TXnMA
Posted on 08/08/2019 5:51:09 PM PDT by robowombat
NTSB: Lack of Navy Oversight, Training Were Primary Causes of Fatal McCain Collision
By: Sam LaGrone August 6, 2019 6:22 PM • Updated: August 6, 2019 8:45 PM
Almost two years after the collision between a U.S. destroyer and a merchant ship off Singapore, the first in-depth independent investigation has determined the most probable cause for the incident that killed 10 sailors was lack of adequate Navy oversight and training.
The National Transportation Safety Board found that the most likely cause of the fatal collision of guided-missile destroyer USS John S. McCain (DDG-56) and chemical tanker Alnic MC on Aug. 21, 2017, “was a lack of effective operational oversight of the destroyer by the U.S. Navy, which resulted in insufficient training and inadequate bridge operating procedures,” reads the investigation.
The conclusion of the report breaks from the Navy’s own assessment of the incident, which placed the blame for the early morning collision almost entirely on the leadership of McCain and not on what the NTSB determined were the service’s own “insufficient training and inadequate bridge operating procedures.”
The 2017 Comprehensive Review of Recent Surface Force Incidents, led by then-U.S. Fleet Forces Command commander Adm. Phil Davidson, placed blame at the feet of the ship’s commander, Cmdr. Alfredo Sanchez, and “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 ship control console operations (steering and throttle control) or associated casualty response procedures.”
Both Davidson and the NTSB report agreed on the basic facts: watchstanders on the bridge had not understood how the Northrop Grumman-designed integrated bridge and navigation system (IBNS) helm controls functioned in depth.
As the warship approached the busy shipping lane off of Singapore, an attempt to split the steering and throttle to two different consoles in fact transferred all controls to the lee helmsman – a sailor who was less familiar with the intricacies of the IBNS and had not slept the night before. The mistake led the helmsman to believe he had lost control of the ship. Meanwhile, the ship’s throttles – operated by touch screen – became unlinked.
“Control of the port shaft and steering was now at the lee helm station, while control of the starboard shaft remained at the helm station,” read the report.
When the helmsman thought he was slowing down both propellers, he was in fact only reducing the speed of the port screw, causing a sharp turn in front of the tanker.
The confusion around how the controls had been configured led to three minutes of the watch being unable to control the ship, allowing McCain to move in front of Alnic MC – unbeknownst to most of the bridge team. The collision occurred shortly after the bridge regained control of McCain.
According to the NTSB report, the watchstanders aboard McCain were qualified to stand their watches under the Navy-wide Personnel Qualification Standard (PQS). However, investigators found that the Navy-approved PQS didn’t address the nuances of the new navigation system.
“The PQS booklet did not specify the transfer of control between bridge stations,” read the report.
McCain was the first ship in U.S. 7th Fleet to be equipped with the IBNS that was installed in 2016 as part of a repair period in Japan.
The destroyer’s enlisted head of the deck department, then-Chief Boatswain’s Mate Jeffery Butler, was in charge of training sailors to operate the new system that replaced the manual throttle controls with touch screens.
During his court martial last year, Butler testified that the extent of training he received to operate the IBNS was an hour-long session with a master helmsman on the waterfront who was familiar with IBNS and then the tech manuals. With that knowledge, he in turn had to train the crew of McCain to operate the IBNS
“[It was] difficult to get training,” he testified. “We asked for the techs to come over, but they never showed.”
Though qualified to stand their watches by Navy standards, the crew’s understanding of the less-than-one-year-old navigation system was poor, the NTSB found.
USS John S. McCain (DDG-56) is pulled towards a pier after departing from a dry dock at Fleet Activities Yokosuka, Japan on Nov. 27, 2018. US Navy Photo
“Their misunderstandings expressed during the post-accident interviews and the misunderstandings of other crewmembers who were permanently assigned to the John S McCain point to a more fundamental issue with the qualification process and training with the IBNS,” the NTSB report found.
In a statement to USNI News, the service acknowledged that it had addressed concerns on IBNS training as part of Davidson’s review and through Secretary of the Navy Richard V. Spencer’s separate Strategic Readiness Review.
“The Navy released 22 fleet advisories governing the safe and effective operation for all variants of ship steering systems, to include IBNS,” reads the statement. “These system-specific advisories validated and updated existing directives governing the configuration, operation, and control of steering and propulsion systems during normal and casualty control scenarios.”
In addition to the unfamiliarity of the controls, the report found that the lack of sleep of the bridge team was a factor in the collision.
“According to Navy records, the 14 crew on the bridge averaged just over 4.9 hours of rest in those 24 hours,” read the report.
In total, the NTSB found seven safety issues associated with the crash.
Safety issues identified in this accident include the following:
The decision to transfer the location of thrust control on board the John S McCain while the vessel was in a congested waterway
The lack of very high frequency radio communications between the vessels
The automatic identification system data transmission policy for Navy vessels
The procedures for the transfers of steering and thrust control on board the John S McCain
The training of Navy bridge watchstanders
The design of the destroyer’s Integrated Bridge and Navigation System
Navy watchstanders’ fatigue
The fatal collisions of McCain and USS Fitzgerald (DDG-62), plus two other incidents in the Western Pacific, prompted the Navy to take a holistic look at how it operates its surface forces and trains its surface officers and enlisted sailors. The service has said it has implemented more than 100 changes to that end.
The NTSB? They investigate Amtrak crashes..and 737s that land on the Hudson.
O...m...g....
Yeah, I thought that was weird as well. Maybe there is some sort of conflict of interest somewhere up the chain of command?
It does seem odd. USAF accidents that don’t involve civilian resources are subject exclusively to a USAF accident investigation board.
Gotta be because the system is so complex the Navy can’t figure it out?
That doesn’t sound good.
Could it be because of the involvement of the merchant that the NTSB was called in?
One obvious problem is the abolition of the Surface Warfare Officer School. That was the worst sort of idiocy.
When the USS John S. McCain (DDG-56) collided with the chemical tanker Alnic MC, the Alnic MC was traveling at 8 nauts.
From my experience paint dries faster than a ship traveling at 8 nauts.
Gross incompetence by all those involved on the USS John S. McCain is my conclusion.
“The proximate cause of this incident was negligence on the part of.....”
You gotta be effin' kidding me.
The fatal collisions of McCain and USS Fitzgerald (DDG-62), plus two other incidents in the Western Pacific, prompted the Navy to take a holistic look at how it operates its surface forces and trains its surface officers and enlisted sailors. The service has said it has implemented more than 100 changes to that end.
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The statement above, in my opinion, is BS. For 50 years federal politicians pimping for votes have slowly, by legislation and regulation, inexorably degraded our Navy in a thousand ways but at the top is leadership and character.
The top of that chain is the Naval Academy. when we see in that venerable institution lesbians being treated as equals to strong men (needed in combat), and when we see strong men turned down for entry to allow a particular minority person in the school, and when we see homosexuals commanding straight men, and when we see Trans-Sexuals commanding men, and when we see 90lb women with a bun of hair on the back of their head trying to shoot a dual 50 caliber machine gun, and when we see a 90 lb woman standing guard at the gangplank of a multi billion dollar warship ...…………………..all any thinking person with a functioning brain can possibly conclude is that our once proud Navy has been degraded by the politicians that the citizens of the US put in office. Instead of court martialing some hapless Chief Petty Officer, let’s start court martialing politicians for anything and everything up to and including spitting on the street! Accountability has been legislated out of America as most evidenced by Nancy Pelosi’s 803,000 dollar taxpayer funded retirement check voted in and approved by the Uni Party.
You gotta be effin' kidding me."
I agree. I always wondered why someone didn't just grab the wheel and make a tight turn. Or put the ship in "full reverse." I was on the USS Pulaski when it was new. If you went from "all stop" to "full flank," the shafts would spin so fast that you would have a rooster tail.
It seems we've made things too complicated.
Obviously, more diversity training is needed.
It has a throttle controlled by touchscreen. What if they lose power? I hope there’s a manual backup.
“take a holistic look”
WTF?
(A guy I work with said that women on board the ship he served on were called ‘drains’)
TXnMA
Thank you, TXnMA...I will check it out. Hope all is well.
Shoot, what if the touchscreen simply locks up? And it will. At the worst possible time.
A ship named after that Ace John crashes. Bad ju-ju!!!!
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