A US Navy report detailing the events and actions that led to the collision between USS Fitzgerald and ACX Crystal off the coast of Japan on June 17th and the collision between USS John S McCain and merchant vessel Alnic MC on August 21st has found that both accidents were preventable.
Chief of Naval Operations Admiral John Richardson said that the respective investigations found multiple failures by watch standers that contributed to the incidents.
The report stated that the collision between Fitzgerald and Crystal was avoidable and resulted from an accumulation of smaller errors over time, ultimately resulting in a lack of adherence to sound navigational practices. Specifically, Fitzgerald’s watch teams disregarded established norms of basic contact management and, more importantly, the leadership failed to adhere to well-established protocols put in place to prevent collisions. In addition, the ship’s triad was absent during an evolution where their experience, guidance and example would have greatly benefited the ship.
USS JOHN S MCCAIN
The US Navy statement said that the collision between John S McCain and Alnic MC was also avoidable and resulted primarily from complacency, over-confidence and lack of procedural compliance.
“A major contributing factor to the collision was sub-standard level of knowledge regarding the operation of the ship control console. In particular, McCain’s commanding officer 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”, the US Navy said.
With regard to procedures, no one on the Bridge watch team, to include the commanding officer and executive officer, was properly trained on how to operate correctly the ship control console during a steering casualty.
The Fitzgerald timeline appeared to indicate a sequence of decisions and oversights that put her into close-quarter situations more than once on the night Fitzgerald and ACX Crystal collided. Standing orders required that the CO always be notified of such events, but this was not the case.
The Navy concluded that the Fitzgerald collision was avoidable. Specifically, she appears to have violated COLREGS in several ways:
- She was not operated at a safe speed appropriate to the number of other ships in the immediate vicinity.
- She failed to manoeuvre early as required with risk of collision present.
- She failed to notify other ships of danger and to take proper action in extremis.
- Watch standers performing physical look out duties did so only on Fitzgerald’s left (port) side, not on the right (starboard) side where the three ships were present with risk of collision.
- Watch team members responsible for radar operations failed to properly tune and adjust radars to maintain an accurate picture of other ships in the area.
- Supervisors responsible for maintaining the navigation track and position of other ships were unaware of existing traffic separation schemes and the expected flow of traffic, and did not utilize the Automated Identification System to gather information on nearby vessel traffic.
- Her approved navigation track did not account for, nor follow, the Vessel Traffic Separation Schemes in the area.
The report also identified systemic factors, including issues with training deficiencies and excessive workloads. CNO Richardson said that the Navy was committed to fixing these problems. “We must never allow an accident like this to take the lives of such magnificent young Sailors and inflict such painful grief on their families and the nation,” Richardson said in a statement, concluding that “we must do better.”