Post 9x Collision at Sea-Conclusion Part1
“Act as if the safety of the ship depends on you. Sometimes it does.”
“Sometimes “stop” is good progress”
Introduction
It isn’t easy to learn how to be safer by reading accident investigation reports. In this post, I focus on the Findings of the Navy report of the collision, which start on page 59 and break causality into training, seamanship and navigation, and leadership and culture. People that read the report will not learn very much about how to be more reliable. The purpose of this post is to explain why.
Safety Protocols
The U.S. Navy has many protocols for safe underway operations. Despite standard practices like navigation briefings, specific watch organizations tailored for risk, special qualifications, selecting personnel for particular situations based on their experience and skill, setting equipment lineups to maximize reliability, and assigning additional supervision (n.b. not the Commanding Officer), Navy ships still run aground and collide with other ships. Even if safety practices are NOT ignored, they can be challenging to apply and poorly understood and thus done badly or impacted by unplanned changes.
Managing operations safely is a dynamic balance of checklists, procedures, briefings, training, watch team backup, supervision, mitigation of known risks, choosing personnel with experience appropriate for the risk environment, and auditing. I have addressed each of these safety and good seamanship practices in this series. All play a role for safe outcomes, but each is ineffective without diligent performance and auditing to check results.
Navy Report Findings and Causality for the Collision
The Navy report noted, “no single person bears full responsibility for this incident. 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”1. It is certainly true that a lack of preparation will leave a crew unprepared, but not particularly insightful. The findings from the Navy’s report don’t provide insight about what to do differently. A summary of the specific findings from the Navy Report with my comments follows:
Training
“… [F]our different Sailors were involved in manipulating the controls at the SCC.” I don’t understand why this was placed in the category of training. Fact: four different sailors were involved in the shift of steering control. Question: what is the connection between the number of sailors involved and training?
“[The] Aft Steering Helmsman failed to first verify the rudder position … prior to taking control.” True, but was he trained to do this? The report provided no information about loss of steering training or drills. Thus we don’t know if the performance of the Aft Steering Helmsman was contrary to their training or it wasn’t included in their training. There is no mention of officer supervision in Aft Steering, a notable omission. If one was posted, what were they doing?
“Several Sailors on watch … were temporarily assigned from USS ANTIETAM (CG 54) with … inadequate training to compensate for [significant steering control system] differences.” How would training have made a difference since the personnel responsible for system training on JSM had inadequate knowledge (see next finding)?
“Multiple bridge watchstanders lacked a basic level of knowledge on the steering control system (IBNS-Integrated Bridge and Navigation System), [personnel responsible for training on the system] had an insufficient level of knowledge [as well as t]he senior most officer responsible for these training standards.” This illustrates the importance of rigor in and audits of training and qualification programs as I noted in posts 9s and 9t. The problem is that the people responsible for rigor and audits didn’t know they didn’t understand the system. What exactly is a “basic level of system knowledge”? Would it have been possible to get such knowledge given the deficiencies in IBNS technical documentation noted in the Admiralty court opinion? So much for training the USS ANTIETAM sailors.
Seamanship and Navigation
There are lots of “if only” statements in this section.
“Much of the track leading up to the Singapore Traffic Separation Scheme was significantly congested and dictated [setting additional watchstanders with more experience].” This is obvious: the CO shouldn’t have made CO Decision 1. What can be learned from this? Don’t do what he did.
“If the CO had set Sea and Anchor Detail [before] entering the Singapore Strait TSS, then it is unlikely that a collision would have occurred.” Possibly, but collisions occur even when the SAD is set. If only the CO had set the SAD, he wouldn’t have needed to order the change to the steering control configuration. This is another “don’t do what he did.”
“The plan [to set] the Sea and Anchor Detail [after entering the TSS-Soule] was a failure in risk management, as it required watch turnover of all key watch stations within a significantly congested TSS and only 30 minutes prior to the Pilot pickup.” It is hard to argue with this finding. By definition, a collision at sea is a failure in risk management. What is to be learned? Risk management failures are bad.
“If JOHN S MCCAIN had sounded at five [sic] short blasts or made Bridge-to-Bridge VHF hails or notifications in a timely manner, then it is possible that a collision might not have occurred.” Possibly, but it is an if only observation. “If only” they had done the right things, they would have prevented the collision.
“If ALNIC had [done several things], then it is possible that a collision might not have occurred.” This is speculative. It is not very helpful referring to what Bridge personnel on another ship could have done. The NTSB report came to the opposite conclusion. We can’t understand why this difference exists between the two reports because the author of the Navy report doesn’t provide any rationale for this conclusion.
Leadership and Culture
“The Commanding Officer decided not to station the Sea and Anchor detail when appropriate, despite recommendations from the Navigator, Operations Officer and Executive Officer.” This is true, but incomplete. Under what circumstances should a CO override the recommendations he gets from subordinates? What process should he use? The lesson can’t be to accept all the recommendations you get.
“Principal [Bridge] watchstanders including the Officer of the Deck … and the Conning Officer … did not attend the Navigation Brief.” This is true, but meaningless as I noted in previous posts. The knowledge problems that were most closely connected to the collision were the lack of proficiency with loss of steering control casualty response and IBNS technical knowledge and procedures, which are not typically covered in Navigation Briefs.
“Leadership failed to provide the appropriate amount of supervision in constructing watch assignments for the evolution by failing to assign sufficient experienced officers to duties.” This is probably true, but what is “appropriate” supervision, and who, exactly, should have provided it?
“The Commanding Officer ordered an unplanned shift of thrust control from the Helm Station to the Lee Helm station, an abnormal operating condition, without clear notification.” How is splitting control “an abnormal operation”? What does “clear notification” mean?
“No bridge [supervisory] watchstander … ordered steering control shifted from the Helm to the Lee Helm station as would have been appropriate to accomplish the Commanding Officer’s order.” The key question is what was the normal practice on JSM, not what a third-party judges after the fact as the appropriate order. It wasn’t clear from either report that watchstanders just began changing the configuration without an order. Lacking a procedure and process for the transfer, why would it have been “appropriate” to give a specific order? Was making such a control shift without an order customary?
“Senior officers failed to provide input and back up to the Commanding Officer when he ordered ship control transferred … in proximity to heavy maritime traffic.” Which senior officers? According to the NTSB report, the only other senior officer on the Bridge at the time was the XO. Were others present? If so, what were they doing, and did they have the opportunity to intervene without making things worse? At least the Navy report author didn’t write“close proximity to heavy maritime traffic” (eye roll).
“Senior officers and bridge watchstanders did not question the Helm’s report of a loss of steering nor pursue the issue for resolution.” True, but not useful for learning what to do differently given the near-total darkness of the Bridge, the lack of training, low system knowledge, and all the other things happening at the same time.
Some readers of my series on the JSM-ALNIC collision have personal knowledge about design issues and problems at more senior levels of the chain of command outside the ship that were not documented in either the NTSB or Navy report. Investigation reports almost never provide exhaustive coverage of all problems because they are bounded by specific choices made by senior leaders that are beyond the scope of this blog. In the final analysis, you can only learn from what has been documented unless you were a witness.
In my next conclusion post, I will untangle causality for the collision to demonstrate what can be learned from careful report reading and keeping mental biases in check.
End Notes
1. 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, https://www.doncio.navy.mil/FileHandler.ashx?id=12011. 7. Findings, p.59.
