HRO 9i Collision at Sea-Sequence of Events6

This entire post is devoted to just a single minute from the event timeline. I think it is important to slow things down (okay, way down) to get a better understanding of what was happening on the Bridge of the JSM when the CO gave the order to add an additional watchstander for ship control.

I abbreviated the reference details to conserve space. Refer to the original post for the complete information.

References

(a) Navy Report of the Collision https://www.doncio.navy.mil/FileHandler.ashx?id=12011.

(b) National Transportation Safety Board (NTSB) Report of the Collision https://www.ntsb.gov/investigations/accidentreports/reports/mar1901.pdf

(c) International Rules of the Road https://en.wikisource.org/wiki/International_Regulations_for_Preventing_Collisions_at_Sea.

(d) U.S. Navy Regulations, Chapter 8, https://www.secnav.navy.mil/doni/US%20Navy%20Regulations/Chapter%208%20-%20The%20Commanding%20Officer.pdf

(e) Standard Organization and Regulations of the U.S. Navy, OPNAVINST 3120.32D CH-1, dtd 15 May 2017, https://www.secnav.navy.mil/doni/Directives/03000%20Naval%20Operations%20and%20Readiness/03-100%20Naval%20Operations%20Support/3120.32D%20W%20CH-1.pdf

Summary of the Incident

The USS JOHN S MCCAIN (JSM) was overtaking the ALNIC MC in the westbound lane of the Singapore Strait Traffic Separation Scheme when bridge watchstanders thought they lost steering control (but they didn’t). While the crew attempted to regain control of forces they unwittingly released, the JSM unintentionally turned to port into the path of the Alnic MC. The resulting collision killed 10 Sailors, injured 48 more, and caused over $100 million in damage.

Sequence of Events (review of previous posts)

20 August 2017 (the day before)

The 0200-0700 OOD and Conning Officer were not present at the Navigation Brief for entering port (ref(a), p.60). It is hard to know what impact this had on the collision the next day.

The JSM Commanding Officer (CO) chose not to station the Sea and Anchor detail until after the ship entered the Traffic Separation Scheme (TSS) (ref (a), p.60).

21 August 2017 (the day of the collision)

The time of sunrise was 0658

0115 The CO came to the Bridge (normal under the circumstances based on my experience and ref (a), p.45)

0518 The ALNIC MC entered the Singapore Straight TSS (ref (b), p.11). The JSM was north and outside the TSS, overtaking the ALNIC at twice its speed (18kts vs. 9kt).

Sequence of Events (NEW)

0519-0520 The “Commanding Officer noticed the Helmsman (the watchstander steering the ship) having difficulty” so he ordered the OOD to station a Lee Helmsman (ref (a), p.46).

I think a better description is:

The “Commanding Officer noticed the Helmsman (the watchstander steering the ship [and controlling its engines]) having difficulty [attempting to comply with orders for rapid changes in heading and speed as the OOD prepared to enter the Traffic Separation Scheme]” so he ordered the OOD to station a Lee Helmsman (ref (a), p.46). I added “attempting to comply with orders for rapid changes in heading and speed” because neither report states this and is the only logical reason for any difficulty the Helmsman was having short of an epileptic seizure.

It takes a lot of skill on the part of both the Conning Officer and the Helmsman to maneuver a Navy ship in close quarters to other ships. It is possible to get bogged down in the formality orders and repeat-backs when anticipation and quick responses are necessary. There are ways to reduce the complexity of orders to the helm (steering the ship) that reduce length of orders and repeat-backs, but the details are beyond the scope of this post. However, these aren’t frequently practiced.

The Context

Neither the Navy nor the NTSB report of the collision made it clear what was happening on the Bridge at the time the CO gave the order and watchstanders tried to carry it out. This gap in the reports seriously undermines the ability to learn from the event. Both reports provided details about button pushing at the Ship Control Station and the operating modes of the ship’s rudder and engine control system. They focused on what happened *while* the order was being carried out. Those details are necessary for what I call “investigative completeness,” but aren’t helpful for learning what I consider the most important lessons from the collision. We can’t consider those lessons unless that gap is filled.

The Navy report stated that the “unplanned shift caused confusion in the watch team” (ref (a), p. 46). The NTSB report noted only that “the CO decided to man the lee helm station so that the helmsman, who was controlling both steering and propulsion from the helm station, could concentrate on steering alone” (ref (b), p.10). It says nothing about confusion among Bridge watchstanders.

It is essential for my purposes to provide a clear description of the situation of the ship and what the OOD was trying to manage at the time of the CO’s order. Otherwise, it is impossible for anyone that is not an experienced Navy OOD to understand the risk context of the CO’s order and the timing for carrying it out.

Orders have three components that are observable and don’t require mind reading: the situation or context of the ship at the time the order was given, the order itself and the way (when and how) it was carried out. It is always useful to know the goals of the person giving the order and how they made sense of the situation, but that information resided in the CO’s head and is discussed in the reports. I don’t consider the consequences of the order to be an actual part of the order because there are so many unknowns involved.

First, the context of the order. I found it a challenge to construct this because the reports described pieces of the situation in widely separate parts of their narratives of the sequence of events. After reading the reports many times, I was able to devise a concise description of the context of the CO’s order to change the configuration of ship control. This is what I think the context was when the CO gave his order:

As the JSM was entering the high traffic area of the TSS in the dark, overtaking the ALNIC at twice its speed at a distance less than 2000 yards 45 degrees off the JSM’s port bow, with several other ships within 2000 yards of both JSM and ALNIC, the OOD and Conning Officer were trying to make sense of the situation and interpret the significance of near continuous reports from Bridge watchstanders, the navigation team, and the Combat Information Center to safely operate the ship, the CO ordered a change of watchstanders responsible for ship control.

This is not a criticism of the CO. It is only a description of what I think was happening when he gave his order.

Maneuvering a ship at high speed in relation to other nearby ships operating independently at night is one of the hardest things an OOD and Conning Officer ever do. This is what commanded their attention when the CO gave the order. Other than reports from the Combat Information Center and various electronic aids on the Bridge, the two officers responsible for ship safety can only assess the course of other ships and thus risk of collision with their own ship by interpreting their navigation lights. This is exceedingly difficult, particularly when other ships are close, because the lights of close and far ships can overlap visually.

From the Navy report, we only know that the Bridge watchteam was “confused” by the CO’s order. Since the “watchteam” isn’t a person, WHO exactly was confused and WHY? Most importantly, what EXACTLY was confusing to the OOD, the officer responsible for making sure the CO’s order was carried out? Neither report provided any information about these questions and guessing isn’t a reliable learning strategy. I have no idea what the OOD was thinking nor what his or her state of confusion was. Neither does anyone else who reads the reports.

The second component to analyze is the order the CO gave. The reports didn’t provide any details about how he gave the order. We don’t know if he communicated any expectations about when and how to carry it out. Standard Navy protocol on the Bridge is for the CO to give any orders to the OOD and the reports give us no reason to believe anything else occurred on the JSM. The only other thing noted about the CO’s order in the Navy report was that the change to ship control was “unplanned” (ref (a), p. 46). There is nothing else that can be learned from the CO’s order.

In my next post, I will continue the analysis of the observable components of the CO’s order with what we know about the way it was carried out. Forewarning: I am not going to describe who pushed which button of the Steering Control System. You can learn everything there is to know about that from the Navy and NTSB reports.