OpsLens

Navy Releases Findings about Recent Collisions at Sea

“If we take our eye off the fundamentals, we become vulnerable to mistakes at all levels of command,” said Chief of Naval Operations Admiral John Richardson.

The U.S. Navy released a summary of findings from investigations into two collisions at sea that occurred earlier this year.

The USS Fitzgerald (DDG-62) collided with Motor Vessel ACX Crystal in June 2017, while the USS John S McCain (DDG-56) collided with Motor Vessel Alnic MC in August 2017. Both collisions occurred in the 7th Fleet area of operations.

Both collisions were found to be avoidable and due to lack of procedural compliance, poor seamanship, and other factors.

The Chief of Naval Operations, Admiral John Richardson, said in a briefing that “these were fundamental mistakes of ship-driving.” This includes maintaining awareness of maritime traffic, how to respond in close proximity situations, and how to operate ship equipment.

The Fitzgerald collision

The USS Fitzgerald and Motor Vessel ACX Crystal collided on June 17, 2017 in the maritime approaches to Tokyo. The Fitzgerald is based in Yokosuka, Japan and was participating in routine operations.

The ship was at “darkened ship,” meaning that the only exterior lights illuminated were those required by international maritime safety procedures. The Fitzgerald was transiting in the Mikomoto Shima Vessel Traffic Separation Scheme, an area established to facilitate safe passage of ships going in and out of port.

According to International Nautical Rules of the Road, the Fitzgerald was required to yield to the Crystal. Neither ship “took such action to reduce the risk of collision until approximately one minute prior to the collision.”

The collision resulted in the deaths of seven sailors onboard the Fitzgerald and significant injuries to others, requiring three to be medically evacuated from the ship. The injured included the Commanding Officer, who was in his cabin at the time of the incident.

In the case of the Fitzgerald, the Navy report outlined that “numerous failures occurred on the part of leadership and watchstanders.” The report noted that while multiple factors played a role in the collision of the Fitzgerald, the “lack of preparation, ineffective command and control, and deficiencies in training and preparations for navigations” resulted in an unprepared crew.

“In the Navy, the responsibility of the Commanding Officer for his or her ship is absolute,” the report said.

Four main areas were identified in the findings of the investigation as being of specific relevance: training, seamanship and navigation, leadership and culture, and fatigue. In all areas, supervisors and command leadership failed to take action to prevent unsafe situations from developing.

The McCain collision

The USS John S McCain and Motor Vessel Alnic MC collided on August 21, 2017 in the Straits of Singapore. The McCain, also homeported in Yokosuka, Japan, was on a scheduled six month deployment and approaching Changi Naval Base, Singapore for a scheduled visit.

The collision resulted in the deaths of ten sailors onboard the McCain.

The findings specifically found that a lack of knowledge of the proper operation of the ship’s steering and propulsion systems was a factor in the collision. This was compounded with the high volume of maritime traffic operating in the Straits of Singapore.

The report specified that though the ability to steer the ship was not lost, it was unknowingly transferred to another control station. This led the watchstander responsible for steering to believe that the ship had lost steering control. When control was assumed by another watchstander at a remote location, the rudder was in a position that led to a drastic turn to port, or left.

Upon reporting the perceived loss of steering, the ship slowed to 5 knots. However, only one of the two propulsion shafts was slowed, which further caused the ship to execute an uncontrolled turn to the left.

The ship was able to regain steering control and correct propulsion, but it was already on a collision course with the Alnic. The personnel on watch did not perceive the threat of collision, in part because they did not understand the “forces acting on the ship” as well as not remaining aware of the Alnic’s course.

Personnel on the ship, including those responsible for training and qualifications, did not properly understand how the ship’s equipment functioned. There were also personnel temporarily assigned to the ship from the USS Antietam, which has “significant differences between the steering control systems.”

Another factor was the lack of additional personnel needed to safely operate the ship in a Traffic Separation Scheme, known as Sea and Anchor detail. Although the ship entered the Straits of Singapore at 5:20 am, the detail was not scheduled until 6:00 am.

The report included that the Navigator, Operations Officer, and Executive Officer recommended the additional personnel of Sea and Anchor detail earlier than ordered by the Commanding Officer.

Properly qualified and trained watchstanders may have impacted the McCain’s ability to maintain steering control and respond to increased traffic in the Straits, making the collision avoidable.

Search and Rescue efforts were conducted by ship personnel with the assistance of the USS America, the Republic of Singapore, the Royal Malaysian Navy and Maritime Enforcement Agency, the Indonesian Navy, and the Royal Australian Air Force. Recovery efforts were continued when the McCain returned to Singapore harbor.

Three main areas were identified in the findings of the investigation as being of specific relevance: training, seamanship and navigation, and leadership and culture.

Systemic review

The report acknowledged the “need for the navy to undertake a review of wider scope to better determine systemic causes.”

The Chief of Naval Operations, Admiral John Richardson, provided a summary and commentary from the Pentagon on November 2.

“If we take our eye off the fundamentals, we become vulnerable to mistakes at all levels of command.”

The Comprehensive Review of Surface Force Incidents conducted by U.S. Fleet Forces Commander, Admiral Phil Davidson, looked at the two incidents from this summer as well as cases going back ten years. The review found that “over a sustained period of time, rising pressure to meet operational demands led those in command to rationalize declining standards.”

The CNO acknowledged that these increased demands have led to declining standards of performance. The high operational tempo specific to the 7th Fleet makes it a particularly vulnerable area to this way of thinking. The investigation focused on the incidents in the 7th fleet but the Navy’s intention is to “study this at all levels of command” and report their findings to their supervising commands.

Questions arose related to the role that fatigue and sleep deprivation played in these collisions. The Navy has begun a mandatory circadian rhythm cycle, requiring sailors to get a minimum of 6-8 hours of sleep within a 24-hour period.

Actions to remedy the problems include “restoring a deliberative scheduling process in the 7th Fleet, conducting comprehensive ready-for-sea assessments for all Japan-based ships, establishing the Naval Surface Group in the Western Pacific… establishing and using a near-miss program to understand and disseminate lessons learned, and establishing policies for surface ships to routinely actively transmit on their Automatic Identification system.”

All immediate actions focus on developing a true understanding of ships’ readiness and planning accordingly. This is intended to provide ships that are ready to conduct safe operations at sea, rather than responding to operations with ships that are not qualified to conduct them.

The responsibility rests with the individual commander to accurately report their unit’s readiness, including when they are not sufficiently prepared to undertake a mission. The CNO referenced the Comprehensive Review’s identification of the need to create a climate or culture that allows for commanders to say when they are “stretched too thin.”

A Marine Casualty Investigation, conducted by the United States Coast Guard on behalf of the National Transportation Safety Board, is ongoing. A Marine Casualty Investigation is done when a collision occurs between U.S. and foreign registered vessels.

Independent review of unmanned or autonomous ship-driving developments and future technology was also mentioned by Admiral Richardson. This technology is being studied and explored independent of the review of recent incidents.