USS John S, McCain is carried aboard the heavy lift transport MV Treasure, Oct. 11, 2017. Treasure will transport John S. McCain to Fleet Activities Yokosuka, Japan for repairs.

Seventeen American Navy Sailors were killed in a pair of collisions involving two guided-missile destroyers this summer in the Pacific region, and the final Navy report on the incidents, released Wednesday, described the events succinctly, if damningly. “The collisions,” the report said, “were avoidable.”

The crashes involving the USS Fitzgerald and the USS John S. McCain, the report went on to describe, occurred after a series of missteps and critical failures of leadership that allowed controllable situations to become uncontrollable.

Indeed, part of the fallout of the incidents was the leadership of both destroyers losing their jobs. And in a first since World War II, Vice Adm. Joseph Aucoin, the 7th Fleet’s commanding officer, was also relieved of duty because of the collisions as well as incidents involving two guided missile cruisers in his area of operations this year.

The new Navy report, among other things, also puts to rest uncertainty surrounding the collisions, including suggestions that hackers might have caused the warships to collide with the commercial vessels.

The truth, it turns out, was a bit more quotidian. With fewer ships, the Navy has been forced to curtail maintenance and training for Japan-based ships for years to meet operational commitments in the region. As a result, ships like the USS Fitzgerald and USS John S. McCain, went to sea with expired training certifications and operated on waivers granted through the chain-of-command, as many ships of the Japan-based Seventh Fleet had done so for years.

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In 2015, the Government Accountability Office issued a report on the 7th Fleet’s training certifications for the cruisers and destroyers under its command, all of which are based at Yokosuka, Japan. The GAO reported then that only 7 percent of those certifications were deficient among the 11 ships, but, in June, just before the USS Fitzgerald collided with a cargo ship, the GAO found that 37 percent of those training certifications were expired, with the majority having been expired for at least five months. As John H. Pendleton, a director at the GAO, said in September, “The Navy is caught between unrelenting demands and a shortage of ships.”

And this is a large part of not only the Navy’s problem, but for the American military as well. The current U.S. Navy fleet is 20 percent smaller than it was two decades earlier, yet the ships are being deployed at the same rate, and often for longer periods. These continuous deployments are especially true for forward based warships like the those assigned to 7th Fleet.

For U.S.-based warships, the Navy executes what it calls the Optimized Fleet Response Plan. The OFRP is a 36-month period where ships will go through four phases during its deployment cycle. Six months are designed for maintenance, eight months for training, six to seven months of deployment, and 15 months of sustainment, wherein the ships will operate from their home ports but be kept ready to provide a surge capability should the need arise.

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But Japan-based destroyers and cruisers don’t have this luxury of a deployment cycle; instead those ships are considered in permanent deployment status, and they have no ramp up for deployment or ramp down post-deployment. As a result, regular maintenance and training needs of those ships has often been ignored or only given partial attention.

The GAO reported that its analysis of the difference between U.S-based ships and those in Japan was staggering. For U.S.-based cruisers and destroyers, the Navy plans on having them available for deployment 41 percent of the time, with the remaining 59 percent for maintenance and training. The ships based in Japan planned to spend 67 percent at sea by contrast, with just 33 percent of the time slotted for maintenance. There was all of zero percent of the time allotted for training.

USS John S. McCain sits aboard MV Treasure as it is prepared to sail to Japan for repairs. The extent of the damage can be seen. USN photo.

With a pace like that, it was only a matter of time before an incident occurred. In fact, according to the Navy report on the two collisions, the USS Fitzgerald had a near collision in May and no effort was made by the destroyer’s command to determine how the incident almost happened. With no investigation, there were also no corrective actions. Two months later, seven sailors on the Fitzgerald would be dead, and a large number would have to make a horrific escape from a flooded berthing area to survive.

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Two months after that, another 10 sailors would drown after their berthing compartment was compromised during a collision aboard USS John S. McCain. It was only after 17 sailors died that the Navy admitted there was a problem with the forward-deployed warships in Japan.

USS Fitzgerald

As previously reported on Foxtrot Alpha, the USS Fitzgerald collided with the container ship ACX Crystal on June 17, when the guided missile destroyer was approximately 56 miles southwest of Yokosuka, Japan. The Fitzgerald’s home port is at Yokosuka; the ship had left port less than 24 hours earlier for routine operations. The destroyer and its crew had spent its first day at sea conducting training evolutions and equipment loading operations.

US Navy diagram of the paths of the USS Fitzgerald and ACX Crystal. USN

At 11 p.m. local time, the ship’s commanding and executive officers left the bridge of the destroyer just as the ship was entering an area where “moderately dense” commercial shipping traffic was increasing, according to the report. The sea was calm at two to four feet. Visibility was unrestricted with scattered clouds and a bright moon. The collision would occur less than three hours later, with both ships within sight of land, as the Fitzgerald was heading almost directly south as it continued its outbound transit from home port.

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The Navy has determined that multiple failures of the ship’s crew led to the collision. These failures include lapses in safety planning, adherence to proper navigation practices, the proper execution of basic watch standing practices, use of available navigation tools, and no deliberate and effective responses when in extremis. As the Fitzgerald moved through established maritime traffic separation schemes, the destroyer approached three merchant vessels all of which were on its starboard side. As each ship was initially tracked, it was determined that all three merchants would have a closest point of approach that would be at a minimal distance; all three ships, in other words, were at risk of hitting the Fitzgerald.

The destroyer had found itself in a “crossing situation” with the three merchants, according to the International Rules of the Nautical Road. As the ship with vessels to its starboard side, the Fitzgerald was obligated to maneuver to avoid either colliding with any of the ships or crossing ahead of them. If the the Fitzgerald did not maneuver to avoid impact, the other vessels would be required to act to maintain a safe separation distance.

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For 30 minutes prior to the collision, neither the destroyer nor the ACX Crystal took any action to avoid the other ship, until one minute before impact. At 1:30 a.m.—the time of the collision—the destroyer was headed south at 20 knots.

On the bridge of the destroyer, meanwhile, confusion reigned. The Officer of the Deck, who is responsible for the safe operation of the ship, and his assistant, the Junior Officer of the Deck, were unable to make a decision regarding how to avoid the three merchants. In fact, the Officer of the Deck initially had no intent of doing anything, as he confused the ACX Crystal for another merchant which was predicted to pass farther away from the Fitzgerald. By the time the Officer of the Deck realized the ACX Crystal was on a collision course with the destroyer, it was too late. According to the report, the officer “exhibited poor seamanship by failing to maneuver as required, failing to sound the danger signal and failing to contact the Crystal on Bridge to Bridge radio.” In addition, the officer did not call the commanding officer according to procedure. Further, no collision alarm was sounded before the impact, providing no warning to the crew, much of whom was sleeping.

The bridge was not the location of the only failures that night. The Fitzgerald’s Combat Information Center, which collects all information produced by the ship’s sensors, did not provide required assistance to track the merchant ships. It was so bad, in fact, that according to the report, “watch team members were not familiar with basic radar fundamentals, impeding effective use... [Team members] failed to properly tune and adjust radars to maintain an accurate picture of other ships in the area.”

USS Fitzgerald arrives in Yokosuka, Japan after the collision. USN photo.

The most striking failure, though, involves the absence of lookouts. There were lookouts, in fact, but only on the port side of the destroyer; there were no lookouts standing watch on the starboard side, where the three commercial ships that presented the most danger were.

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Further problems: The officers in charge that night were unaware of existing traffic separation schemes, while members of the bridge watch team who did identify problems and mistakes did not challenge them, leaving the errors to pile up without correction. Indeed, the approved navigation track for the Fitzgerald’s outbound track did not account for, or follow, the established traffic separation schemes in the area.

None of which excuses the commanding officer, who is responsible for every aspect of their ship, a responsibility which is absolute. The Navy report makes this clear.

“Many of the decisions made that led to his incident were the result of poor judgment and decision making of the Commanding Officer,” the report says. “That said, no single person bears full responsibility for this incident. The crew was unprepared for the situation in which they found themselves through a lack of preparation, ineffective command and control, and deficiencies in training and preparations for navigation.”

USS McCain

Just over two months after the Fitzgerald was involved in her collision, the Navy suffered another collision involving a guided missile destroyer. The destroyer was the USS John S. McCain, also a forward-deployed warship based in Japan, which collided with the oil and chemical tanker Alnic MC. The McCain was halfway through a six-month deployment in the Western Pacific on the morning of August 21 when the crash occurred around 50 nautical miles east of Singapore. The destroyer was approaching the Singapore Strait and the Strait of Malacca as it headed for a port visit at Changi Naval Base. The straits are among the busiest in the world with an average of 200 ships passing through them each day. On the morning of the collision, the moon had already set, skies were overcast with no illumination and the seas were calm, with one to three-foot swells.

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Unlike on the Fitzgerald, the commanding officer was on the bridge at the time of the collision, which would occur at around 5:24 a.m. The officer had been on the bridge since 1:15 a.m., while the executive officer showed up a few hours later. The command recognized the danger of operating in a high traffic area, especially at night.

US Navy diagram showing the paths of USS John S. McCain and Alnic MC. USN

At 5:19 a.m., the commanding officer noticed the Helmsman—the sailor responsible for steering the ship—was having trouble maintaining course while simultaneously trying to adjust the throttles for speed control. The commanding officer then ordered additional measures to take control, but the “unplanned shift,” the report states, “caused confusion in the watch team, and inadvertently led to steering control to be transferring to the Lee Helm Station without the knowledge of the watch team.”

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Not knowing that steering had been mistakenly transferred, the Helmsman thought steering had been lost, just as the McCain entered the Middle Channel of the Singapore Strait, where a high density of shipping traffic awaited them. At 5:20 a.m., the McCain entered the channel and, a minute later, the Helmsman reported that steering was lost.

Steering, of course, was not actually lost, but it was believed lost, and during the switch in control, the rudder went center. Prior to the switch, the ship had been steering one to four degrees of right rudder, which meant that when the rudder went center, the destroyer’s course began to drift left. That was happening while the ship’s commanding officer ordered it slowed from 20 knots to five. But the Lee Helm only slowed one of the ship’s propellers, and for 68 seconds the other propeller turned at 20 knots before the mistake was recognized. The combined effect of wrong rudder direction and the two shafts working against each other caused the McCain to execute an un-commanded turn left into an area of heavily congested traffic, bringing it dangerously close to three different vessels, including the Alnic MC.

US Navy diagram showing the position of the bridge watchstanders on USS John S. McCain. USN

Situational awareness on the bridge, meanwhile, had been lost, as the crew was tunnel-visioned on the loss of steering report and the corrective measures underway to regain control. Steering was quickly restored, but within minutes, at 5:24 a.m., the American warship and the oil and chemical tanker collided. Prior to the crash, neither ship sounded the five short blasts of ship whistles to warn of danger, and no attempt was made to make contact via radio.

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During the investigation, it was determined that, before impact, four different sailors had manipulated the controls necessary for maneuvering the ship. In addition, several sailors on watch during the collision were on temporary duty from USS Antietam, a guided missile cruiser also based in Japan that had significant differences with their steering control systems, compounding the issue during critical moments. The Antietam had run aground in January 2017 in Tokyo Bay releasing 1,100 gallons of hydraulic fluid.

The Navy’s report also said that the commanding officer did not station the Sea and Anchor detail, which would have posted additional personnel prior to entering the congested waters, despite recommendations from the navigator and other officers. Many of the watchstanders that were posted lacked even a basic understanding of how the steering control system worked, including supervisors who were responsible for training them. Even more troubling, the report says, “Senior officers and bridge watchstanders did not question the Helm’s report of a loss of steering nor pursue the issue for resolution.”

Making Necessary Changes

When Adm. John M. Richardson appeared before the Senate Armed Services Committee in September, he delivered assurances that the Navy was going to fix the problems that had plagued the Fitzgerald and McCain. And on Tuesday, a day before the report was released, the Navy established a new command that would oversee the training and certification of Japan-based warships.

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That command will be based in Japan and will have the final say whether a ship can deploy or whether it needs remedial. In a released statement, Adm. Scot H. Swift said that he was forming the command to “address an organizational gap... that allowed a culture to grow myopically focused on operations to the detriment of readiness.”

The first commanding officer of the new command is Capt. Rich Dromerhauser, who previously had been the skipper of USS Fitzgerald from 2008-2010. Under his leadership, the command will initially report directly to Swift, but eventually will be absorbed by Naval Surface Forces command.

A sample circadian rhythm watchbill for the U.S. Navy surface fleet that provides for dedicated sleep time. USN chart

Another change on the horizon for the Navy surface fleet is the implementation of a watch system based on the circadian rhythm, and shipboard duties that will allow sailors to get more periods of rest. Traditional Navy routines have sailors on a “five and dime” schedule, meaning the sailor stands watch for five hours then has 10 hours off watch. But those 10 hours off watch are not solely free time, and consist of regular work hours, ship wide training, sleeping, eating and everything else that goes on, all of which must be squeezed in this constantly rotating schedule. The new system is intended to be better adapted to sailors actual sleep cycles, and was ordered to be in place by December 20.

Sailors form the USS Fitzgerald prepare to receive awards for their damage control efforts after the collision. USN photo

After the McCain accident, the Navy ordered its commands to take an operational pause to go over navigational and safety rules and regulations. Overconfidence, inattention to detail, and, above all, complacency are the three biggest contributing factors to these collisions.

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Yet, somehow it is still difficult to understand how poorly trained the crews were in some very critical areas of seamanship and navigation. Still, when it came to damage control, the training was exceptional, as both crews managed to save their ships, and many lives, following the accidents. Crews that dedicated deserved far better than what they got.