On 29 July 1967 an F-4 Phantom awaiting launch on the flight deck of USS Forrestal (CVA 59) accidentally fired a rocket into another parked aircraft. Several hundred gallons of jet fuel spilled onto the flight deck and ignited. The resulting fire engulfed several other aircraft and caused ordnance on those aircraft to explode. The burning fuel then made its way into the ship’s interior through holes created by exploding bombs. The fire, which took over twenty-four hours to extinguish completely, resulted in 134 sailors killed and 161 injured. The ship was under repair for two years at a cost of $72 million.
The Navy quickly convened two investigations. The investigation focusing on the Forrestal fire uncovered serious deficiencies in ship-wide predeployment training, individual training, and firefighting equipment quantity, standardization, and distribution. The more wide-ranging investigation of aircraft carrier operations identified fleet-wide issues with aircraft carrier design, such as how burning fuel would drain from the flight deck; the ability of crew to escape from dark, smoky compartments; and general announcing systems that were unintelligible on a noisy hangar deck. Some items, such as the location and required effectiveness of flight deck firefighting equipment, were common to both reports.
Most of the recommendations were accepted and implemented over time. Ship alteration packages were prepared to implement some of the recommendations on existing ships, and firefighting improvements were incorporated into two aircraft carriers then under construction, Nimitz (CVN 68) and Dwight D. Eisenhower (CVN 69). In addition, new research and development projects were initiated, damage control training centers expanded, and training requirements improved.
While the Forrestal fire was a tragedy for the Navy, it led to improvements in training, equipment, and design that are in use to this day. The Navy’s response to the Forrestal fire—the studies, reviews, decisions, and follow-through—provides a valuable example of organizational learning that is relevant to today’s decision makers.