The Navy on Wednesday released the first official report explaining the specific actions leading up to and causes of the separate collisions of two Arleigh Burke-class guided missile destroyers in the Pacific this past summer.
In a direct telling of the events it plainly explained how crew leaders and members made numerous mistakes leading up to the collisions.
“Both of these accidents were preventable and the respective investigations found multiple failures by watch standers that contributed to the incidents. We must do better,” Chief of Naval Operations Adm. John Richardson, said in a summary of the report.
The USS Fitzgerald (DDG-62) collided with the merchant vessel ACX Crystal during night hours on June 17 off the coast of Japan resulted in severe damage to the destroyer and the deaths of seven U.S. sailors (Defense Daily, June 19). The Navy found that this mishap was avoidable and “resulted from an accumulation of smaller errors over time, ultimately resulting in a lack of adherence to sound navigational practices.”
The Navy noted in the report summary that specifically that DDG-62’s watch teams disregarded norms of basic contact management and leadership did not adhere to established protocols put in place to prevent collisions. Moreover, the top three commanding officers, the triad, were “absent during an evolution where their experience, guidance and example would have greatly benefited the ship.”
In the report summary the Navy said this collision was also avoidable and “resulted primarily from complacency, over-confidence and lack of procedural compliance.”
One major factor in the collision was a sub-standard level of knowledge regarding operation of the ship control console. DDG-56’s commanding officer particularly “disregarded recommendations from his executive officer, navigator and senior watch officer to set sea and anchor watch teams in a timely fashion to ensure the safe and effective operation of the ship,” according to the report.
Moreover, the investigation found that nobodyo n the Bridge watch team, including the commanding and executive officers, were properly trained on how to correctly operate the ship control console during a steering casualty.
Richardson commented that the Navy must never allow this kind of accident to take sailors’ lives. “Our culture, from the most junior sailor to the most senior Commander, must value achieving and maintaining high operational and warfighting standards of performance and these standards must be embedded in our equipment, individuals, teams and fleets.”
“We will spend every effort needed to correct these problems and be stronger than before, Richardson added.
The Navy determined five main failures on the part of leaders and watchstanders that led to the Fitzgerald collision including failures to plan for safety, adhere to sound navigation practice, execute basic watch standing practices, properly use available navigation tools, and respond deliberately and effectively when in extremis.
In the 30 minutes leading up to the collision neither the Fitzgerald or the Crystal took proper maneuvering actions to remain clear of each other until about one minute before collision. “Eventually, the Officer of the Deck realized that FITZGERALD was on a collision course with CRYSTAL, but this recognition was too late,” the report said. The Crystal also did not take any action until it was too late.
The report damningly found that watch team members were not familiar with basic radar fundamentals, watchstanders performing physical look out duties only did so on the left/port side, not the right/starboard side where ship collision was possible, key supervisors responsible for navigation and tracking other ships were unaware of traffic separation schemes and did not use the Automated Identification System that provides updates of ship positions via GPS.
Moreover, the report found the bridge and Combat Information Center (CIC) teams did not effectively communicate or share information and the Navy command leadership allowed the schedule events leading up to the collision tire the crew.
“The command leadership failed to assess the risks of fatigue and implement mitigation measures to ensure adequate crew rest,” the report said.
Separately, the McCain collision was caused by a loss of situational awareness due to mistakes in operating the ship’s steering and propulsion system while in a high density of maritime traffic, failed to follow the International Nautical Rules of the Road, and watchstanders had insufficient proficiency and knowledge of their systems.
The CO noticed the helmsman was having trouble maintaining both course and speed/throttle so he ordered that speed be shifted to another station. This unexpected order inadvertently resulted in the crew transferring both speed and steering to the new station. Because he helmsman expected only speed control to move, they perceived a loss of steering.
This steering changed caused the rudder to be centerline/amidships. This moved the ship’s course to the left because it had previously been steering a few degrees to the right. The CO slowed the ship but the two speed shafts were not coupled so it took over a minute before both were properly reduced as ordered.
The overall result of the wrong rudder direction and shafts working opposite to each other cause an un-commanded turn to the left/port side in the heavily congested traffic area near three ships, including ALNIC MC
The CO and others on the bridge then lost situational awareness. “No one on the bridge clearly understood the forces acting on the ship, nor did they understand the ALNIC’s course and speed relative to JOHN S MCCAIN during the confusion,” the report said.
The ship finally regained steering but the action was too late and the ships collided.
The report noted neither ship sounded audio blasts warning each other of danger and neither attempted Bridge to Bridge communications.
Regarding the steering issues, the report noted that “several Sailors on watch during the collision with control over steering were temporarily assigned from USS ANTIETAM (CG-54) with significant differences between the steering control systems of both ships and inadequate training to compensate for these differences.
It also said that several watchstanders “lacked a basic level of knowledge on the steering control system, in particular the transfer of steering and thrust control between stations.”
Following a Tuesday closed Senate Armed Services Committee briefing on the report, Chairman John McCain (R-Ariz.), thanked the CNO and Adm. Philip Davidson, commander of Fleet Forces Command, in a statement “for a forthright and transparent briefing on the comprehensive review of recent Navy collisions at sea.”
Noting how the briefing and report described the basic problems leading to the collisions and corrective actions, McCain said “Time is of the essence in fixing the problems, and Congress must provide the necessary resources in a timely and predictable manner.”
The chairman reiterated his concern that a failure to properly train, fund, and equip the military “directly contributed to these collisions” and the committee will conduct close oversight of the navy’s efforts to correct the deficiencies to ensure this kind of calamity does not repeat.
Sen. Roger Wicker (R-Miss.), Chairman of the Seapower Subcommittee, responded to the briefing and report in a speech to the full Senate noting this reinforces the need for a 355-ship Navy.
“The review makes it clear that we are not doing right by our sailors, or the Navy, or the taxpayers in terms of making sure these brave men and women have what they need…We need to enhance training and readiness, and we need to recognize that the size of the fleet has contributed to the problem,” Wicker said.
“Simply put, we need to acknowledge that the Navy has a supply-and-demand problem. We are asking too few ships to do too many things for American security, and that needs to be rectified,” he added.