Thursday, November 02, 2017

The FITZGERALD and MCCAIN’s MEMO - The Problem is Us

There will be more to come from the ongoing investigations in to the collisions of the USS FITZGERALD (DDG 62) and USS MCCAIN (DDG 56) that took place earlier this year. At each release, we should take some time to look at what is being presented and not just focus on the unit level failures – which are legion – but use those data points to see where they point towards the larger factors that led them to their unnecessary but logical end.

Earlier this week, the 72-page “MEMORANDUM FOR DISTRIBUTION” became available. You can read it all embedded below.

We must give credit to “Big Navy” here once again. This is about as transparent as you will get from any military service of any nation. It is of great credit to our service culture that we are doing this. Sure, there are things we can improve – all human institutions need improvement – but we should all acknowledge the goodness in this transparency. We appear to be focused on the right things, and BZ to those who gave the D&G to do so, and put this together.

It can be uncomfortable to do such investigations. It can be embarrassing. It can be unpleasant – but it is absolutely the only way you can find a way to learn, take action, and strive to make changes to make sure it does not happen again.

As you read this, you will soon start to realize that it was all preventable. Ships and crews have found themselves with the same challenges for thousands of years – from oar to nuclear power. Leadership, human factors, and the even the ergonomics of the human-machine interface – it all is there to either make an uneventful watch, or disaster.

There are some technical issues one could focus on here if you wanted, but they are at best a tertiary factor. In a read of this very "just-the-facts" MEMO, everything thread I start to pull leads to the unit level leadership first, and then in the direction towards fleet, community, and service level issues that created the conditions for these unit level failures to manifest themselves.

To set a tone, I am going to pull in to Surface Warfare mishaps something from the Aviation side of the house. We are all Navy officers, so this is more than fair. All credit here goes to our friend Herb Carmen, CAPT, USN (Ret) who pointed us this way on twitter.

Your reference is OPNAV INSTRUCTION 3750.6R, Appendix O, Paragraph A. In part,
Human error continues to plague both military and civilian aviation. Yet, simply writing off aviation mishaps to "pilot error" is a simplistic, if not naive, approach to mishap causation. Further, it is well established that mishaps are rarely attributed to a single cause, or in most instances, even a single individual. Rather, mishaps are the end result of a myriad of latent failures or conditions that precede active failures. The goal of a mishap investigation is to identify these failures and conditions in order to understand why the mishap occurred and how it might be prevented from happening again in the future.

As described by Reason (1990), active failures are the actions or inactions of operators that are believed to cause the mishap. Traditionally referred to as "pilot error", they are the last "unsafe acts" committed by aircrew, often with immediate and tragic consequences. For example, an aviator forgetting to lower the landing gear before touch down or flat-hatting through a box canyon will yield relatively immediate, and potentially grave, consequences.

In contrast, latent failures or conditions are errors that exist within the squadron or elsewhere in the supervisory chain of command that effect the tragic sequence of events characteristic of a mishap. For example, it is not difficult to understand how tasking crews at the expense of quality crew rest, can lead to fatigue and ultimately errors (active failures) in the cockpit. Viewed from this perspective then, the unsafe acts of aircrew are the end result of a chain of causes whose roots originate in other parts (often the upper echelons) of the organization. The problem is that these latent failures or conditions may lie dormant or undetected for hours, days, weeks, or longer until one day they bite the unsuspecting aircrew.

The question for mishap investigators and analysts alike, is how to identify and mitigate these active and latent failures or conditions. One approach is the "Domino Theory" which promotes the idea that, like dominoes stacked in sequence, mishaps are the end result of a series of errors made throughout the chain of command. A "modernized" version of the domino theory is Reason's "Swiss Cheese" model that describes the levels at which active failures and latent failures/conditions may occur within complex flight operations (see Figure 1).

Why would the Surface community want to benchmark an Aviation-centric instruction’s attitude as opposed on focusing on unit level failures? Here are 17 reasons;

- GMSN Kyle Rigsby of Palmyra, Virginia, 19 years old.
- YN2 Shingo Alexander Douglass, of San Diego, California, 25 years old.
- FC1 Carlos Victor Ganzon Sibayan of Chula Vista, California, 23 years old.
- PSC Xavier Alec Martin of Halethorpe, Maryland, 24 years old.
- STG2 Ngoc Turong Huynh of Oakville, Connecticut, 25 years old.
- GM1 Noe Hernandez of Weslaco, Texas, 26 years old.
- FCC Gary Rehm, Jr., of Elyria, Ohio, 37 years old.
- ETC Charles Nathan Findley of Amazonian, Missouri, 31 years old.
- ICC Abraham Lopez of El Paso, Texas, 39 years old.
- ET1 Kevin Sayer Bushell of Gaithersburg, Maryland, 26 years old.
- ET1 Jacob Daniel Drake of Cable, Ohio, 21 years old.
- ITl Timothy Thomas Eckels Jr. of Baltimore, Maryland, 23 years old.
- ITl Corey George Ingram of Poughkeepsie, New York, 28 years old.
- ET2 Dustin Louis Doyon of Suffield, Connecticut, 26 years old.
- ET2 John Henry Hoagland III of Killeen, Texas, 20 years old.
- IC2 Logan Stephen Palmer of Harristown, Illinois, 23 years old.
- ET2 Kenneth Aaron Smith of Cherry Hill, New Jersey, 22 years old.

Not waving bloody shirts around, but this should focus the mind. This is not an academic exercise, or some Black Swan event – this is a scenario x2 that people have been warning about for years. We don’t just have bent steel and bruised egos here – these are lessons written in the blood of 17 Sailors who we like to say are our most important assets.

Back to the document in questions. I highly encourage everyone to read it in full – and good people can come away from reading it with different areas of concern – and that is fine. For this retired CDR, here is what got the attention of my highlighter;

By 0130 hours on 17 June 2017, the approximate time of the collision, FITZGERALD was approximately 56 nautical miles to the southwest of Yokosuka, Japan, near the Izu Peninsula within sight of land and continuing its transit outbound. The seas were relatively calm at 2 to 4 feet. The sky was dark, the moon was relatively bright, and there was scattered cloud cover and unrestricted visibility.
Weather; not a factor.
In accordance with the International Rules of the Nautical Road, the FITZGERALD was in what is known as a crossing situation with each of the vessels. In this situation, FITZGERALD was obligated to take maneuvering action to remain clear of the other three, and if possible, avoid crossing ahead. In the event FITZGERALD did not exercise this obligation, the other vessels were obligated to take early and appropriate action through their own independent maneuvering action. In the 30 minutes leading up to the collision, neither FITZGERALD nor CRYSTAL took such action to reduce the risk of collision until approximately one minute prior to the collision. FITZGERALD maintained a constant course of 190 degrees at 20 knots of speed.
No unusual circumstances. From a seamanship point of view, thousands of identical scenarios each hour of each night around the world.

The Officer of the Deck, the person responsible for safe navigation of the ship, exhibited poor seamanship by failing to maneuver as required, failing to sound the danger signal and failing to attempt to contact CRYSTAL on Bridge to Bridge radio. In addition, the Officer of the Deck did not call the Commanding Officer as appropriate and prescribed by Navy procedures to allow him to exercise more senior oversight and judgment of the situation.

The remainder of the watch team on the bridge failed to provide situational awareness and input to the Officer of the Deck regarding the situation. Additional teams in the Combat Information Center (CIC), an area on where tactical information is fused to provide maximum situational awareness, also failed to provide the Officer of the Deck input and information.
As you will see over and over; yes there is individual failure, but this is actually a systemic failure. No one gets to be OOD overnight. No one gets to be the senior officer in CIC by fogging a mirror. These are, in theory, highly trained professionals who have invested years to be standing that watch. At a minimum, the basics should be instinct, should be expected – should be reinforced by the entire watch team because that is what we do. This did not happen in isolation. This is not the first time any of this took place. 

Why, on this ship on this watch, did this happen? What were the conditions that created such an environment?

Of the 42 Sailors assigned to Berthing 2, at the time of collision, five were on watch and two were not aboard. Of the 35 remaining Sailors in Berthing 2, 28 escaped the flooding. Seven Sailors perished.

Some of the Sailors who survived the flooding in Berthing 2 described a loud noise at the time of impact. Other Berthing 2 Sailors felt an unusual movement of the ship or were thrown from their racks. Other Berthing 2 Sailors did not realize what had happened and remained in their racks. Some of them remained asleep. Some Sailors reported hearing alarms after the collision, while others remember hearing nothing at all.

The occupants of Berthing 2 described a rapidly flooding space, estimating later that the space was nearly flooded within a span of 30 to 60 seconds. By the time the third Sailor to leave arrived at the ladder, the water was already waist deep. Debris, including mattresses, furniture, an exercise bicycle, and wall lockers, floated into the aisles between racks in Berthing 2, impeding Sailors’ ability to get down from their racks and their ability to exit the space. …
Not a minor detail. If you read the post-battle reports from prior wars of the last century, this is almost an exact repeat of what you saw early on. “Gear adrift” is not a punch line. Ship’s clutter is not just an eyesore. One hopes this is being looked at very close.

The next pull-quote I had to read twice, as it reflects the nature of Sailors as I know them. Hollywood and the usual suspects put a lot of false ideas about how trained professionals act in times of crisis.

If this does not let you know that we have the Sailors we need, I don’t know what to tell you. If this doesn’t tell you the exceptional quality of today’s young men and women, I don’t know what will. We just need to make our Navy as good as they are.
Sailors recall that after the initial shock, occupants lined up in a relatively calm and orderly manner to climb the port side ladder and exit through the port side watertight scuttle. Figure 14 provides an example of the route Sailors would have taken from their racks to the port side watertight scuttle on a ship of the same class as FITZGERALD. They moved along the blue floor and turned left at the end to access the ladder. Figure 14 provides an example and sense of scale. Even though the Sailors were up to their necks in water by that point, they moved forward slowly and assisted each other. One Sailor reported that FC1 Rehm pushed him out from under a falling locker. Two of the Sailors who already escaped from the main part of Berthing 2 stayed at the bottom of the ladder well (see Figure 8) in order to help their shipmates out of the berthing area.
How often do we train how to egress from berthing or watch stations? 

This next part reminded me of an interview with one of the three survivors of the sinking of the HMS Hood. The navigation officer let the Signalman step through the hatch first. That second was all it took for one person to survive and the other not.
One Sailor escaped via the starboard side of Berthing 2. After the collision, this Sailor tried to leave his rack, the top rack in the row nearest to the starboard access trunk, but inadvertently kicked someone, so he crawled back into his rack and waited until he thought everyone else would be out of the Berthing 2. When he jumped out of his rack a few seconds later, the water was chest high and rising, reaching near to the top of his bunk.

After leaving his rack, the Sailor struggled to reach the starboard egress point through the lounge area. He moved through the lounge furniture and against the incoming sea. Someone said, “go, go, go, it’s blocked,” but he was already underwater. He was losing his breath under the water but found a small pocket of air. After a few breaths in the small air pocket, he eventually took one final breath and swam. He lost consciousness at this time and does not remember how he escaped from Berthing 2, but he ultimately emerged from the flooding into Berthing 1, where he could stand to his feet and breathe. He climbed Berthing 1’s egress ladder, through Berthing 1’s open watertight scuttle and collapsed on the Main Deck. He was the only Sailor to escape through the starboard egress point.
Again, the quality of our Sailors today are in line with the finest traditions of our service. Don’t let anyone tell you otherwise.
After escaping Berthing 2, Sailors went to various locations. Some assembled on the mess decks to treat any injuries and pass out food and water. Others went to their General Quarters (GQ) stations to assist with damage control efforts. Another Sailor went to the bridge to help with medical assistance. One Sailor later took the helm and stood a 15-hour watch in aft steering after power was lost forward.
All officers need to be prepared to be the senior officer present afloat. I’m not sure when the last time a ship lost their CO in such a situation. I don’t care if you are the XO or the junior ENS who just reported aboard. Think about it.
Five Sailors used a sledgehammer, kettlebell, and their bodies to break through the door into the CO’s cabin, remove the hinges, and then pry the door open enough to squeeze through. Even after the door was open, there was a large amount of debris and furniture against the door, preventing anyone from entering or exiting easily.

A junior officer and two chief petty officers removed debris from in front of the door and crawled into the cabin. The skin of the ship and outer bulkhead were gone and the night sky could be seen through the hanging wires and ripped steel. The rescue team tied themselves together with a belt in order to create a makeshift harness as they retrieved the CO, who was hanging from the side of the ship.

The team took the CO to the bridge, where a medical team assessed his condition. As he was being monitored by personnel on the bridge, his condition worsened. A team of stretcher bearers moved the CO from the bridge to the at-sea cabin at 0319, and shortly thereafter, due to the severity of his injuries, he was medically evacuated from the ship at 0710 to USNHY via helicopter.
In “8. Findings,” this should be in bold and needs a lot of investigation and details. Note the plural. Note where the ship is. This is about as damning as you can get.
FITZGERALD officers possessed an unsatisfactory level of knowledge of the International Rules of the Nautical Road.
This is simply amazing.
Watchstanders performing physical look out duties did so only on FITZGERALD’s left (port) side, not on the right (starboard) side where the three ships were present with risk of collision.

Key supervisors responsible for maintaining the navigation track and position of other ships:

Were unaware of existing traffic separation schemes and the expected flow of traffic.
This is not a YP full of 3/C MIDN.
The Officer of the Deck, responsible for the safe navigation of the ship, did not call the Commanding Officer on multiple occasions when required by Navy procedures.

The command leadership did not foster a culture of critical self-assessment. Following a near-collision in mid-May, leadership made no effort to determine the root causes and take corrective actions in order to improve the ship’s performance.
Though only touched on briefly, I hope in follow-on reports we see a lot more on this topic. Fatigue makes even the best professional act like an amateur.
The command leadership allowed the schedule of events preceding the collision to fatigue the crew.

The command leadership failed to assess the risks of fatigue and implement mitigation measures to ensure adequate crew rest.
Fair warning to all, these moments in the timeline are hard to read or even understand. This didn't happen in isolation; there is an entire watch team seeing this go down;
2350 - FITZGERALD overtook a contact on the left (port) side within 3 nautical miles and no report was made to the Commanding Officer as required by his Standing Orders procedures. No course and speed determinations were made for this vessel by watchstanders.

0000 - FITZGERALD was in vicinity of four commercial vessels, two of which were within 3 nautical miles and no report was made to the Commanding Officer as required by his Standing Orders procedures. No course and speed determinations were made for this vessel by watchstanders.

0015 - FITZGERALD was passing two commercial vessels, one of which was within 3 nautical miles and no report was made to the Commanding Officer as required by his Standing Orders procedures. No course and speed determinations were made for this vessel by watchstanders.
This is strange, as if the OOD decided that he/she would have their own Standing Orders – or was just erratic in application. Either way, huge bells should have been going off for the entire watch team after this.
0034 - Four vessels passed down the left (port) side with closest point of approach at 1500 yards. The Commanding Officer was informed. No course and speed determinations were made for these vessels. Radar contact on them was not held.
Did you catch that? No radar contact at 1,500 yards. No, I don’t understand – but I believe it based on what I’m reading. Perhaps best covered in a classified annex.
0058 - FITZGERALD was in the vicinity of five commercial vessels. Three of these passed on the left (port) side within 3 nautical miles and no report was made to the Commanding Officer as required by his Standing Orders.
I’m open to suggestions people – but this is more than just a case study. We need to have a full re-enactment on video to get the full measure of what reads as collective madness. That use of “madness” hyperbole? Well …
0108 - FITZGERALD crossed the bow of a ship at approximately 650 yards, passed a second vessel at 2 nautical miles, and a third vessel at 2.5 nautical miles. No reports were made to the Commanding Officer as required by his Standing Orders procedures. No course and speed determinations were made for this vessel by watchstanders.
I’ve got nothing.

5-minutes is forever in an unfolding situation like this. The crew had one last chance. It seems that the JOOD finally stepped up – but …
0120 - The watch stander responsible for immediate support to the Officer of the Deck, the Junior Officer of the Deck, reported sighting CRYSTAL visually and noted that CRYSTAL’s course would cross FITZGERALD’s track. The Officer of the Deck continued to think that CRYSTAL would pass at 1500 yards from FITZGERALD.

0122 - The Junior Officer of the Deck sighted CRYSTAL again and made the recommendation to slow. The Officer of the Deck responded that slowing would complicate the contact picture.

0125 - CRYSTAL was approaching FITZGERALD from the right (starboard) side at 3 nautical miles. FITZGERALD watchstanders at this time held two other commercial vessels in addition to CRYSTAL. One was calculated to have closest approach point at 2000 yards and the other was calculated to risk collision. No contact reports were made to the Commanding Officer and no additional course and speed determinations were made on these vessels.
Then everything just came apart at the officer level. Panic? Vapor lock? Who knows, but what a terrifying four minutes on the bridge for the junior personnel on watch.
0125 - The Officer of the Deck noticed CRYSTAL rapidly getting closer and considered a turn to 240T.

0127 - The Officer of the Deck ordered course to the right to course 240T, but rescinded the order within a minute. Instead, the Officer of the Deck ordered an increase to full speed and a rapid turn to the left (port). These orders were not carried out.
Here is the kicker. 90-seconds to collision, one person on the bridge did not have vapor lock? Sal’s favorite rate;
0129 - The Bosun Mate of the Watch, a more senior supervisor on the bridge, took over the helm and executed the orders.
I do have a quibble with how this was worded. For the non-Navy types; to be clear, the BMOW is not an officer. That is an enlisted person – often quite junior. I’ll let BM3 (SW/AW) Charlesa Anderson, USN school you if you need a refresher.

In any event, too late;
As of 0130 - Neither FITZGERALD nor CRYSTAL made an attempt to establish radio communications or sound the danger signal.

As of 0130 - FITZGERALD had not sounded the collision alarm.
0130:34 - CRYSTAL’s bow struck FITZGERALD at approximately frame 160 on the right (starboard) side above the waterline and CRYSTAL’s bulbous bow struck at approximately frame 138 below the waterline.
The report has plenty of pics of the damage. If you wish to see them, go below.

Part II: MCCAIN: It is important to remember that this took place a few months after FITZGERALD. What happened then was in the mind of the MCCAIN’s CO and the crew. Like her sister ship, this story will have you shaking your head is disbelief.

There is a trend here.
- Loss of situational awareness in response to mistakes in the operation of the JOHN S MCCAIN’s steering and propulsion system, while in the presence of a high density of maritime traffic.

- Failure to follow the International Nautical Rules of the Road, a system of rules to govern the maneuvering of vessels when risk of collision is present.

- Watchstanders operating the JOHN S MCCAIN’s steering and propulsion systems had insufficient proficiency and knowledge of the systems.

In the predawn hours of 21 August 2017, the moon had set and the skies were overcast. There was no illumination and the sun would not rise until 0658. Seas were calm, with one to three foot swells. All navigation and propulsion equipment was operating properly.

At 0418, JOHN S MCCAIN transitioned to a Modified Navigation Detail due to approaching within 10 nautical miles from shoal water. This detail is used by the Navy when in proximity of water too shallow to safely navigate as occurs when entering ports. This detail supplemented then watch team with a Navigation Evaluator and Shipping Officer, providing additional personnel and resources in the duties of Navigation and management of the ship’s relative position to other vessels.
There are no external factors. This is all internal.

So the chain starts;
Although JOHN S MCCAIN entered the Middle Channel of the Singapore Strait (a high traffic density area) at 0520, the Sea and Anchor Detail, a team the Navy uses for transiting narrower channels to enter port, was not scheduled to be stationed until 0600. This Detail provides additional personnel with specialized navigation and ship handling qualifications.

Why the delay?
In general, people don’t know their equipment because it isn’t a priority. They don’t train in casualty modes. They haven’t been trained enough to recognize anything but the most normal or permissive environments. They have not seen or been trained to recognize primary and secondary indications that is causing a ship to act one way or another – or the multiple causes of a single symptom.

When you have good people, good equipment, and external conditions are within norms – most of the time the problem is inadequate training and/or experience from top to bottom.

At 0519, the Commanding Officer noticed the Helmsman (the watchstander steering the ship) having difficulty maintaining course while also adjusting the throttles for speed control. In response, he ordered the watch team to divide the duties of steering and throttles, maintaining course control with the Helmsman while shifting speed control to another watchstander known as the Lee Helm station, who sat directly next to the Helmsman at the panel to control these two functions, known as the Ship’s Control Console. See Figures 3 and 4. This unplanned shift caused confusion in the watch team, and inadvertently led to steering control transferring to the Lee Helm Station without the knowledge of the watch team. The CO had only ordered speed control shifted. Because he did not know that steering had been transferred to the Lee Helm, the Helmsman perceived a loss of steering.
This begs the question: had the crew on watch ever trained how to do this? The CO seemed to know what he was doing – but it does not seem that the bridge crew knew what to do and to ensure that it was done correctly - or to communicate to the watch team what they were doing.

I won’t go in to it more here, but you will also see some of the ergonomic issues with modern bridge systems. With your eyes closed or from the other side of the bridge – simple things such as Helm and Lee Helm status/inputs/are not readily apparent.

This describes the problem;
Steering was never physically lost. Rather, it had been shifted to a different control station and watchstanders failed to recognize this configuration. Complicating this, the steering control transfer to the Lee Helm caused the rudder to go amidships (centerline). Since the Helmsman had been steering 1-4 degrees of right rudder to maintain course before the transfer, the amidships rudder deviated the ship’s course to the left.

Additionally, when the Helmsman reported loss of steering, the Commanding Officer slowed the ship to 10 knots and eventually to 5 knots, but the Lee Helmsman reduced only the speed of the port shaft as the throttles were not coupled together (ganged). The starboard shaft continued at 20 knots for another 68 seconds before the Lee Helmsman reduced its speed. The combination of the wrong rudder direction, and the two shafts working opposite to one another in this fashion caused an un-commanded turn to the left (port) into the heavily congested traffic
area in close proximity to three ships, including the ALNIC.
There was no way to readily tell things weren’t what they should have been.
Although JOHN S MCCAIN was now on a course to collide with ALNIC, the Commanding Officer and others on the ship’s bridge lost situational awareness. No one on the bridge clearly understood the forces acting on the ship, nor did they understand the ALNIC’s course and speed relative to JOHN S MCCAIN during the confusion.
Training? Ergonomics? Experience? All three? Everyday ops is not where you find your problems - it is when the system is stressed. That concept applies here, but everyday ops that became stressed due to pure human factors.

Another common theme; failure of basics.
Despite their close proximity, neither JOHN S MCCAIN nor ALNIC sounded the five short blasts of whistle required by the International Rules of the Nautical Road for warning one another of danger, and neither attempted to make contact through Bridge to Bridge communications.
Also common with the FITZGERALD is the apparent fragility of our communication systems. What would happen in combat? Is your ship training for this?
Most of the electronic systems on the bridge were inoperable until the two ships parted. Main communications systems on the bridge stopped working after the collision and the bridge began using handheld radios to communicate with aft steering. Sound powered phones, which do not require electrical power to transmit communications, and handheld radios were the main means of communication from the bridge. Aft Internal Communications, a space adjacent to Berthing 5 with communications control equipment, quickly flooded and was likely responsible for the loss of bridge communications.
Seconds and moments in time. Gear adrift. There are constants and restraints that determine who lives and who does not.
Two Sailors who were in Berthing 5 at the time of the collision escaped from the space. The first Sailor was on the second step of the ladder-well leading to the deck above when the collision occurred. The impact of the collision knocked him to the ground, leaving his back and legs bruised. Fuel quickly pooled around him and he scrambled up and back onto the ladder.

The Sailor climbed out of Berthing 5 through the open scuttle, covered in fuel and water from the near instantaneous flooding of the space. He did not see anyone ahead of or behind him as he escaped. He reported seeing two other Sailors in the lounge area, one preparing for watch duties and another standing near his rack. Both of these Sailors were lost, along with the eight shipmates who were in their racks to rest at the time of the collision.

The second Sailor who escaped from Berthing 5 heard the crashing and pushing of metal before the sound of water rushing in. Within seconds, water was at chest level. The passageway leading to the ladder-well was blocked by debris, wires and other wreckage hanging from the overhead. From the light of the battle lanterns (the emergency lighting that turns on when there is a loss of normal lights due to power outage) he could see that he would have to climb over the debris to get to the ladder-well.
The findings section is just plain sad to read. So avoidable and points to a huge shortfall; fundamentals.
… no single person bears full responsibility for this incident. The crew was unprepared for the situation in which they found themselves through a lack of preparation, ineffective command and control and deficiencies in training and preparations for navigation.

Because steering control was in backup manual at the helm station, the offer of control existed at all the other control stations (Lee Helm, Helm forward station, Bridge Command and Control station and Aft Steering Unit). System design is such that any of these stations could have taken control of steering via drop down menu selection and the Lee Helm’s acceptance of the request. If this had occurred, steering control would have been transferred.

When taking control of steering, the Aft Steering Helmsman failed to first verify the rudder position on the After Steering Control Console prior to taking control. This error led to an exacerbated turn to port just prior to the collision, as the indicated rudder position was 33 degrees left, vice amidships. As a result, the rudder had a left 33 degrees order at the console at this time, exacerbating the turn to port.

Several Sailors on watch during the collision with control over steering were temporarily assigned from USS ANTIETAM (CG 54) with significant differences between the steering control systems of both ships and inadequate training to compensate for these differences.

Multiple bridge watchstanders lacked a basic level of knowledge on the steering control system, in particular the transfer of steering and thrust control between stations. Contributing, personnel assigned to ensure these watchstanders were trained had an insufficient level of knowledge to effectively maintain appropriate rigor in the qualification program. The senior most officer responsible for these training standards lacked a general understanding of the procedure for transferring steering control between consoles.

If the CO had set Sea and Anchor Detail adequately in advance of entering the Singapore Strait Traffic Separation Scheme, then it is unlikely that a collision would have occurred. The plan for setting the Sea and Anchor Detail was a failure in risk management, as it required watch turnover of all key watch stations within a significantly congested TSS and only 30 minutes prior to the Pilot pickup.

If JOHN S MCCAIN had sounded at five short blasts or made Bridge-to-Bridge VHF hails or notifications in a timely manner, then it is possible that a collision might not have occurred.

The Commanding Officer decided not to station the Sea and Anchor detail when appropriate, despite recommendations from the Navigator, Operations Officer and Executive Officer.

Principal watchstanders including the Officer of the Deck, in charge of the safety of the ship, and the Conning Officer on watch at the time of the collision did not attend the Navigation Brief the afternoon prior.

No bridge watchstander in any supervisory position ordered steering control shifted from the Helm to the Lee Helm station as would have been appropriate to accomplish the Commanding Officer’s order. As a result, no supervisors were aware that the transfer had occurred.
As with FITZGERALD, the timeline tells the story in a nightmare way;
0521 - The first watchstander reported to After Steering. JOHN S MCCAIN did not have a complete delineated list of personnel to man After Steering in the event of a casualty or problem.

0522:45 - The Executive Officer noticed the ship was not slowing down as quickly as expected and alerted the Commanding Officer. In response, the Commanding Officer ordered 5 knots. This order was echoed by the Conning Officer. The CO did not announce that he had taken direct control of maneuvering orders as required by Navy procedures.

0523:06 - The port shaft continued to slow. The starboard shaft was ahead at a speed of 87 RPM and 100.1% pitch. The port shaft order at this time was 32 RPM at 81.1% pitch. JSM was on course 192T, speed 15.6 knots and turning to the left at a rate of approximately 0.5 degrees per second.

0523:27 - Aft Steering Helmsman took control of steering. This was the fifth transfer of steering and the second time the Aft Steering unit had gained control in the previous two minutes.

0523:44 - JOHN S MCCAIN was on course 177T, speed 11.8 knots, and was slowly turning to the left port at a rate of approximately .04 degrees per second. The ordered and applied right 15 degree rudder checked JOHN S MCCAIN’s swing to port and the ship was nearly on a steady course.

0523:58 - ALNIC’s bulbous bow struck JSM between frame 308 and 345 and below the waterline.
Read it all.
This was the fifth transfer of steering and the second time the Aft Steering unit had gained control in the previous two minutes.
We claim to be the world’s premier naval power. Our forward deployed forces are supposed to be our first line of defense.

We have work to do.

We have a lot of “who” and “what,” but those are just waypoints on where this needs to go; “why?”

The most important word in the English language, “why.” If, in the end, the “why” stays inside the lifelines of the ship and WESTPAC, then I’m afraid we have not done our job correctly.

When I look at who is leading this process and what I have seen so far, I think we are going in the direction of the correct “why.”

More to follow, but so far, indications are good.

This afternoon, David Larter at DefenseNews is reporting on the release of the Comprehensive Review by Fleet Forces Command. Once I get a copy and review, I’ll post my thoughts here early next week.

At the unit level, we’ve heard a lot about how technology or training methodology means that, “We don’t need to do X or Y anymore.” Well, that X and Y were usually fundamentals and offline systems. Hopefully we will continue to address these failed assumptions – because the requirement is all in black and white in this MEMO.

I also hope that we don’t just take action towards unit level failures. As I outlined earlier this year when these events started taking place – there are larger, institutional problems at play. They are harder fixes to both do and measure – but we know what they are and how to fix them. I hope we include lessons from the earlier Balisle Report when all is said and done, otherwise we are simply going to repeat this.

To repeat; I believe we have the right leadership focused in the right direction here – but we need to see sustained action through institutional inertia.

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