NTSB report for USS McCain Collision

[Adelie]

Summary: https://www.ntsb.gov/news/press-rele...R20190805.aspx
Report: https://www.ntsb.gov/investigations/...ts/MAR1901.pdf

[hpeer]

The NTSB determined the probable cause of the collision 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. Contributing to the accident were the John S McCain bridge team’s loss of situation awareness and failure to follow loss of steering emergency procedures, including the requirement to inform nearby vessel traffic of their perceived loss of steering.

I added the bolding to highlight just where the NTSB laid the blame-squarely on Navy Brass. Crew actions were CONTRIBUTING factors.

[psk125]

What are they doing transferring thrust and helm control stations in the middle of one of the busiest places for shipping in the world? Talk about lack of situational awareness! That’s like telling your carpool seat mate to take over the wheel and gas pedal during your rush hour commute because you want to take a sip of coffee and a bite of donut. It was 05h24, so they obviously needed more coffee. Oh, and hey, listen to and use VHF to find out what others are up to out there? Really? This is the U.S. Navy? Doesn’t seem to be the same one J.P.Jones got started.

[SailOar]

An article on ProPublica regarding the McCain collision.

Collision Course

When the USS John S. McCain crashed in the Pacific, the Navy blamed the destroyer’s crew for the loss of 10 sailors. The truth is the Navy’s flawed technology set the McCain up for disaster.

[Checkswrecks]

Originally Posted by psk125

What are they doing transferring thrust and helm control stations in the middle of one of the busiest places for shipping in the world? Talk about lack of situational awareness! That’s like telling your carpool seat mate to take over the wheel and gas pedal during your rush hour commute because you want to take a sip of coffee and a bite of donut. It was 05h24, so they obviously needed more coffee. Oh, and hey, listen to and use VHF to find out what others are up to out there? Really? This is the U.S. Navy? Doesn’t seem to be the same one J.P.Jones got started.

I retired from the NTSB aviation side and regularly saw people do the darnedest things when confronted by surprise, even when trained well. We worked an L-1011 accident investigation where the First Officer was supposed to perform the takeoff. The airplane accelerated till it had flying speed (V1) then rotated the nose gear up (Vr) and the stall shaker went off with the stall warnings. They clearly had enough speed to fly and were accelerating at 16 feet above the ground when the F/O relaxed back pressure on the controls. Suddenly the inertia of the nearly half million pound airplane was down and an instant before it hit hard was when he told the Captain:

"Your airplane."


All the poor Captain could do was try to get it to the best possible stop with most of the runway behind them. The wing broke, a fuel fire erupted, they hit a noise barrier, and 10 people got hurt but fortunately nobody was killed. https://en.wikipedia.org/wiki/TWA_Flight_843

[psk125]

The guys on the bridge should not have been “surprised”. They KNEW they were headed into one of the busiest traffic areas on the planet. They had the best radar and radio equipment in the world to provide them information on the existing situation: positions, headings, and speeds of every ship in a possible 50(?) mile radius. They had watchstanders to provide visual reports. They were on a destroyer - one of the most speedy and maneuverable vessels in the US fleet. And someone decided to switch helm stations in the middle of this, and did it wrong, so that they thought they’d lost control when they hadn’t? This is not like a plane with alarms going off 16’ off the ground, and the F/O handing it off to the Captain. This was a self-inflicted wound, with the people in charge losing control because of things they themselves did. Perhaps the comparison to having a carpool partner take the wheel is not a good one. Perhaps this was more like deciding, when coming to a traffic circle, to try driving with your feet instead of your hands. Not a good choice. Having systems that have too many bells and whistles in congested and stressful situations is not smart. What might happen in battle ? Will we be running into our own ships?

[hpeer]

DAKOTA BORDEAUX HAD RARELY traveled outside his home state of Oklahoma before he joined the Navy in February 2017. He’d certainly never seen the ocean.
But only four months later, Bordeaux was standing at the helm of the USS John S. McCain, steering the 8,300-ton destroyer through the western Pacific

Recruit training, or "boot camp," will be approximately seven weeks long

https://www.bootcamp.navy.mil/what_to_expect.html

The guy has been out of a 2 month boot camp 2 month, surly he has had a week leave in there, and then being flown to Japan, and then he gets in the ship. So at MAX he has been on ship maybe 6 weeks, almost surely this is his first cruise.

And they let him touch the helm? WTF?

And then he gets Prosecuted and some of the blame? An even bigger WTF! This poor guy is barely qualified to swap the head.

To me that is a MASSIVE failure. And I don’t see any recognition of this failure in the report. Which is the biggest WTF!!!

I’m not familiar with the commercial training regulations. Would someone please give a brief overview of the required training for a raw new hire on commercial ship.

[Breaking Waves]

Originally Posted by hpeer

And I don’t see any recognition of this failure in the report. Which is the biggest WTF!!!

yea, agreed.

The crew training and qualification failure here is just massive. As is the leadership failure to properly assess when someone is competent.

The touch screens may (or may not - they might have been just fine if the crew was competent) be a problem but they are a side issue.

And this has been a theme across the range of Navy accidents, not just this one. The Captain in the Porter incident clearly was not competent to handle a moderately busy crossing situation.

[requiem]

Originally Posted by Breaking Waves

The crew training and qualification failure here is just massive. As is the leadership failure to properly assess when someone is competent.

The touch screens may (or may not - they might have been just fine if the crew was competent) be a problem but they are a side issue.

Agree. I can make criticisms of the touch screens, and the report covers some of those issues, but based on the screenshots in the article the situation described should not have occurred. The displays appear to indicate which station has control of each function, and the stations are also labeled.

A combination of fatigue and the classic "did you check if it's plugged in?" type of brain hiccup would explain much. I assume most people have experienced something "hiding in plain sight" on a computer screen, or not noticing when they've inadvertently toggled a setting (particularly rampant on touch screens). What's troubling is that, with so many people in play, no-one had the presence of mind to catch or check for such an error.

Reading the report, I see:

1. Initial error with the transfer, and a secondary error with the throttle ganging (both should have been caught and corrected with a visual double-check).
2. Skipping the first step in the emergency procedure since the OOD thought it was redundant due to the system being in "backup manual" mode. (This uncertainty over how the override-to-manual button worked should have been identified and resolved as part of training.)
3. Steering control bounced from lee helm to aft steering to helm and back to aft steering. (By this point, I think everyone was blindly running their own checklists and overall awareness had gone out the window.)

I don't see that training would have required more than an hour or two at most. Certainly a few weeks of helm time and drills would have been appropriate to help understanding take root, but this is not rocket surgery.

[psk125]

Originally Posted by requiem

I don't see that training would have required more than an hour or two at most. Certainly a few weeks of helm time and drills would have been appropriate to help understanding take root, but this is not rocket surgery.

How long would it take to schedule an hour or two of training for each crew member assigned for helm duty? Perhaps more than a month, what with rotations and other assignments? And the system would need to be working properly in order for crew to learn properly. Since it was reported NOT working so much of the time, how much rescheduling of the training would then need to be done to bring everyone up to speed on the working system? Three months? There would also need to be additional training on how to use the “backup-manual” mode- which did not exist. Hmmm. Also, some of the labels that make it clear what shows on the screens have been added by the authors of the report to make it clear to readers what is showing on the screens. It may not be so obvious to crew, especially when some of the functions may have been cut off by having the system in “backup manual” modes, and the system perhaps not working properly then, either.

[requiem]

Originally Posted by psk125

How long would it take to schedule an hour or two of training for each crew member assigned for helm duty? Perhaps more than a month, what with rotations and other assignments?

This is certainly an organizational issue. If training is critical, it can be made to happen. If the crew is not properly trained on such basic elements, is the ship fit for sea? I recall from this and other cases that there was significant pressure to "make do".

Another ProPublica story on the training and readiness problem in general is found here: https://features.propublica.org/navy...-cause-mccain/

Originally Posted by psk125

Also, some of the labels that make it clear what shows on the screens have been added by the authors of the report to make it clear to readers what is showing on the screens.

Yes, the ProPublica story added some labels, but really those aren't needed to understand the controls. Here are the parts of the screen I'm really keying off:

Steering:

Thrust:

[psk125]

But are those screens showing the actual situation when in “manual backup” mode, or do they show what was the last thing they showed before the switch? Like this website shows the thread most recently posted to at the top of the thread listings when you open the heading. If you don’t log off the site, that same thread will be at the top of the listings hours later on your screen, even if other threads have had postings made more recently. You have to log back in to reset the screen. We don’t know how the system works and are shooting in the dark at best here.

[requiem]

Originally Posted by psk125

But are those screens showing the actual situation when in “manual backup” mode, or do they show what was the last thing they showed before the switch? Like this website shows the thread most recently posted to at the top of the thread listings when you open the heading. If you don’t log off the site, that same thread will be at the top of the listings hours later on your screen, even if other threads have had postings made more recently. You have to log back in to reset the screen. We don’t know how the system works and are shooting in the dark at best here.

That is possible, but I think it's quite unlikely. Websites work differently from applications of this sort; they have an stateless request->response architecture and all the useful features you've come to expect on modern web apps have essentially been jury-rigged to work on a protocol (http) that was not designed to support them. This is also why many sites don't have them. For the application to operate in the manner you've described would imply significant failures across the software development lifecycle. (I'm not going to say impossible, because someone will always surprise you with a particularly braindead design, but sufficiently improbably as to discount it.)

While I don't have the IBNS technical manual at hand, the NTSB did, and I think these excerpts from the report support my thinking:

p25: Although the IBNS touch-screen displays for both SCC stations would have indicated that the lee helm station had control of steering, the helmsman, lee helmsman, and BMOW did not recognize that control had been transferred.

p27: In addition to the control stations, the John S McCain had numerous displays on the bridge and on the bridge wings that showed the propeller pitch and turns. When NTSB investigators visited a similarly equipped Navy destroyer, they noted that the displays were visible from almost anywhere on the bridge. During the accident sequence,the throttles remained mismatched for over a minute, but the CO, OOD, conning officer, and other bridge watchstanders did not recognize the lee helmsman’s error, and, consequently, no actions were taken to correct it.

In each of these instances, a simple sanity check (take a breath, take a look at the screen) would have revealed the problem. Unfortunately once people start to panic and pick a path to hurry down all sorts of things can be missed. For example, the un-ganged throttles should have been visible, but if the lee helmsman assumed they were ganged, changed the port throttle, and didn't look at the screen to confirm the change you'd get this:

p.27: The lee helmsman told investigators that, after the transfer of control, he re-ganged the throttles. Then, when ordered to slow the ship to 10 knots, he stated that he reduced port thrust and that starboard thrust was also reduced because the throttles were ganged.