Chapter 5 - A Different Kind of Failure
Nobody fired a weapon that morning. That fact was important, and later everyone would be tempted to make it sound as though it meant nobody had been in danger.
Mara found the diagnostic crew near the secondary fixture, not the one Hale had touched. Two technicians stood behind a painted line while a contractor named Neil Foster leaned into an access bay with one arm extended. The mount had begun a slow movement that was supposed to stop at a marked position. It was moving farther than expected.
“Stop,” Mara shouted.
Ortiz had already reached the local supervisor. A horn sounded, abrupt and ugly, and the motion ceased. Foster pulled his arm back so fast he struck his elbow against the frame.
He swore and backed away, cradling it. No one spoke for several seconds.
“Everybody clear?” Mara asked.
Foster nodded, then winced. “I think so.”
“Don't tell me what you think. Let the medic look at you.”
“I hit my funny bone. I'm not dying.”
“Good. Then you can be annoyed with me on the way to Medical.”
He tried a crooked smile. It didn't last.
The supervisor, a civilian named Glenn Rusk, pulled his safety glasses off. “We were doing a bench diagnostic. The email said preparatory work could continue.”
“Who signed your permit?” Ortiz asked.
Rusk pointed to the board. An old authorization sheet hung under a plastic clip. It had a green stamp on it and yesterday's date.
Ortiz looked at Mara. “That's my copy. I should've pulled it when we suspended the event.”
Mara shook her head. “I should've checked all related work areas.”
Hale and Decker came around the corner fast enough that an enlisted driver had to jog to keep up.
“What happened?” Hale asked.
“Unexpected movement during a diagnostic on a related fixture,” Mara said. “No firing, no serious injury reported yet. One man struck his elbow. We're treating it as a near miss pending review.”
Hale saw Foster walking toward a waiting vehicle. “Was that caused by the problem on the main unit?”
“We don't know.”
“Was it caused by my touching the housing?”
“No, sir. Different fixture.”
He looked surprised by the direct answer. “Then why are we standing here?”
“Because the work proceeded under a schedule that wasn't corrected everywhere.”
His eyes moved to Decker. The commander said, “I sent the hold to operations. I didn't realize the contractor team had a separate work order.”
“Neither did I,” Mara said.
The admiral rubbed his forehead. “The system just failed to stop?”
“That's what we're investigating. We don't have enough evidence yet to attribute it.”
Hale looked at the sheet hanging under the clip. “Who is responsible for removing an expired permit?”
“Several people,” Ortiz answered. “One of them is me.”
The admiral frowned. “I wasn't speaking to you.”
“I know, sir. But I am.”
It was the first time Mara had heard Ortiz's voice carry that much weight. Hale appeared ready to answer sharply, but he looked again toward the vehicle carrying Foster.
“Get me the medical update,” he said instead.
By afternoon the fixture was locked out for further independent evaluation, the accident-prevention staff had photographs, and the contracting officer was trying to determine which invoices would still be payable. Foster's elbow was badly bruised but not broken. His wife picked him up because he couldn't comfortably drive his manual-transmission truck.
Mara saw them at the clinic. His wife had a grocery list sticking out of her purse and looked angry in the tired, quiet way of somebody whose day had already been difficult before it got worse.
“He said it was routine,” she told Mara.
“It was supposed to be controlled work,” Mara replied. “Our communication failed.”
“My husband always says that,” the woman said. “Controlled. Routine. And then he comes home and tells me there was some little thing nobody expected.”
Foster shifted in the chair. “Amy.”
“No, I'm not mad at her. I'm asking if somebody is going to change how this works.”
Mara didn't offer a promise about the entire Navy. “We're stopping this evaluation until the problem is understood. And I'm going to make sure your account is in the record.”
Amy looked down at her husband and straightened the corner of his sling. “Okay,” she said. It wasn't forgiveness. It was a starting point.
A corpsman followed them to the exit with a printed card explaining how Foster could arrange a follow-up visit if the swelling didn't ease. Foster's wife tucked it into the front pocket of her bag, where Mara noticed a birthday card with a cartoon dinosaur. Amy caught her looking. “Our son's six tomorrow,” she said. “I was supposed to pick up his cake.” Foster raised his uninjured hand. “I can still pick up a cake.” Amy stared at him, then shook her head and laughed once, not because any of this was funny but because they were both exhausted. Mara offered to carry their things to the car. Amy said they were fine. Mara let them go.
Outside the clinic, Ortiz was waiting with two cups of terrible coffee. She gave Mara one.
“I should have fought you harder yesterday,” Ortiz said.
“You did raise it.”
“Then I went away when you told me to write it down.”
Mara took the coffee. “You had no reason to think I'd leave it off the summary.”
“That doesn't help much.”
“No.”
They stood in the shade of the clinic entrance while two corpsmen carried boxes inside. Ortiz's sleeve was still marked with gray grease. Mara remembered all the times she'd said trust the data, as though collecting numbers were the same thing as listening to the person who collected them.
“Next time,” Mara said, “if I dismiss something you believe is unsafe, go straight to Range Control.”
Ortiz eyed her. “Even if it makes you mad?”
“Especially then.”
Her phone rang. Sloan wanted them both back. The independent diagnostic team had reviewed the configuration records for the two fixtures.
May you like
There was no single broken part.
There were two different versions of the same approved configuration circulating on the range.
