From Maritime Reporter: Groundings result from compound errors

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Groundings result from compound errors


Even the most sophisticated warship can find herself someplace she doesn’t want to be:  aground.


Professional mariners know that the consequences of grounding run from a minor delay in meeting the schedule to total destruction.  Professional mariners also know that problems have a way of compounding themselves.  The U.S. Navy’s most serious grounding occurred in 1923 at Honda Point, Calif., when seven destroyers, operating at night in fog, followed one another onto the rocky coast (see related story).  Some of those destroyers had the latest radio navigation systems.  That was a long time ago, but there is a lesson for all of us, even today, that even with automated bridge systems and electronic navigation, warships and commercial vessels can make a series of errors that can lead to grounding.  The common thread in all of these incidents is that these groundings could have been prevented.


Capt. Brian Boyce, USN (Ret.), instructor navigation for Marine Safety International (MSI), in <?xml:namespace prefix = st1 ns = “urn:schemas-microsoft-com:office:smarttags” />Norfolk, offers some lessons on groundings that somebody learned the hard way.  Many of the mistakes that resulted in groundings are common threads in multiple incidents.  And while these incidents apply to naval vessels, they are germane to seafarers everywhere.


A guided missile frigate (FFG) was entering Ponce, Puerto Rico, in 1996.  The commanding officer (CO) deferred to the pilot’s advice, but the ship found herself outside the channel.  The navigation team’s plot held the ship outside the channel and warned the CO and the conning officer.  The pilot disagreed with the warnings from the navigator and the team in Combat Information Center (CIC), and did not follow their recommendations to get back into the channel until it was too late.  The subsequent investigation found that the pilot was fatigued.  But the report also noted that the ship was able to determine that it was outside the channel – despite the sharp disagreement of the pilot – and did not take timely appropriate action.  Lessons learned:  Complacency, and expecting things to go well and being unprepared for when they don’t is one common thread.  There is a failure to recognize that an error chain is developing.  The failure to react to early clues and slow or stop the ship is another common thread. 


A recently commissioned guided-missile destroyer DDG was completing a port visit in 1996 at St. Maarten in the Netherlands Antilles following Combat Systems Qualification Testing (CSQT) Type Training in the Puerto Rican Operation Area.  The navigation brief was held early on a Sunday morning, and was not conducted professionally.  Last-minute changes to the watch bill resulted in key members of the navigation detail who had not attended the brief.  The charts used were not up to date.  Throughout the process, CIC was not engaged and did not offer recommendations. Although it appeared that the ship had a safe track planned for departure from the anchorage, once underway, they found their desired course was blocked by an inbound cruise ship.  The CO improvised a new departure plan, but failed to involve the key team members (Conn, Nav, CIC) on the new plan. 


No one had the same vision as to what the new plan was. As they drove south to cross the bow of the inbound cruise ship, the conning officer was preparing to come right to pass the inbound ship starboard to starboard when the navigator recommended coming left to avoid shoal water (a reef) off the starboard bow. Once in extremis, the ship failed to take immediate action.  After a short (but very costly) delay, the ship decided to come left, but they turned too little too late.  Ten minutes after getting underway from her anchorage, the DDG ran aground on Proselyte Reef.  Proximate causes were lack of situational awareness with respect to the well-charted reef, failure to use the whole team, and poor planning. This was compounded by the late departure and need for hurry to make their next event.  It took $10 million and nine months to repair the ship.  Lessons learned:  The ship’s team did not react to very significant error chain clues.  They also did not have a slow-and-stop abort plan in their tool bag. 


An FFG grounded off Alexandria, Egypt, in 1999.  Although the Port Directory was specific in directing where to meet the pilot, the ship did not follow the stipulation and proceeded into port prematurely.  It was late in the day and they were probably anxious to get into port.  Once in the narrow channel, the FFG encountered an outbound Navy CG.  This forced the FFG to turn to seaward and head back out.  After the CG cleared, the FFG again attempted to enter the channel but were directed by the port authority to return to sea. This time, the conning officer miscalculated his position and against the navigator’s strong recommendation, he turned the ship into danger and the FFG ran aground.   Lessons learned:  Poor planning, lack of teamwork, fatigue and confusion caused this incident.



A U.S. Navy amphibious ship (LST) taking part in the UNITAS 2000 exercises with South and Central American navies, and was preparing for a pre-dawn amphibious landing exercise when she ran up onto the rocky bottom.  The 522-foot ship, carrying 240 Marines and their equipment, was operating in darkness and fog.  It was getting ready to deliver eight vehicles to the beach, when it hit a reef, opening up a 40-foot long hole.  No one was injured, but the ship was declared a total loss, stripped, used as a gunnery target and sunk.  The ship was using the Global Positioning Satellite  (GPS) for navigational fixes, but was plotting them on Chilean charts.  Lessons learned:  GPS uses a point at the Earth’s center as a datum, but the Chilean charts used a point on a promontory of land (see related story).  The difference was disastrous.


An amphibious transport (LPD) grounded in the Suez Canal in 2000.  The LPD was anchored in Great Bitter Lake and was preparing to depart for northbound transit of the waterway. The ship had a safe plan but when the pilot boarded, the plan was changed to one that would save some time and distance.  The original plan had the advantage of operating inside the well-marked channel; the new plan was well outside the channel and relied on reference to a small number of buoys marking the general anchorage area. Except for buoys, the area is featureless.  As the ship transited north, they lost situational awareness and when attempting to enter the main channel grounded outside of it. Lessons learned:  The basic cause here was failure to craft a safe plan when the pilot asked for a change or failure to adhere to the old plan.


“Quite often when we review the circumstances of a grounding it is apparent that one or more members of the team recognized that the ship was standing into danger,” says retired Capt. Jim Barber, author of Naval Shiphandler’s Guide, published by the Naval Institute Press.  “Yet through timidity, failure to communicate clearly, or because their warning was ignored the ship went aground.  Any discrepancy between navigation teams must be immediately addressed and resolved without the ship proceeding further into possible danger.”


No one source of information is infallible, and no individual is immune to error, Barber says.  “Thus for critical matters such as navigation in restricted waters we rely on multiple teams and multiple sensors.  Three teams, the conning party, the Navigator and his assistants, and CIC must be mutually supportive.  All use the same planned track, and if circumstances require deviation from the plan it is vital that everyone understand the new plan.”


According to Boyce, ships rarely ground in familiar waters. “Unfamiliar waters require very careful planning and a very disciplined approach to execution.  All the available tools for knowing where the ship is relative to danger have to be used and the team has to be proficient in how to use them. The ship must have a full toolbox of abort and fail-safe maneuvers and be prepared to stop or slow when the ‘risk meter’ goes into the red.  A non-complacent attitude of ‘chronic unease’ is absolutely necessary and communications among all the key team members must be effective.”


Ships have access to new and better technology, but they also need the best available training on how to use it, says Boyce. 


Barber agrees.  “GPS is so convenient and usually so accurate that there is a strong temptation to rely upon it to the virtual exclusion of other sensors.  This is a mistake.  We need to habitually compare GPS results with all other sensors, particularly including fathometer, radar, and visual.”


Retired Rear Admiral Dave Ramsey says that responsibility for collisions must often be placed above the shipboard level.  “Senior leadership needs to take an interest in what's happening.  We need to get the right technology on our ships, and we need to make sure our people know how to use it.  For example, there’s no standard fleet course that teaches Automated Radar Plotting Aides.  We still have Navy people who don't know how to use it.”


“In the commercial world the causes of groundings show similar error chains,” says MSI’s Ed Lynch.  “Complacency or fatigue on the part of the pilot and the bridge team not taking charge early enough.  The bridge team does not give the pilot the assistance requested or he does not ask for their assistance or ignores the info provided.”


Planning and anticipation are important.  Says Barber, “We must think through in advance how to react to potential problems.  What if we have an engine or rudder malfunction?  In what direction is deep water?  Where are the shoals and narrow places in the channel?  Current?  Ship traffic?  Danger bearings?  The ship control party must be prepared to react appropriately to any emergency.”  


In unfamiliar waters a written plan and a carefully considered track are particularly important, Barber says.  “Any requirement to deviate from the plan is a red flag and needs prudent evaluation.  Saving a few minutes at the price of a riskier transit is almost never justified.”




Destroyers end up on the rocks

One mistake follows another


The Navy's greatest navigational tragedy took place in September 1923 at an isolated California coastal headland known as Honda Point. Officially called Point Pedernales, Honda Point was not far from the busy Santa Barbara Channel.


Thirteen destroyers of Destroyer Squadron (DesRon) 11 departed San Francisco for a two-day cruise to San Diego. The squadron comprised the five ships of Destroyer Division (DesDiv) 33, led by Delphy (DD-261), followed by S.P. Lee (DD-310), Young (DD-312), Woodbury (DD-309) and Nicholas (DD-311); six ships from DesDiv 31, with Farragut (DD-300) followed by Fuller (DD-297), Percival (DD-298), Somers (DD-301), Chauncy (DD-296) and Kennedy (DD-306); and three ships from DesDiv 32, Paul Hamilton (DD-307), Stoddert (DD-302) and Thompson (DD-305).


The ships formed a column on the squadron leader Delphy.  The flagship broadcast an erroneous report–based on an improperly interpreted radio compass bearing–showing the squadrons position about nine miles off Point Arguello. From that position the ships plotted a dead reckoning course.  An hour later, the destroyers turned east to enter what they believed was the Santa Barbara Channel, though it could not be seen because of thick fog. Unusually strong current complicated the navigational situation.  When Delphy turned, the other ships followed, but they were not where they thought they were, and seven of them ran aground along the rocky coast.


There were eight hundred officers and men on those ships, but only twenty-three lives were lost. All seven vessels: the Delphy, S.P. Lee, Young, Woodbury, Nicholas, Fuller and Chauncey were declared total wrecks.


The ships were employing a new radio compass system.  The system was working, but the bearings received were misinterpreted. The official investigation said the groundings were attributable to “bad errors in judgment and faulty navigation.”  In an endorsement to the record of the court of inquiry, the Chief of the Bureau of Engineering said: “The Bureau desires to emphasize the fact that such devices as radio compasses, sonic depth finders, etc., are reliable only to the extent that they are operated properly, and recommends that the attention of the forces afloat be directed to the necessity for continuous training in their use.”






A standard point of reference


By Robert Freeman,

Office of the Navigator of the Navy


Since antiquity, mapmakers have struggled with the problem of representing a bumpy, ellipsoid (the earth) on a flat, rectangular surface (the map).  To do this requires some compromise in the relative position of individual points to each other.  Historically, mapmakers have picked a point of interest to them to be the center of their depiction, and placed various features in their relative position to that point.  For instance, an early English mapmaker might have chosen to place England at the center of his chart. More than just having personal appeal, this makes sense in terms of accuracy, since the farther one is from the reference point, generally, the less accurate the depiction.


This was fine for giving a general depiction of landmasses and water bodies. By laying a coordinate system (longitude and latitude, for example) over the geographical features, you could provide a frame of reference that could be shared by other users.  But maps based on different central points could differ radically in the coordinate position of a location away from those centers.


In the modern world of interoperability and precision positioning, this problem is greatly amplified. The solution is to reference each chart and map to a “datum.”


A datum is a mathematical model of the shape of the earth used as a basic reference to calculate position coordinates, heights, and distances, as well as to make maps and charts.  The datum defines the point from which all positions are referenced.  For example, the WGS 84 point of origin is the center of the earth's mass, as measured by the 1984 World Geodetic Survey (hence WGS 84).  The North American Datum, NAD 27, is referenced to a ranch in Kansas, considered to be the approximate center of the continental United States.  For the Tokyo datum, all points are referenced to the center of Tokyo.


There are literally hundreds of datums in use.  The DOD standard datum is WGS 84, and this is the one to which GPS defaults, but there is no “world standard datum.”  GPS gives positions based on WGS 84, so a position plotted on a chart using a different datum could differ by as much as a half mile with respect to ports, and up to two miles with respect to isolated islands!  Several ships have run aground due to a poor understanding of datums!


This problem becomes more critical when the subject is targeting.  During the military action in Lebanon in 1983, Marine Corps spotters ashore were directing the naval gunfire from a battleship.  Unfortunately, the ship was using WGS 72 coordinates, while the Marines were using European Datum coordinates.  The target was missed and shells landed uncomfortably close to friendly forces.  Fortunately, there were no casualties!


Until a world standard datum is adopted, the solution to this problem must reside in training.  And while algorithms exist for translating from one datum to another, this is no substitute for understanding.  GPS is a wonderful innovation for navigation, providing instantaneous, real-time fixes at an accuracy that far exceeds conventional methods.  But navigators must be aware of its limitations and understand how to compensate when using charts based on other datums.





Edward Lundquist is a retired U.S. Navy captain.  He is a senior technical director for Anteon Corporation, Washington, DC

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