Navigation Brief
This is an e-newsletter originally published September 4, 2020
ALEXANDRIA – Good Evening, Drifters
The National Transportation Safety Board put out its report on the Fitzgerald collision today. We have discussed that collision in this space at length here:
We need to talk about the Fitzgerald: The Drift Vol XVII
Much of what is in the NTSB report is not new to anyone who read the Fort Report discussed above, but any time we get a fresh set of eyes on a familiar problem, it’s worth having a look. I wrote a story offering a broad overview of the report, as well as recounting an interview with the Surface Warfare Boss Vice Adm. Roy Kitchener, in a story that you can find here:
National Transportation Safety Board faults US Navy for Fitzgerald collision
How about we take a look at what NTSB came up with.
Let’s Drift.
Fitzgerald Again
As I intimated in my introduction, there is not much new to be found in this report. The basic story is the same: The Fitzgerald, steaming near Tokyo in heavy traffic, failed to maneuver to avoid a collision with the container ship ACX Crystal. The officer of the deck failed to properly track the Crystal, as well as several other close-call contacts that evening, and violated the Commanding Officer’s standing orders by not waking him when there was doubt about the Crystal’s course.
Further, the OOD did not coordinate with CIC on the surface picture, but CIC watchstanders were not any more effective that evening than the bridge watchstanders, not tracking the surface picture and not reporting to the bridge on what they saw.
Here’s the breakdown of their findings:
- The Officer of the Deck was poorly trained, did not know how to respond in the situation and did not understand bridge resource management.
- The crew was fatigued. Several events throughout the day required the bulk of the crew, meaning watchstanders did not have adequate rest prior to going on watch.
- The ship was not broadcasting its position over the Automatic Identification System.
- The Fitzgerald did not follow the rules of the road for avoiding collisions at sea by failing to maneuver, even though it was the giveway vessel in the situation.
- The CO did not adequately gauge or act to mitigate the risks on Fitzgeralds chosen track, and furthermore did not ensure more experienced watchstanders were on watch in such a heavily trafficked area.
- The Fitzgerald was underway for pre-deployment certifications, but the ship would have had to cram the schedule in order to achieve all its certifications. The Navy did not perform adequate oversight to the ship’s schedule that could have prevented the crew having to operate near redline.
Things that Jump Out
The general mess that was the CIC watch that evening grieves me. This part especially makes me angry:
Excerpt: At least some personnel in CIC did see contacts but did not apparently share this information with other CIC watchstanders. The optical sight system operator, who reported to the surface warfare coordinator as part of the surface watch, told investigators that he visually observed at least 80 contacts using his line of sight camera.
The surface warfare coordinator stated that pop-up targets would appear on his radar scope and the surface warfare supervisor’s scope had a lot of clutter. Despite the clutter, however, he did not advise any of his supervisors so a technician, who was part of the watch bill, could look at the scope to determine if the issue was related to equipment tuning or operator error. The COLREGS call for every vessel to use all available means appropriate to determine whether risk of collision exists.
It’s a complete mystery to me why neither the SWS nor the SWCC decided to call the duty combat systems and ask why their radar return sucked. A half-decent ET would have been able to tell right away that, as we learned in the Fort Report, the radar was set up for open-ocean steaming, not short-range, close-to-land steaming in heavy traffic.
The second thing that jumps out is this moment between the OOD and JOOD, when clearly the captain should have been called.
Excerpt:The JOOD told investigators that she went to the starboard bridge wing and looked at the ACX Crystal through a large set of binoculars called “big eyes.” She said that there was a second vessel behind the ACX Crystal and that she urged the OOD to come look through the big eyes, which she did. The JOOD said she told the OOD to slow the destroyer’s speed, but that the OOD replied that a slowdown would make the situation worse.
The OOD told investigators that she thought about turning to starboard and going astern of both vessels but decided against this maneuver because that course would take the destroyer closer toward land. At this time, the vessel was 8.2 miles offshore from the Izu Peninsula.
“Would make the situation worse?” This is a contact that the JOOD an OOD are discussing and disagree on, and to say any course of action would make the situation “worse” means you believe it’s not great to begin with. There is no doubt they should have called the captain in that moment per the CO’s Night Orders.
Finally, the mystery course change.
There’s a mystery course change here that is new information not in the Fort Report, and the NTSB couldn’t explain it. It was, however, the fatal mistake that doomed Fitzgerald that evening.
Excerpt: According to the Fitzgerald’s deck log, at 0122, a course change was ordered to 200° (from 190°). About a minute and a half later, at 0124, ARPA information from the Wan Hai 266 showed that the destroyer had come right, to the new course.
The reason for this course change was not revealed during post accident interviews. A study performed by the NTSB determined that the Fitzgerald would have passed 0.5 nautical miles ahead of the ACX Crystal if the Fitzgerald had remained on a course of 190° instead of changing to 200°.
…
This course change proved to be a critical error, and investigators were unable to determine the reason for it. The NTSB conducted a Vehicle Performance Study using GPS data as well as course and speed data for the Fitzgerald, ACX Crystal and Wan Hai 266, to recreate the tracks of the vessels leading up to the accident. The study found that if the Fitzgerald had not made the course change from 190° to 200° 8 minutes before the collision, the destroyer would have passed ahead of the ACX Crystal with a CPA of about 1,000 yards, or about 0.5 nautical mile.
Therefore, the NTSB concludes that the NTSB Marine Accident Report 25 Fitzgerald’s unexplained small course change to starboard minutes before the collision put the vessel on a collision course with the ACX Crystal.
Given the timeline in the report, it seems as if this may have been the maneuver the bridge ordered to avoid ACX Chrystal, only it was precisely the wrong maneuver. (This is something they could have determined if someone, ANYONE, had decided to plot this on a maneuvering board.) However, it is never explained and will likely remain a mystery.
The last thing I’ll leave you with is these particularly profound two paragraphs from NTSB on the Navy’s role in this accident. It doesn’t require much comment, it speaks for itself, save to remind that “Condition III” steaming is basically fully manned and ready for a broad spectrum of operations.
Excerpt: Based on watchbills reviewed by the NTSB, the ship appeared to be manning and operating equipment in accordance with Condition III requirements. However, based on work/rest records reviewed by the investigators, it was apparent that the ship was unable to meet the criteria of ensuring the crew was able get [the required] 8 hours of rest each day, given their schedule of operations. It is conceivable that this level of manning degraded the watchstanding capability, as well as other operational duties among critical personnel.
Gaps in manning, combined with a lack of experience and training as well as an aggressive schedule, can lead to crew errors. A “can do attitude,” which the Navy discussed in its own comprehensive review, can often lead to positive thinking and increased morale. However, without the necessary resources to keep that momentum going, over a period of time, it can lead to erosion of training, morale, and degradation in performance and can desensitize senior leaders to the operational risks associated with this high-tempo work environment. The NTSB concludes that the Navy failed to provide effective oversight of the Fitzgerald in the areas of operations scheduling, crew training, and fatigue mitigation.
Let’s go to The Hotwash.
The Hotwash
Straight to the links tonight.
More Reading
Trouble in Columbia Land: Budget dysfunction threatens delays to US Navy’s Columbia program
US Navy’s new amphibious landing craft are coming off the lines
Sam LaGrone with more on the course change mystery: NTSB: ‘Unexplained’ Course Change Was ‘A Critical Error’ in Fatal USS Fitzgerald Collision
Littoral Combat Ship USS Sioux City Joins SOUTHCOM Anti-Drug Mission in First Deployment
Norway Expands Key Arctic Port For More US Nuke Sub Visits
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