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Lessons from the 2017 US Navy collisions

Part-1: Common reasons for the USS Fitzgerald, the USS John McCain, and the USS Lake Champlain accidents

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Everything starts and ends with leadership. Nothing else we accomplish, no other priority we pursue, is of much consequence if we do not have sound and effective leadership in place to enact it. We all have a responsibility to develop our own leadership potential and that of the Sailors’. 

- Admiral Michael G Mullen, USN

 


The US Navy is a powerful navy, both in terms of sophisticated ships and highly trained navigators. When three of its ships collide in separate incidents, within months of each other, it’s a matter of concern for all users of the sea.

Just as we pass the first anniversary of these collisions, I will be sharing my own analysis of these collisions in a series of articles. The aim of this study is to assess what the commercial shipping industry can learn from these accidents.

First up, we must appreciate the transparency of the US Navy in sharing their findings externally, and look at their own conclusions regarding the role of its own ships in these accidents, in their own words. In the below table, I’ve mapped common findings from the three reports.

USS Fitzgerald USS John McCain USS Lake Champlain
Collided with the ACX Crystal off Japan on 21st June 2017 with the loss of seven lives. Collided with the Alnic off Singapore on 21st August 2017 with the loss of ten lives. Collided with fishing vessel Nam Yang 502 on 9th May 2017 in the Sea of Japan. Thankfully, there were no major injuries.

Failure to adhere to sound navigation practice.

One of them being that the ship was not operated at a safe speed appropriate to the number of other ships in the immediate vicinity.

Failure to execute basic watch-standing practices.
The officers possessed an unsatisfactory level of knowledge of the International Rules of the Nautical Road. Failure to follow the International Nautical Rules of the Road, a system of rules to govern the maneuvering of vessels when risk of collision is present. Shipboard training programs regarding the International Rules of the Nautical Road were ineffective, and the officers possessed insufficient knowledge of these Rules.

Failure to execute basic watch standing practices.

One of them being that the watch-standers performing physical look out duties did so only on FITZGERALD’s port side, not on the starboard side where the three ships were present with risk of collision.

Failure to adhere to sound navigation practices.

One of them being that they failed to make proper use of lookouts

Watch team members were not familiar with basic radar fundamentals, impeding effective use. Watch standers operating the steering and propulsion systems had insufficient proficiency and knowledge of the systems. Watch team members were not familiar with basic radar fundamentals, impeding effective use.
Failure to properly use available navigation tools. Failure to properly use available navigation tools.
Failure to respond deliberately and effectively when in extremis. Loss of situational awareness in response to mistakes in the operation of the JOHN S MCCAIN’s steering and propulsion system, while in the presence of a high density of maritime traffic. Failure to respond deliberately and effectively when in extremis. The bridge team was inexperienced and had not discussed or trained for emergency actions.
Failure to plan for safety. Leadership failed to provide the appropriate amount of supervision in constructing watch assignments for the evolution by failing to assign sufficient experienced officers to duties.
FITZGERALD’s approved navigation track did not account for, nor follow, the Vessel Traffic Separation Schemes in the area.
Supervisors and watch team members on the bridge did not communicate information and concerns to one another as the situation developed. The bridge team and Combat Information Center team did not communicate effectively.
The Officer of the Deck, responsible for the safe navigation of the ship, did not call the Commanding Officer on multiple occasions when required by Navy procedures The Commanding Officer decided not to station the Sea and Anchor detail when appropriate, despite recommendations from the Navigator, Operations Officer and Executive Officer. The Officer of the Deck, responsible for the safe navigation of the ship, did not call the XO on multiple occasions when required by the CO’s Standing Orders.
Key supervisors in the Combat Information Center failed to comprehend the complexity of the operating environment and the number of commercial vessels in the area.
In several instances, individual members of the watch teams identified incorrect information or mistakes by others, yet failed to proactively and forcefully take corrective action, or otherwise highlight or communicate their individual concerns.
Key supervisors and operators accepted difficulties in operating radar equipment due to material faults as routine rather than pursuing solutions to fix them.
The command leadership did not foster a culture of critical self-assessment. Following a near-collision in mid-May, leadership made no effort to determine the root causes and take corrective actions in order to improve the ship’s performance. Watchstanders did not maintain proper logs, and supervisors failed to recognize that junior watchstanders were not maintaining the surface contact log as required.
The command leadership was not aware that the ship’s daily standards of performance had degraded to an unacceptable level.
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. The crew was ultimately unprepared for the situation in which they found themselves through a lack of preparation, ineffective command and control, and deficiencies in training.
Principal watchstanders including the Officer of the Deck, in charge of the safety of the ship, and the Conning Officer on watch at the time of the collision did not attend the Navigation Brief the afternoon prior. This brief is designed to provide maximum awareness of the risks involved in the evolution.
Leadership failed to provide the appropriate amount of supervision in constructing watch assignments for the evolution by failing to assign sufficient experienced officers to duties.
Senior officers failed to provide input and back up to the Commanding Officer when he ordered ship control transferred between two different stations in proximity to heavy maritime traffic.
Senior officers and bridge watchstanders did not question the Helm’s report of a loss of steering nor pursue the issue for resolution.
If JOHN S MCCAIN had sounded at five short blasts or made Bridge-to-Bridge VHF hails or notifications in a timely manner, then it is possible that a collision might not have occurred. LAKE CHAMPLAIN did not sound signals with the ship’s whistle to indicate turns to port or starboard.

The US Navy’s analysis and Admiral Michael G Mullen’s own quote confirm what I mention in my book Golden Stripes- Leadership on the High Seas- that ‘all accidents are, at some level or the other, failures of leadership at sea’. Subsequent articles will examine these collisions one by one, and possible solutions. Watch this space.

The article pays respect to the mariners who lost their lives in these tragedies. One of the ways to honour their memory is to ensure such accidents never happen again to any mariner, anywhere.


#GoldenStripesLeadership #LessonsFromSea #Mariners #CaptainParani #MaritimeLeadership

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Two Groundings, One Safety-Culture

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A culture of safety starts with leadership, because leadership drives culture and culture drives behaviour. Leaders influence culture by setting expectations, building structure, teaching others and demonstrating stewardship’.
- Rex W Tillerson, Chairman and CEO, Exxon Mobil, and 69th US Secretary of State


In February 2015, while on passage from Belfast to Skogn, Norway the general cargo vessel Lysblink Seaways ran aground at full speed, near Kilchoan, West Scotland.
The Lysfoss ran aground in 2001, under similar circumstances while on passage from Lysekil in Sweden to Belfast.

The first three alphabets of the two ship’s names are the same. So, are their groundings a coincidence? Not when you consider that the UK MAIB found that the ships shared a similarly deficient safety culture. The findings indicated that the shortcomings identified with the Lys Line safety culture in 2001 were still prevalent on Lysblink Seaways at the time of the accident, despite the change of ownership. But how can we explain the concept of safety culture to seafarers?

Models help us understand abstract concepts. And if it’s based on something familiar, even better. That’s why in my book Golden Stripes- Leadership on the High Seas, under the section Safety Leadership, I’ve explained the concepts of safety management and safety culture through the Safe-Man model - based on the popular Pac-Man game.

safety culture

Imagine yourself and your shipmates as Safe-Men (Safe-Man 1 and 2). The game is to fulfil a task, such as navigating through a narrow channel, carrying out a crank-case inspection, or hot-work in a tank. Implementing all the safety management barriers such as checklists, use of required equipment help us work in the ‘Safe Zone’, where the risks are reasonably low.
Now, three of the devils (Hazard, Risk, and Accident) are locked under barriers, while one (Unexpected New Hazard) roams free trying to catch you by surprise. Throughout the game you also watch out for the other members of your team. Because if any of the devils catch even one of your crew or ships (Safe-Men), the game ends.

The game also has power pellets, or energizers which once eaten by Pac-Man weaken the devils while gaining him more points. Similarly, a robust safety culture is the energiser which helps the Safe-Men carry out their tasks every day, while keeping dangers at bay.

Like all good things in life, a good safety culture doesn’t just happen. It requires intentional leadership to create, maintain, and inspire such a culture. In fact, every member of the team should feel enthusiastic, even overzealous, about their safety culture. This is where safety moves from the realm of safety management to safety leadership. Here are my seven leadership strategies for a strong safety culture:
1. Create symbols
2. Open feedback channels
3. ‘Hands-On’ risk management
4. Share stories
5. Enforce Routines
6. Reinforce
7. Decide ‘safety-first’

On the Lysblink Seaways, the Chief Officer had consumed half a litre of rum before his night navigation watch. He fell asleep and missed an alteration of course. The ship grounded on a rocky shore at a speed of over 13 knots. The ship was later declared a total loss. Though this may seem like the reckless act of an individual, the investigation report found that there were systemic failures in safety leadership.

An earlier audit had found that the navigators had not renewed their 5-yearly Bridge Resource Management Training as required by the Flag-State rules. A Flag State recommendation required another crew member to be placed as a look-out during darkness hours but this was not done. On this ship, it had become regular practice to disregard the company procedure of using the dedicated ‘dead-man’ alarm system. The ‘enforce routines’ power-pellet was never used, weakening the safe-man’s ability to play the game.

Random alcohol tests were never carried out on this ship. These ‘feedback channels’ were not utilized. The significant consumption of alcohol by the crew from the ship’s bonded stores was not flagged by the company. Many of the findings regarding the implementation of the safety-management manual which came to light after the accident should have been identified during routine internal audits. The ‘reinforce’ energizer was not used effectively.

The company which operated the Lysblink Seaways had few years earlier, bought the company which operated the Lysfoss but the lessons from the Lysfoss grounding had not been applied on the Lysblink Seaways. Not ‘sharing stories’ meant one safe-man could not learn from the other.

On the Lysfoss, detailed passage-plans and master-night-order book were not used, which otherwise are powerful ‘symbols’ of a working safety management system.
The investigation report also found that the master’s familiarity with the navigation routes had caused him to adopt a relaxed attitude to the proximity of navigational dangers. ‘Hands-On risk management’ and safety leadership was lacking.

Research shows that workplaces with a healthy culture are 49% less likely to have accidents and 60% less likely to make errors in their work. Help your colleagues understand how safety culture provides us the energy to work safely, day after day. Feel free to use the Safe-Man model to explain how it works. Do remember that poor safety culture can ground a ship- maybe even two.

 

Captain VS Parani, FNI, FICS, CMarTech-IMarEST is the author of Golden Stripes- Leadership on the High Seas, the world’s first book on leadership for mariners, by a merchant-mariner. Whittles Publishing, ISBN: 978-184995-314-6. He can be reached at parani.org. (https://www.amazon.com/Golden-Stripes-Leadership-High-Seas/dp/1849953147)

Reference: MAIB report 23/2002 (Lysfoss) and MAIB report 25/2015 (Lysblink Seaways)

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Social Media for Seafarers: The Digital Semaphore

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“You are what you share.”

― Charles W. Leadbeater, We Think: The Power Of Mass Creativity


Social media for seafarers is almost a lifeline- giving them the ability to connect with friends and family even from the opposite corner of the globe. It connects, informs and entertains. I certainly love seeing pictures of sunrises from the middle of the Pacific, or time-lapse videos of ships passing through canals.

But like every technology, it pays to use it smartly. The rules for social media use for mariners are just about the same as for other professionals- these are more than social graces- they are practical.

social media

Legal implications

What you post on the internet never goes away- never ever. It is common for employers, insurers and law-enforcement agencies to check your online profile. Before you share anything, ask yourself if you would be comfortable having your family or colleagues read about it?

If you’re frustrated with things happening at work or in your life- social media is not the place to vent. Besides, offensive or untrue posts can give sufficient reason for disciplinary, or even legal action.

Few weeks ago, a video of a seafarer being killed by a wire under tension was shared on social media. Though this was a shocking video which can help understand the dangers at sea- such graphic images are hard for family members of the deceased seafarer to watch. In any case, it is unwise to post personal injury photos and videos as these can have serious impact on legal or claims proceedings.

Ensure what you post complies with the laws of your state, or the place that you are visiting. Do not share anything which could contravene intellectual property laws (photos, movies, technical manuals for example).

These days it’s quite common to see drone photography of ships appear on social media. Be aware of local regulations (and fines) for the use of drones in port.

Security

Do you put up a poster outside your house to tell everyone where you are travelling- especially when you are going to join ship for several months? If not- why do it online? Do check the privacy settings for your accounts- including the geo-tag options.

When sharing pictures of friends and family, especially young children- take care. Ask your friends or colleagues if they’re OK with you sharing a photo with them online.

Do change your passwords every three months and check routinely that your account has not been hacked.

Company Policy

Read your company policy on social media use. Check what you can share, and what you cannot about the company. If in doubt, ask your HR Department. Particularly check if you are allowed to share photos and documents of your ships, especially:

• The location and cargo on your ship. This information in the wrong hands could be used for targeted piracy, smuggling or theft.
• Maintenance work, especially that done in dry-dock.
• Demolition photos of the ship. Even if the ship was recycled in compliance with the relevant conventions, these photos could end up on newsfeeds and raise un-necessary questions.
• Security arrangements on the ship or in the port.
• Emergencies. While it’s good to capture evidence on camera, beware of sharing it with the external world, especially the media- it can hurt your employer’s position and reputation.

Even an innocuous photo- such as of crew celebrating with non-alcoholic beer can create a negative perception. Once the images are out there, damage control is difficult. You don’t have to share everything that’s going on in your life, or all that you feel.

What you like, comment, or share is watched by the world and recorded for ever. Think before you post.

Distraction

In August 2007, a collision between the fishing vessel Vertrouwen and the motor cruiser James 2 resulted in the cruiser sinking with loss of 3 lives. Vertrouwen’s skipper used his mobile phone to send a message on social media to a friend and neglected his lookout duties.1

Do not use social media during work hours, especially if you are on watch. Period.

Are you neglecting your normal relationships?

Be mindful if your internet activity is weakening your social interaction with your shipmates while at sea. The ship is your home away from home. Nothing can replace the good time and support one can share during face-to-face conversations. Sadly, most ships these days don’t even bother to have a TV in their lounge- and seafarers stick to their own personal devices. Is it then a coincidence that suicide rates among seafarers have tripled since 2014?2

That said, I’ve met some very interesting people through social media, and learned a lot in the process. I don’t even have to remember birthdays- I get prompts so I can wish my friends on their special day.

With around 2.5 billion social network users worldwide, and growing- it’s a powerful tool. Use it effectively, and - stay social.

And please share this post!

 


Captain VS Parani, FNI, FICS, CMarTech-IMarEST is the author of Golden Stripes- Leadership on the High Seas.

1: MAIB report 02/2018
2. https://www.ukchamberofshipping.com/latest/breaking-taboo-seafarer-mental-health/

Related link: Intertanko Social Media guidance for seafarers http://www.intertanko.com/upload/106576/Social_Media_Guidance.pdf

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Steer Your ‘Leader’ Ship

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‘The problem in my life and other people’s lives is not the absence of knowing what to do but the absence of doing it’.

- Peter F. Drucker, management expert

 

 

 

Most of us maritime professionals may, through our competency exams, diplomas and training courses, gradually build our knowledge to a level which is good enough to perform our respective jobs- maybe even excel in it. That helps us to know what to do, why to do it and how to do it well. That helps us to lead with expertise.

Still, we need to be motivated enough to want to do our jobs, and alert enough to be able to do it well, consistently. To intentionally develop the mindsets and abilities to do what we need to do is to lead oneself.

But even the most accomplished professionals drift from their course, as we too may have done have at some time or the other in our career. Sometimes, we get distracted and lose focus. The tanker Attilio Levoli grounded off Southampton, and one of the factors reported was the Master’s use of the ship’s mobile phone distracting him from his navigational duties during a critical manoeuvre.

Another accident report mentioned a crew member who was walking up the stairs to his cabin with a cup of coffee and a hard-drive after watching a movie in the lounge. He stumbled- as he was not holding the rails, he fell and injured his face. He had to be repatriated home for facial surgery.

There may be days when we may simply be fatigued, or stressed, or feel unwell. Lack of sleep is a big leadership killer. The UK Marine Accident Investigation Branch reported that 'a third of all groundings involved a fatigued officer alone on the bridge at night'. Take for example the grounding of the Danio in the Farne Islands nature reserve, off the east coast of England. The chief officer, who was the officer on watch, had fallen asleep. We all know the days we are irritable and moody when we haven’t slept well -we get into an unhelpful state of mind which could cause us to make wrong decisions.

When we do not organize our time and work space, it comes back to trouble us. On the El Faro, the ship suffered loss of propulsion when it was manoeuvring to disembark the Pilot at San Juan. The investigation determined that an Oiler mistakenly closed the lube oil outlet valve instead of the salt water cooling valve. The error caused the flow of lube oil to the main turbine and gravity tank to stop. The rest of the crew responded by securing the main steam turbine and locking the shaft to prevent bearing damage. This incident was caused by a lack of adequate marking and organization of the workspace.

The sea does not care if we have a problem at home, or we don’t feel motivated enough to do a good job. A single mistake can result in grievous harm to ourselves, our team on board, the ship, the crew and the environment. However, it is possible to navigate through all these challenges and steer yourself to successful leadership. The steering model helps us remember the steps that we can take to ensure that we are at our best every day. The model is explained in detail over five chapters in the book Golden Stripes- Leadership on the High Seas.

steering model

The steering model expands to practical steps such as time management, the essentials of planning on board and helpful habits.

For example, there are tips on how to retain our attention during routine tasks:

  • give yourself time so that you are not rushed despite any distractions that may come up at the last minute
  • set up a ‘red bridge’ status so that non-essential tasks give way to high-priority tasks such as manoeuvring
  • stay ‘mindfully manual’ with techniques such as ‘pattern-interrupts’
  • engage your senses to be aware of all the cues that your workspace is offering you to react in time, and
  • to focus with techniques such as getting in the zone for a task based selective focus and a five-minute preparation.

Leading yourself is all about you. You must lead yourself before you think of leading others. You are the person everyone on the ship and ashore count on to make it happen. It is you, and only you, who is responsible for what you are able to accomplish. You can and should steer your own ‘Leader’ ship.

 

Captain VS Parani, FNI, FICS, CMarTech-IMarEST

Author, Golden Stripes- Leadership on the High Seas (https://www.amazon.com/Golden-Stripes-Leadership-High-Seas/dp/1849953147)

This article also appeared in the Safety4Sea Log May 2018 edition (https://safety4sea.com/steer-your-leader-ship/)

 

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