Post 9w: Collision at Sea-What to do? Pt 4c Commanding Officers

References

(a) Energetic Tank, Inc v. Unknown Defendant, 18-cv-1359 (PAC) (RWL) (United States District Court, Southern District (S.D.) New York, 2022), retrieved from https://casetext.com/case/in-re-energetic-tank-inc-2

(b) Chief of Naval Operations. (2017). Memorandum for distribution, Enclosure (2) report on the collision between USS JOHN S MCCAIN (DDG 56) and motor vessel Alnic MC, retrieved from https://www.doncio.navy.mil/FileHandler.ashx?id=12011.

(c) National Transportation Safety Board. (2019). Maritime accident report: Collision between US Navy destroyer John S McCain and tanker Alnic MC Singapore Strait, 5 miles northeast of Horsburgh Lighthouse august 21, 2017. NTSB/MAR-19/01 PB2019-100970, retrieved from https://www.ntsb.gov/investigations/accidentreports/reports/mar1901.pdf

Introduction

I recently learned of an Admiralty court decision published in 2022 that apportioned liability for the collision between the USS JOHN S MCCAIN (DDG 56) and M/V ALNIC, reference (a). The issue was tried in November 2021 as a bench trial over five days in November 2021. The judge’s opinion was that the crew of the JSM was 80% responsible for the collision and the crew of M/V ALNIC 20% responsible. The opinion record is public and can be quickly located with the search term: Energetic Tank, Inc., 18-cv-1359 (PAC) (RWL). The document provides the Court's findings of fact and conclusions of law based on documentary evidence and depositions that were not part of the Navy or NTSB reports. It motivated me to write another post to extend and clarify some things I wrote in my prior blog posts that were based solely on those reports.

Note to readers: in all my other posts in this series, I have used inline citations, which is the standard for academic publication. This post uses endnotes to improve the flow of the text for readers.

Issues Clarified by the Admiralty Court Opinion

IBNS Training

The Navy report noted that Sailors from USS ANTIETAM (CG 54) on watch during the collision had “inadequate training”1 on the IBNS (Integrated Bridge and Navigation System). It further stated that “[m]ultiple bridge watchstanders [not just those from USS ANTIETAM] lacked a basic level of knowledge on the steering control system, in particular the transfer of steering and thrust control between stations”2.

I learned two things from reference (a) that weren’t clear from the Navy and NTSB reports. First, that “MCCAIN's crew had no specific training for the new IBNS touchscreen”3. This statement made by a senior-enlisted member of the crew in a court deposition suggests that the crew alone was responsible for conducting training based on inadequate technical documentation that was the responsibility of the Naval Sea Systems Command (NAVSEA).

Second, that the IBNS “changed the entire concept of the steering system” away from the traditional steering wheel4. According to the JSM’s Chief Engineer, “given its many differences from a traditional steering console, learning the new IBNS touchscreen through on-duty experience alone would be “‘un-realistic’”5.

IBNS Technical Documentation

The Navy report doesn’t mention IBNS technical documentation. The NTSB concluded that “the steering and thrust control written operating procedures … were inadequate”6. The NTSB cited deficiencies in both the IBNS EOSS and the system technical manual. Noting that training was not provided to the crew when the IBNS was installed in 2016, it would be unreasonable to expect a year later any crew to have trained themselves and somehow overcome the serious deficiencies with the NAVSEA technical documentation.  This was something I didn’t emphasize sufficiently in my prior posts.

IBNS Reliability

Neither the NTSB report nor the Navy report described the technical problems the JSM had been experiencing with the IBNS since installation in 2016. In numerous paragraphs, the NTSB report described how the IBNS was designed to operate, not how it actually operated. Reference (a) noted “[a]t the time of the collision, MCCAIN had unaddressed casualty reports concerning major IBNS crashes-some of them still outstanding since the system's installation a year earlier. … Commander Sanchez [expressed] frustration [in an email to Navy technicians] that the IBNS was ‘unstable, albeit safe to navigate, and the multiple cascading node crashes are a distraction [to watchstanders]’”7.

The lack of system reliability documented only in reference (a) makes it easier to understand why the CO’s “preferred ‘work  around’ for IBNS glitches was to [operate in] backup manual mode …”8. The NTSB report stated “[t]he CO preferred backup manual mode when the ship was docking or undocking, and he stated that the change on the morning of the accident was made to mitigate risk”9. The NTSB report does not provide a clear statement of the risk the CO was seeking to mitigate by the choice of IBNS operating mode. The operating mode the CO chose “affected steering control in ways that neither he nor his crew understood”10.

CO Decision 1 Rationale

Reference (a) provided more details on the CO’s rationale for his decision not to station the Sea and Anchor Detail (SAD) prior to entering the TSS. My focus in a prior blog post on this decision was not to examine the CO’s risk management, but rather his decision to stick with his decision despite the recommendations from three of his subordinates to station the SAD earlier. This is the learning opportunity for Commanding and other senior Officers, not avoiding “a failure in risk management”11.

In my post on CO Decision 2, the decision to change the steering configuration in the dark while overtaking the ALNIC at high speed and entering the TSS, I discussed using Klein’s12 protocol for conveying Commander’s Intent and receiving feedback: Situation, Task, Intent, Concerns, and Calibration. There are two significant challenges for Calibration that may not be obvious from Klein’s description of Calibration.

First, reducing or checking your biases so you don’t rapidly dismiss other perspectives and recommendations is not easy. Your judgment and decision making are heavily influenced by an array of biases. What makes reducing your biases particularly difficult is we tend to think biases are things that *other* people have while ours are invisible to us. Naive realism, our deep conviction that our view of the world is the true one, is another barrier to recognizing our biases. We believe that the people who see things differently from us are the biased ones. This is a critical defect in self-awareness for which there is no cure. One mitigation is curiosity. You can take note of your emotional reaction to the recommendation you are getting. If you can feel yourself strongly disagreeing with someone and becoming angry, you aren’t thinking clearly.

The second challenge to getting calibrated by others is creating emotional safety so that people will take the risk of disagreeing with you. Many times, I had the experience that people disagreed with me without initially being willing to do so openly. As a leader, I worked at becoming skilled at reading body language and facial expressions. I found that both were good indications that people had other ideas or thought my perception of what we faced, my intent or my concerns were flawed. If you convey situation, intent, task, concerns, and don’t receive any calibration, consider stopping the risk management meeting and reconvening later when people can provide calibration. As Reactor Officer, I often sought feedback from senior enlisted personnel I knew were obstreperous and sometimes hard to work with. I met them in private so they would be less inhibited about disagreeing with me. Because I knew going into the meeting that they would likely find fault with my plan, I could steel myself against a strong emotional response. I *expected* them to disagree with me and was genuinely curious about what the disagreement would be.

(New) CO Decision Zero

Based on communication with a former DESRON Commander with four command-at-sea tours and reader of these posts, there was another crucial CO Decision that we can learn from, CO Decision Zero: choosing a time of arrival pierside in Singapore that required a transit of the TSS in the dark. Ships are seldom directed by supervisory authorities *when* to enter port.

We don’t know from any of the reports, but an understanding of the normal protocols for Navy ships entering port suggests that the CO of the JSM likely had wide discretion for when to arrive in port. What we can learn from this decision is that senior leaders often have the discretion to modify the mission or task to reduce the risk thus reframing the entire context of the mission.

In my next two posts, I will provide some concluding thoughts that summarize what I think can be learned from the collision of the USS JOHN S MCCAIN (DDG 54) and M/V ALNIC.

Endnotes

1. Navy Report, p.39

2. Navy Report, p.39

3. Energetic Tank, Inc v. Unknown Defendant, 2022, Finding 31, p.6

4. Energetic Tank, Inc v. Unknown Defendant, 2022, Finding 4, p.3

5. Energetic Tank, Inc v. Unknown Defendant, 2022, Finding 31, p.6

6. NTSB Report, Section 2.5 Operating Procedures, p.33

7. Energetic Tank, Inc v. Unknown Defendant, 2022, Finding 32, p.6

8. Energetic Tank, Inc v. Unknown Defendant, 2022, Finding 33, p.6

9. NTSB report, p.9

10. Energetic Tank, Inc v. Unknown Defendant, 2022, Finding 33, p.6

11. Navy Report, p.60

12. Klein, G. (2004). The power of intuition: How to use your gut feelings to make better decisions at work. Currency, pp. 201–207