The collisions of the USS Fitzgerald (DDG-62) and USS John S. McCain (DDG-56) lost Navy lives and resulted in the permanent removal of officers at various high levels. It is time for the Navy to employ a fresh approach to collision avoidance. But this begs the question: what can be done?
I have a website and am currently attempting to put together a coherent description of the John S McCain accident for the benefit of my readers. I have chosen this accident it because it seems to highlight the problems with the equipment. Some of it is quite difficult to understand particularly if you are not a US Navy person, but as you dig into it you’ve got to be amazed. Why were the people on the bridge entirely concerned with what was happening inside the space, rather than what was happening outside? It was because the equipment provided to steer the ship and to change the speed is very difficult to operate, and requires training far beyond that needed for what we might call ordinary marine operations. I go back to the quote from the judge who chaired the Ocean Ranger enquiry and would suggest that it be written in words two feet high on the wall of the senior admiral’s office.
IT IS THE ESSENCE OF GOOD DESIGN TO REDUCE THE POSSIBILITY OF HUMAN ERROR AND OF GOOD MANAGEMENT TO ENSURE THAT EMPLOYEES RECEIVE TRAINING ADEQUATE TO THEIR RESPONSIBILITIES.
It’s not that the equipment is hard to operate(after all, a wheel’s a wheel), it’s that even though it’s not difficult to operate they did not have the basic training required for it.
Their CO(most of their bridge officers, actually) had an incorrect assumption of how it worked, and two of the people who should be strong on it and provide backup(BMOW and JOOD) were TAD from another ship(a cruiser) with a different bridge and helm setup. These people were allowed to stand the watch with no further training.
I asked three or four of our helmsman, and several of our bridge officers including our Navigator how the series of events on JSM could have happened. All of them essentially shrugged and went “That shouldn’t even be possible, the system is designed to stop exactly that from happening.”
The JSM watchstanders skipped steps in the loss of steering procedure, sadly it was the step that would have instantly shifted steering control back to the helmsman. They then obviously had some comms problems, as seen by the transfer of helm control between the bridge and aft steering a couple of times in semi-quick succession.
“If only” we might say. It was not just a wheel, it was a wheel from which the control could be transferred elsewhere, and I assume that since no-one accepted the control the steering remained in limbo until accepted by the After Control. And I was really interested in the statement that the helmsman had been required to use starboard wheel to counteract the current. If that was so his reference was a course provided by an outside source (GPS?) not the gyro. Also how the other bridge positions would have steered the ship had they accepted control - on a computer screen? It may all seem simple to the Navy people but not to the rest of us.
Some of the suggestions in this article for reducing the size of the crowd on the bridge are good and mirror many of the comments on the gcaptain forum but putting more reliance on electronics and getting rid of bridge lookouts indicates the author doesn’t get it 100 percent.
That is quite an assertion and not supported by any evidence yet. And likewise I have none to make any counter claim either but that is a very definitive statement (“It was because…very difficult to operate” “requires…training far beyond…ordinary”).
My thoughts too tend to your question:
And it seems plausible to me as well that at least some people were preoccupied with steering and engine order issues BUT I don’t see equipment complexity rising to the “it was because” level of definitive-ness.
Oh it sure seems they did not understand how to operate it and for all the people on the bridge that more timely oversight did not catch the issues more quickly. All those folks in the chain and not one tasked to make sure the instructions were carried out? Seems an active supervisor of that station could give steering back to the helmsman and “ganged” control of the shaft to the lee helm with simple looking over the shoulders and direct instruction or even smacking hands and tapping screens/actuating switches. The navy’s version of bridge resource management is not plain to me from the report but surely they have enough personnel and can task them to keep way out of trouble. But back to my point…
According to Wikipedia the Arleigh Burke class is at 62 ships with possibly another 42 more planned for in flight 3. The first was commissioned in 1991. It’s hard (but not impossible having been briefly exposed to USN engineering / project management) to believe that the system still had fatal flaws in it by now. This is not to say all old or numerous systems are perfect and can not be improved. So naturally complexity should be examined and “continuous improvement” demands feedback and changes where appropriate BUT…
Sometimes that sort of analysis and quick solution allows the real problem to be covered over or shunted aside. For all the training USN ships seem to be engaged in I have a hard time understanding how operation of that console is not second nature to anyone who’s job requires them touching it. I mean routine and non-routine ops. Switching these functions seems a completely routine situation and an acknowledge / action /confirmation / reporting sequence of events should have been governing this and corrections immediately taken.
Some other thread or news story involving Senator McCain mentions the crews are exhausted. Exhausted from so much training? If so how does a guy who takes over this lee helm responsibility not notice one shaft slowing down when he commanded it to? Presumably he has all the control, instrumentation and status indications right in front of him/her. Likewise does not the helmsman have access to a status indication that steering was not lost but only that another station had it? It’s more likely to me he/she didn’t know where to look than that information is not available. But perhaps our recent navy contributors could make this more clear.
So if they are exhausted from so much training one must ask is it the right training. @Barrien seems to be in the best position to let us know about that. That area was generally explored earlier though where it was explained bridge ops can often take a backseat to other duties. And the OP linked article is I think making an attempt to say “back to basics”, ship specific understanding of equipment, etc.
So claiming it is due to equipment complexity may steer focus from real training issues and bridge resource management issues. Also sometimes equipment “fixes” only make it even more complex or result in unintended consequences.
But I look forward to your piece, please let us know when it is posted.
I’d bet someone knew what was going on but just didn’t say anything. A petty officer might not have spoken up to correct or inform an officer, or the officers might not have asked if anyone knew what was happening. I’ve seen the Navy do it. I’ve seen it done as a civilian. Tradition. Like the Korean Airlines co-pilot that crashed the plane instead of informing his superior officer.
You would have a more informed feeling about that than I would. I just think that falls into “bridge resource management” bucket or beyond that in a “corporate culture” bucket rather than in an “equipment too complicated” bucket. Obviously all should be looked at and acted on, hope it doesn’t end with the publication of the report.
Chopshopscotty, Agree with you there. I’m 20 years Navy and now 19 years MM. Too Damn many folks on the bridge with too many non watch standing issues and reports and conversations going on.
Thinking out of the Box, make a new Warrant category for Ship handling and turn it over to them, 24/7 all they would do is stand bridge watches day in and day out. No other concerns eating up their attention or rest periods.
No chasing the next desk job shore. Professional ship handlers and nothing else. Keep that bridge clear of non watch standing events, persons, reports, concerns etc…
When I stood watch on the bridge of CG Cutters there was zero conversations, reports or issues discussed on the bridge underway except as pertaining to the watchstanding situation. If the Navy is using the bridge for anything but watchstanding they should stop.
Something about that doesn’t make sense. I see that layout and it must have been as arranged just before this (page 47):
At 0519, the Commanding Officer noticed the Helmsman (the watchstander steering the ship) having difficulty maintaining course while also adjusting the throttles for speed control. In response, heordered the watch team to divide the duties of steering and throttles, maintaining course control with the Helmsman while shifting speed control to another watchstander known as the Lee Helm station, who sat directly next to the Helmsman at the panel to control these two functions, known as the Ship’s Control Console. See Figures 3 and 4. 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. The CO 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.
Here’s two people sitting side by side. Steering went from one station to the other (NO MENTION OF THE AFT STATION YET). Could it be the HMI for these stations are so poor that the operators don’t get visual feedback as to which station has control of steering and throttles? That’s not a complex piece of equipment that would be a poorly designed one though.
Wouldn’t the helmsman elbow the lee helmsman and say hey I just gave you the throttles can you see it? Or Hey I gave you the throttles but I just lost steering control, do you have it? These are not extraordinary questions to think or ask out loud IF you deeply know the systems and understand it’s features and know how it works.
I sure wouldn’t comment on how many on a bridge is too many BUT in this case, couldn’t one of the other jamokes (since they seemed to be under the impression this was an “unplanned” transfer and “caused confusion”) look over their shoulders and make sure? Looks like plenty of other eyeballs there for lookout, plotting or whatever else was going on up there. Too much like hindsight? Maybe.
and I assume that since no-one accepted the control the steering remained in limbo until accepted by the After Control.
Steering is never in limbo.
They accidentally transferred steering from the helm to the lee helm, instead of the throttle controls. They transferred steering and control of the port(but not stbd) shaft. This is also what led to the port shaft being slowed to 10, and then 5 knots while the starboard shaft remained at 20 knots until right before the collision.
Normally any of those actions require a two-step process(control being requested by the station who wants in, then the station that has it allowing it). The configuration they were in, however, only required one step - requesting it. This is how the lee helm took steering away from the helmsman, he requested it on accident when trying to request throttle control. He then failed to realize he had it, which is what led them to incorrectly believe they had a loss of steering casualty.
Steering control bounced between the helm and after steering because they both have a button that essentially means “holy shit I’m in an emergency give me the steering control RIGHT NOW.” They are the only two stations on the ship that have this button. Both the helmsman and the aft steering helmsman pushed the button a few times, bouncing steering control between the two of them. In fact, right before aft steering manned up, the helmsman had taken control of steering back from the lee helm via that button. They had full, operational steering from the helm for about 10-15 seconds before aft steering took it and they started bouncing it between themselves. But no one noticed that control had switched back to the helm, despite that being exactly what that button is for.
There’s eleven people on that bridge already and they are missing a few at that. I used to enter Tokyo Wan safely with three and that includes the pilot I picked up a few miles back.
All three of us had our heads on a swivel and an awareness of the big and little picture, time to turn, next course, is it clear to turn etc… Over taking vessels?? No one is focused on a single dial or screen. but glean info from them often to reconfirm or recalculate.
The old riverboats may of had the right idea. The Captain ran the vessel and the Pilots in the Pilot house did the ship handling, navigating undisturbed.