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Safety Recommendation Details

Safety Recommendation M-19-009
Details
Synopsis: This report discusses the August 21, 2017, collision between the US Navy destroyer John S McCain and the tanker Alnic MC. The John S McCain was overtaking the Alnic MC in the westbound lane of the Singapore Strait Traffic Separation Scheme when the destroyer had a perceived loss of steering. While the crew attempted to regain control of the vessel, the John S McCain unintentionally turned to port into the path of the Alnic MC. As a result of the collision, 10 John S McCain sailors died, 48 were injured, and the vessel sustained over $100 million in damage. No one was injured on the Alnic MC, and the vessel sustained about $225,000 in damage. There was no report of pollution. This report identifies the following safety issues: the decision to transfer the location of thrust control on board the John S McCain while the vessel was in a congested waterway, the lack of very high frequency communications between the vessels, the automatic identification system data transmission policy for Navy vessels, the procedures for the transfers of steering and thrust control on board the John S McCain, the training of Navy bridge watchstanders, the design of the destroyer’s Integrated Bridge and Navigation System, Navy watchstanders’ fatigue, and Navy oversight of the John S McCain. As a result of this investigation, the National Transportation Safety Board makes new safety recommendations to the US Navy.
Recommendation: TO THE UNITED STATES NAVY: Issue guidance to your ships’ crews emphasizing the importance of the appropriate use of very high frequency radio for safe navigation.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Marine
Location: Singapore, OF, Singapore, Republic of
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA17PM024
Accident Reports: Collision between US Navy Destroyer John S McCain and Tanker Alnic MC Singapore Strait, 5 Miles Northeast of Horsburgh Lighthouse
Report #: MAR-19-01
Accident Date: 8/21/2017
Issue Date: 8/6/2019
Date Closed:
Addressee(s) and Addressee Status: United States Department of Defense, Department of the Navy (Open - Initial Response Received)
Keyword(s):

Safety Recommendation History
From: United States Department of Defense, Department of the Navy
To: NTSB
Date: 10/30/2019
Response: -From Richard V. Spencer, Secretary of the Navy: Thank you for your letter of August 6, 2019, which referenced the National Transportation Safety Board's (NTSB) Safety Recommendation Transmittal Letter M-19-008-014 as part of the reported collision between the USS JOHNS. MCCAIN (DDG 56) and Tanker ALNIC MC, Singapore Straits, five miles northeast of Horsburgh Lighthouse, August 21 , 2017, MAR-1101. The Navy fully supported NTSB's investigation into the MCCAIN collision by cooperating with on scene U.S. Coast Guard investigators, designating a technical representative, providing documents, written submissions, demonstrations of equipment and NTSB access to Navy ships. This reflects our commitment to do everything possible to minimize the risk of similar mishaps. My appreciation for NTSB safety recommendations does not imply concurrence on findings or lack of findings, especially relating to ALNIC MC issues being litigated in U.S. District Court. Following the incidents in 2017, the Navy conducted specific incident investigations and recognized the need to address larger issues regarding safety, manning, training, operations, equipment, governance, funding and command and control. In response to this incident and others, the Navy conducted a Comprehensive Review and Strategic Readiness Review that culminated in over 100 recommendations to increase safety and improve operations. The Navy increased the operational oversight, training and qualifications for all surface vessel bridge watch teams through the establishment of the Readiness Reform and Oversight Council. This senior level panel orchestrated and directed reforms that encompass all items referenced in your letter, which are specified below with the corresponding recommendation number and the Navy's response bullet directly following. (M-19-9) "Issue guidance to your ships' crews emphasizing the importance of the appropriate use of very high frequency radio for safe navigation." • Very High Frequency (VHF) I Bridge-to-Bridge (BTB) communications are addressed within several governing instructions. o Commander, Pacific Fleet Operations Order (OPORDER) 2000 addresses the use of BTBNHF communications within numerous sections, to include its usage in conjunction with Prevention of Incidents On and Over the Waters Outside the Territorial Seas (INCSEA) and the Code for Unplanned Encounters at Sea (CUES). The OPORD also addresses BTBNHF usage in conjunction with the operation of the Automated Information System (AIS) o Surface Ship Navigation Department Organization and Regulations Manual (NA VDORM) addresses proper BTB communications and verification of proper BTB settings within the Entering Port/Restricted Waters Checklist, the Getting Underway Checklist, Low Visibility Checklists, as well as the Navigation Assessment Checklist. o Navigation Seamanship and Ship-handling Training (NSST INST) addresses voice communication within the Watch Team Evaluation Grade Sheet and the Bridge Resource Management Grade Sheet. o Principles of Commanding Officers Standing Orders provide specific guidance to ensure safe operation and effective employment. This instruction states that offship reporting requirements, to include BTB emergency calls, should be addressed as part of the ship's standing orders. • Effective BTB communications (to include VHF radio) in accordance with International Rules of the Road requirements, is addressed within all Surface Warfare Officer School (SWOS) courses involving Navigation, Seamanship, and Shiphandling training and/or assessment. Bridge Resource Management Workshops (BRMW) conducted throughout the Surface Force also address this recommendation. • The Navy updated Personnel Qualification Standards for Bridge and Combat Information Center watchstations including navigation, radars, control systems, and team performance related to navigation and contact management and avoidance.

From: NTSB
To: United States Department of Defense, Department of the Navy
Date: 8/6/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. The attached letter from the NTSB Chairman provides information about the NTSB’s June 19, 2019, report Collision between US Navy Destroyer John S McCain and Tanker Alnic MC, Singapore Strait, 5 Miles Northeast of Horsburgh Lighthouse, August 21, 2017, MAR-19/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (M-19-8 throughn -14). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this/these recommendation(s). Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. This letter provides information about the National Transportation Safety Board’s (NTSB) June 19, 2019, report, Collision between US Navy Destroyer John S McCain and Tanker Alnic MC, Singapore Strait, 5 Miles Northeast of Horsburgh Lighthouse, August 21, 2017, MAR-19/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, the NTSB identified the following safety issues: • The decision to transfer the location of thrust control on board the John S McCain while the vessel was in a congested waterway • The lack of very high frequency radio communications between the vessels • The automatic identification system data transmission policy for Navy vessels • The procedures for the transfers of steering and thrust control on board the John S McCain • The training of Navy bridge watchstanders • The design of the destroyer’s Integrated Bridge and Navigation System • Navy watchstanders’ fatigue • Navy oversight of the John S McCain Accordingly, the NTSB makes the following safety recommendations to the Navy: (Additional information regarding these recommendations can be found in the noted sections of the report.) • Issue permanent guidance directing destroyers equipped with the Integrated Bridge and Navigation System to operate in computer-assisted steering modes, except during an emergency. (M-19-8) (See section 2.2, pages 25–26) • Issue guidance to your ships’ crews emphasizing the importance of the appropriate use of very high frequency radio for safe navigation. (M-19-9) (See section 2.3, page 30) • Ensure that the modernization of complex systems, such as steering and control systems within the Integrated Bridge and Navigation System, incorporates the design principles set forth in ASTM International Standard F1166, Standard Practice for Human Engineering Design for Marine Systems, Equipment, and Facilities. (M-19-10) (See section 2.4, pages 32–33) • Revise written instructions for bridge watchstanders on destroyers equipped with the Integrated Bridge and Navigation System to include operating procedures for shifting steering and thrust control between all bridge stations. (M-19-11) (See section 2.5, page 33) • Revise Integrated Bridge and Navigation System (IBNS) technical manuals to include a description of and procedures for ganging and unganging throttles and ensure that revised technical manuals are distributed to IBNS-equipped ships. (M-19-12) (See section 2.5, page 33) • Revise the training standards for helmsman, lee helmsman, and boatswain’s mate of the watch for destroyers equipped with the Integrated Bridge and Navigation System to require demonstrated proficiency in all system functions, including the transfer of steering and thrust control between all bridge control stations. (M-19-13) (See section 2.6, pages 33–34) • Institute Seafarers’ Training, Certification and Watchkeeping Code rest standards for all crewmembers aboard your vessels. (M-19-14) (See section 2.7, page 35) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (M-19-8 through -14). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.