Home » Documents » USS Fitzgerald, USS John S. McCain Collision Report


USS Fitzgerald, USS John S. McCain Collision Report

The following is a summary of findings from investigations into the collisions of guided-missile destroyers USS Fitzgerald (DDG-62) and USS John S. McCain (DDG-56), released to the public on Nov. 1, 2017.

From the Summary:

USS FITZGERALD

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, 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 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. With regard to procedures, no one on the Bridge watch team, to include the commanding officer and executive officer, were properly trained on how to correctly operate the ship control console during a steering casualty.

  • Mike Mulligan

    FUMING JIANG
    Senior Safety Officer, OSART Team Leader at IAEA
    Decline is the force of the nature, however deviation is a choice.

    One of the challenges the power industry face is the drift of standards and expectations and normalization of deviations even without noticing it. Leadership and organizational effectiveness were the contributors to these issues most of the cases.

    We have a saying that when you establish a high standard, you may achieve a median result; when you establish a median standard, you most probably will achieve low result; when you set low standards, nothing can be achieved.

    The keys to avoid unintended drifts and normalization of deviations are to set high standards, keep vigilant on the standards and expectations established, continue challenge the status quo and look for fresh and critical perspectives from outside to improve. It is the responsibility of the leadership team to challenge and bring the behaviors and conditions back to standards and expectations and beyond rather than rationalize these deviations.

    A deviation not challenged is a deviation accepted and later it will become a standard in the organization.

    • Mike Mulligan

      So why can’t I cut a sentence or paragraph out of the navy report and put it on this page to help me explain my point? Is it another silly unquestionable rule like a darken ship? I don’t care how darken you make that ship…the satellite infrared detector can pickup turbine exhaust heat.

      • Sumdumchief

        Ever been to sea? At night?

        • Mike Mulligan

          On the surface, or underwater? I would say rarely at night, and a few more during daylight. I worked back aft. I spent a few times in a moonless night in a Nevada in a desert night. I was all alone. I was many tens of miles from humanity. The universe was so beautiful, I couldn’t stop crying. I am a avid cyclist. Just bought a beautiful new mountain bike. I live in a rural environment. A real treat for me is to ride my on my local roads without any lights on. On the edge of visibility where you could only see shadows , to where you almost have to guess where to go on the road or trail. Sometimes you have to look up to the tips of the trees, to figure out where the road is. But you guys are on a multi billion dollar vessel, heavily trained and instrumented up. There are no excuses!!!

          • Mike Mulligan

            Excuse me. I plied the oceans on a submarine. The vast amount of times was underwater. We navigated the world through passive sonar. We were always blind. Basically navigating the world through hearing, no other instrumentation. We chased many bad guy submarines though only hearing…passive sonar. Near the surface, it was through a periscope. It had a very limited field of view.

          • Sandra Wyman

            Mike-Darken ship has nothing to do with hiding the ship. Open up a copy of the COLREGS or at least stand a conning watch . . .ships are identified at night by the pattern of their navigational lights, placement of mast and port and starboard running lights . . . darken ship is to make sure that the OOD sees what he think he sees, all you see at night of a ship are pin pricks of light on the horizon from that you get to figure out which way it is going and how fast . . .a porthole showing white lights and overpowering the green starboard light would lead to a collision in a hurry.

    • Mike Mulligan

      These guys inspect reactors and their regulators world wide.

      The “International Atomic Energy Agency” is the world’s central intergovernmental forum for scientific and technical co-operation in the nuclear field.

      The Corporate Operational Safety Review Team (OSART) – composed of the UN International Atomic Energy Agency (IAEA), as well as experts from Finland, France, Romania and the United States – reviewed the operations at the nuclear facility using IAEA’s safety standards, and proposed recommendations for improvement.

      So the head of Naval Reactors who oversees all Naval reactors is running the punishment gig?

    • draeger24

      nice quote….it is also in our society as a whole “defining deviancy down”.

  • Western

    I read the report. I had no idea it was this bad out there. I feel incredibly sad and very concerned for our Navy. I hope there is some real substantial internal review taking place. I hope that review is shared.
    I’d be very interested in a follow up with the fleet to determine what related corrective actions have been taken place in training, watchstanding and leadership. I’d also be interested in learning what happens to the existing officers and chiefs on the Fitz and McCain.

  • Paul Stanley

    Nice report……I continue to be appalled that a CO would allow a man-of-war to be operated in such a poor state of readiness, training, standing orders, leadership.
    Sure, up-temp activities, but being at sea is an opportunity to train, train, train.
    Terrible, fire the ilk.

  • draeger24

    the reliance upon tech has brought complacency. Every sailor should have to do manual navigation by fixes, running fixes, reports on LOPs from the bridge wings, and celestial navigation with NO other tools than pencil, paper, chart, sextant. Learning the MO-Board, manually, using speed wheel and paper, should be a must….these engage the brain, help critical thinking and logic skills, and give an appreciation for the tech…these should be quarterly tests for the bridge watch – turn off all the tech and make manual nav a must. From appearances and the bridge log, does anyone notice that the CO gave the wrong starboard engine orders (if I am reading this correctly) and didn’t seem to know much about “steering” with his engines (or am I missing something). There used to be seamanship/steering contests for SWOs decades ago….is this still the case?
    Lastly….let’s get rid of the nonsense….all the “Diversity Months”…sexual harassment training, diversity training, and the rest of the nonsense….train for war, not the peace.

    • NatSher

      I’m guessing it had nothing to do with CIC as radar is useless when the ship you’re tracking is only a few hundred feet away. It has to do with JOs in training on the bridge. Complacent lookouts. Missing triad. Dipshit captain on the McCain. And lack of training overall on the McCain I’m guessing. But I’m speculating you understand and we won’t know much more til more is released

      • draeger24

        I don’t disagree….this is creeping incrementalism in reliance on tech and not teaching the basics.

  • publius_maximus_III

    From the USS Fitzgerald report, one caption reads:

    “Figure 9 – Non-watertight door frame from Berthing 2 to the ladder going up to Berthing 1 Access Trunk. There is no hatch at the top of this ladder to prevent water from flooding up into Berthing 1.”

    What is troubling about this statement is, why would the Navy go to so much trouble to install two water tight hatches with scuttles between Berthing 2 and Berthing 1 (directly above it) on the port side, and not install a water tight connection between the same two spaces on the starboard side, at least based on this caption, which may be in error?

  • Phil Taylor

    Just finished the report. What a horror story! Brought to mind the “Melbourne Evans Incident” film we watched in OCS, SWOS, and that I showed to my Middies when I was an instructor. I vowed that (a collision at sea) would never happen on my watch. Question: Do modern tin cans utilize a DRT? It sure seems like neither OOD nor CIC had any sort of grasp on situational awareness. Nobody called the Old Man? Sounds like an organizational state-of-nature. These events didn’t just “happen”; a LOT of effort went into this tragic, perhaps criminal, sequence of screw-ups. Fix it, dammit!!!

    • NatSher

      Not sure a DRT is really the thing to rely on in an emergency breakaway situation.

      • Phil Taylor

        Neither McCain nor Fitz situations had anything to do with emergency breakaway, an emergency maneuver normally associated with an UNREP. What a DRT can provide is an excellent strategic overview of the tracks of contacts relative to your own ship’s position. The Dead Reckoning Trace of the principals involved used to be a critical piece of evidence in the investigation of any collision at sea. Maintained in CIC, the DRT info can REALLY help you to NOT run into a merchie!!!

  • NatSher

    It seems like the fault lies mostly with the MCCain. The McCain is operated by primarily merchant marines and the Fitz is all Navy. This is where you find your issue in my opinion. The Fitz set sea and anchor an hour before the McCain was even in site. The McCain didn’t set it in a timely fashion it sounds like. Although, this may or may not have had anything to do with the collision. They said the ships triad wasn’t on the bridge during the emergency breakaway. This is where it fell apart if I had to guess. The OOD was probably a JO who didn’t know how to react in an emergency.

    • Rob-26

      Nothing you wrote makes the least bit of sense. The Fitz and McCain did not collide with each other.

  • Rob-26

    The more interesting of the two reports is by far the McCain. Not for what it included but for what it left out. Examples

    From the report
    “At 0519, the Commanding Officer noticed the Helmsman having difficulty maintaining course while also adjusting the throttles for speed control. In response, he ordered the watch team to divide the duties of steering and throttles, maintaining course control with the Helmsman while shifting speed control to the
    Lee Helm”

    Is this Helmsman trained at all? Whatever. Okay, Helm should keep steering, Lee should get throttle. It appears that order was not followed as ordered but who, specifically should have followed it? I’m guessing the Conn but it never says.

    From the report
    This unplanned shift caused confusion in the watch team, and inadvertently led to steering control transferring to the Lee Helm Station without the knowledge of the watch team.

    This is passive voice because the steering control did not transfer itself.
    Who specifically did the transfer? Did they do this without telling
    the Helm (as it appears)? What exactly did [somebody] transfer to the
    Lee? Steering and throttle, it appears, but that gets boiled out later.

    From the report
    The Commanding Officer had only ordered speed control shifted. Because he did not know that steering had been transferred to the Lee Helm, the Helmsman perceived a loss of steering.

    Again, passive voice. Why? Who did the transfer?

    From the report
    Steering was never physically lost. Rather, it had been shifted to a different control station and watchstanders failed to recognize this configuration.

    Who did the shifting? Was it the Conn?

  • Paul Cadeau

    I am a Canadian Cdr. (ret) with 38 years service. 18 years at sea and with many combined ops with the USN. I have many friends and the world of respect for both the USN and her crews. I notice no reference to the practice of allocating the CO of a ship a set amount of money to conduct his business for a year. In my time, COs who spent all the money on maintenance and training got good performance reports COs who spent more than allotted got lower reports, and COs who gave money back to the navy because they didn’t need it all got superior reports and promotions. In my opinion this practice encouraged COs to skip essential maintenance and training requirements to make themselves look good. Naval ships are built tough but maintenance does not go away; it just piles up.Training does not go away either. Is there any thought of looking at this practice?

  • OldSaltUSNR

    Just saw that this report had come out, and guess I’m late here to the game.

    I was just a “supply puke” on board my first ship. Back in the 1980’s, even I had taken celestial navigation courses (just squeaked by; the P3 Airdale who tutored me just shook his head and cried half the time) and hours of mo-board. I was trained to stand a bridge watch, and Supply Officer’s (on my particular ship) stood JOOD, when we were understaffed. With that background, the stuff I read in this report shocks me.

    When we went through the Strait of Malacca 6x, the Captain or the X.O. (who was a Silver Star awarded Vietnam Vet, who the Captain and crew had absolute faith in) were on the bridge the entire evolution. Ditto when navigating through any complex waters. In fact, if I recall correctly, we had a modified Sea and Anchor detail in place during those periods (e.g. after steering manned, extra lookouts, DC manned, etc.). I can’t imagine the least qualified OOD on my ship – and I worked with knew these officers – would fail to sound collision when the ship was in imminent danger. I can’t imagine the JOOD or QM watch stander would not have suggested it (perhaps shouting it!). Our crew was very well trained, and I had confidence in both the C.O., our officers, and sailors.

    I was also shocked to hear (from a commenter in another BLOG) that the Clinton era Navy eliminated the 16 week basic SWO course, in favor of CD-ROMs (to cover legal and admin training). So, the US Navy has not been formally training SWO’s “hands on” in the basics, before they hit the fleet, for over 25 years? Yeah, I guess that’d eventually leave a “dent” somewhere, in this case, in two $Billion DDG’s.

    As it’s said, “success has many fathers, but failure is an orphan”. However, reasons for this failure seem obvious. In fact, failure appears to have been engineered into the solution the Navy chose for it’s future decades ago. I honestly never thought it was this bad. I truly wonder how the US Navy will successfully fight the next war. I’m not questioning the loyalty, courage, or intensity of today’s officer’s and crew. However, the apparent systemic issues evidenced by these two incidents may cripple them during war time.

    • chartman07

      As a 20 year QM – this was the type of event I would lose sleep thinking about. I spent thousands of “additional” hours on the bridge ensuring my team was “awake and functioning well.” In my later years, I extended that effort to the officers. Many of which kept worse hours than the enlisted. Men and women get tired and they make terrible choices…or in these cases – too late making the choices. To me – I never lost the gravity of my position on the ship…safe navigation of the ship every minute she was underway – no matter WHAT was going on inside/outside the ship. You said you were shocked – I am angry that these watch teams (Bridge and Combat ) failed the crew. 20 kts in a busy sea-lane? Unfathomable! Modified or full blown Sea & Anchor not in place? Seriously? Two hours into the watch – the cascading set of events could have been interrupted at almost any point – and were not. I am sorry for the crew we lost. I am sorry for the crew that did their best to save lives. I am sorry for the CO who never got a chance to save his shipmates and ship from disaster. Hopefully this will be apart of training for future teams.

      • OldSaltUSNR

        Thanks for your service, QM. You volunteered (presumably) and served; not many of our generation did.

        I say the same thing to my son-in-law (Marines), and the military friends of my kids who came through our house over a eight year period. He volunteered out of high school in 2006 and made two tours in Iraq when the “post 9/11 just war” thingy was past, and at a time when half the country once again considered our troops, Marines, and sailors to be “baby killers”. These kids were not drafted, yet they volunteered, served, and went to war. I think that they’re going to give the “greatest generation” legacy a run for their money in 30 years. But that’s another subject ….