HRO 9b Collision at Sea-Sequence of Events1

This post begins the sequence of incident events with my commentary as an HRO learning opportunity. While both the Navy and NTSB reports have sequences of events, they are not the same and don’t offer the commentary that I do.

References

I abbreviated the reference details below to conserve space. Refer to the post 9a for the complete information.

(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.

Summary of the Incident

The John S McCain was overtaking the Alnic MC in the westbound lane of the Singapore Strait Traffic Separation Scheme when bridge watchstanders had a perceived loss of steering. While the crew attempted to regain control of the vessel, the John S McCain unintentionally turned to port into the path of the Alnic MC. The resulting collision killed 10 John S McCain Sailors, injured 48 more, and caused over $100 million in damage to the destroyer.

The use of “perceived” to describe the loss of steering control is intentional. The steering system remained operational throughout the incident, but the bridge watchstanders didn’t realize how to control it. Unfortunately, other than exonerating the hardware itself (design and operating instructions are other matters), it worked out the same as losing steering control.

Chronology of Events

20 August 2017 (the day before the collision)

Afternoon (time not given in the accident reports) - John S McCain senior leaders convene a Navigation Brief for entering the Singapore Strait and the port of Singapore. This is a common feature of High Reliability Organizing (HRO): a pre-event brief to discuss the planned operation with key actors identified and present, the procedures to be used, precautions, emergency procedures, and any special risks. Holding a brief is not so hard. Doing it well takes discipline and practice.

In nuclear HRO, there is no brief without a list of names and their assigned roles. This sentence is worth explaining in detail. “There is no brief” means it doesn’t qualify as a brief without this list present at the beginning. This list of names and roles is called a watchbill in the Navy (a bill or list of who will be on “watch” in a particular role during the procedure or event like entering port). I am not familiar with any regulation that requires this list be present during a brief. It is a nuclear best practice that has become a requirement.

The reason for requiring a watch bill before the brief can start is two-fold. First, it focuses the participants on what is expected of them in the role they occupy. Navigational briefs can be thought of as informal rehearsals that actors use in a play. The briefs cover important information to be exchanged, standard reports to be used, potential problems, and how the “actors” will respond to them. Second, having the key players identified by name and role gives senior leaders an invaluable opportunity to check their understanding during the brief with questions such as, “Ensign Soule, when the Navigator makes this report, what action will you take?” Without a watch bill at the brief, it really isn’t a safety rehearsal. It is just a general summary of what is going to happen. At the first navigation brief I attended in my Navy career, I only learned that I was going to be the the officer responsible for ship control right after the CO asked, “Who is going to be the Conning Officer?” at the end of the brief. This is not a “best practice.”

The Findings, section 7.3 of the Navy report (ref (a)), noted that "Principal [Bridge] 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” (p. 60). The NTSB omitted this fact from its report (ref (b)).

The absence from the Navigation Safety Brief of the two principle Bridge watch standers responsible for safe maneuvering of the ship at the time of the collision didn’t cause the collision, but was still a risk. It is impossible to tell from the either report how the risk was mitigated, if the CO was aware of their absence, who made the decision to hold the brief without them, why the CO approved their absence if he was aware of it, if the absence of key watchstanders from navigation briefs was a routine occurrence, how these two officers obtained the information provided at the brief, and if the absent officers were able to rehearse key aspects of the procedures to be used for controlling the ship in the special circumstances of maneuvering in restricted waters and entering port. These are significant omissions from the reports for understanding the risk management process used by the CO and other senior leaders. It is easy to read the Findings of the Navy report and think, “Wow, that’s not right,” but you can’t learn very much from it other than “Don’t be that guy that decides to do that!”

In my next post, I will discuss the second key decision made by the CO the before the collision: stationing the Sea and Anchor Detail *after* entering the restricted waters on the approach to Singapore.