The fundamentals of running aground

Often, the best way to salvage something from the wreckage of an otherwise stellar career cut short by a bad day at sea is to look at what went wrong - and by example hope younger officers will learn.

I have nothing one way or another to say about CDR McClure, but some of the things that happened that day on her ship should be looked at with a clear, learning eye.

Lost situational awareness, sloppy navigation and faulty navigational gear caused the destroyer Arleigh Burke to run aground at high speed while en route to port May 15, according to a mishap report obtained Wednesday by Navy Times.

The incident, which cost the ship’s captain, Cmdr. E.J. McClure, her command, caused no more damage than some paint scraped off the hull. No sailors were injured and no damage estimates were included in the report.

The details.

The mishap occurred while the ship was traveling at 25 knots about three miles northeast of Cape Henry Light, near the entry to the Chesapeake Bay on the way into Norfolk. The ship remained stuck in the sand for an hour after the grounding.

One factor that could have contributed to the mishap was a spot award of the Navy Achievement Medal to a crew member in the pilot house. The ceremony lasted two minutes and the ship ran aground 14 minutes later. The report states that the ceremony was not included in the navigation brief and “adversely impacted” McClure’s situational awareness.
...
The mishap report identifies several things that went wrong on the afternoon of May 15 and requests an investigation of the command’s claim that its Navigation Sensor System Interface and the Battle Force Tactical Training system were not reliable. The ship’s navigator had so lost faith in the electronics that he previously wrote a “point paper on the ship’s NAVSSI issues and forwarded it to the CO,” the report states.
...
According to the report’s timeline, there were points during the trip when the ship’s crew did not know exactly where they were. Two minutes before the accident, the report says, McClure and her navigator disagreed over which buoy they were seeing.

The ship was also going too fast for local restricted waters, according to the report. Once the ship completed its Engineering Operations Certification in the Virginia Capes area earlier in the day, McClure and the navigator “realized they were behind schedule” to meet the local pilot off Norfolk. A person unidentified in the report “had previously explained to the CO that there was no rush to get in. That person had the authority to change the pilot pickup time and not to worry about arriving” at the set location by 6 p.m.

At the time of the grounding, the ship was going 25 knots, according to the report, “despite briefed 18-knot transit due to perceived pressure to ensure on-time arrival.”

Navigation inconsistencies are cited throughout the report, and some information on the ship’s location was not available to investigators, such as radar tapes that had been recycled too much to be useful, and the Combat Information Center shipping log that “contained no information.”

It is that 2-minutes prior "Ummmm, where are we..." conversation that gets me in the gut. The frag pattern is rather large.

The executive officer, Lt. Cmdr. Allen Hobbs, and two other officers were administratively disciplined by strike group commander Rear Adm. Dan Holloway on July 3. They remain with the ship.

Capt. Larry Tindal, commodore of Destroyer Squadron 2, was on board at the time of the mishap. The report says Tindal “failed to recognize the risk associated with conducting an awards ceremony on the bridge during a restricted waters transit with excessive speed.”

Tindal remains commodore after a nonjudicial “meeting” with Holloway earlier this summer.

In addition to McClure, Hobbs and Tindal, the “opinions” section of the report also identifies failures by the officer of the deck, the navigator, navigation plotter, navigation log keepers on the bridge and in the combat information center, piloting officer, CIC watch officer, conning officer and the junior officer of the watch.

Ungh. I think the HTs came through OK though....

---

UPDATE: I usually try not to get too technical here, but there is a very good Shoefest going on over at SailorBob on the subject (thanks for the plug PoopDeck1). Ming posted a message from early AUG that VADM Etnyre put out that is worth reading - and doesn't get too far in the weeds - so even the general audience can glean some good things. First sentence of paragraph 6 should be chiseled above the head right off the bridge. In whole.

R 071832Z AUG 07
FM COMNAVSURFOR SAN DIEGO CA//N00//
TO ALNAVSURFOR
INFO CNO WASHINGTON DC//N84/N86//
COMUSFLTFORCOM NORFOLK VA//N37//
COMNAVSURFLANT NORFOLK VA
COMNAVSURFLANT NORFOLK VA
PEO IWS WASHINGTON DC//1/2/6//
PEO IWS WASHINGTON DC//1/2/6//
COMSPAWARSYSCOM SAN DIEGO CA//PMW170//
NMAWC CORPUS CHRISTI TX
COMNAVSEASYSCOM WASHINGTON DC//N53C//
COMNAVSEASYSCOM WASHINGTON DC//N53C//
SPAWARSYSCEN CHARLESTON SC//34/34B/34D/342/343/345// USNA ANNAPOLIS MD
CENSURFCOMBATSYS DAHLGREN VA//00// SWOSCOLCOM NEWPORT RI//N72//
COMSPAWARSYSCOM SAN DIEGO CA//PMW170// COMAFLOATRAGRU ATLANTIC NORFOLK
VA COMAFLOATRAGRU MAYPORT FL COMAFLOATRAGRUPAC SAN DIEGO CA
COMAFLOATRAGRUMIDPAC PEARL HARBOR HI COMAFLOATRAGRUMIDPAC PEARL HARBOR
HI COMAFLOATRAGRUWESTPAC YOKOSUKA JA AFLOATRAGRUPACNORWEST EVERETT WA
COMDDGRON NORFOLK VA COMFFGRON MAYPORT FL COMLHDRON NORFOLK VA
COMLSDLPDRON SAN DIEGO CA COMNAVSURFOR SAN DIEGO CA//N7// COMNAVSURFOR
SAN DIEGO CA//N7//
BT
UNCLAS //N02300//
MSGID/GENADMIN/COMNAVSURFOR/3626//
SUBJ/SURFACE NAVIGATION LESSONS LEARNED AND BEST PRACTICES//
REF/A/DOC/CNAF-CNSF/24FEB2005//
AMPN/REF A IS COMNAVAIRFORINST-COMNAVSURFORINST 3530.4A (NAVDORM).//
POC/xxxxxxx/LT/CNSF/FORCE NAVIGATOR/TEL: 619-437-xxxx/
EMAIL: MICHELLE.xxxx(AT)NAVY.MIL//
RMKS/1. SAFE NAVIGATION REQUIRES THE FUSION OF DATA FROM SHIPBOARD NAVIGATIONAL EQUIPMENT AND APPLICATION OF BOTH ELECTRONIC AND VISUAL DATA BY KNOWLEDGEABLE SAILORS TO BUILD THE MOST ACCURATE NAVPLOT. A RECENT SHIP GROUNDING LESSON LEARNED WAS UNDERSTANDING THE CORRECT ALIGNMENT OF NAVIGATION EQUIPMENT AND FAILURE TO USE PROPER NAVIGATION PROCEDURES.

2. PROPER EQUIPMENT SETUP IS A PREREQUISITE TO GETTING ACCURATE INFORMATION. SPECIFICALLY, FAILURE TO SET UP THE WSN-7 FOR AT-SEA OPERATION IAW CSOSS AND INCORRECT SELECTION OF POSITION SOURCE AT THE COMDAC DISPLAY ON THE BRIDGE BEGAN AN UNBROKEN CHAIN OF ERRORS THAT ULTIMATELY RAN THE SHIP AGROUND. PRIOR TO GETTING UNDERWAY, THE WSN-7 WAS INCORRECTLY LEFT IN DOCKSIDE CONFIGURATION - MANUAL VELOCITY (VMAN) EQUAL TO 0.0 KTS AND AUTOMATIC DAMPING (AUTOD). THE SHIP SHOULD HAVE ENABLED THE WSN-7 VELOCITY REFERENCE TO VGPS (GPS) OR VSYN (RODMETER; VGPS IS PREFERRED) MODE. BECAUSE THE WSN-7 WAS IN VMAN MODE WITH A SPEED INPUT OF ZERO WHILE THE SHIP WAS ACTUALLY NAVIGATING AT MORE THAN 15 KNOTS IN RESTRICTED WATERS, THE SYSTEM COULD NOT ACCURATELY APPLY THE CALCULATED VELOCITIES, WHICH ARE USED TO GENERATE UPDATED ESTIMATED POSITIONS (EP). ONCE THE EP SEPARATED FROM THE GPS FIX POSITION THE INS BEGAN REJECTING GPS INPUTS. BECAUSE OF POOR OPERATOR KNOWLEDGE OF THEIR DISPLAY SYSTEMS, THE SHIP WAS RELYING SOLELY ON WHAT THEY THOUGHT TO BE GPS INPUTS TO FIX SHIP'S POSITION AND NEITHER NAVIGATION TEAM RECOGNIZED THEY WERE PLOTTING COMPROMISED INS POSITIONS.

3. AS THE SHIP PROGRESSED DOWN ITS TRACK, WSN-7 POSITION ERROR GREW TO MORE THAN 4000 YARDS IN A PERIOD OF LESS THAN 30 MINUTES. THIS WAS NOT DUE TO ANY WSN EQUIPMENT FAILURE; THIS WAS THE NORMAL RESULT OF NOT PROPERLY ALIGNING THE WSN, WHICH IS WHY ADHERENCE TO CSOSS IS SO IMPORTANT.

4. ALL SHIPS MAY USE GPS AS THEIR PRIMARY FIX SOURCE IN ALL WATERS. HOWEVER, IN RESTRICTED AND PILOTING WATERS THE NAVIGATION TEAM MUST DETERMINE SHIP'S POSITION BY OTHER MEANS AT NO GREATER THAN EVERY THIRD FIX INTERVAL. NO ONE FIX SOURCE SHOULD BE SOLELY RELIED UPON. SHOULD GPS FIGURE OF MERIT (FOM) OR ESTIMATED POSITION ERROR (EPE) FALL OUTSIDE ACCEPTABLE ACCURACY LIMITS THE SHIP'S NAV TEAM WILL SHIFT TO AN ALTERNATE FIX SOURCE AS THE PRIMARY FIX SOURCE.
ACCEPTABLE FIX ACCURACY (READ IN TWO COLUMNS):
AREA FIX ACCURACY/GPS FOM
RESTRICTED WATERS 50 YARDS/FOM 2
PILOTING WATERS 100 YARDS/FOM 4
COASTAL WATERS 500 YARDS/FOM 6
OPEN OCEAN 1500 YARDS/FOM 7
EFFECTIVE IMMEDIATELY, ALL SHIPS WILL LOG GPS FOM FOR ALL FIXES WHEN
GPS IS THE PRIMARY FIX SOURCE. GPS FOM WILL BE LOGGED IN THE STANDARD BEARING BOOK OR SHIPS POSITION LOG AS APPROPRIATE. THIS CHANGE WILL BE INCLUDED IN THE NEXT REVISION TO THE NAVDORM.

5. ONLY SHIPS CERTIFIED TO NAVIGATE USING ECDIS-N MAY USE ECDIS-N AS THE PRIMARY NAV PLOT. SHIPS MUST MEET ALL OF THE FOLLOWING REQUIREMENTS TO BE CERTIFIED ECDIS-N: HAVE OPNAV-APPROVED SOFTWARE/ HARDWARE CONFIGURATION INSTALLED, SUCCESSFULLY COMPLETE ECDIS-N NAVCERT, HAVE REQUIRED NUMBER OF VMS OPERATOR GRADUATES ONBOARD, SUCCESSFULLY COMPLETE CREW CERTIFICATION, AND BE APPROVED TO NAVIGATE USING ECDIS-N BY TYCOM. SITUATIONAL AWARENESS TOOLS ARE NOT AUTHORIZED FOR USE AS THE PRIMARY NAVIGATION PLOT. SHIPS NOT AUTHORIZED TO NAVIGATE USING ECDIS-N MAY USE POSITION DATA FROM ELECTRONIC SOURCES, BUT THE PRIMARY NAV PLOT MUST REMAIN ON PAPER CHARTS - ACCEPTABLE FIX SOURCES ARE GPS(PPS), VISUAL, AND RADAR. STRICT COMPLIANCE WITH REF A, THE NAVDORM, IS NOT NEGOTIABLE. DESPITE THE WSN-7 POSITION ERRORS, THIS GROUNDING COULD HAVE BEEN AVOIDED HAD THE NAV TEAM SIMPLY ADHERED TO BASIC NAVIGATION STANDARDS.

6. SEAMANSHIP AND NAVIGATION ARE CORE COMPETENCIES. THESE LESSONS LEARNED ARE WORTH REPEATING AND CAREFUL REVIEW ON EACH SHIP IN THE FORCE. VADM ETNYRE SENDS.//

BT
#0000
NNNN