When Ships Collide: Implications of Context, Compliance, and Readiness

When Ships Collide: Implications of Context, Compliance, and Readiness

Last week, when the USS Fitzgerald collided with a Philippine cargo ship, many people wondered in this day and age how such things can happen. Doesn’t modern technology exist like radar and radio communications to prevent this? Weren't both crews alert and on watch? Even if the technology systems failed, couldn't the crews have maneuvered each ship out of the way of the oncoming ship? Further, what can such mishaps tell us about organizational ethics and compliance failures?

In catastrophic situations like these, typically no one error leads to the accident. Typically, a series of events occur: unheeded warnings, human and system errors, environmental errors, and other intangibles, which lend themselves to accidents like this happening. The US Navy’s protocol is for nearly constant training and drills to minimize the chance of this happening. However, it is nearly impossible to train for every potential circumstance or contextual situation.

I was on the USS Eisenhower (CVN-69), an aircraft carrier, returning from a six-month Mediterranean deployment when we ran into an anchored Spanish Collier (the Urduliz) at 0821 on August 28, 1988 near the Hampton Roads Bridge Tunnel, just 4,000 yards from our home pier.

How do I know? I was on the USS Eisenhower (CVN-69), an aircraft carrier, returning from a six-month Mediterranean deployment when we ran into an anchored Spanish Collier (the Urduliz) at 0821 on August 28, 1988 near the Hampton Roads Bridge Tunnel as we were sailing back to Norfolk, VA, just 4,000 yards from our home pier.

That morning, all crew were not on watch—instead, we were in our dress whites, preparing to man the rails. When a ship is underway, it tests a series of daily alarms, including general quarters and a collision alert, at the same time every morning. On that fateful morning after the scheduled test, at 0819, the collision alert sounded, and very shortly afterward the ship listed hard from port to starboard. Now, if you haven't sailed on an aircraft carrier, one thing to note is that unless you are in the roughest seas, you wouldn't even know you were underway. It's like walking around any office building. So, to feel the 1,092-foot ship move this way was unnerving, to say the least.

Luckily, no serious injuries occurred on either vessel. Millions of dollars of damage befell the Eisenhower, and we pulled into port with the evidence of the collision. Ultimately, the commanding officer lost his ship, and his naval career was basically ended. You can read a full summary of the report here. One of the major causes for the collision was the lack of a harbor pilot (the waterway and navigational buoys had been adjusted since the departure six months earlier) and a reliance by certain “officers of the deck” on the whims of the ship's navigator.

Let's think about the deadly collision of the USS Fitgerald with the Philippine cargo ship. What could have potentially caused this accident?

According to the Japanese Coast Guard, the accident happened around 1:30 AM, local time.

This is significant for a couple of reasons. The mid-watch on ships runs from 10:00 PM until 2:00 AM. You typically take the watch over at fifteen minutes before the watch and also want to walk through your watch station before you relieve your shipmate. So, this collision happened at watch turnover time from mids to the dog watch, or 2:00 AM to 7:00 AM timeframe. Also, this was at night. Note the reverse track the destroyer took after the collision. This would be standard after a collision as the crew circles back to search for any sailors who may have fallen overboard.

The combination of watch turnover, time of night and other factors likely were contributory of this fatality-producing accident. Because the Philippine cargo ship was three times as large as the US Naval ship, it created more damage to the destroyer. If you haven't been on board a combatant ship before, you may not know that much of the ship's crew sleeps at or below the waterline. This, I believe, is why our sailors perished. They were in berthing or other areas in the middle of the night, below the waterline, which was breached during the accident.  This caused the spaces to quickly flood, probably while the sailors were asleep.

Numerous investigations of this incident will continue for years to come, with lessons learned shared with others so, hopefully, similar accidents can be avoided.

If you work in the world of compliance or other risk-based training, these incidents offer important lessons:

  • Train in a variety of contexts, the more realistic the better. If the situations you train in aren't real or legitimate, or don't stretch the imagination of your learners, it is harder to prepare them for real-life situations.
  • Don’t limit training to optimal conditions; much of what goes wrong occurs when conditions are not ideal, when employees already are under stress or fatigued.
  • Design training around the weakest points in a process to test how employees respond when the process is most vulnerable. This may yield the best lessons and the greatest preparation for future situations.
  • Incorporate past failures into future training to reinforce prior lessons and test employees’ new aptitudes.
  • Don’t train just to the specific incident; many problems occur in situations not currently envisioned. Train employees to holistic problem recognition, evaluation and resolution so that they can apply skills learned in one situation to others that are unforeseen.


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Written by Darin Hartley, M.Ed., US Navy Veteran, Director of Marketing

Posted in Code of Conduct, Compliance Training, Ethics and tagged , , , , , , , , , , , , , .