The following is from the May 22, 2013 U.S. Pacific Fleet investigation findings from the Jan. 17, 2013 grounding of the minesweeper USS Guardian (MCM-5). The report was released by the Navy on June 20.
Causation: This tragic mishap was wholly preventable and was the product of poor voyage planning, poor execution, and unfortunate circumstances. This investigation uncovers no single point of failure; instead, there were numerous links in the error chain leading up to the grounding. Had any one of which been appropriately addressed, the grounding would have been prevented. USS GUARDIAN leadership and watch teams failed to adhere to prudent, safe, and sound navigation principles which would have alerted them to approaching dangers with sufficient time to take mitigating action. The watch team’s observations of visual cues in the hours leading up to the grounding, combined with electronic cues and alarms, should have triggered immediate steps to resolve warnings and reconcile discrepancies. Further, notwithstanding multiple, readily- available sources of accurate information, the leadership and watch teams relied primarily on an inaccurate Digital Nautical Chart (DNC) coastal chart during planning and execution of the navigation plan. Finally, USS GUARDIAN leadership failed to exercise due diligence to ensure the watch teams were knowledgeable and proficient, and failed to recognize that key personnel transfers within the navigation team had degraded USS GUARDIAN’s navigation capability to an unacceptable level. Ultimately, the lack of leadership led to increased navigational risk to the ship and her crew.