Chief of Naval Operations (CNO) Admiral John Richardson recently released an outline of the results of the two recent collisions—USS Fitzgerald (DDG-62) and USS John S. McCain (DDG-56), as well as appointing Naval Reactors to look at accountability across the two events and assign punishment. Like many career naval officers, this chain of events has given me pause and caused me to reflect on the inquiry I led and wonder about outcomes that were accepted at the time. After the USS Porter (DDG-78) collided with an oil tanker in August 2012, I was appointed investigating officer; the images of damage to the ship and the stories recounted by the Sailors have stuck with me over the years. As a disclaimer, I also should mention that my signature is on the officer of the deck qualification for one of the officers involved in these recent events.
In the CNO report, there is mention of the balance between the need to release information in the interest of lessons learned and the need to protect privacy during litigation. While it makes sense to delay release of findings until the investigations are complete, a decision to withhold the results from the fleet beyond would be troubling. A retired judge advocate general who works for a maritime law firm recently explained to me that admiralty courts allocate damages based on the “percentage of fault” as determined by the investigation, meaning it is not in the interest of either party to share information with the public before an admiralty court issues a finding (not to mention that some information might prove embarrassing). This process could take years, which helps explain the Navy’s decision process and policy, but doesn’t make it any easier to bear.
That said, the initial reports have a good deal of information that will be useful to the fleet; the results of the investigation are ship-centric, as appropriate, and the Fleet Forces and other investigations (such as National Transportation Safety Board) will yield different. As Rear Admiral Terry McKnight noted in a recent Proceedings Today article, that it is probably wise to ensure that a true root-cause analysis has been completed before making sweeping changes.
In our private lives, accountability applies mainly to personal actions, from signing a check to driving a car. There are laws and regulations that we are expected to know, and when we break them, there are accepted legal precedents and guidelines for punishment. In general, there are two factors considered in such legal cases: the causes and the results. In general, there is a set penalty for violating the law regardless of the results; I have a few speeding tickets to offer as evidence. Intent can also be a mitigating factor; the legal outcome changes, however, if the intentional offense—speeding, driving under the influence, etc.—results in injury or death. There also can be civil or financial liability from insurance companies or personal injury lawsuits. Ashore, in our private lives, we make our choices, do our best, and live with the consequences.
At sea, the scenario changes. Outside of U.S. waters, where the Coast Guard has jurisdiction over maritime traffic, vessels are subject to the international rules of the road, but infractions are normally not noted or enforced unless there is a catastrophic event such as a grounding or a collision. Enforcement then falls to the parent nation, and judicial processes (in the case of a U.S. Navy ship, the Uniform Code of Military Justice) can be applied. The Fitzgerald investigation states, “In the Navy, the responsibility of the Commanding Officer for his or her ship is absolute. Many of the decisions made that led to this incident were the result of poor judgment and decision making of the Commanding Officer. 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.” Based on a reading of both reports, this statement could have applied to the John S McCain collision, and, in many ways to the Porter. It is worth considering how many factors are common not only to the two recent collisions, but to the Porter collision as well.
Expanding the study would provide some interesting trends. A basic comparison of the two incidents with my recollection from the Porter yields some interesting parallels—in each case with at least one of the two recent incidents:
- Understanding and adherence to rules of the road, specifically sound signals and maneuvering requirements when in sight of each other.
- Lack of understanding in the tuning and operation of radar equipment (and by extension, steering machinery controls).
- Improper interaction between the Commanding Officer and Bridge team with respect to giving orders and taking recommendations from bridge team.
- Combat Information Center failure to understand the challenging surface picture and provide support.
- Failure to capture lessons learned from a recent near miss and make improvements to procedures and policies.
- Failure to note and understand the nature of traffic in a traffic separation scheme—i.e., cutting across a known traffic pattern and thus raising the chance of interaction with other vessels.
- Safe Speed; although a factor in all three events, only one of the two recent investigations notes this as a contributing factor (the Fitzgerald and the John S. McCain seem to have been operating at about the same speed [20 knots] in about the same traffic situation). The rules of the road are detailed but are subject to some interpretation (in my experience, each senior mariner has his or her own definition, will be quick to defend it, and an examination of past history would show that he or she did not always adhere to it). The below diagram represents an attempt to “bin” specific noted issues as they relate to the three similar incidents.
Fig. 1 – Areas of potential commonality – causal and/or contributing – among past collisions.
When one opens the aperture to look at the similarities between the three events, the fact that they occurred five years apart should give pause and perhaps steer the lens of accountability into a wider view—what decisions and policies allowed many of the issues that led to the Porter collision to persist and perhaps multiply to the extent that eerily similar events occurred. There will be accountability within the lifelines of both ships, as there was with the Porter, but already the axe has swung at several levels of the chain of command, from the commodore to the strike group commander to the fleet fommander. Others may follow, or be impacted indirectly.
There may be other lessons to be drawn from a host of parallel cases in cause and in the only event that comes close in effects (the USS Cole). This group would include Porter but also collisions such as the USS San Jacinto(CG-56)/Montpelie (SSN-765) and the Winston S. Churchill (DDG-81)/McFaul (DDG-74) in 2006, as well as groundings in recent memory (the USS Antietam [CG-54] and the USS Champion [MCM-4], even the USS Arleigh Burke [DDG-51] and the USS Port Royal [CG-73]—there may be others). Without getting into detail and veering into conjecture, several of these incidents had consequences for the careers of either some of the crew or some of the supervisory chain of command. Some points to consider for some of the key players in the chain of command:
- There are several instances in these cases where the crew appeared to demonstrate a lack of knowledge or failure to act in accordance with accepted norms and rules. Some are examples concrete, and some are rather subjective. This group can include direct watchstanders, whose actions—or lack thereof—may have directly contributed to the collision, and those in responsible positions who knew—or should have known—of deficiencies in knowledge, training, or material condition. A caveat: as a former commanding officer, I often am skeptical of statements like “failed to take corrective action on known materiel discrepancies.” I can recall many materiel deficiencies that were uncorrected for years due to lack of funding, lack of time for repairs, or lack of technical support. I also can recall training events—from seamanship to navigation—which were delayed or waived due to extenuating circumstances. The real question is, was the impact recognize and mitigating factors put in place? Other reports, from the Balisile report to the Fleet Forces investigation, speak to manning and training deficiencies—to what extent are the crew responsible, and to what extent the system? One of the collision reports notes the presence of Sailors from another ship who were not as familiar with the ship’s specific systems, but why were they there? As a former force manning officer who recommended dozens of cross-decks to my old boss to fill deployment shortfalls, I think I know the answer. If this is the case, what are the broader implications for any ship where cross-deck personnel are used to fill manning gaps left by the “system,” and is the ship alone responsible for addressing any deltas in training or system-specific experience?
- Ship leaders. Captains, executive officers, and a command master chief have already been relieved. According to some reports, they may be subject to other consequences ranging from a court-martial to a “show cause” hearing. In these cases, it will be difficult to discern, as John Paul Jones stated, “well intentioned mistakes from malfeasance.” There may even be a case for comparison with other command leadership who were relieved due to malicious and cruel treatment of the crew—how do the actions of these officers compare in intent and consequences?
- Operational leadership. Since my major command tour was as a CO, I cannot personally speak to the burden of a squadron commander, but my interactions with peers in this position speak to the difficulty of knowing how a subordinate command operates at sea, as well as the challenges of running a warfare commander staff while keeping tabs on several ships that may be geographically separated. The removal of the commodore and strike group commander in these cases does seem to be an extraordinary event—a look at past mishaps rarely shows this level of accountability, although I can recall a few cases after similar incidents where commanding officers and senior officers, while not fired, did not advance to 06, flag, or receive a second star as would have been expected, but the only paper trail in these cases resides inside the lifelines of selection boards—and Navy Times.
Big Navy. Higher echelons may be impacted—the relief of commander, Seventh Fleet, albeit at the end of his term, is one example. Even the CNO has stated “I own this.” What are the long-term implications for Navy leadership Time will tell. The below chart is an attempt to summarize where the responsibilities for different levels of the process lie:
Fig. 2 – Graphical Representation of levels of Responsibility, Authority, and Accountability.
But let’s get back to where we started—the difficult task of assigning and defining accountability. In the Navy, we often conflagrate the phrase “to be held accountable” with “you’re fired,” but this is one-dimensional. Accountability can take many forms—from the legal and punitive standpoint, to the very personal relationship between a commanding officer and his crew. This is a complex issue: when the USS Indianapolis (CA-35) was torpedoed and sunk after delivering parts of the atomic bomb, the commanding officer was court-martialed, later committed suicide, and eventually was exonerated. The commanding officer of the Cole was never charged or convicted, but his career was ended. He then took it upon himself to visit the families of each crew member who was killed under his command. While the current plan places both collisions under one umbrella, the events leading to the collisions diverge starkly with the role of the commanding officer and executive officer. In one case, they will be held responsible for the actions of the crew (which they trained and certified) while they slept; in the other case, as in the Porter incident, the commanding officer’s actions, while apparently well-intentioned, seem to have directly contributed to the result. I make these comparisons not to imply that any outcome is preferable to, only to show that everyone’s role and level of culpability and accountability will be unique and complex. In addition, an entire generation of leaders—including those now retired—put their signatures on a variety of documents, from fitness reports to qualification letters to selection board results, that stated, “this person has met my standards to stand this watch” or “to command a Navy ship.” We, too, are accountable.
Why does this matter enough to write about? Five years ago, I spoke with a junior sailor from the Porter, who had her hand on the door to the passageway leading to the weather decks just as the space in front of her was demolished by the impact. Shaken but uninjured, she told me, “Well, I just hope we can learn from this.” A friend in Japan who spoke with a John S. McCain sailor a few days after that ship’s collision relayed the conversation to me. My friend asked, “Did you guys go over the lessons from [the] Fitzgerald?” The sailor responded, “No, those have not been shared with anyone yet. We did talk about it a bit, but figured it would never happen to us.” I look back and realize that after the Porter investigation I accepted the lack of transparency and did not push to share the lessons we identified. The JAGMan was complete, and we went about our business. Some of the lessons were incorporated into the surface warfare officer school training pipeline, including a realistic simulation of the scenario, but considering recent events I wonder if we did enough.
For example, the outcome of the Porter investigation was influenced by a coincidental digital recording of the bridge conversations leading up to the collision—there was some discussion about mandating such recording devices for certain events like transits, but it never came to fruition—would it have been helpful in these cases? Perhaps. This point was driven home by a recent conversation in a different ship’s wardroom, where officers shared that they had not seen “anything official” on either of the recent collisions. I followed this with an extensive Internet search for “USS Porter collision lessons” that yielded mainly CDR Salamander blog posts and Proceedings contributions. These led me to a tough conclusion: we did not do enough.
This time it is different. People died in this year’s collisions. The Navy has embarked on a level of near- and long-term self-examinations with a depth and breadth that appears to be unprecedented; some level of accountability will undoubtedly follow. But the more important question will come long after the courts have adjourned. For now, the best level of accountability will occur across the force and must permeate from the deckplates of each ship—as if this had occurred on board—by asking hard questions like:
- As a commanding officer, how does my presence on the bridge affect the watch team’s decision-making process?
- Do my watchstanders feel they can (and know that they should) call me whenever there is doubt?
- Are my watch teams communicating effectively both on the bridge and between the combat information center and the bridge?
- Do my watch standers understand their equipment (radar, navigation system, helm, lee helm, AIS)?
- Are my watch standers comfortable using bridge-to-bridge and sound signals to communicate with traffic?
- Do I have a fatigue mitigation plan? Does my watch rotation and daily routine support protected sleep and focus on alert watchstanders?
- Have I fostered an environment where people share mistakes and learn from them?
- How robust are my self-assessment processes—and are they brutally honest?
There are questions that will be asked by the highest echelons of the Navy regarding training, manning, and policy that are worthy of—and undergoing—comprehensive review, but they all lead to a single important goal: given that our sailors will continue plying the same dangerous waters around the world, what actions will make them safer?
