This is my final post in the JSM-ALNIC collision series. It is an overview of the mindset that I encourage others to adopt for learning from official accident reports.

This is the second post of conclusions from the collision between JSM-ALNIC Aug 2017. Like the Navy report, I concluded that there was no single party responsible, but I propose my own version of causality for the accident. While many parties external to the ship bear responsibility, I restricted my analysis to the actions of the crew and the conditions on the ship because that is the only data available.

I’ll publish the conclusion to my series on the August 2017 collision between JSM and ALNIC in three parts due to length. This is part 1. It isn’t easy to learn how to be more reliable by reading accident investigation reports. Even when they are well-written (rare), it takes work and clear thinking (rarer still) to avoid mental biases like thinking, “those idiots!” Each investigation report is a case study that readers have untangle to understand and apply to their own circumstances.

An Admiralty court decision that apportioned liability for the JSM-ALNIC collision was published in 2022. Based on depositions for the trial, it is a valuable source of information. Reading it gave me an opportunity to reconsider and amplify some of the conclusions I reached in previous posts. I added CO Decision Zero, which predated the other two in time, as another opportunity for learning from the collision.

JSM Commanding Officer (CO) Decision 1 was not stationing the Sea and Anchor Detail prior to entering the Traffic Separation Scheme (TSS), contrary to Principle A of HR Watchstanding (see Post 9u). Continuing the exploration of what can be learned from specific CO decisions, the focus of the this post is what can be learned from CO decision 2: changing the configuration of the ship’s steering control system when ship conditions were not stable (overtaking another vessel at high speed while entering the TSS).

Commanding Officers (COs) are ultimately responsible for the safety of their ship, but they don’t exercise this responsibility effectively by routinely inserting themselves into operations. The CO of the USS JOHN S MCCAIN took charge of ship safety entering the Singapore Strait Traffic Separation Scheme. By doing so, he created a situation in which he had no backup when he gave the watch team more than they could handle.

BLUF: A department head can contribute to reliability by deciding which equipment and procedures are safety critical, guiding the high reliability development of junior officers, and taking the lead on safety of ship risk management.

BLUF: This post continues my series on the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 near Singapore. It is the second part of my answer to “What can you do?” after reading the investigation reports. This post continues the theme with specific recommendations for junior officers in an organization. I will follow this post with a focus on actions for Department Heads and Executive Officers.

BLUF: This post is part of my series on the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the near Singapore. It begins where the Navy and NTSB reports finish. It is the first part of my answer to the question, “What can be learned?” based on my assertion that the improved safety and and reliability possible through High Reliability Organizing have little to do with what you read in official investigations.

This post is the third and final one exploring my own ideas about Weick and Sutcliffe’s (2007) High Reliability Organizing principles oriented toward problem anticipation, Preoccupation with Failure. Following this post, I shall return to my shamelessly idiosyncratic review of the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the Straits of Singapore that led to the deaths of 11 US Sailors.

BLUF: This post explores the second High Reliability Organizing principle oriented toward problem anticipation, Reluctance to Simplify. These posts are part of a shamelessly idiosyncratic review of the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the Straits of Singapore that led to 11 US Sailor deaths. The series lets me apply my perspective and experience to illustrate key HRO concepts that might be hard to identify from the investigation reports alone.

BLUF: This post explores the first of three High Reliability Organizing principles oriented toward problem anticipation, Sensitivity to Operations. Subsequent posts will address Reluctance to Simplify and Preoccupation with Failure. It is part of a shamelessly idiosyncratic review of the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the Straits of Singapore. The series uses my perspective and experience to illustrate key HRO concepts that are hard to identify from the investigation reports alone.

BLUF: This post continues using the five principles of High Reliability Organizing (HRO) as a lens for reviewing the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the Straits of Singapore. The series uses my perspective and experience to illustrate key HRO concepts that are hard to identify from the investigation reports.

BLUF: This post is the first of several using HRO to analyze 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. The series uses my perspective to illustrate key HRO concepts that are hard to identify from the investigation reports.

With the review of the sequence of events and supplemental information complete, this post returns to James Reason’s accident causality model to “sort” the facts 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. The series is based on my perspective on HRO to illustrate key concepts that are hard to identify from the investigation reports.

BLUF: This post provides supplemental information from the Navy and NTSB reports that are most helpful for understanding of the context. The additional data includes training, qualification, and technical information about ship control systems related to the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the Straits of Singapore. The series uses my perspective on HRO to illustrate key concepts that are hard to identify from the investigation reports.

BLUF: This post returns to the review 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. The series uses my perspective on HRO to illustrate key concepts that are hard to identify from the investigation reports.

BLUF: This post returns to the review 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. The series uses my perspective on HRO to illustrate key concepts that are hard to identify from the investigation reports.

BLUF: This post continues the description of the high workload on the Bridge before the collision of the USS JOHN S MCCAIN (DDG 56) with Motor Vessel ALNIC MC on 21 August 2017 in the Straits of Singapore. The series is devoted explaining key concepts of HRO in context. The prior post emphasized the attention an OOD must devote to the environment external to the ship. This post describes the internal focus the OOD has to maintain as well (post 9g).

BLUF: This is a brief departure from 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. The series is devoted explaining key concepts of HRO in context. This post helps non-Navy Surface Warfare Officers understand the high mental workload on the Bridge before the collision. It emphasizes the attention an OOD must devote to the situational features external to the ship.