Collisions at Sea & Three Lost Aircraft

Is This a High-Reliability Organization?

Over the course of a deployment, the USS Harry S Truman had these incidents:

• One aircraft was shot down by one of the battle group’s cruisers (pilot and NFO ejected and recovered).
• Two other aircraft and a helicopter were endangered during the same evolution.
• One aircraft and an aircraft tug were lost overboard during a turn to avoid a missile strike.
• One aircraft was lost overboard when an arresting cable failed due to poor maintenance (pilot and NFO ejected and recovered).
• The carrier collided with a merchant ship when approaching the Suez Canal.

Here are two videos that describe what happened.

And here is a link to the redacted Command Investigation into the collision:

Investigation Report

Root Causes

The collision investigation report listed these root causes (and much more supporting information):

• Poor seamanship by the Officer of the Deck (OOD).
• The Navigator abdicated his responsibility for safe navigation.
• The collective navigation, seamanship, and shiphandling training and experience of the bridge, combat, and the Tactical Operations Plot were low, and they were unable to identify or break elements in the error chain; they did not recognize the risk; and they failed in the basic principles of bridge resource management.
• The Navigator and Officer of the Deck failed to ensure the Bridge and Tactical Operations Plot worked as a team.
• There were multiple failures in decision-making.
• The bridge team was not adaptable and flexible.
• There was a lack of situational awareness of the bridge and the combat team.
• The Commanding Officer of the carrier abdicated his responsibility for safe navigation during the approach to the Suez Canal.

These don’t sound like root causes to me. They seem like poorly defined causal factors.

The “Contributing Causes” included included in the report seemed closer to root causes. They included:

• Fatigue and operational stress.
• Can-Do attitude.
• Overconfidence and complacency.
• Lack of watch team cohesion.
• Poor culture.
• Lack of key personnel.
• Lack of a questioning attitude and forceful backup.
• Lack of watchstanding formality.
• Limited number of experienced Command Duty Officers Underway.

Unfortunately, many of the recommendations were redacted. I would guess the redacted recommendations were disciplinary.

In the other three incidents, staffing, equipment condition/failures, maintenance, and poor communication appear to be the causes of poor performance.

Set Up To Fail

Lacking the skills and experience to do your job can be deadly at sea. Add to that broken equipment, a high operational intensity, fatigue, and the Navy culture of Git-R-Done, and you have a recipe for disaster. In this case, they were lucky that no one was killed. But perhaps close to a billion dollars of damage was done. But these incidents certainly don’t indicate a high-reliability organization. Would you like to read more about high-reliability organizations and the fight against the normalization of deviation? See THIS LINK.