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Report cites 'sudden turn' by USS John S. McCain before fatal collision

Mar 8, 2018 10:38 AM

Singapore investigators detail 'missteps' after a transfer of propulsion controls

Courtesy Singapore Ministry of Transport

The following are excerpts from a report by the Transport Safety Investigation Bureau of the Singapore Ministry of Transport:

(SINGAPORE) — In the pre-dawn hours of Aug. 21, 2017, the Liberian-registered Alnic MC and the U.S. naval vessel USS John S McCain collided in the westbound lane of the Singapore Strait, in Singapore territorial waters about 4.6 nautical miles (nm) from Horsburgh Lighthouse. The collision resulted in 10 fatalities on USS John S McCain.

Conclusions

From the information gathered, the following findings are made. These findings should not be read as apportioning blame or liability to any particular organization or individual:

• The collision between USS John S. McCain (JSM) and Alnic MC (AM) as they were transiting through the Singapore Strait happened because of a sudden turn to port by JSM, which caused it to head into the path of AM.
• JSM’s sudden turn to port was due to a series of missteps that took place after a transfer of propulsion controls, which led to a confusion as to which station had steering control, and an unintentional reduction of the port engine throttle which increased the rate of JSM’s turn to port.
• JSM’s crew did not recognize the processes involved in the transfer of propulsion and steering control. The crew were likely to have lacked the requisite knowledge of the steering control system due to inadequacies in training and familiarization.
• When AM’s bridge team saw JSM turning, it presumed that JSM would be able to safely pass ahead. The collision happened within three minutes of JSM turning to port, and the actions taken by AM were insufficient to avoid the collision. AM’s bridge team was not manned in accordance with the company’s SMS (safety management system), and the master did not have full support on the bridge.

Safety actions

During the course of the investigation and through discussions with the investigation team, where applicable, the following safety actions were initiated:

• The company (Stealth Maritime Corp. S.A.) has increased its oversight of its managed ships and is considering implementing remote VDR auditing to assess the effectiveness of its SMS on board ships.
• The company has reviewed its SMS to ensure prescribed requirements for safety of navigation are adhered to, and taken measures to ensure effective bridge team management on board its vessels.
• Following the collision, the U.S. Navy issued a directive to all their assets to switch on the AIS, particularly in areas of high vessel traffic density, to enable their ships to be identified by merchant vessels and VTIS authorities.
• Reportedly concerned about the workload of crew on naval vessels, the U.S. Navy would be looking into increasing the manning levels, in addition to instituting circadian rhythm-based watch schedules in lieu of traditional five-on, 10-off watch schedules to address matters relating to fatigue.
• To improve situational awareness capabilities, the U.S. Navy is looking to reintroduce maneuvering boards or manual acquisition of all surface contacts with an initial CPA of 5,000 yards or less, and to put crew through a bridge resource management course.

Click here to view the complete report.

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