HRO 9f Collision at Sea-Sequence of Events5

BLUF: This is Part Five of the sequence of events associated with the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the Straits of Singapore. It is part of a series devoted explaining key concepts of HRO in context and continues with the day before the collision.

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

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 forces they unwittingly released, the JSM unintentionally turned to port into the path of the Alnic MC. The resulting collision killed 10 Sailors, injured 48 more, and caused over $100 million in damage.

Sequence of Events (review)

20 August 2017 (the day before)

The JSM Officer of the Deck and Conning Officer that would be on watch at the time of the collision were not present at the Navigation Brief for entering port (ref (a), sec 7.3, p.60).

The Commanding Officer decided not to station the Sea and Anchor Detail (SAD) until 0600. This was after the ship was scheduled to enter the TSS (ref (a), sec 7.3, p.60).

Sequence of Events (NEW)

21 August 2017 (the day of the collision)

Note: The time of sunrise was 0658

0115 The CO of the JOHN S MCCAIN came to the bridge (ref(b), p.9). It is common for COs to do this when they expect to get a lot of reports from the Officer of the Deck (OOD) about other ships. The CO wouldn’t be getting any sleep anyway.

0145 - 0205 The 02-07 watch relieved the previous watch.

0500 Reveille (with few exceptions, this means everyone has to get out of bed)

0518 The ALNIC MC entered the westbound lane of the Singapore Straight Traffic Separation Scheme (TSS) (ref (b), p.11). The JSM was north and outside the TSS traveling at 18 kts, about twice as fast as the ALNIC.

A TSS is a designated traffic-management system, adopted by the International Maritime Organization (IMO) that separates vessel traffic proceeding in opposite or nearly opposite directions by the use of a separation zone or line, traffic lanes, or other means. TSSs are generally located in areas of high shipping traffic like the Singapore Straight.

Far from the coast and in low traffic areas when rapid changes in ship speeds are not anticipated and risk of collision is low, US Navy ships normally have a single enlisted man controlling operation of the rudder and engines, the Helmsman. He or she operates under the direction of a single officer (the Conning Officer). The OOD supervises both. The JSM SAD included a Master Helmsman (a watchstander who has undergone more rigorous qualification and with more experience steering the ship than a standard Helmsman), a Lee Helmsman (only controlling the engine throttles), and a Helm Safety Officer. A Helm Safety Officer provides backup to the Conning Officer (the officer with authority to issue maneuvering orders) by observing the Master Helmsman and Lee Helmsman to ensure that they correctly respond to the maneuvering orders. It is normal practice to add a Master Helmsman and Helm Safety Officer during higher risk maneuvering operations. Entering and leaving port or maneuvering in a TSS are just a few examples.

0519 “The Commanding Officer noticed the Helmsman (the watchstander steering the ship) having difficulty maintaining course while also adjusting the throttles for speed control” (ref (a), p.45).

0520 While the ship was traveling at 18 knots approaching the TSS in near-total darkness, the Commanding Officer ordered the OOD to to alter the ship’s rudder and engine control configuration by stationing a Lee Helmsman (ref (a), p.46). This required both a turnover from the existing Helmsman to the new Lee Helmsman and a change to the steering and engine control station.

This was a change to the Navigation Brief conducted the day before and had not been briefed to watchstanders. “This unplanned shift caused confusion in the watch team” (ref (a), p.46). The Navy report does not describe the confusion or which individuals were confused. The NTSB report did not refer to any confusion among the Bridge watch team. The NTSB report noted that the "original plan, per the navigation brief held the day prior to the accident, was to split the duties of the helmsman and a lee helmsman when the sea and anchor detail was set at 0600” (ref (b), p.28). Before commenting further on the order by the CO, a digression is necessary to explain what it is like to be the Officer of the Deck on a U.S. Navy warship.

There many features of the task environment on the Bridge of a Navy ship entering areas of high traffic that impact the watchstanders, raising their stress levels and taxing their abilities to cope with the situation. Unless you have been OOD or Conning Officer entering an area of high shipping traffic in darkness without the Sea and Anchor Detail set, you have no idea what terror really is. This kind of stress taxes resources, presents many risks that can be perceived as threatening the safety of the ship and its crew (not to mention careers), and can have a cumulative, negative effect on performance (Cohen, 1980).

* Cohen, S. (1980). Aftereffects of stress on human performance and social behavior: a review of research and theory. Psychological Bulletin, 88(1), 82-108.

The change ordered by the CO was an important interruption to the high task load that already existed for the Officer of the Deck (OOD) and Conning Officer. Both reports lack a sufficient description of the stressful environment on the Bridge of a Navy warship entering port and the task demands on the OOD and Conning Officer. To give readers a better sense of what it’s like, my next two posts will review the task load of an OOD and Conning Officer on the Bridge of a U.S. Navy warship. Following those posts, I will return to the sequence of events.