Recently it was my honor to participate in a panel hosted by the U.S. Naval Institute (USNI) Defense Forum to discuss the United States Fleet Forces (USFF) Comprehensive Review of the recent collisions in the Commander, Seventh Fleet Area of Operations. Along with my esteemed peers, retired Navy Captains Kevin Eyer and Gerry Roncoloto, we were asked a set of questions and then the floor was opened to the audiences. The video is available at the USNI website, but there were some items that did not make the discussion and, based on some of the feedback after the event, perhaps worthy of further discussion in this forum. Rather than try to interpret or elaborate on the comments of my fellow panel members, I chose to provide my notes and comments, annotated with any clarifications. This is not an exact transcript; a few were comments were not included in the discussion, but are annotated here with an asterisk. Each comment is based on personal experience or available documentation, and represent just one person’s opinion/recommendation. For what it’s worth, here goes:
Admiral Pete Daly: You have all read the Comprehensive Review. Based on your experience and what actions you see there—has it been “comprehensive” enough? Any important omissions? Anything included in the Review that surprises you?
- Context—In preparing for this session, I read the two recent Government Accountability Office (GAO) reports, the USFF Fleet Review, and Sailor 2025. I tried to look at them all as part of a larger look at recent events – my experience is mainly at the shipboard and type-commander (TYCOM) staff level, so mainly I focused on these areas. Based on the individuals on the team and the areas they visited, which are extensive, I would say yes.
- Fatigue—I was happy to see the detailed review of fatigue and crew endurance. The Navy Postgraduate School, Navy Safety Center, Operational Stress Control team have worked for years to advocate for a more proactive approach on this topic and as happy as I was to see these action items, I was also sad to see that it took this event to have this go from best practice to policy.
- Manning—What caught my eye was on page 143: the USFF notes in an enclosure (page 143) that the “gaps at sea” has grown by 400 percent from 1,500 to 6,500 in the past 12 months and is expected to get worse before it gets better. That is earth shattering to me as a root cause of the fatigue issue—I would have like to see a much more robust list of actions to address manning. I felt that there was a decent discussion of the impact of manning gaps and policy, but very little in the way of action items. GAO studies starting in 2010 through this year go into detail about the need to review OPNAVINST 100.16L and look at the three-section underway manning model and Standard Navy Work week, and note that of a total 11 recommendations—the Navy has implemented only one. Many of the actions are in place, but the timeline to roll them out is massive in terms of years. It’s time to speed up.
- Sustaining Change—In my mind the most critical finding was in the “sustaining change” discussion, paragraph 8.2.4, that states that we “lack a comprehensive way to capture lessons and get better – we chip around the margins. In the absence of an enduring program systemic change and long-lasting improvements will not occur.” This hit home for me since I was the investigating officer for the USS Porter (DDG-78) 2012, and it was eerie to read the same things throughout this report that were in my JAGMAN in 2012. The only reason the Porter accident did not result in casualties was that the ship was fully laden and the bulbous bow went underneath the ship. This was a shot across the bow of astronomical proportions—I was on the TYCOM staff at the time—and in my opinion we could have done more.
Admiral Daly: If the Comprehensive Review is right that the collisions were “avoidable”—do we have flawed decisions by these commanding officers and crews or do we have a flawed system that produced them?
- Root Cause—I know the legal process will likely prevent it, but I think it would be good to know from the individuals involved, the “why” related to their actions. On the Porter we had an audio tape, and it completely changed our understanding of the dynamics on the bridge, even after we had interviewed everyone. We also don’t really know the “why” details of those who were relieved – did they fail to act on known issues, or fail to be aware of issues they should have known? The answers to those questions could lead in different directions.
- Accountability—We have seen accountability up the operational chain, but the man-train-equip side—TYCOM, USFF and PACFLT, even OPNAV—many of the decisions that we live with were not made by the incumbents—how do we hold the system accountable? Maybe we need to do the same deep dive on a ship that has not had a collision to see how they fare—if they have the same issues, we have a deeper problem. I do think several of the action items in the report address these system issues and the review teams are prepared to look deeper at several of them. The Secretary of the Navy review seems to be targeted at the larger “system” and will be just as interesting.
- Remote Areas—Having spent my time in the East Coast, I am not familiar enough with the Japan process to provide meaningful comment on the resource allocation management program (RAMP) or the issues specific to that area. I would comment that there is danger of the same issues in other areas like Bahrain and Rota. From my travels, I have seen some of the same indicators in those ports—manning shortages on ships filled by staff, which leaves a void at the immediate superior in command (ISIC), and a fluid schedule that compresses training time. The results could be the same—remember the Porter was in the Commander, Fifth Fleet Area of Operations.
Admiral Daly: If there are experience, training, or culture gaps, how do we prevent another incident until all these actions detailed in the Comprehensive Review catch up?
- Fatigue Mitigation—Aggressively pursue the crew endurance process and recognize that large parts of the Fleet have not received the briefings—lots of skepticism out there. Expand the process by educating the afloat training group teams and bridge resource management instructors to get the message consistent. I recommend every 0-6 and above and ever E-7 and above be required to attend the NPS/SURFOR Crew Endurance Brief—I have seen the lights come on in the audience as they learn the science behind circadian watch rotations and sleep hygiene. This is in addition to the planned incorporation into pipeline training like Surface Warfare Officer School (SWOS) and the Senior Enlisted Academy. The SURFOR instruction is sighed out and it is both detailed and comprehensive, but this is a culture change, and it will take a generation to “bake it in.” *Along those lines, maybe consider providing a FitBit for every Sailor and hold them personally responsible for their sleep habits. When I suggested this recently a friend said “we will never do that because we won’t like the answer.” The Australians already do this.
- Bride Resource Management—Lots of bridge resource management (BRM) action items are listed in the Comprehensive Review. The Navy probably will need to need to increase BRM requirements aligned to the Optimized Fleet Response Plan (OFRP) and increase the throughput. Maybe a ship sends its teams in the maintenance phase and again to a refresher before deploying. These are part time positions now—the Navy might consider stabilizing the process with a more robust infrastructure and a footprint in all remote homeports and align with the already solid training at SWOS simulators. This also leverages the teams and may force the ship to write watchbills sooner and leverage the team building that a circadian fixed watch rotation can provide.
- *Operational Stress Control Team/Afloat Culture Workshop—Leverage two powerful tools that already exist: The Navy has an Operational Stress Control (OSC) Team and the Afloat Culture Workshop (ACW). These could be leveraged to meet some of the Human Factors requirements—they are not mentioned in the report. The OSC helps crews build resilience, and the ACW is a process that uses senior reserve officers to interview the entire crew and hold a mirror up to the commanding officer. These supposedly are mandatory but not enforced across the force as far as I can tell. Anecdotally, it is tough to schedule them in FDNF where they are needed most.
- Senior Enlisted Experience to sea—To address experience gaps immediately, designate three key billets as E-9 billets at sea: 3-M system coordinator, combat systems maintenance manager, and top snipe (without offsets)—get experienced folks back on ships in billets that will have a huge impact (and don’t try to offset them by removing other billets). If they don’t want to go to sea, they can choose to retire and open up a spot for the next E-8.
- Get the Word Out—We need to get the lessons to the fleet in a digestible format. This is a great report, but it is a pretty long read—maybe consolidate the lessons into a booklet or a video—the Safety Center has a great facility for this, has great experience, and could turn one out in a few months for free. I am not sure, but I think the most recent video about collisions is the 1969 Melbourne–Evans collision from 1980s. Every SWO recalls the line from the movie “It’s too close for MOBOAR [the maneuvering board]—we’ll have to eyeball it in”; maybe it is time for a new one. This would allow rapid dissemination of teaching points, appeal to all levels, and keep the teaching points consistent.
- SNWW and Manning Models—This is a big one: Don’t wait for more studies: take action—change appendix D to use a baseline condition III manning model to four teams instead of three. This is not a new recommendation; in a Naval Engineering Journal “Article of the Year” in 2007 by a former Navy Manpower Analysis Center CO and Naval Postgraduate School (NPS) researcher (the late Captain Mike Firehammer and Dr. Nita Shattuck), called title “Avoiding a Second Hollow Force”—these well-qualified individuals made two recommendations: Use of circadian watchbills and a change to the underway manning model. This approach is supported by NPS and GAO studies. My recommendation is to stop studying it and do it—maybe study it in parallel. This simple change would push critical sailors (watchstanders and maintainers) back to the ships. This would take a while to percolate through the system (another reason to do it now and study it in parallel!) but it supports several of the Comprehensive Review action items (watch standing, maintenance, fatigue) and will be absolutely necessary to address many of the human performance items. I have also written extensively on this topic and can provide lots of background on this if desired.
Thedamaged USS Frank E. Evans (DD-754) being escorted to the auxiliary repair drydock USS Windsor (ADR-22) at Subic Bay, after it had been in involved in a collision with the Australian aircraft carrier HMAS Melbourne on 3 June 1969. Photographer PN2 Ralph Treser.
Final thoughts?
- Innovation—Innovation is one our core strengths—look at Aegis/ballistic-missile defense, Tomahawk, electronic navigation—but think about the circadian watch concept – if an idea that was grounded in science, spreading on its own across the fleet, and costing nothing, took ten years and—in the end—a catastrophic event to break through the corporate hubris, what other ideas are out there being worn down by the “conventional wisdom” or the acquisition sponsorship process? It could be in cyber, weapons, shipbuilding, or something else.
- “Can Do” Culture – I have been asked what the difference was between my 0-5 and 0-6 tour and my answer is “I learned to say no.” As a first-time commanding officer, I felt pressure to prove myself that—in retrospect—caused me to take on risk and in at least one case resulted in a Sailor getting hurt. As an 0-6, when tasked to complete a towing exercise the week after taking command with a new crew and my first time on that class of ship—I said no. It is also important to note that my boss at the time accepted “no” for an answer, which is an important facet of the conversation oft overlooked!
*These points were not address during the panel, due to lack of time.
