HRO 9k Collision at Sea
This post provides supplemental information from the Navy and NTSB reports about training, qualification, technical documentation, procedures, Navy assessment and certification processes, seamanship and navigation, and leadership aboard the USS JOHN S MCCAIN (DDG 56) (JSM). They are labeled “deficiencies” in the reports, but I think it is better to just call them facts without that judgment. I have received comments (thanks for all of them) from people that disagree with my reticence to label some actions “errors.” More readers may disagree with this approach, but haven’t sent me comments. I know it is not what you are accustomed to doing. It probably doesn’t “feel” right either. Do your best to suspend disagreement (something close to “Gee, that’s an interesting approach; I wonder why he’s doing that?”) and I will make my rationale clearer in subsequent posts.
I abbreviated the reference details 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
The NTSB concluded that the inability to maintain course due to a perceived loss of steering, the mismatch of port and starboard throttles producing an unbalanced thrust, and the brief but significant port rudder input from After Steering (after they took control a second time) combined to bring the JSM into the path of the ALNIC MC (ref (b), p.28). That’s a summary of the actions that lead to the collision. There’s more you need to know.
NTSB Additional Data
The NTSB accident report provided contextual information after their detailed, if incomplete, description of the sequence of events prior to the collision. These data included the backgrounds, experience, training (ref (b), pp 17-20), and actions of personnel on the Bridge at the time of the collision (ref (b), pp 25-32). The facts that are most useful for understanding the context of the collision are:
The OOD was qualified by the CO three weeks before the collision. The NTSB report doesn’t say anything more. It is possible that the OOD was the most junior qualified OOD on the ship at the time of the collision.
The Conning Officer was commissioned on June 23, 2017 and joined the ship on June 30, 2017. He stood his first conning officer watch six weeks before the collision.
The BMOW joined the JSM on May 21, 2017 on temporary assignment from the ANTIETAM. The ANTIETAM did not have the same Integrated Bridge and Navigation System (IBNS), the interface for the Steering Control System (SCS), as the JSM.
The Helmsman enlisted in the Navy in February 2017 and joined the JSM on May 27, 2017. He qualified as helmsman, lee helmsman, and lookout 7 weeks before the collision.
The Lee Helmsman joined the JSM on temporary assignment from the ANTIETAM on May 26, 2017. He completed his Personal Qualification System (PQS) requirements and was qualified as Helmsman and Lee Helmsman eight weeks before the collision.
The JSM CO signed the qualification card of the Lee Helmsman from the ANTIETAM shortly after he arrived. The CO signed the qualification card of the BMOW from the ANTIETAM on the day he arrived without underway experience with JSB Bridge equipment. There are no details in either report about the qualification process.
PQS is a Navy-wide system that specifies the minimum standard for personnel to qualify at a particular watchstation. A crewmember must demonstrate knowledge and proficiency by completing tasks developed for that watchstation. Completion of the tasks is certified by a qualified individual. Contrary to the NTSB report, PQS does not “mandate” the minimum standard for qualification because, as noted by the NTSB, individual units are allowed tailor the Navy-wide PQS as they deem appropriate. The PQS used by JSM did not require a demonstration of the ability to transfer helm and engine control between bridge stations.
NTSB Analysis
The NTSB report provided a detailed analysis of factors related to the collision (ref (b), pp 25-32). The most relevant are:
Based on inspections and testing of system components conducted by the Navy, the NTSB concluded that the functioning of the electrical, mechanical, and hydraulic components of the JSM’s steering, propulsion, and associated control systems was not a factor in the accident.
It is unclear who actually transferred steering to the lee helm station. Both the BMOW and the Lee Helmsman reported that they were taking actions to transfer thrust, not steering control.
The typical configuration of the SCS on the JSM was backup manual mode. Unlike computer-assisted modes, this enabled any station to take control of the system unilaterally, without action or acknowledgement by the other station. This is what allowed control transfer of the engines to the lee helm station and then allowed After Steering to take control a second time immediately prior to the collision when the margin for error was zero.
The CO told the NTSB that he believed that backup manual mode provided a “more direct form of communication between the steering and SCC.” He further noted that COs of other ships had told him they also preferred to operate in backup manual mode. Although the written guidance for system operation (Engineering Operational and Sequencing System, EOSS) stated that the normal mode of operation was computer-assisted manual, the use of backup manual mode was common onboard the JSM and other similarly equipped ships. However, operating in backup manual mode removed one safeguard against an inadvertent transfer of steering control: the requirement for two watchstanders in different locations to take action to complete the transfer.
Contrary to the JSM's emergency procedure for a loss of steering, the Helmsman did not press the emergency-override-to-manual button following his announcement of the loss of steering. The Helmsman told investigators that he thought the button would send control of steering to After Steering (not so). The OOD ordered the Helmsman to proceed to the next step in the emergency procedure instead. She told investigators that she skipped the first step of the loss of steering casualty procedure because she believed the system was already operating in backup manual mode (it wasn’t).
The JSM had numerous displays for propeller pitch and RPM. When NTSB investigators visited a similarly equipped Navy destroyer, they noted that the displays were visible from almost anywhere on the Bridge. During the final four minutes between the initiation of steering control transfer until the collision, the throttles remained mismatched for over a minute without anyone noticing.
The NTSB noted that "changes to critical equipment configuration or setup are not advisable during higher risk maneuvering operations, unless the changes cannot be avoided." The NTSB concluded that the decision to change the configuration of the JSM’s critical maneuvering controls while the destroyer was close to other vessels increased the risk of an accident. I would go further. It didn’t cause the collision, but it was the triggering event that resulted in the collision.
NTSB Technical Concerns
The NTSB found the EOSS, system technical manual and the JSM’s written procedures for operating the IBNS inadequate in that (ref (b),p 33):
the EOSS did not contain steps for transferring engine control between bridge stations,
the EOSS had no procedures for ganging and unganging throttles,
the EOSS had no notes or warnings about actions that automatically unganged the throttles, and
the technical manual did not contain instructions for ganging throttles or the meaning of the “ganged” indicator on the graphical interface, and
the ship's written operating procedures lacked guidance for shifting steering from one bridge station to another.
NTSB Assessment of Navy Oversight
The NTSB found fault with the operating procedures, PQS, and training provided to the JSM for the IBNS. According to the NTSB, the JSM crew’s inability to effectively respond to the steering emergency raised questions about the Navy’s assessment and certification processes. The NTSB report did not specify what these questions were or whether they actually reviewed specific assessment and certification processes, however.
The NTSB further noted that Navy has no fatigue mitigation program or standards for ensuring crewmembers have adequate rest prior to taking their watches. This is common practice in aviation and other fields. The 14 watchstanders on the Bridge averaged about 5 hours of rest in the 24 hours prior to the collision. Some had significantly less (ref (b), p 36).
Bridge watchstanders did not appear to understand the steering system, both normal operating modes and casualty response (ref (b),p 33).
Findings of the Navy Report (summary)
The Navy report found fault with the crew’s training (including senior officers), the rigor of the qualification program, general seamanship and navigation risk management, compliance with the International Rules of the Road, and leadership provided by the CO and others. Some key findings:
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 (ref (a), p 59).
The senior officer responsible for the training standards for Bridge equipment didn’t understand the procedure for transferring steering control between consoles (ref (a), p 59).
“Senior officers failed to provide input and back up to the Commanding Officer when he ordered ship control transferred between two different stations in proximity to heavy maritime traffic” (ref (a), p 60). The only senior officer on the Bridge identified in the reports at the time of the CO’s order was the XO. It is unclear why the term “officers” was used in the Navy report. This sentence appeared in a section titled “Leadership and Culture,” but the word culture appears only in the title of the section. There is no mention of culture anywhere else in the report.
In my next post, I will return to James Reason’s (1997) model for organizational accidents. I will classify activities by JSM personnel or existing conditions as either latent, triggers, or actions that precipitated the collision after the trigger. In a future post, I will also return to the five principles of High Reliability Organizing articulated by Weick and Sutcliffe (2015).
* Reason, J. (1997). Managing the risks of organizational accidents. Routledge.
* Weick, K.E., Sutcliffe, K.M. (2015). Managing the unexpected: Assuring high performance in an age of complexity (3rd ed.). Jossey-Bass.
