GROUNDING INCIDENT

GROUNDING INCIDENT PLOTTED AFT WSN-7 AND LOGGED FURUNO POSITIONS STARTING AT 1600Q QMCM(SW) FAHEY OPNAV N84N3 FINAL Brief: Rev 1.0

Learning Objectives • Upon completion of this Lecture the Student will: • Understand the Navigator’s responsibility to ensure proper navigation equipment setup, operation and maintenance; • Understand the purpose for following required Navigation procedures; • Understand how to recognize and prevent faulty electronic positions from being used.

KEY TO DISPLAY 36 FOOT SAFETY DEPTH WSN PLOT FURUNO PLOT CGOUTLINE RE-PLOT DONE USING VMS 7.7.1. THIS SYSTEM WAS NOT ON BOARD

T- 1600 NAVIGATION DETAIL SET AT 1530; SHIP MILLING AROUND, SPEED 5 KNOTS, AT THE TERMINUS OF THE SOUTHERN TSS, 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- SYSTEM UNDAMPED (EXCESSIVE TIME)- AT LEAST 84 MINUTES OF UNDAMPED OPERATION . THE SYSTEM THEN COUPLED TO IT’S VELOCITY REFERENCE: VMAN, WHICH IS SET TO 0.0KTS.

Aft WSN 5 Kts Ord 1600Q 1545Q Error 223

T- 1610 SHIP MOVES TOWARDS THE TSS, BUT DRILLS CONTINUE. SEA AND ANCHOR WILL BE SET ONE MINUTE AFTER THIS; ONE MINUTE LATER 15 KNOTS WILL BE ORDERED. BOTH NAVIGATION TEAMS ARE USING NAVSSI (COMDAC) NRS’S FOR POSITIONS; HOWEVER, ONLY THE CIC TEAM LOGS THE POSITIONS. THE BRIDGE LOGS FURUNO GPS POSITIONS. INVESTIGATORS DETERMINE BOTH NRS’S ARE SHOWING INS2-- AFT WSN-7-- POSITIONS, NOT GVRC1 OR GVRC2 AS REQUIRED.

T- 1618 BY 1618 THE ENG DRILLS ARE OVER AND THE SHIP IS HEADED IN. 22 KNOTS HAS BEEN ORDERED AND THE EOOW IS BRINGING UP THE TWO OFF-LINE MAIN ENGINES. THE BLACK WSN REPLOT IS SLIGHTLY TO THE EAST OF THE FURUNO POSITION AND 3-MINUTE FIXES HAVE BEGUN. THE BEARING RECORDER, NEWLY ABOARD, WAS DIRECTED TO LOG FURUNO POSITS, ALTHOUGH THE NAV PLOTTER ONLY PLOTS THE WSN-7 POSITION FROM THE COMDAC DISPLAY.

T- 1621 THE SHIP IS HEADING UP THE TSS, 25 KNOTS ORDERED AT 1620. THE SEA AND ANCHOR OOD TOOK THE WATCH AT THE SAME TIME. AT ABOUT 1620, ONE MAIN ENGINE WAS PUT ONLINE, EXIBITED HIGH VIBRATIONS AND WAS AUTOMATICALLY TAKEN OFF-LINE. IN THREE MINUTES THE SEA AND ANCHOR CONNING OFFICER WILL ASSUME THE WATCH. BASED UPON THE WSN DATA, THE SHIP IS ON COURSE 294.8T AT 22.8KTS.

Aft WSN 5 Kts Ord 1600Q 1615Q 1630Q 1545Q Error 223 25 Kts Ord 15 Kts Ord 22 Kts Ord

T- 1627 THE BRIDGE NAV TEAM, SEEING THAT THE SHIP WAS GETTING TO WITHIN 2NM OF ‘RESTRICTED WATERS’, PLOTTED A 1627 INS2 FIX AS THEY SHIFTED TO EVEN- MINUTE (2MIN) FIXES. CLOSE EXAMINATION SHOWS THAT THE 1627 FURUNO POSITION IS ALREADY AHEAD OF THE 1628 INS2 POSITION- A TOTAL ERROR OF OVER 800 YARDS. DESPITE THE AVAILABLE NAVAIDS IN THEIR HOME WATERS, THE SHIP IS NOT PLOTTING ANY OTHER FIX SOURCE. COG- 300.6T, SOG- 23.1KTS INS2 1628Q FURUNO 1627Q

T- 1630 THE SHIP HAS PASSED BUOY SET 7 AND 8 AND IS SETTING UP FOR THE TURN TO 316T. THE FURUNO POSITIONS START TO RAPIDLY SEPARATE FROM THE INS2 POSITIONS BOTH NAV TEAMS ARE PLOTTING, AND ACTUALLY PLOTS AHEAD OF THE 1632 INS2 POSITION. THE CURRENT ERROR IS 1200YDS, A 50% INCREASE IN 3 MINUTES. THE INS BEGINS REJECTING THE GPS FIXES. COG- 302.0T, SOG- 22.9KTS FURUNO INS2

T- 1634 WITH BUOYS 9 AND 10 ASTERN OF THE SHIP, BUT COMDAC SHOWING 9 AND 10 AHEAD OF THE SHIP, CSE 316T IS ORDERED. AN IMPROMPTU EVENT BEGINS ON THE BRIDGE. THIS LASTS SEVERAL MINUTES. THE SHIP IS 1200 YARDS FROM THEIR 36-FOOT SAFETY DEPTH. THE POSITION ERROR HAS INCREASED TO 1622YDS. SINCE BOTH TEAMS ARE PLOTTING INS2, THEIR FIXES COMPARE WITHIN THE 25YDS REQ’D BY THE CO. COG- 302.2T, SOG-22.0KTS

T- 1636 THE SHIP STEADIES ON CSE 315T. THE 1636 INS POSITION ISN’T VISIBLE ON THIS CHART. A 1MC ANNOUNCEMENT IS MADE AS THE SHIP PASSES BUOYS 11/12. THIS SLIDE OFFERS THE BEST EXAMPLE OF THE WORSENING POSITION ERROR. THE COMDAC LOG OF THE 1638 GVRC1 POSITION IS CLOSE BY THE 1638 FURUNO AND 1642 INS2 POSITIONS, BUT THE 1638 INS2 POSITION IS 1.28NM ASTERN, WITH INS1 CLOSE BY. GVRC2 IS WITHIN 20YDS OF GVRC1. COG- 315.3T, SOG-22.6KTS

FURUNO 1640Q BY THIS TIME ALL EVENTS ARE COMPLETE. DUE TO THE CLEAR SKIES, THE BRIDGE IS HAVING PROBLEMS SEEING THE BUOYS DUE TO GLARE. THE NAVIGATOR IS LOOKING AT COMDAC TO CONFIRM THE PLOTTED (INS2) POSITIONS. NOTICE HOW AT 1640 THE SHIP WILL BE ABEAM OF BUOYS 13/14, BUT THE COMDAC WILL SHOW THEM ABEAM OF 11/12. THE FIRST VISUAL LOP, TO CHESAPEAKE LIGHT, IS LOGGED BUT NOT DRAWN ON THE CHART BECAUSE IT DOES NOT COMPARE WITH THE PLOTTED FIX. COG- 315.7T, SOG-23.6KTS T- 1638 FURUNO 1638Q INS2 1640Q

T- 1640 SHIP IS JUST ABEAM OF BUOYS 13/14. THE NAVIGATOR HOLDS THE SHIP ON TRACKS AND RECOMMENDS ‘MAINTAIN COURSE AND SPEED’. SET/DRIFT 140T AT 0.4 KTS. ONLY ONE BUOY SET REMAINS BEFORE THE TURN, BUT COMDAC SHOWS THAT SET 13/14 IS STILL AHEAD OF THE SHIP. TWO VISUAL LOP’S ARE LOGGED BUT NOT DRAWN ON THE CHART. COG- 315.5T, SOG- 24.0KTS

T- 1642 SHIP IS AT THE TOP OF THE TSS, ABOUT TO ENTER THE PRECAUTIONARY AREA. BUOYS 15/16 ARE OFF THE PORT BOW. THE SHIP HAS COME OVER TO 316T. THE POSITION ERROR HAS INCREASED TO 1.71NM. NAV HOLDS THE SHIP ON TRACK AND RECOMMENDS MANTAINING COURSE AND SPEED. DUE TO THE INS2 ERROR HE BELIEVES THAT HE STILL HAS THIS BUOY SET PLUS ONE MORE SET BEFORE THE TURN. COG- 317.0T, SOG- 24.3KTS FURUNO

T- 1644 THE SHIP IS IN THE PRECAUTIONARY AREA WITH CAPE HENRY ABOUT 3.3NM TO PORT; 1.73NM OF ERROR EXISTS. TWO MORE VISUAL LOP’S ARE LOGGED BUT NOT PLOTTED. A TOTAL OF SEVEN HAVE BEEN RECORDED SO FAR. COMBAT HASN’T LOGGED ANY RADAR LOP’S; THE SHIP DOESN’T EXPECT ANY RADAR FIXES UNTIL THE SHIFT TO THE NEXT CHART, 12222. COG- 316.7T, SOG- 24.1KTS BUOY NCE

T- 1646 ABOUT THIS TIME, PROBABLY AFTER THE NAV REPORT, THE CO ASKS THE NAVIGATOR IF THE BUOY TO PORT IS CH; HE RESPONDS THAT IT’S ACTUALLY RED 16, AND PASSES A 290T BEARING TO CH, BASED UPON THE COMDAC DISPLAY. THE INS2 POSITION IS 1.98NM BEHIND THE SHIP’S TRUE POSITION. THE 290T BEARING POINTS TO BUOY RED 2C. NO-ONE USES THE SPS-73 RADAR TO LOOK FOR BUOY CH’S RACON. TWO MORE UNPLOTTED LOP’S ARE LOGGED. COG- 316.9T, SOG- 24.6KTS BUOY NCE

T- 1648 BUOY 2C THE SHIP HAS PASSED IT’S NORMAL TURN POINT AND IS ONLY 1650 YARDS (LESS THAN 2MIN AT 25KTS) FROM THE 36-FOOT SOUNDING DIRECTLY AHEAD. DUE TO THE 1.91NM POSITION ERROR, BOTH NAV TEAMS ARE SETTING UP FOR THE TURN AROUND BUOY CH. IN ONE MINUTE THE NAVIGATOR WILL RECOMMEND HIS SECOND CONSECUTIVE ‘MAINTAIN COURSE AND SPEED’. THE 1646 SET/DRIFT WAS 148T @ 0.2 KTS. COG- 317.3T, SOG- 24.9KTS 290T

T- 1650 BASED UPON WSN DATA, AT 16:50:02 THE SHIP BEGAN PITCHING UP AS IT STARTED TO GO AGROUND. IT STOPPED MOVING NORTHWARD 71 SECONDS LATER. CIC WAS MARKING 500 YARDS TO THE TURN; THE BRIDGE WAS AT 1000 YARDS. THE SHIP THOUGHT IT HAD LOST STEERAGEWAY, OR HAD AN ENGINEERING CASUALTY. THE POSITION ERROR IS NOW 2.15NM. COG- 318.8T, SOG- 22.9KTS BUOY 2C

Aft WSN 5 Kts Ord 1600Q 1615Q 1630Q 1.6’ Deviation (Long) 1545Q Error 223 Grounding 25 Kts Ord 15 Kts Ord 22 Kts Ord 1.4’ Deviation (Lat)

T- 1652 SHIP’S REPORTED AGROUND POSITION. THE SCHULER OSCILLATION MADE THE INS2 POSITION MOVE IN A BUTTON HOOK TO THE SOUTH-WEST ACROSS CAPE HENRY, THEN UP TOWARDS BUOY 2C. AT 1830 THE WSN-7 TECH REPORTED THAT THE WSN’S HADN’T RECEIVED UPDATES FOR THE PAST TWO HOURS. ONCE HE ALIGNED THE WSN’S TO THE GVRC’S, THE POSITION ERROR DIMINISHED.

T- 1652 SHIP’S REPORTED AGROUND POSITION. THE SCHULER OSCILLATION MADE THE INS2 POSITION MOVE IN A BUTTON HOOK TO THE SOUTH-WEST ACROSS CAPE HENRY, THEN UP TOWARDS BUOY 2C. AT 1830 THE WSN-7 TECH REPORTED THAT THE WSN’S HADN’T RECEIVED UPDATES FOR THE PAST TWO TWO HOURS. ONCE HE ALIGNED THE WSN’S TO THE GVRC’S THE POSITION ERROR DIMINISHED.

Aft WSN 5 Kts Ord 1600Q 1615Q 1630Q 1.6’ Deviation (Long) 1545Q ~ Time of Aft INS reset Error 223 Grounding 25 Kts Ord 15 Kts Ord ~ Time underway 22 Kts Ord 1.4’ Deviation (Lat) ‘Hook’

Grounding Incident Swiss Cheese Model of Confounding Factors

Swiss Cheese Failure to adhere to WSN-7 CSOSS procedures 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 How a degraded WSN-7 position led to the grounding. WSN-7 was in a Schuler Oscillation that created a 4300yd position error.

OVERVIEW Actual Position Plotted Position

SUMMARY FIX SOURCES • Authorized Sources: GPS, Visual, Radar, Composite, in all waters. INS in open ocean, (absolute last resort in restricted waters). NAVSSI Blended (RTS) position …NEVER AUTHORIZED… • Single Source: GPS only authorized source in all waters, however all sources must be verified with other source at least every third fix. • Every CO has to specify fix source priority in the NAVBILL for all waters.

SUMMARY AUTHORIZED PROCEDURES • CSOSS: Verify proper procedures are followed for various operations, Getting U/W, Anchorage, Entering Port, etc. • NAVDORM: Six rules of DR, Alternate sources, Proper checklist preparation and usage. Proper Logging. Proper detail setup and manning • BRM: Ensure bridge is utilizing radar, Communication circuits, Backing each other up.

SUMMARY • STT: Always have STT on station. EVERY transit is a training opportunity. • Display Setup: Know your choices, and know your equipment- setup, procedures, and standards. NAVBILL must specify settings to ensure safety. IN CONCLUSION: “Trust But Verify” and Demand Proper Procedural Compliance.

End

GROUNDING INCIDENT