What Has the Navy Learned from Collisions at Sea?

Video of an Accident in 1969

I was still in high school when this accident happened…

But the accident seems strikingly similar to more recent accidents where junior officers made mistakes in the middle of the night resulting in ships colliding.

Common Factor: Discipline

What is one of the US Navy’s swiftest actions after a collision at sea? Discipline.

You would think that after all the discipline that has been handed out after collisions, Officers or the Deck would stop making errors that cause collisions, and Commanding Officers would be better leaders. After all, look at all these examples going back to 1945…

And that’s just the most serious incidents before the Fitzgerald and the McCain collisions.

Do the similarities in these incidents indicate anything?

Discipline is Ineffective at Preventing Future Accidents

Firing the Commanding Officer after a collision at sea or a vessel grounding is standard procedure in the US Navy. Many senior officers will swear that it is necessary. The CO must be held accountable!

But if the factors that caused the collision are:

• fatigue
• poorly trained officers
• excessive operating tempo (too many missions for too few ships)
• insufficient staffing
• poorly human-factored displays and controls
• insufficient maintenance (backlogged due to budget constraints and repair parts/facilities unavailability)

How does holding someone accountable fix these problems? Are the Officer of the Deck or the Commanding Officer in control of these factors?

For example, about 20 years ago, the decision was made by senior naval leaders to:

• Cut staffing aboard modern ships
• Reduce conventional training of junior officers and instead give them a CD with training on it (that they could review in their spare time)
• Implement more automation to reduce requirements for trained crewmembers
• Shift responsibility for more maintenance to shore repair facilities and reduce maintenance personnel on the ships
• Reduce the number of ships to cut the Navy’s budget

This was done because, after all, the cold war was over, and the operating tempo in the Navy would be reduced.

The War on Terror increased problems because budget cuts reduced training for ships because the money was needed for the wars in Iraq and Afghanistan.

Also, senior brass decided that the career development of officers would be changed, and tours in other branches (liaisons with the Air Force, the Army, or the Executive Branch or non-seagoing jobs in Iraq or Afghanistan) would substitute for experience at sea.

Thus, the seagoing senior officers (COs, XOs, and Department Heads) who now have the responsibility to train more junior officers have less experience and training because of decisions that reduced their training and experience when they were junior officers.

What about the operating tempo? Did it decrease?

NO!

It might even be worse now than at the height of the cold war when we fought in Viet Nam.

But are any of these decisions discussed when an accident happens?

No.

Just blame (and punish) the OOD and the Captain. Have a Navy-wide safety standdown. And pledge to take other unspecified actions to ensure “this accident will never happen again” without addressing the underlying root causes.

Ineffective Root Cause Analysis and Corrective Actions

If you never find the real root causes of the collisions and take effective actions to change the system, you will continue to have serious collisions for the same reasons.

In fact, perhaps the best performance indicator for the effectiveness of your root cause analysis and corrective actions is the prevention of future accidents.

However, major collisions at sea don’t happen frequently.

For example, the two collisions in 2017 of two separate DDGs with commercial vessels that resulted in 17 dead sailors are rare. Two collisions in a short period of time are abnormal. Usually, there are several years (but less than a decade) between major accidents aboard Navy vessels (including fires, groundings, and collisions).

So, it can appear that discipline and stand-downs work because major accidents are infrequent. However, if the underlying problems aren’t solved, the problems are lying in wait for another crew on another ship.

Why Does This Bother Me?

Stopping major accidents and the loss of the lives of sailors is personal to me. I was an officer aboard two Navy cruisers and was personally responsible for the lives of over 100 people.

When I was the OOD, I bore responsibility for any collision or grounding.

Luckily, I made the right decisions and avoided potential accidents.

I was part of a system that included fatigue.

But since I left the Navy back in 1985, the staffing, training, and maintenance problems have gotten worse.

Perhaps now is the time for the U.S. Navy to learn the fundamentals of root cause analysis and apply them to prevent future accidents.

To learn about advanced root cause analysis training, CLICK HERE.

And to see the upcoming dates and locations for that training, CLICK HERE.