“4 Safety Recommendations Issued Based on Investigation of USS Fitzgerald Collision” –NTSB

Note the classic “Constant Bearing, Decreasing Range.” You may have to enlarge the plot, but there are six parallel bearing lines in the illustration above. 

The NTSB has issued four safety recommendations as a result of the investigation of the collision between collision between US Navy destroyer Fitzgerald and Philippine-flag container ship ACX Crystal in Sagami Nada Bay off Izu Peninsula, Honshu Island,
Japan July 17, 2017

Always important to learn from others, and, the Coast Guard participated in the investigation.

As a result of its investigation the NTSB issued three safety recommendations to the Navy and one to Sea Quest Management Inc., the operator of the ACX Crystal. Two safety recommendations issued to the Navy call for review and revision of fleetwide training and qualification requirements for officers of the deck related to the collision regulations, as well as review and revision of bridge resource management training. The third recommendation to the Navy seeks the broadcast of automatic identification system information when in the vicinity of commercial vessel traffic, at all times, unless such broadcast could compromise tactical operations. The safety recommendation issued to Sea Quest Management Inc., seeks additional training for navigation officers on collision avoidance regulations, radar and automatic radar plotting aids.

You can see the entire NTSB report here. If this proves anything, it is that 13 tired people who sorta know what they are doing, are no substitute for one well rested person who really does know what he or she is doing.

It was a beautiful night, good visibility, sea state 1–2, north winds 11–16 knots, air
temperature 68°F (20°C), and sea temperature 62.6°F (17°C.).

On board the Fitzgerald, the OOD had believed during the approach that the destroyer would clear both crossing vessels (the ACX Crystal and the Maersk Evora, or possibly the Wan Hai 266 and the ACX Crystal). The OOD told investigators that she saw the ACX Crystal’s superstructure about a minute before the collision and she realized the Fitzgerald was not going to clear the containership. According to the OOD, she initially ordered the conning officer to come hard right, however, she cancelled that order before the conning officer could relay the order to the helmsman. The OOD said she then ordered hard left rudder and ahead flank speed. The BMOW, who was standing near the helmsman, stated that the OOD “gave the order all ahead full for 25 knots, and right after that, all ahead flank.” He went on to say that when the OOD gave the order for “hard left rudder” he “just grabbed the wheel” (from the helmsman) and “put it over.”

A review of Fitzgerald engine parametric data indicated that both the port and starboard engine throttle settings were simultaneously advanced by increments at 0130:06, 0130:14, and 0130:22. Engine monitoring data indicated that both engines responded to the requested commands.

At 0130:32, with the Fitzgerald traveling at 22.1 knots and the ACX Crystal at 18.4 knots, the vessels collided. Neither the Fitzgerald nor the ACX Crystal bridge teams sounded any alarms or made any announcements to warn their crews of the impending collision.

What I remembered, from many years ago, was when “in-extremis” both ships should turn right, but apparently that is not viewed as definitive now. Still, it looks like it would have been the best choice here, if you had failed to act early enough to avoid the in-extremis situation in the first place. If you want to review the rules, you can find them here. Rules 7, 8, and 17 apply.

The XO did not trust the OOD, but did not say anything to the CO, when the watch bill for this high traffic transit was planned. Nor did he remain on the bridge during that OOD’s watch.

Fatigue was also a killer, and the constantly rotating watch bill did not help.

“…watchstanding period for each watch team would shift with each cycle of the watch rotation. For example, the watch team that had the 0200–0700 watch would next have the watch from 2200–0200 that evening, and then have the watch from 1700–2200 on the following day. Following this accident and the McCain/Alnic MC collision, which occurred about 2 months later in August 2017, the Navy mandated “circadian watch bill” schedules that followed set watch times each day.”

There was also an inexperienced “conning officer” who relayed orders from the OOD to the helm. This does not seem to have caused the collision, but it could not have helped.

5 thoughts on ““4 Safety Recommendations Issued Based on Investigation of USS Fitzgerald Collision” –NTSB

  1. The sleeper here was the tendency of Naval vessels not to use AIS. In a non tactical situation it amounts to little more than an unjustified arrogance.
    You can say the the merchant world is too dependent on the electronics but unfortunately that is the way of the world.

  2. i know that since this collision and the other incidents, I have noticed USN vessels using AIS more (but not always) near the Hampton Roads area.

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