Monday Minute - Summary of the Navy's Official Incident Review

The Accidents of Navy Warships Call for Better Command and Control

You may not be aware of this, but the U.S. Navy had 12 surface fleet “incidents” in the past decade, four in the last year. I'm sure you have heard of some of these in the news, as the loss of life and details surrounding the incidents are hard to imagine with modern, combat-ready warships operating in open oceans. How a warship could possibly collide with a much larger merchant vessel is beyond comprehension. Yet it keeps happening.

Below is the recently released official summary of these incidents, and the conclusions and action recommendations from the U.S. Fleet Forces Command review. It is heavy reading, but I broke up some of the lengthy paragraphs to ease reading, and one can see how these situations spiraled out of control. Perhaps we can learn something from this report that better qualifies our own vessel operation, even if only mentally.

When I was online to clarify some points last week, I happened upon a live online press briefing of this report, with an Admiral discussing the findings to an audience of naval officers and press. It seems the whole thing is finally being addressed, and the events signal that changes are necessary in the way the Navy operates its fleet in today's world.

If you aren't interested in reading the entire report and details, the events surrounding the U.S.S. McCain (DDG 56) are the most mind-boggling as to the inherent dangers of system redundancy, and the lack of a master reset button!

(To read the full report,


Summary of 2017 Mishaps

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USS John S. McCain (DDG 56) Collision with ALNIC MC

On the morning of 21 August 2017 USS John S. McCain was preparing to enter the Singapore Strait for transit to Sembawang, Singapore. The ship completed a full Navigation Brief the day before that included the estimated time of 0500 to enter the Traffic Separation Scheme (TSS) and subsequent passage in close proximity to shoal water.

Although the Executive Officer (XO) and Navigator recommended setting the Sea and Anchor Detail at 0500, the CO decided to delay stationing the detail until 0600 in order to give the crew more time to rest and to minimize the chance of a man overboard during hours of darkness. As mitigation, the CO planned to be on the Bridge for the entire transit and in fact arrived on the Bridge at 0115 and remained there until after the collision. Of the Bridge watchstanders, the Junior Officer of the Deck (JOOD), the Boatswain’s Mate of the Watch (BMOW), and the eventual Lee Helmsman (Lee Helm) were on temporary duty from the USS Antietam (CG 54) to provide these Sailors underway time for qualifications while USS Antietam was under-going repairs.

Although the watchbill listed the USS Antietam Sailors as qualified, the BMOW and JOOD qualification dates coincided with the day they reported to USS John S. McCain, and they conducted no requalification events. The Lee Helm qualified as Helm/Lee Helm within a few weeks of reporting to USS John S. McCain. After entering the TSS, the CO noticed that the Helmsman was having difficulty both steering the ship and adjusting the ship’s speed due to prevailing environmental conditions.

The CO ordered the OOD to separate the control of steering and thrust to two separate stations: the Helm and Lee Helm. While attempting to execute this order, the Bridge watchstanders unintentionally transferred steering control to the Lee Helm console and “un-ganged” the throttles (i.e., separated the port and starboard throttle controls from a coupled control to individual throttle control).

Complicating the execution of the order was a series of watch reliefs for meals then in progress among the various watchstations and a lack of posted procedures for transfer of throttle and steering control.

Recognizing that he no longer had control of steering, the Helmsman announced a loss of steering (system) casualty (malfunction). The After Steering station was manned in short order and attempted to take emergency control. Due to confusion on the Bridge about the nature of the casualty and the operation of the Ship’s Control Console (SCC), steering control would be inadvertently transferred among various controlling stations four times within the two minutes leading up to the collision.

As a result of this perceived lack of steering control, the ship began a slow turn to port. After hearing the Loss of Steering casualty the CO directed the OOD to slow the ship. The OOD ordered 10 knots and the Conning Officer duly gave the order. The Lee Helm executed the order and slowed the port shaft, but did not recognize that the throttles were not linked and that he had control only of the port shaft.

Unrecognized by the watchteam, control of the starboard shaft remained at the Helm station for more than 60 seconds after control of the port shaft was taken by the Lee Helm. The speed change to the port shaft slowed the ship but also increased USS John S. McCain’s rate of turn to port as the starboard engines and shaft remained ordered to 20 knots.

The CO then ordered a speed of 5 knots, but the Lee Helm’s actions only reduced power to the port shaft due to the individual throttle control. The starboard shaft still remained at 20 knots, exaggerating the rate of turn even further.

About three minutes after the reported Loss of Steering casualty began, USS John S. McCain regained positive steering control in After Steering and answered Right 15 degrees rudder. About this same time throttles were matched at the Lee Helm and the starboard engine and shaft slowed to 5 knots.

These actions were too late to avoid collision with the ALNIC. At about 0524, and because of the port turn induced by the loss of steering control and thrust control actions, the USS John S. McCain crossed in front of ALNIC, whom the USS John S. McCain had just passed ahead of, and USS John S. McCain was struck on her port quarter.

Despite what the watchstanders believed, there never was a loss of steering casualty.

Primary causes of the collision were leaderships’ loss of situational awareness in a high traffic area and failure to follow safe navigational practices, coupled with watchstanders who were not proficient with steering control operations or engineering casualty response procedures.

Contributing to the collision were failures in basic watchstanding and seamanship among the Bridge and Combat Information Center (CIC) teams; a failure by these same watchteams to take clear and decisive action to avoid collision when in extremis; and the failure of the Commanding Officer in assigning and changing watchstanders, in ordering equipment configuration changes in the TSS, and in failing to take prudent measures to mitigate these risks.

This critique of USS John S. McCain does not imply that ALNIC mistakes and deficiencies were not contributing causal factors in the collision.


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USS Fitzgerald (DDG 62) Collision with ACX CRYSTAL

On 17 June 2017, USS Fitzgerald was attempting to cross a highly congested sea lane at night. While maneuvering to pass merchant and fishing vessels and complete the crossing, watchstanders failed to visually differentiate between two vessels in close proximity and did not calculate the closest point of approach using all available means before making a final crossing maneuver.

Watchstanders in CIC were inattentive, disengaged in developments on the Bridge, and unaware of several nearby vessels, specifically, a Philippines-flagged commercial containership named the ACX CRYSTAL.

As the CRYSTAL and USS Fitzgerald approached each other, the OOD became aware of the ships’ relative positions and realized action was necessary. The OOD first decided to alter course to starboard, but then evaluated there was insufficient sea room to turn to starboard without colliding. The OOD then ordered the Conning Officer to come to full speed, and then flank speed ahead, and then ordered a full, and then hard left rudder.

The actions were delayed as the Conning Officer “froze” in the moment. The OOD and the Conning Officer both began to shout orders to the helm. Eventually, the Boatswain’s Mate of the Watch put the rudder over hard left and pushed the ship’s throttles forward. These actions occurred just 30 seconds prior to the impact, and the USS Fitzgerald had briefly started coming left and increasing speed by the time of impact.

The merchant vessel's port bow (left front) impacted USS Fitzgerald's starboard side amidships (right middle). At no time leading up to the collision did the USS Fitzgerald or CRYSTAL watchstanders attempt to communicate over radio, or take decisive action to avoid collision.

The collision resulted from a compilation of failures by leadership and watchstanders to plan for safety, appropriately adhere to sound navigation practices, execute basic watchstanding principles, properly use navigation tools, and deliberately and effectively respond when in extremis.

This critique of USS Fitzgerald does not imply that CRYSTAL mistakes and deficiencies were not contributing causal factors in the collision.


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USS Lake Champlain (CG 57) Collision with Nam Yang 502

On 9 May 2017, USS Lake Champlain was escorting an aircraft carrier. A Republic of Korea fishing vessel, Nam Yang 502 was operating in the same area, with USS Lake Champlain watchstanders intermittently tracking Nam Yang 502 for over an hour on a constant course and speed. USS Lake Champlain watchstander awareness of the vessel was inconsistent due to their poor RADAR operating technique and some inoperable commercial radar (backup) equipment.

The Bridge and CIC watchteams were undisciplined in their communications and failed to coordinate common situational awareness and agreement on the safety of planned maneuvers. While changing course to maintain relative position with the escorted aircraft carrier, the USS Lake Champlain turned in front of the fishing vessel without realizing the risk of collision. The Bridge watchteam was slow to react and executed improper and untimely maneuvers in an attempt to avoid collision, and the Nam Yang 502 struck USS Lake Champlain amidships on the port side.

Minutes before the collision, USS Lake Champlain’s Bridge watchstanders attempted to contact Nam Yang 502 on the radio and simultaneously signaled the fishing vessel using the ship whistle. Nam Yang’s global positioning system and radio were not working properly. Further, Nam Yang did not attempt to communicate with USS Lake Champlain or take immediate action to avoid collision.

 The collision occurred because an inexperienced Bridge team failed to follow safe navigational practices and take proper actions to avoid collision. This critique of USS Lake Champlain does not imply that Nam Yang mistakes and deficiencies were not contributing causal factors in the collision.


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USS Antietam (CG 54) Grounding

On 31 January, 2017, USS Antietam moved from her berth in Yokosuka to an anchorage in Tokyo Bay to take on supplies before a planned transit to conduct local area training. The navigation plan and brief noted the prevailing environmental conditions (high wind and current) but did not account for them during the approach to anchorage.

After maneuvering to avoid shipping, USS Antietam turned to its anchorage using a different approach course than planned. Wind and current pushed USS Antietam south of the intended anchorage point, toward the nearest charted shoal. USS Antietam was 114 yards away from the planned anchorage point when the order to “let go the anchor” was given, however, the CO believed the ship was only 50-75 yards away from the planned anchorage.

The dropping of the anchor was delayed because a retaining pin had been inserted backwards, making it difficult for deck personnel to remove it. When the anchor was finally released, the ship used less than half the amount of chain required to hold the ship in place under that day’s conditions.

Recognizing continued wind-induced drift toward the shoal, the CO decided to bring up the anchor and reposition to the planned anchorage point. Internal miscommunication delayed anchor retrieval. As USS Antietam continued to drift toward the shoal, the CO delayed adding power or maneuvering into the wind until the anchor was retrieved, believing the greatest risk was damaging the ship’s SONAR dome by increasing speed while the anchor was underfoot.

Once the anchor was retrieved and as power was added, the blades of both propellers struck bottom.

 The grounding was a result of the Bridge watchteam’s failure to counter USS Antietam’s movement towards shoal water, poor seamanship while anchoring, leadership’s delayed response when steering into danger, and the watchteams inability to provide forceful backup in an extremis situation.


1.3 Summary of Findings and Actions


1.3.1 Poor seamanship and failure to follow safe navigational practices.

In each case, Bridge and CIC watchstanders did not maintain situational awareness and recognize that a significant error chain was in motion. Once confronted with an extreme situation, watchstander actions failed to comply with procedures as outlined in governing directives, as well as common customs of service, such as standard commands.

Additionally, watchstanders did not take emergency actions, to include sounding alarms, signaling to the other ship, or warning the crew. In every mishap, departures from procedures or approved customary practices were deemed to have directly contributed to the mishap.

Action:  Improve seamanship and navigation individual skills training for Surface Warfare Officer candidates, Surface Warfare Officers, Quartermasters and Operations Specialists.

Action:  Create an objective, standardized assessment program to periodically assess individual seamanship and navigation skills over the course of a Surface Warfare Officer’s career.

Action: Numbered Fleet Commanders establish appropriate policies for surface ships to actively transmit and use Automatic Identification System (AIS) when transiting high traffic areas.


1.3.2 Degraded watchteam performance

Each of the four Bridge and CIC teams involved in the mishaps did not work with each other to solve problems as an effective team.

Command leadership on these ships failed in their absolute responsibility to develop and properly balance their watchteams with depth and experience to foster consistent superior performance. Bridge and other CIC watchstanders did not perform their duties as primary advisors to the OOD for the safe navigation of the ship as required by Commanding Officer’s Standing Orders and higher level instructions.

Action:  Improve current seamanship and navigation team training and certifications to include assessment in emergency and in extremis environments.

Action: Improve shore-based Bridge trainers and add CIC functionality to team training facilities. Action: Integrate Bridge and CIC evaluations for unit level seamanship and navigation training scenarios in shore-based team trainers, and during at sea training and certifications events.


1.3.3 Erosion of crew readiness, planning and safety practices

The readiness generation model for ships based in Japan does not support the training needs for these ships. The increase in operating tempo in the Western Pacific combined with longer and more complex maintenance and modernization periods, has effectively reduced the amount of time Yokosuka-based ships have to train and certify in the existing Forward Deployed Naval Force (FDNF) – Japan readiness generation model.

FDNF-Japan surface forces must be committed to a new model tailored to supporting operational requirements while preserving time for maintenance and training. This review endorses COMPACFLT’s actions to conduct a hull-by-hull material review of FDNF-Japan ships’ material condition, review the certifications of each FDNF- Japan ship, and implement a zero-based readiness review of the FDNF Japan continuous readiness generation cycle.

Action: Conduct comprehensive Ready for Sea Assessments to determine the material and operating readiness for all Japan-based ships.

Action: Develop a force generation model for ships based in Japan that addresses the increasing operational requirements, preserves sufficient maintenance and training time, and improves certification accomplishment.


1.3.4 Headquarters processes inadequately identified, assessed, and managed operational risks

Higher headquarters readiness processes were not rigorously executed to provide leadership appropriate information to make employment decisions. The mitigation plans developed for expired training certifications for Yokosuka-based ships almost universally identified insufficient training time to complete the certifications as a cause, and rescheduling of training as the mitigation.

As a result, employment decisions were made without adequate assessment of the readiness risk of reduced training. Additionally, no independent organization was providing oversight to the certification process to ensure standards were maintained.

Action: Permanently establish Naval Surface Group Western Pacific as an echelon 4, Immediate Superior in Command administrative headquarters responsible for maintaining, training and certifying FDNF Japan ships.

Action: Restore the SEVENTH FLEET deliberate employment scheduling process to improve operational planning and risk management.

Action: Cancel all existing Risk Assessment Mitigation Plans (RAMP) until all Ready for Sea Assessments (RFSA) are complete. Action: Establish a single Echelon 2 higher headquarters responsible for the readiness generation of all Navy forces.


1.3.5 Assessments do not reinforce effective learning

Surface ships, Type Commanders headquarters, and safety organizations have not all instituted a culture of critical assessment and continuous improvement. Unit evaluation processes are mainly focused on analyzing specific events and do not provide a broader view of performance over time.

Additionally, the numerous external assessments that are performed do not always provide sufficient critical examination of a crew’s performance to drive learning and improvement. Safety programs and safety reporting and analysis systems to develop and promulgate lessons learned and feedback from significant events are also inadequate.

The lack of objective performance measures prevents the identification of trends so action can be taken on problems before they become hazardous.

Action: Perform a baseline review of all inspection, certification, assessment and assist visit requirements to ensure and reinforce unit readiness, unit self-sufficiency, and a culture of improvement.

Action: Establish and utilize near miss reporting processes to share lessons across the surface force.

Action:  Improve Naval Safety Center and fleet and force headquarters safety programs and data analysis to provide predictive operational safety and risk information.


1.3.6 “Can-do” culture undermined basic watchstanding and safety standards

Historically, our can-do culture has often differentiated us from our adversaries and has been pivotal in bringing victory against overwhelming odds. A can-do culture, when self-inspired, is a virtue that the Navy relies on to be successful.

The can-do culture becomes a barrier to success only when directed from the top down or when feedback is limited or missed. We want that can-do culture and must build the experience and temperament in our Commanders and crews that will reinforce its virtue.

The prevailing belief of Japan-based ships and higher headquarters was that a high pace of operations equates to a high state of proficiency. In part, this belief led to an undervaluing of human performance factors, such as fatigue.

When combined with an absence of foundational training and critical assessment, this attitude induced a slow erosion of standards, and organizational drift from the deliberate processes used to manage time, resources, rest and a commitment to safety as a way of operating. Action: Improve Operational Risk Management training and education at all Surface Warfare Officer School milestone courses.

Action: Establish a comprehensive fatigue and endurance management policy to implement fatigue recovery standards and codify a circadian ship and watch rotation routine for surface ships.

Action: Establish human performance expertise at all Type Commander staffs.


1.3.7 Surface ship Bridges not modernized as an integrated control room

U.S. Navy Bridge equipment modernization has occurred without centralized oversight of the cumulative effect of equipment and configuration changes on the Bridge. Technology intended to simplify navigation, improve situational awareness for smaller watchteams, and increase flexibility for ship control is complex, and in some cases, more difficult to operate.

Force wide, the transition from legacy to modern systems has been slowed due to lack of funding and has resulted in unique Bridge configurations and wide variances in configurations from ship-to-ship, even within the same ship class.

However, from the perspective of individual ships, technological change can appear rapid and disjointed. Gaps between the foundational training provided to enlisted crewmembers, and the complexity of the technology used in modern ship control consoles, make it difficult for ships’ personnel to retrain and requalify for operating and technical proficiency.

Action: Consolidate responsibility and authority for Bridge system modernization and improve methods for human systems integration.

Action: Establish formal policy for requalification requirements for personnel temporarily assigned to ships and when changes in equipment configuration occur.

Action: Accelerate plans to replace aging military surface search radars and electronic navigation systems.

Action: Improve stand-alone commercial radar and situational awareness piloting equipment through rapid fleet acquisition for safe navigation.


1.4 Conclusion

The U.S. Navy operates in an environment constantly subject to change. Amidst these changes, the Navy is expected to adapt quickly and operate effectively. Many of its leaders resourcefully find ways to generate strong teams in this environment and use resources effectively to succeed.

However, continued success is not guaranteed. The surface force must seek and trend precursors that lead to significant mishaps at sea. The commonalities among the four mishaps discussed in this document originated in a failure to properly plan and prepare, and ultimately manifested in unnecessarily pressurized execution of these important seamanship evolutions.

Systemic issues at higher levels also adversely affected organizational processes at the unit level. Even when presented with information that indicated standards of readiness were not met, rather than taking pause and determining what was needed to correct the problem, the force was conditioned to mitigate the risk only through the delay of some training action that would ultimately lessen the impact on operational missions, and then proceed on those same missions without real risk mitigation.

All levels of command must evaluate the sufficiency of internal programs and processes to self-assess, trend problems, and develop and follow-through on corrective actions. This kind of assessment must be an integral part of our everyday culture, as it is an essential aspect of ensuring the Navy’s ability to safely and effectively perform its missions at sea.

Continuous improvement processes must account for human factors in individual and team performance, to include individual and operational fatigue. These factors may determine mission outcomes regardless of other readiness indicators. Knowing that human induced errors are part of any system, we must account for them as risks to be mitigated for overall mission accomplishment, whether the team is a division, a ship, or a Fleet, System Command or Type Command headquarters.

Effective internal and external assessments that document these tendencies reduce vulnerabilities, and will improve Navy’s surface force operational effectiveness at all levels. Some of the challenges identified by this comprehensive review are not unique to the surface force.

The increasing demand for forces, ever-pressurized maintenance cycles, and understanding the human performance elements of operational safety cut across all Navy communities. As such, each community leader should examine the results of this comprehensive review and assess the principles of the findings for broader applicability.

Accordingly, there must be more consistent and disciplined processes at the Fleet and Type Commander staffs, with clear guidance, responsibility, authority, and accountability for readiness, training and operations. This will set the conditions for our ships to maintain the highest levels of readiness and superior performance in the missions the Navy asks of them.

Similarly, effective improvements to surface force operations and training can also be made at the command level so that ships, squadrons and crews are trained, certified, rested, responsive, and ready to go.