The is a US Navy photo of an Arleigh Burke Class Destroyer the John Paul Jones.

On August 21 2017 the USS John S McCain was in collision with the merchant ship Alnic MC with the loss of ten lives on the naval vessel. Subsequent to the collision and that of the earlier collision between the USS Fitzgerald and the ACX Crystal, the US Navy has issued a couple of documents intended to inform those  interested in the events themselves, and how the Navy intends to move forward to prevent them happening again. 

The accidents are still the subject of investigation by the NTSB and the USCG but there is enough out there for us to form a view. For the purpose of this article I am concentrating on the John S McCain accident which illustrates many of the problems the Navy appear to have.

THE SHIPS

The USS John S McCain, a Flight 1 Arleigh Burke Class Destroyer,  was commissioned in 1994 at Bath Iron Works. It is 505 ft long and has a complement of 281 crew. Its four gas turbines develop about 100,000 bhp and are connected to two shafts with five bladed CP propellers, giving a speed of about 30 knots.  Predominantly it is a guided missile carrier allowing it to engage in anti-aircraft warfare and subsea warfare by means of anti-submarine rockets. The class has also carried and used Tomahawk cruise missiles.

The Alnic MC is a chemical/refined product tanker capable of carry about 12,000 m3 of fluids. It is registered  in Liberia. It was built in 2007.

PREAMBLE

The John S McCain had recently received the upgrade to the “Integrated Bridge Navigation System” (IBNS), a process which is being carried out on all the class between 2015 and 2021 by Northrop Grumman.

This is a photo of the control station of an Arleigh Burke destroyer the USS Dewey from Northrop Grumman website– I think this might be a  Beta setup, since the screens look a bit like the ones shown on the diagram of the IBNS console but surely the Lee Helm on the starboard side has proper engine controls.

 On the day of the accident the ship, destined to dock at the Changi Naval Base, was approaching the Singapore Strait Traffic Separation scheme from the north. The report says that the ship was in the “physical posture” known as “Modified Zebra” in which the watertightness is maximised within certain limitations, still allowing personnel to transit between different areas. It was also in “Darkened Ship” where all exterior lighting is extinguished except for the navigation lights and its AIS was not in operation. The moon was not to rise until 0623 and the sun at 0658. It was dark.

 There seem to have been thirteen people in the wheel house as the ship approached the strait.

The steering was controlled at the helm control (HELM) in “Back-up Manual”, it could if necessary be made available at the Lee Helm, The Helm Forward Station, the Bridge Command and Control station and the Aft Steering unit. On US Navy ships the HELM is generally the main position from which steering takes place, the Conning Officer issues the direct instructions to the Helmsman, and the more senior officers issue general instructions as to what the ship is required to do. The LEE HELM seems to be traditionally the position from which the engines will be controlled. Old photos show a man at the telegraph. On this vessel the LEE HELM can also control the rudders via a computer terminal and at the HELM and the LEE HELM positions the speed is controlled via a computer interface, either by a touch screen or a computer track ball.

Of the bridge watchstanders the Junior Officer of the Deck (JOOD), the Boatswain’s Mate of the Watch (BMOW) and the eventual Lee Helmsman were on temporary duty from the USS Antietem (CG 54) to provide these sailors with “underway time” for qualification while the USS Antietem was being repaired ( after running aground). The watchbill determined that these sailors were qualified to operate systems on the bridge of the ship, but their qualification date co-incided with the day they had reported to the ship. The Lee Helm was recently qualified for the position. It is also stated in the reports that the process was complicated by meal reliefs, although nothing further is said about that.

THE SEQUENCE OF EVENTS

I have chosen to add information and description where possible to the time line although this is not how the reports present the information. I am not claiming that this is 100% correct, getting a coherent time line has been extremely difficult, and to get this far I have had to read through the reports many times.

20 August 2017.

1300. The crew are prepared for the Singapore Strait transit. The Executive Officer and the Navigator recommend setting the “Sea and Anchor Detail”  at 0500 but the Commanding Officer decides to leave it until 0600 to provide the team with more rest.

1730. The Commanding Officer retires to rest.

1904. Vessel navigation lights energised (US Navy speak for being switched on).

2115. Watertight condition maximised.

21 August 2017.

0115. The Commanding Officer arrives on the bridge.

0216. Watchstanders (?) ungang the controls so that the gas turbines drive the shafts separately (No-one has ever said why this was done, but it might have been to improve manoeuvring capability).

0300. The current approaching 3 knots requires specific steering adjustment (one assumes to maintain the course as charted).

0418. Additional watchstanders arrive as the “Modified Navigational Detail” due to the ship being within 10 miles of shoals. The additions were  “Navigational Evaluator” and a “Shipping Officer”. The “Sea and Anchor Detail” a team which would probably have included a “Master Helmsman” and a qualified “Engineering Lee Helmsman”, and which would have provided manning for the After Steering Position (according to the guys on gCaptain) were not to have assembled until 0600.

0427. Course alteration/s to avoid traffic in the approach to the separation zone.

0430. The Executive Officer arrives on the bridge.

0437. A number of steering orders given to avoid traffic.

0444. The ship steadies on a course of 227 deg, intending to enter the westbound traffic separation lane.

0454. The Alnic MC is identified on radar (I’m not sure whether this is an AIS identification or just seen as an echo) 8 miles ahead. There is no discussion amongst the watchstanders as to what to do about the contact or the surrounding vessels.

0457. Speed increased to 17 knots and almost immediately reduced to 16 knots.

0500. Personnel are called to prepare for entering port. The navigator informs the OOD that the previous manoeuvres have resulted in the ship being behind schedule and so recommends an increase in speed to 18 knots.

0500-0524. Several vessels are overtaken, the closest approach about 550 metres.

0513. The ship is steady on a course of 226 deg at a speed of 18 knots.

0514. Speed increased to 20 knots.

0518. Course altered to 230 deg. The helmsman is “compensating for the effects of the current with starboard rudder of between 1 and 4 degrees” (This is apparently a Navy way of describing the environmental effects on the steering).

0519 and in the minute there-after. The Commanding Officer notices that the Helmsman at the HELM is having trouble maintaining the course and simultaneously adjusting the engine controls, so orders that the steering should be separated from the propulsion. He intends that the Helmsman continue steering at the HELM and that the Lee Helm takes over the control of the ship’s speed at the LEE HELM position, but the steering is accidentally disconnected from the HELM and because it is in Back-up Manual it is offered to all the other control stations (Lee Helm, Helm Forward Station, Bridge Command and Control Station and Aft Steering Unit). The system design is such that any of these stations can take control of steering via a drop down menu. If this had occurred, steering control would have been transferred and its operation continued.

0520. “Supervisory watch stations” report that the density of the traffic has resulted in AIS clutter and that therefore it is useless. Apparently this is a known problem of the ship’s systems, that the charting system is overwhelmed by a concentration of AIS information.

0520:03. The warship is overtaking the Guang Zhou Wan, making 18.6 knots over the ground. The Alnic MC is close on the port bow, making 10 knots approximately.

0520.39 The Lee Helm has taken control of the steering in computer assist mode. The rudder automatically takes up the midships position.

0520.47. The Lee Helm takes control of the port shaft. Both shafts at 87 rpm and the propellers at 100% pitch. This is not quite as intended since the shafts are “unganged” i.e. disengaged and the HELM still has the starboard shaft, but the Lee Helm and everybody else are unaware of the configuration.

0521. The Helmsman reports loss of steering to his immediate supervisor (the Conning Officer?) and he is told to report it to the OOD, which he does. The ship is now on a course of 228 deg at 18.6 knots and turning slowly to port. At this time the Alnic MC is on the port beam at about 500 metres distance – a couple of ship’s lengths. The Conning Officer orders the Helmsman to shift steering control to the offline steering units 1A and 2A ( these are screens available to the senior officers on the bridge at which control would be accessed by means of a drop down menu, but this is the only mention of 1A and 2A.) After Steering requirement is announced.

0521.55. The first watchstanders report to After Steering although the ship did not have a list of personnel to man the aft steering.

0522. The ship is now on a course of 216 deg at a speed of 18.4 knots and still turning to port. The Commanding Officer issues an instruction that the NUC lights should be exhibited and the order is carried out.

0522.05. The Lee Helm now has control of the port and starboard shafts, both still turning at 87 rpm with pitch at 100%. The Commanding Officer orders a reduction in speed to 10 knots.

0522.07. The Lee Helm lowers the speed of the port shaft to 44 rpm/100% pitch, but no-one is aware that the starboard shaft is still at 87 rpm/100% pitch. The rudders are amidships, no-one is steering (I don’t think).

0522.40. The ship is still turning to port now on a course 204 deg speed 16.6 knots.

0522.45. The Executive Offshore notices that the ship is not slowing as quickly as required and alerts the Commanding Officer, who orders 5 knots, the order echoed by the Conning Officer (The CO has not announced that he has taken command).

0523. The warship now on a course of 194 deg. Speed 15.8 knots. The Alnic MC heading 230 deg is on the port beam at a little under 400 metres distance. After Steering takes control of the steering in Back-up Manual.

0523.06. The John S McCain is still turning to port. Port shaft 32rpm/100% pitch. Starboard shaft 87rpm/100% pitch (There has been discussion on gCaptain that the CPP would operate in conjunction with the shafts at moderate revolutions but maybe not true for this ship).

0523.16. The Helmsman takes control of the steering at the HELM station in Backup Manual mode.

0523.24. Someone matches the throttles at the Lee Helm. The ship heading south speed 13.8 knots.

0523.27. Aft Steering take control of the steering for the second time. The fifth change of steering station. Probably at this time the person taking control did not check the rudder position and it is hard aport, increasing the turn to port before the rudders are returned to the midships position.

0523.44. The course 177 deg. Speed 11.8 knots, still turning to port. 15 deg starboard rudder applied and the course steadied.

0524. The bulbous bow of the Alnic MC strikes the John S McCain port aft. Emergency actions commence. After steering still has control of the steering.

0524.24. Engines all stop. Ship still turning to port at 5 knots.

0526. General quarters Damage control initiated.

The first of the two Navy reports goes into considerable detail about the rescue efforts for which many seamen were commended but they do not have a place in this review. We are trying to determine what happened and why, rather than how effective the emergency processes were.

FROM THE US NAVY DOCUMENTS.

I have necessarily had to condense what I have presented as has everyone else who has written about this accident, and have concentrated on the operation of the bridge systems. The following are modified extracts from the Comprehensive Review.

Watchstanders on USS John S. McCain did not have the training or knowledge on the modes of operation of the Integrated Bridge and Navigation System, particularly relating to the ship’s steering controls. They unknowingly transferred control of steering away from the Helmsman while shifting modes of operation. The designed responses of the IBNS when shifting modes also creates known vulnerabilities that have not been clearly communicated to the operators on ships with these systems.

Because steering control was in Back-up Manual at the HELM station, the offer of control existed at all the other control stations (Lee Helm, Helm forward station, Bridge Command and Control station and Aft Steering Unit and maybe the HELM as well). System design is such that any of these stations could have taken control of steering via drop down menu selection and the Lee Helm’s acceptance of the request, if this had occurred would have transferred steering control.

The Comprehensive Review considered that the Integrated Bridge Navigation System provided controls and information which were “inconsistent with best practices in industry for safety critical control panels”. For instance the touch screen for throttle control is considered unusable. Eight of the first 12 ships receiving the installation immediately reported intermittently losing throttle control when changing speed quickly. It also states “unnecessary complexity in equipment or inadequate training for operators creates a latent hazard that may not be revealed during training or assessment of proficiency in conducting normal operations”.

The review went on to say that there is a tendency of designers to add automation without considering the effect to operators who are trained and proficient in operating legacy equipment. Similarly, attempts to add flexibility with alternate modes of control demand operator attention to track modes of operation and stay aware of differences in system behavior. Surface force IBNS operators interviewed noted the on densely packed display areas the frequency of faults is distracting, leading to normalization over time.

The Comprehensive Review goes into much detail about the training processes used for US Navy officers, and they are extensive. It goes on to recommend a review of the training of officers and the means by which it might be improved and also addresses the problems created by moving seafarers from non-operational ships to operational ones, both to fill gaps in the manning and to validate their training.

COMMENT

Just for a start I can’t imagine a touch screen being an effective means of controlling engine power. If this was what was available to the Helmsman no wonder he was having problems. The old system automatically had the Lee Helm in position to operate the engines, and so one assumes that the intent of the new system was to remove the requirement for the Lee Helm. This is not explicitly stated in the report although the intent to reduce manning is identified.

The short report suggests that if the Alnic MC had blown five short blasts or attempted VHF communication the collision might not have occurred, but if we just look at the time line, and remember that it is the duty of the overtaking vessel to keep out of the way, such a suggestion is probably unrealistic. We should put ourselves in the place of the watchkeeper on the merchant ship in congested traffic, trying to keep a handle on everything that was going on, but probably in his or her favour the ship was trogging along pretty slowly. Since the warship was not using AIS, if it was seen at all the watchkeeper might have noticed a dark shape sneaking up the starboard side at high speed, and probably would have ceased to take it into account for any action. Then suddenly the thing veers across the intended course close ahead, and even worse slows down drastically. It is a nightmare scenario probably made impossible by the likelihood that the watchkeeper was absolutely banned from operating the engine controls.

And if we put ourselves on the bridge of the warship, they are used to being close to other vessels, and so maybe thought nothing of the proximity of the ships they were passing, and I note that the Commanding Officer’s station is in the starboard corner of the bridge. This probably means that if he was looking out the Alnic MC was going to disappear from view, obscured by the uprights of the bridge windows, But surely someone could have told him that collision was imminent. This is one of the many points made in the recommendations for the future. The whole bridge team has a responsibility, and they need to be trained suitably for the task.

I have suggested that the IBNS system being installed on the destroyer class is too complex, but Navy people on the gCaptain forum have been good enough to describe exactly how easy it is to use, and can’t understand why on earth it was not operated properly. However, the reports say that the “Back-up Manual” steering was used because people did not understand the computer presentation. It could be that the back-up manual system altered the means by which the steering could be transferred, but no-one has actually said this. The Navy have accepted that the IBNS suffers from identified faults, one of which is screens crowded with information and error messages. Maybe those on the bridge of the John S McCain just thought it was a software problem.

The Comprehensive Review has identified numerous means by which the performance of those on the bridges of US Navy ships might be improved, but I have found that, unfortunately, the further away from the ship you get the more difficult it is to change anything. At least they could start on the bridge itself and have a look at the Integrated Bridge Navigation System.

 This is a diagram of the IBNS control station from one of the reports. It seems that the Helmsman would operate the engines using the touch screen or a track ball with his left hand.  

And for those who think that the only problem was lack of training I attach the following from IACS Rec 95 – Recommendation for the application of SOLAS Reg V/15.

Navigational systems and equipment should be designed with the aim of:

- … presenting the information in a clear and unambiguous manner, using standardized symbols and coding systems for controls and displays

- indicating the operational status of automated functions and integrated components, systems and/or sub-systems

- minimizing the risk of human error and detecting such error if it occurs, through monitoring and alarm systems, in time for the bridge team and the pilot to take appropriate action.

Finally we should remember that on merchant ships there is maneuvering of the craft when berthing, or in the case of OSVs when at the installation, and their operation on ocean passage; these modes of operation are addressed differently. On passage it is likely that the steering is being looked after by the autopilot and when maneuvering it is probable that all the controls will be operated by one person, quite often the captain, or if not he, someone who has been instructed how to do the job. This would seem to have no relationship with the operation of the controls of US Navy ships, maybe making any comparisons invalid.

 
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