HRO 9c Collision at Sea-Sequence of Events2
I abbreviated the reference details below to conserve space. Refer to the original post for the complete information.
References
(a) Navy Report of the Collision https://www.doncio.navy.mil/FileHandler.ashx?id=12011.
(b) National Transportation Safety Board (NTSB) Report of the Collision https://www.ntsb.gov/investigations/accidentreports/reports/mar1901.pdf
(c) International Rules of the Road https://en.wikisource.org/wiki/International_Regulations_for_Preventing_Collisions_at_Sea.
(d) U.S. Navy Regulations, Chapter 8, https://www.secnav.navy.mil/doni/US%20Navy%20Regulations/Chapter%208%20-%20The%20Commanding%20Officer.pdf
Summary of the Incident
The USS JOHN S MCCAIN (JSM) was overtaking the Alnic MC in the westbound lane of the Singapore Strait Traffic Separation Scheme when bridge watchstanders thought they lost steering control (but they didn’t). While the crew attempted to regain control of the vessel, the JSM unintentionally turned to port into the path of the Alnic MC. The resulting collision killed 10 JSM Sailors, injured 48 more, and caused over $100 million in damage to the destroyer. The damage to the Alnic was trivial.
20 August 2017 (the day before the collision)
Time not Specified - the CO decided not to station the ship’s Sea and Anchor Detail (SAD) until AFTER entering the Singapore Straight Traffic Separation Scheme (TSS).
The NTSB report did not identify this as a decision by the CO, only that he approved the "navigation brief document" (ref (b), p.8). In my experience, it is a document that formalizes the navigation brief normally establishes the time of setting the SAD. In its Findings, the Navy report noted that "The Commanding Officer decided not to station the Sea and Anchor detail when appropriate” (emphasis added, ref (a), sec 7.3, p.60). The Navy report did not define “appropriate” in the context of this risk.
The decision by the CO to set the SAD at 0600 after entering restricted waters near and in the TSS at approximately 0522 carried risk. Whether is was “great,” “grave,” “serious,” or “minor” is a judgment call. Neither the NTSB nor the Navy report explores this decision in detail, but perhaps it doesn’t matter how or why the CO made this decision. What we know is that he did and it had consequences.
To understand better the risk of not stationing the Sea and Anchor Detail (SAD) before entering the zone of high shipping traffic, you have to know that the SAD is “a team the Navy uses for transiting narrower channels to enter port, ... [and] provides additional personnel with specialized navigation and ship handling qualifications” (ref(a), p. 45). The SAD also provides additional watch standers with greater experience (ref (b), p. 28). Finally, many Navy ships (every one that I served on) invoke additional control procedures such as a “restricted maneuvering doctrine” in situations like operating in a TSS. Neither report mentioned additional control procedures.
Having "additional personnel with specialized navigation and ship handling qualifications” (ref(b), p. 28) is useful because of the increased risk of collision or grounding when a ship is entering or leaving port, operating in channels or near shallow water, and in areas of high traffic density that confine its movements within narrow limits.
The additional watch standers of the SAD function like air traffic controllers in aviation to reduce cognitive load of the senior watchstanders. Air traffic controllers manage all aviation traffic, alert aircrews to hazards and other airplanes, and manage entrance to and from runways so pilots can focus on flying their planes safely. Members of the SAD have specific responsibilities to inform the OOD of risks and make recommendations for avoiding them. There are standard communications protocols for doing this, just as in aviation. These features free the CO, the Officer of the Deck (OOD), and Conning Officer (Conn) to focus on maneuvering the ship safely.
Finally, stationing the SAD requires changing nearly ALL watchstanders with important ship control functions in several of the ship’s control stations. The ship control stations involved in maneuvering in restricted waters get congested from all the additional personnel. Controlling the noise from those extra personnel, many talking at the same time, is challenging. The arrival of those additional personnel is hectic (because of all the personnel coming and going),and hard to do when the ship is maneuvering in restricted waters because important orders are often given in quick succession with great consequences for ship safety. Imagine a surgical team changing all its personnel and adding many more that change the responsibilities of the original team in the middle of your open heart surgery!
The ref(a) further noted that the CO made this decision "despite recommendations from the Navigator, Operations Officer and Executive Officer,” (sec 7.3, p.60). The Navy report does not note that these are the three most senior officers responsible to the CO for navigation and operating the ship safely. This conflict of risk management strategies is not mentioned in the NTSB report.
The CO’s rejection of the recommendations by these three officers highlights one of the paradoxes of the Navy’s approach to ship safety, which is both structural and cultural. It is structural in that there is no approved process for questioning the CO’s decisions related to ship safety when a ship is underway because the CO has ultimate responsibility (ref (d)). The cultural paradox is that officers are taught informally that it is their duty to inform the CO when they are putting the ship at risk, but it is up to each individual to decide how to do this.
Once your boss rejects your recommendation, you only have two options. First, ignore it and move on. On a Navy ship underway and in many non-military circumstances, there is no higher authority to whom you can appeal. You could consider your duty to provide counsel to the boss complete after you have made your recommendation. This is easy to do when the stakes are low and the safety of the ship is not at stake. Even when it is, you might get lucky and not suffer bad consequences. Depending on things to work out for the best is not a High Reliability Organizing strategy.
Your second option in organizations like the Navy is document your objections to the boss’s decision in writing. Informally and outside of the Navy, you can quit and walk away. Those actions are simple to write, but both carry career implications. The consequence for writing a letter protesting the boss’s decision in most organizations could be the end of one’s employment. This puts the author of the letter in the position of having to juxtapose their judgment about safety of the ship with their career and prioritize one over the other.
Of course, it is not that simple in real life. When you face a situation in which your experience and judgment differ from your boss, possibly radically, do you just “hope for the best”? What you can do depends a lot on the character and personality of the person you are disagreeing with as well as your own. I will give my thoughts on that challenge in the next post.
