November 20, 2009 | Mark Paradies

MORE on the USS Hartford Collision JAG Manual Investigation

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(USS Hartford returning to port after collision)

Anyone who has ever investigated any major accidents knows that a major accident always has human errors. Never is everything done right and an accident still happens. After the errors are identified, the question an investigator needs to answer is WHY did the individuals involved make the mistakes.

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Also, some of the mistakes will probably be:

– people breaking rules,

– people making bad decisions,

– people not being alert, and

– people not catching errors.

And IF you knew what was going to happen in advance, you could always plan better and avoid the accident. (Hindsight is always 20/20.)

So keep this in mind when you review the JAG Manual Investigation of the collision.

Now for my comments (no particular order – just stream of consciousness when I went through the report).

1. Redacted

There were many pages that were “redacted” – so getting a really clear picture of the details of the investigation was difficult.

2. Reported Root Causes

The “root causes” of the collision were fairly easy to decipher from the report and the attached letters approving the report.

The Commander, Submarine Forces, says:

The cause of this collision was preventable human error.”

But later in his letter he says:

The fact that a preventable collision did occur was due to ineffective and negligent command leadership.

The Commander, US Fifth Fleet, says:

This exceptionally costly and preventable mishap was caused by human error on the USS HARTFORD…

The JAG Manual Investigation Report says:

“The answer to ‘how’ and ‘why’ those promary errors were able to occur near-simultaneously lies within the collision’s root cause: ineffective command leadership {see Findings of Fact 113-195}.

Later (page 12) the report says:

“... the combination of poor tactical planning and poor watchstanding practices cause the collision.”

3. Here’s the Answer – Now Go Find It!

When you start with an answer in mind, finding the cause is easy.

Reading the report, it seemed to me by the questions that were asked and the information that was presented, that the investigator was looking for a particular answer: “Who is to blame”.

Finding that answer is pretty easy on a submarine – the CO is to blame. So all the investigating officer has to do to have a successful investigation is to find evidence that blames the CO.

When I read the report the information that WAS NOT available was more interesting than the information that WAS available.

For example, the were transiting the straight at periscope depth in the dark at about 1AM local time. Yet I didn’t see any formal assessment of fatigue of the watchstanders as a part of the report.

The CO and XO were both asleep when the collision occurred. Why wasn’t one of them in control for this evolution. Again, was fatigue involved?

The “comprehensive plan” for the strait transit was either non-existent or incomplete and the CO didn’t do a good risk analysis before the evolution. The report indicates that this type of report/risk analysis would have made the watchstanders more “situationally aware” and they would have had a “sense of heightened risk” during the evolution. Of course, I ask myself, “Would a piece of paper really do that?” Beyond that, the report doesn’t say if making this type of plan is a standard practice, required, recommended, or why the CO didn’t develop the plan. Again was fatigue involved?

I didn’t see any human factors evaluation of the displays involved. I think this is very important, especially with the training problems that the report pointed out (more on this later).

I also didn’t see the results of past command audits and assessments. If this crew and it’s leadership were so bad, why didn’t the Navy know? Why weren’t the problems picked up prior to deployment of on inspections and assessments?

Maybe the missing facts were in the redacted part of the report.

4. Big Investigation

This was a big investigation. One hundred fourty hours were spent interviewing seventy-five people on the USS Hartford and the USS New Orleans. The investigation took about 40 days (three time-extensions were requested and granted).

Some witnesses were advised of their rights in accordance with Article 31b of the Uniform Code of Military Justice. All witnesses who were advised of their rights waived their rights and participated in this disciplinary investigation. (I wonder if they think that is a good idea now?)

5. Separate Safety Investigation

There was a separate and simultaneous COMNAVCENT Safety Investigation Board (SIB) investigating the collision in addition to the JAG Manual Investigation. The JAG Manual Investigators shared their information with the SIB but the SIB didn’t share “privileged” witness or derivative information with the JAG Manual investigation team.

It certainly would be interesting to review the SIB Investigation Report and compare it with the JAG Manual investigation.

As far as I know, no NTSB investigation was carried out (no civilian transportation involved).

6. Training Problems – Is This a Cause?

Training problems were evident in the report, but the Navy’s training program was never questions.

For example, the report said:

Watchstander level-of-knowledge was poor on the concept of relative motion and on the importance of bearing drift to collision avoidance. The ship’s self-assessment process neither recognized that deficiency nor took action to correct it. nearly every watchstander interviewed, when presented raw bearing information and sonar data, indicated (through their answers) that a constant-bearing-rate contact was of less concern than a high-bearing-rate contact.

Also, the report said:

All JOOWs, most JOODs, and some OODs interviewed had difficulty drawing line-of-sight diagrams for Sonar display data. Most JOOWs, most JOODs, and most OODs stated a high contact bearing rate was a larger concern than a contact with a 0-degree per minute bearing rate.

These “findings” are basic seamanship. How can such findings only apply to one ship? And if they don’t understand basic seamanship, how was a risk analysis going to help?
I think the basic problem here that all submariners face is to potential to confuse a target that is far away (and thus has low bearing rate drift) to a contact that is close and on a collision course (and thus has zero bearing rate drift). This is the same mistake the USS Greeneville made when it collided with and sank the Japanese fishing vessel the Ehime Maru (pictured below).

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7. Everyone Else is a Good Guy

I especially liked this final paragraph before the “Accountability” (i.e. discipline) section of the report:

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I guess from reading this, only the BAD people were on watch that night. And the BAD people set the standards. And the BAD people didn’t prepare adequately. And everyone else was good.
Anyone here a hint of the Salem witch trials in the statement above? (We are all pious and holy except for those bad witches – all problems must be their fault – let’s burn them at the stake!)

8. Accountability.

Millions of dollars of damage was done by this accident so in Navy/government philosophy, somebody needs to be blamed and disciplined.

In Navy tradition, that person should be the CO and the OOD.

However, in this accident, they went much further. The XO (who was asleep and had a later watch) got it.

The Navigator, who was awake a 1 AM and taking a test while listening to an iPod, got it. (I think this creates a new navy standard – Anyone who listens to an iPod while aboard a sub deserves punishment!)

Sixteen other people were disciplined as well.

Twenty people total with ruined careers. On a sub with just over 100 crewmembers, that a pretty high percentage of the people on board.

They must have discovered all the bad ones – perhaps all the bad people in the entire Navy.

Now have nothing to worry about. All collisions at sea involving submarines will cease!

9. Accountability Upward

I saw nothing in the report about overworked crews, exhausted leadership, the toll that stress can take over time, excessive operating/deployment scheduled, to few assets (subs) to cover the missions assigned, …

In other words, the causes of a very well trained crew having an accident as result of being worn out by constant stress in today’s Navy.

No that would point accountability upward. The investigator knew that was the wrong direction to look.

10. Am I Right or Wrong?

You really didn’t have to be too perceptive to find a hint of sarcasm in my writing about this accident and the following JAG Manual Investigation..

If you ask me how I “know” that the investigation was predestined to blame the CO, all I can say is that the Navy hasn’t changed since the days of sail.

Could I be wrong? YES!

Am I wrong? How would we know?

These types of non-independent investigations that are looking for someone aboard the ship to blame don’t provide the facts anyone off the ship needs to make an informed decision.

Thus, I guess at causes based on my experience and what I read between the lines.

I could be right.

I could be wrong.

But I wish they were actually asking the right questions, finding the real root causes, and developing effective corrective actions so that we could save lives and prevent millions of dollars of damage in the future by prevent more collisions at sea.

We didn’t learn from the collision with Ehime Maru and we might not learn from this collision if this is as good as the investigation gets.

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