COMPREHENSIVE REVIEW OF RECENT SURFACE FORCE INCIDENTS 26 OCT 2017 Table of Contents 1. EXECUTIVE SUMMARY .......................................................................................................................................... 5 1.1 Introduction ............................................................................................................................................................ 5 1.2 Summary of 2017 Mishaps .......................................................................................................................... 11 1.3 Summary of Findings and Actions ........................................................................................................... 16 1.3.1 Poor seamanship and failure to follow safe navigational practices .................................... 16 1.3.2 Degraded watchteam performance..................................................................................................... 16 1.3.3 Erosion of crew readiness, planning and safety practices ...................................................... 17 1.3.4 Headquarters processes inadequately identified, assessed, and managed operational risks ............................................................................................................................................................... 17 1.3.5 Assessments do not reinforce effective learning ......................................................................... 18 1.3.6 “Can-do” culture undermined basic watchstanding and safety standards ...................... 19 1.3.7 Surface ship Bridges not modernized as an integrated control room ................................ 19 1.4 Conclusion ............................................................................................................................................................ 20 2. METHOD OF REVIEW ............................................................................................................................................ 23 2.1 Scope ...................................................................................................................................................................... 23 2.2 Comprehensive Review Team membership ....................................................................................... 26 2.3 Structure of the Report ................................................................................................................................... 26 2.4 Areas for Further Study ................................................................................................................................. 27 3. SUMMARY AND ANALYSIS OF MISHAPS ................................................................................................. 29 3.1 Introduction .......................................................................................................................................................... 29 3.2 USS John S. McCain (DDG 56) Collision with ALNIC MC .......................................................... 29 3.3 USS Fitzgerald (DDG 62) Collision with ACX CRYSTAL ............................................................. 31 3.4 USS Lake Champlain (CG 57) Collision with Nam Yang 502 .................................................... 32 3.5 USS Antietam (CG 54) Grounding ........................................................................................................... 33 3.6 Analysis of Past Incidents ............................................................................................................................. 34 3.6.1 Common Causal and Contributing Factors ..................................................................................... 35 3.6.2 Additional Important Factors................................................................................................................... 39 3.7 Summary Findings ........................................................................................................................................... 40 3.7.1 Fundamentals ........................................................................................................................................... 41 3.7.2 Teamwork ................................................................................................................................................... 41 3.7.3 Operational Safety .................................................................................................................................. 41 3.7.4 Assessment ................................................................................................................................................ 42 2 3.7.5 Culture .......................................................................................................................................................... 42 4. INDIVIDUAL TRAINING .......................................................................................................................................... 43 4.1 Introduction .......................................................................................................................................................... 43 4.2 Findings ................................................................................................................................................................. 46 4.2.1 Officer Training .............................................................................................................................................. 47 4.2.2 Officer Career Path ..................................................................................................................................... 49 4.2.3 Enlisted Training ........................................................................................................................................... 52 4.3 Recommendations ........................................................................................................................................... 54 4.3.1 Individual Training ........................................................................................................................................ 54 4.3.2 Officer Career Path ..................................................................................................................................... 56 5. UNIT TRAINING .......................................................................................................................................................... 57 5.1 Introduction .......................................................................................................................................................... 57 5.2 Findings ................................................................................................................................................................. 59 5.3 Recommendations ........................................................................................................................................... 63 6. GENERATION AND EMPLOYMENT OF OPERATIONAL FORCES .............................................. 65 6.1 Introduction .......................................................................................................................................................... 65 6.1.1 Force Generation ......................................................................................................................................... 65 6.1.2 Force Employment ...................................................................................................................................... 67 6.2 Findings ................................................................................................................................................................. 69 6.2.1 Force Generation ......................................................................................................................................... 70 6.2.2 Force Employment ...................................................................................................................................... 73 6.3 Recommendations ........................................................................................................................................... 75 6.3.1 Force Generation ......................................................................................................................................... 75 6.3.2 Force Employment ...................................................................................................................................... 75 7. SEAMANSHIP AND NAVIGATION EQUIPMENT READINESS AND UTILITY ......................... 77 7.1 Introduction .......................................................................................................................................................... 77 7.2 Findings ................................................................................................................................................................. 78 7.2.1 Inspection, Certification, and Assist Visits (ICAV) ....................................................................... 78 7.2.2 Bridge System Modernization and Training .................................................................................... 81 7.2.3 Human Systems Integration (HSI) and Human Factors Engineering (HFE) .................. 87 7.3 Recommendations ..........................................................................................................................................