephanie Foo

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

Mike Love

And then I just remember hearing the engines kind of vvrrvv. And I just hear like, Love, Love, Love. And I was like, what? And I looked up. And holy cow. You know, swung full right. I was maybe-- maybe 60 meters from the side of the ship.

Stephanie Foo

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

Mike Love

It was very, very close. You know, that would have easily, easily, easily killed us all.

Stephanie Foo

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

Mike Love

And I remember him saying like, are you kidding me? You're falling asleep as I'm talking? And as he's yelling at me. And I was like, holy crap. He's yelling in my ear, and I still am that tired that I had fallen asleep.

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.

Mike Love

When you hit a 24-hour mark or so, you're going to get your general tired. You hit that wall where you're like, oh man, I can barely keep my eyes open. And then once you come out of that, you start to suffer loss of motor skills, your finer motor skills, your ability to focus your eyes.

And then, for me anyway, it starts with the auditory hallucinations. And then you'll get the visual hallucinations that will start at the corner of your eyes. Right in the shadows where your eyes kind of can't focus, your brain will be interpreting them as movement.

So as you hit day two or day three, you start to lose the ability to determine between wakefulness and sleep. So you can be talking to someone and actually fall asleep with your eyes wide open. And then the conversation will turn to complete gibberish. Like what are you talking about, dude? What did you just say? What do you mean? I said this.

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.

David Larter

You've got a whole ship of people driving drunk, and that's unacceptable.

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.

Terry Mcknight

The Navy is not Carnival Cruise Lines. This is hard work. People know that their watch-- they know when they're going to stand watch. And they should take the opportunity to be well-rested before they get up there.

Stephanie Foo

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

David Larter

And you need to make sure you're getting the proper amount of sleep so that blah, blah, blah. That it's on you. I'm sorry, Admiral. It's not. It's on you. It's on you to set the conditions where that's not-- oh, well, I didn't sleep. And that's a competition-- where you're not creating competition among people. Oh, I slept less than you. Oh, you slept during the middle of the day. You're a dirtbag.

But that's the mentality. That's the mentality that drives this [BLEEP]. It's, oh, this is a tough job. And sailors just need to man up. And millennials these days are-- you know, they're soft. It's all garbage. It's always been a bad idea. It's always been bad to not let people get enough sleep.

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.

Nita Shattuck

You know, I completely acknowledge that-- when I look at things, my husband laughs at me. And he says, you think it's all about sleep. But fatigue could be the major cause of a lot of this that's going on.

Stephanie Foo

So this report does not convince you otherwise?

Nita Shattuck

Given the timing, given the circumstances that I'm aware of, I think that fatigue is still a big part of this story.

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.

Rear Admiral Jessie Wilson

The ship's routine was very busy that day. And there were indications that certain watch standards were not well-rested, including the commanding officer himself. So more times than not, if one person on the team would have done something differently, would have said something differently, it could have changed the result of the entire event and, in this particular case, could have prevented a collision.

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.

John Mccain

Admiral, is it true that some of our sailors are working 100-hour weeks?

Admiral John Richardson

Sir, I'll not deny that. The sailors are working very hard. We have been doing some work study-- sort of workday type of studies.

John Mccain

OK. But I'll just point out if we know that somebody's working a 100-hour workweek, I'm not sure we need a study.

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.

Brad Martin

That's going to be helpful. But I don't think just fixing that one thing is going to solve the whole problem.

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.

Brad Martin

Ultimately, more people are going to have to be retained or brought in. Putting people through the training pipeline is a tens of millions of dollars type of problem.

Stephanie Foo

Yeah. But then fixing the McCain and the Fitzgerald, those two ships alone is $800 million, so--

Brad Martin

That's a very good point. If we could have spent $70 million to try to get ensured that the manning on those ships was such that we could confidently say they are really ready to go out and operate, it would have been a lot cheaper.

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.

Credits

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.

Greg Devlin

Yes, it is a bomb sitting on a bomb.

Ira Glass

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

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