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NAVIGATION CASE STUDIES

NAVIGATION CASE STUDIES. CAUSES OF MARITIME ACCIDENTS. 16%. 7%. Human Factors. 1%. Equipment Failure. Weather. Other. 76%. (Bureau of Transportation Statistics 2001). ERROR CHAIN. Series of non-serious incidents culminating in a major incident. LINKS IN THE ERROR CHAIN.

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NAVIGATION CASE STUDIES

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  1. NAVIGATION CASE STUDIES

  2. CAUSES OF MARITIME ACCIDENTS 16% 7% Human Factors 1% Equipment Failure Weather Other 76% (Bureau of Transportation Statistics 2001)

  3. ERROR CHAIN Series of non-serious incidents culminating in a major incident.

  4. LINKS IN THE ERROR CHAIN • AMBIGUITY - Things don't add up. • DISTRACTION - Something of relatively minor importance is occupying our attention at the expense of staying focused on more critical tasks.  • FEELING OF UNCERTAINTY / CONFUSION - Usual "rhythm" is "out of sync”.  • BREAKDOWN IN COMMUNICATIONS - People involved in the evolution are not exchanging information in a timely and effective manner. Key people are being kept "out of the loop.“ • IMPROPER WATCHSTANDER - The ship is being handled in an incautious or reckless manner. • DEVIATION FROM PLAN - A good plan is not being followed. • VIOLATION OF ESTABLISHED RULES OR PROCEDURES - We are possibly or knowingly breaking a rule or standard procedure. • COMPLACENCY - An expectation of positive outcome not substantiated by objective reasoning or analysis.

  5. USS LA MOURE COUNTY (LST-1194) 2000

  6. SITUATION • Tasking: Proceeding to anchorage/marine debarkation point for an amphibious assault exercise ICW two Chilean Navy ships. Grounding occurred at 0517Q (local time), 12SEP00. • Navigation teams instead of using NGA charts used UNAUTHORIZEDChilean Chart 206 (Does not utilize WGS-84 Datum). • Weather conditions: - Visibility: 10nm, no moonlight, slight coastal mist - Temp: 60F - Winds: 180-200T, 18-22 kts - Sea state 2 (seas 5-7 ft) - Current: flood - State of tide: low 0253, high 0813

  7. Intended Track by GPS Actual Track Actual Track Intended Track by GPS 0500 Shift Charts 0500 Shift Charts Nav’s Plot (GPS fixes on local Chart) Intended Track 0513 1000 yds abeam Nav’s Intended Track Chart Error 191 deg 1800 Yds GPS Error 191 deg 1800 Yds

  8. LMC TIMELINE • 0445: NAVIGATOR OBSERVES OOD AND OOD UNDER INSTRUCTION (U/I) DIRECTING CONNING OFFICER TO FOLLOW NAVIGATOR'S RECOMMENDATIONS UNLESS SPECIFICALLY TOLD NOT TO. • (NOTE: THIS EVOLUTION IS CONNING OFFICER'S FIRST OTHER THAN OPEN OCEAN STEAMING) • 0511: XO APPROACHES CO AND VOICES CONCERN THAT SHORELINE LOOKS AWFULLY CLOSE IN NOD AND SHIP SHOULD COME RIGHT TO OPEN DISTANCE, JUST TO BE SAFE. • CO ACKNOWLEDGES RECOMMENDATION. ALTHOUGH XO DOES NOT RECALL CO'S EXACT RESPONSE, XO BELIEVES THAT SHIP IS GOING TO COME RIGHT. • 0513: XO QUESTIONS NAVIGATOR TO DETERMINE SHIP'S COURSE. BASED ON NAVIGATOR'S RESPONSE, XO BELIEVES SHIP IS COMING RIGHT. • (NOTE: NAVIGATOR'S RECOLLECTION OF EXCHANGE WITH XO IS THAT SHIP COULD COME RIGHT TO INTERCEPT TRACK, BUT NAVIGATOR RECOMMENDS MAINTAINING COURSE 155.) • LMC DOES NOT ALTER COURSE.

  9. LMC TIMELINE • 0514: CIC REPORTS NO FIX AND RECOMMENDS BARE STEERAGEWAY. • NAVIGATOR NOTES RECOMMENDATION, BUT RECOMMENDS MAINTAINING COURSE AND SPEED. • SINCE CO STANDING NEXT TO CHART TABLE, NAVIGATOR ASSUMES CO HEARS REPORT FROM CIC AND NAVIGATOR'S RESPONSE. • 0515: (APPROX) OS1 (CIC WATCH SUPERVISOR/SHIPPING OFFICER) COMES TO BRIDGE. • OS1 DIRECTS NAVIGATOR'S ATTENTION TO SITUATION AND RECOMMENDS COMING RIGHT TO 220 NOW.

  10. LMC TIMELINE • 0515: CIC RECOMMENDS COURSE 200 VIA 21MC. • OOD DIRECTS CONN TO FOLLOW NAVIGATOR'S RECOMMENDATIONS BECAUSE NAV PLOT IS PRIMARY PLOT. • 0516: CO MOVES TO PORT BRIDGEWING AND OBSERVES ROCKS JUTTING OUT FROM COAST LESS THAN 200 YDS DEAD AHEAD. • CO MOVES TO BRIDGEWING DOOR AND ORDERS "ALL BACK FULL, ALL BACK FULL EMERGENCY.“ XO NOTES SPEED OVER GROUND BETWEEN NINE AND TEN KNOTS ON COMMERCIAL GPS. • 0516: SHIP MISSES FIRST PROTRUSION OF ROCKS.

  11. LMC TIMELINE • 0517: SECOND PROTRUSION OF ROCKS APPEARS DIRECTLY FORWARD OF BOW. • 0517: LMC HARD AGROUND IVO PUNTA ARTIGAS.

  12. INQUIRY REPORT • NAV BRIEF WAS NOT ATTENDED BY 6 OF 15 POSITIONS INCLUDING: • OFFICER OF THE DECK (OOD) • 1ST LIEUTENANT • CONNING OFFICER • PILOTING OFFICER • SHIPPING OFFICER/SENIOR OPERATIONS SPECIALIST (OS). • CO-APPROVED NAVIGATION PLAN INCLUDES TRACK RUNNING 1600 YDS TO • NEAREST SHOAL WATER, ON PORT BEAM. NAVIGATOR AGAIN MENTIONS LACK OF VISUAL NAV AIDS. • THERE IS NO DISCUSSION OF MAKING CIC PRIMARY PLOT DUE TO LACK OF VISUAL NAV AIDS.

  13. USS ARLEIGH BURKE (DDG-51) 2007

  14. ARB TIMELINE • 1600: WAITING FOR END OF ENG DRILLS. • BUOY CB IS JUST TO THE NW OF THE SHIP. • APPROXIMATELY 10 MINUTES EARLIER THE AFT WSN DISPLAYED A ‘223’ ALERT. • 1627: DESPITE THE AVAILABLE NAVAIDS IN THEIR HOME WATERS, THE SHIP IS NOT PLOTTING ANY OTHER FIX SOURCE THAN GPS.

  15. ARB TIMELINE • 1638: THE FIRST VISUAL LOP, TO CHESAPEAKE LIGHT, IS LOGGED BUT NOT DRAWN ON THE CHART BECAUSE IT DOES NOT COMPARE WITH THE PLOTTED FIX. NAV CONTINUES TO USE UNCERTIFIED COMDAC. • 1648: THE POSITION ERROR HAS INCREASED TO 1.98NM. ADDITIONAL LOPs NOT PLOTTED.

  16. BUOY 2C 290T ARB MISSES TURN AND CONTINUES TOWARD SHOAL WATER

  17. 1652: SHIP’S REPORTED AGROUND POSITION.

  18. ERROR ERROR Lack of NAVSSI/ COMDAC knowledge ERROR Perceived pressure to arrive on time ERROR Lack of Situational Awareness ERROR Failure to use proper Navigation procedures ERROR ERROR CHAIN Failure to adhere to WSN-7 CSOSS procedures WSN-7 was in a Schuler Oscillation that created a 4300yd position error.

  19. OVERVIEW Actual Position Plotted Position

  20. USS PORT ROYAL GROUNDING

  21. FACTS • Ship grounded at 2005 Local on 5 FEB 09 • Conducting Pax Transfer south of Honolulu Airport Reef Runway • Just completed first day of Sea Trials testing • Astronomical Data: • Sunset: 1828 • Moonrise: 1428 – 65-70% Illumination • Tidal Data: • LW: 051813W -0.3ft • HW: 060159W 2.3ft • Range: 2.6ft. • WEAX: Partly cloudy. Wind E 5-10 kts. Sea State 1. • Ship was NOT ECDIS-N Certified.

  22. MATERIEL ISSUES • Fathometer Inoperable • The crew thought the fathometer was operable, but realized that it was not shortly after getting underway. • SCC gyro repeater failed • While still in the turning basin a loss of gyro was sounded • Once the problem was isolated to the SCC repeater the Nav detail shifted to relative plot and magnetic headings • Though magnetic headings were required, the plot should have remained true • The Bearing Takers still had accurate gyro bearings • EM Log Inoperable • Not rewired by the shipyard following maintenance • Port and Centerline Bridge SPA-25G repeaters OOC • WSN-7 RLGN not correctly configured

  23. Hickam Wharf (RHIB Destination) Grounding Location PH Entrance Channel

  24. NAV DETAIL NOT STATIONED • Mod-Nav detail consisted of the QMOW and a Nav Evaluator, contrary to NAVDORM, CO’s Standing Orders and Navigation Doctrine (developed by an OSC). • Nav Doctrine requires a Nav. Evaluator and 2 QMOWS on the bridge as well as a Shipping Officer and Navigation Radar Operator in CIC. (Note: only the two most Junior QMs onboard had ever read the Nav Doctrine) • NO extra personnel in CIC • CIC watchstanders engaged in Strike scenario preventing them from focusing on the navigation picture. • At some point, Nav Evaluator assumed duties as plotter, effectively removing himself from his supervisory role and sacrificing situational-awareness. • QMOW was a junior QM with limited plotting experience, so the Nav Evaluator deemed it necessary to take over the plot. • “Who’s Checking the Checker”?

  25. ROOT CAUSES • Failure to adhere to basic navigation principles • Failure to follow established procedures • NAVDORM • CSOSS • Failure to adhere to the basic tenets of Operational Risk Management

  26. ROOT CAUSES • Failure to adhere to basic navigation principles. • NO EVIDENCE of a proper DR being maintained at the plot. • Nav detail not stationed in restricted waters • MOD-Nav detail stationed, though NOT IAW ship’s NAV Doctrine and NOT IAW CO’s Standing Orders • Full Nav Detail not stationed until 10 minutes AFTER ship grounded. • Of note: Logs and records were not adequately maintained so as to provide accurate reconstruction of the event.

  27. NO EVIDENCE OF A PROPER DR • Purpose of a DR: • Projects ship’s position into the future • Allows the navigator to EVALUATE ship’s movements and its proximity to hazards. • The DR is one of the most BASIC FUNDAMENTALS of navigation. Without it, the plot becomes simply a reflection of past history. • Unfortunately, the DR is the most underutilized tools at the QM’s Disposal. • Lack of an effective DR plot is a common issue in almost every grounding incident.

  28. ROOT CAUSES • Failure to adhere to established procedures. • NAVDORM: • Full Navigation Detail was not set in restricted waters • Failed to compare backup fix sources at prescribed intervals using an alternate fix source (visual/ RADAR) • No coordination between Bridge and CIC • CIC not focused on navigation • VMS displayed WSN-7 (RLGN/INS) position vice GPS as required • NAVDORM requires INS to never be used in restricted waters • NAVDORM required FOM 2 (never verified) • Ship relied heavily on VMS, using it almost exclusively even though the Navigation system and crew were not certified to do so.

  29. ROOT CAUSES • CSOSS • WSN-7 not configured per CSOSS • G1 Port closed • EM log set to VMAN=0 (manual speed input at 0 knots) • 72-hour WSN-7 Dockside Calibration not performed properly • 72 hour calibration required once per quarter • Ship’s crew attempted calibration, but completed in 48 hours • 20-Hour Dockside Calibration conducted 10 days prior to underway • Required at WSN-7 startup as long as 72 hour cal is good. • Last GPS fix accepted by WSN-7 four days prior to underway • Not receiving GPS because the G1 port was closed between GVRC and WSN-7 • WSN-7 Tech made a conscious decision to skip steps of CSOSS with no supervisory oversight • Evident because all CSOSS steps were ignored.

  30. VMS ISSUES • 6 hours prior to grounding, VMS position source was shifted from FWD GVRC to FWD RLGN. • There is no indication from any log, or via interview as to who shifted the position or why • This was a major contributing factor to the grounding • Many alarms were received and disregarded • Prior to shifting, VMS received 20 “Position Discrepancy” alarms from 0830-1200 • VMS received 380 “Position Discrepancy” alarms between 1200-2003. • A simple review of the alarms and a questioning attitude would have prompted corrective action.

  31. VMS ISSUES • Operators not proficient in verifying proper sensor configuration • Operators not sensitive to alarm conditions • In short, the Nav Team relied solely on VMS without question.

  32. RISK-FACTORS TO CONSIDER • Ship had just completed a 4-month drydock period • Nav Team proficiency level is LOW. • Operational proficiency is LOW • Status of navigation equipment untested • First underway period for new CO. • Second command-tour • Last command tour ended in 2004 • Crew tired after aggressive first-day Sea Trials agenda. • Sense of urgency to get riders off the ship?

  33. NAVIGATION CONCERNS • Team Proficiency • Piloting can be a perishable skill. • Coordination issues with Bridge/CIC? • Proximity of shoals and other hazards • Did they NEED to be where they were? • Waning light conditions • Low-Speed maneuverability issues

  34. NAVIGATION QUESTIONS • Were tripwires in place and briefed? • Danger bearings • Danger ranges • Danger soundings • Were the plans for navigation, contact, management and ship-control meshed as one?

  35. SUPERVISORY ISSUES • Senior leadership experience not brought to bear • CO distracted by strike-scenario, making frequent trips between bridge and CIC • XO and OPS directed to supervise boat operations • NAVDORM requires XO to supervise navigation while in restricted waters • Nav Evaluator assumed duties as Plotter • Lost situational awareness when duties became single-scope and had NO supervisory oversight. • Resulted in a one-man navigation detail • Navigator not involved until after the grounding.

  36. INQUIRY BOARD • Mission saturation on the first day of sea trials created an environment that allowed operations to be executed without being properly briefed. • Although key watchstanders were qualified, they were not proficient due to extended time in port. • Procedures were not adhered to. • Bridge, Nav and CIC teams did not work together to assess the situation and prevent the ship from standing into danger. • Did not recognize visual cues/aids to verify ship’s position against primary plot.

  37. INQUIRY BOARD “THE SIB REJECTED NAVIGATIONAL EQUIPMENT ERROR AS THE CAUSE OF THE MISHAP. ALTHOUGH THIS EQUIPMENT PROVIDED ERRONEOUS TRACK INFORMATION AND HAMPERED SITUATIONAL AWARENESS, OTHER  MEANS WERE AVAILABLE TO ASSESS THE SHIPS POSITION.”

  38. THE BOTTOM LINE • Navigation and ship handling skills are perishable and must be thoroughly evaluated pier side after an extended in port period. • All pre-underway checks need to be completed properly and all CSOSS procedures need to be thoroughly followed. • Procedural Compliance (NAVDORM, CSOSS, Standing Orders, etc.) is not a goal, it is a STANDARD!

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