Generic Cause Analysis of the Navy’s Ship Collision/Grounding Problems

Why Do I Care?

First, let me state that the reason I am so focussed on the failures of the Navy to implement good root cause analysis is that I spent seven years in the Navy and have compassion for the officers and sailors that are being asked to do so much.

Our sailors and officers at sea are being asked to do more than we should ask them to do. The recent fatalities are proof of this and are completely avoidable. The Navy’s response so far has been inadequate at best.

What Should the Navy Be Doing?

What should the Navy being doing? A thorough, advanced root cause analysis and generic cause analysis of the collisions and grounding in the 7th Fleet.

If you know me, you know that I think they should be using TapRooT® RCA to do this.

Using the TapRooT® System, once you complete the analysis of the specific causes of a particular accident/incident, the next step is to identify the Generic Causes of the problems that caused that particular incident. Generic Causes are:

Generic Cause

The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes of specific root causes.

The normal process for finding generic causes is to look at each specific root cause that you have identified using the Root Cause Tree® Diagram and see if there are any Generic Causes . The three steps used in TapRooT® RCA to do this are:

1. Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
2. Ask: “Does the same problem exist in more places?
3. Ask: “What in the system is causing this Generic Cause to exist?”

It is helpful to have a database of thoroughly investigated previous problems when answering these questions.

TapRooT® Users know about the Root Cause Tree® Diagram, the Root Cause Tree® Dictionary, and the Corrective Action Helper® Guide and how to use them to perform advanced root cause analysis and develop effective corrective actions.

If you haven’t been trained to use the TapRooT® System, I would recommend attending the 5-Day Advanced TapRooT® Root Cause Analysis Team Leader Training or reading the TapRooT® Essentials & Major Investigations Books.

Navy Accident Generic Causes

Unfortunately, we don’t have all the data from the recent and perhaps still incomplete Navy investigations to perform a TapRooT® Root Cause Analysis. What do we have? The press releases and news coverage of the accidents. From that information, we can get a hint at the generic causes of these accidents.

Before I list the generic causes, we are guessing at and discuss potential fixes. Hhere is a disclaimer. BEFORE I would guarantee that these generic causes are accurate and that these corrective actions would be effective, I would need to perform an in-depth investigation and root cause analysis of the recent accidents and then determine the generic causes. Since that is not possible (the Navy is not a TapRooT® User), the following is just a guess based on my experience…

Generic Causes

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

5. INADEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

Some of these problems should be fairly easy to fix in six months to two years. Others will be difficult to fix and may take a decade (if there is the will to invest in a capable fleet). All of the problems must be fixed to significantly reduce the risk of these types of accidents in the future. Without fixes, the blood of sailors killed in future collisions will be on the hands of current naval leadership.

How to Fix These Generic Causes

5. INADEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

Fixes

• Establish a crew teamwork training class oriented toward surface ship bridge watch operations that can be accomplished while ships are in port.
• Conduct the training for all ships on a prioritized basis.
• Integrate the training into junior officer training courses and department head and perspective XO and CO training.
• Conduct underway audits to verify the effectiveness of the training, perhaps during shipboard refresher training and/or by type command staff.

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

Fixes

• Develop a standard watch rotation schedule to minimize fatigue.
• Review underway requirements and prioritize to allow for adequate rest.
• Allow daytime sleeping to reduce fatigue.
• Minimize noise during daytime sleeping hours to allow for rest.
• Review underway drills and non-essential training that adds to fatigue. Schedule drills and training to allow for daytime sleeping hours.
• Train junior officers, senior non-commissions officers, department heads, XOs, and COs in fatigue minimization strategies.
• Implement a fatigue testing strategy for use to evaluate crew fatigue and numerically score fatigue to provide guidance for COs when fatigue is becoming excessive.

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

Fixes

This corrective action is difficult because a thorough training requirement analysis must be conducted prior to deciding on the specifics of the corrective actions listed here. However, we will once again guess at some of the requirements that need to be implemented…

a. SEAMANSHIP/SHIP DRIVING/STATION KEEPING

Fixes

Driving a ship is a difficult challenge. Much harder than driving a car. In my controls and human factors class, I learned that it was a 2nd or 3rd-order control problem and these types of problems are very difficult for humans to solve. Thus, ship drivers need lots of training and experience to be good. It seems the current training given and experience achieved are insufficient. Thus these ideas should be considered:

• A seamanship training program be developed based on best human factors and training practices, including performing a ship driving task analysis, using simulation training, models in an indoor ship basin, and developing shipboard games that can be played ashore or at sea to reinforce the ship handling lessons. These best practices and training tools can be built into the training programs suggested below.
• Develop a ship-handlling course for junior officers to complete before they arrive at their first ship to learn and practice common ship-handling activities like man overboard, coming alongside (replenishment at sea), station keeping, maneuvering in restricted waters, contact tracking, and contact avoidance in restricted waters.
• Develop an advanced ship-handling course for department heads that refreshes/tests their ship-handling skills and teaches them how to coach junior officers to develop their ship-handling skills. This course should include simulator training and at-sea ship handling practice, including docking scenarios, anchoring, restricted waters, and collision avoidance.
• Develop an advanced ship handling course for COs/XOs to refresh/test their ship handling skills and check their ability to coach junior officers’ ship handling skills. This course should include simulator training and at-sea ship handling practice, including docking scenarios, anchoring, restricted waters, and collision avoidance. The course should also include training on when the CO should be on the bridge and their duties when overseeing bridge operations in restricted waters, including when to take control if the ship is in extremis (and practice of this skill).
• Develop a simulator test for junior officers, department heads, XOs, and COs to test their ship-handling and supervisory skills to be passed before reporting to a ship.
• Develop bridge team training to be carried out onboard each ship to reinforce crew teamwork training.

b. NAVIGATION

Fixes

• Perform a task analysis of required navigation shipboard duties, including the impact of new technologies and manual duties when new technologies fail (i.e. with no shipboard computerized aids).
• Develop a navigation training program based on the task analysis for junior officers, department heads, XOs, and COs. This program should be completed prior to shipboard tours and should include refresher training to be accomplished periodically while at sea.

c. ROOT CAUSE ANALYSIS

Fixes

• Develop a department head leadership program to teach advanced root cause analysis for shipboard incidents.
• Develop a junior officer root cause analysis course for simple (lower risk) problem analysis.
• Develop a senior officer root cause analysis training program for XOs, COs, and line admiralty to teach advanced root cause analysis and review requirements when approving root cause analyses performed under their command. (Yes – the Navy does NOT know how to do this based on the current status of repeat incidents and the accident reports.)

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

Fixes

• Develop a senior officer (Captain and above) training program to teach when a CO or line responsible admiral should “push back” when given too demanding an operational schedule. This ability to say “no” should be based on testable, numerically measurable statistics. For example, shipboard fatigue testing, the number of days at sea under certain levels of high operating tempo, the number of days at sea without a port call, staffing levels in key jobs, + more…
• Review undermanning and conduct a root cause analysis of the current problems being had at sea and develop an effective program to support at-sea commands with trained personnel.

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

Fixes

• Develop a numerically valid and researched guidance for the number of ships required to support deployed forces in the current and projected operating tempo for a minimum of two ocean conflicts.
• Use the guidance developed above to demonstrate to the President and Congress the need for additional warships.
• Evaluate the current mothball fleet and decide how many ships can be rapidly returned to service to support the current operating tempo.
• Review the mothballed nuclear cruiser and carrier fleet to see if ships can be refueled, updated, and returned to service to support the current operating tempo and create a better nuclear surface fleet carrier path.
• Establish a new ship-building program to support a modern 400-ship+ Navy by 2030.
• Establish a recruiting and retention program to ensure adequate staff for the increased surface fleet.

Note that these are just ideas based on a Generic Cause Analysis of press releases and news reports. Just a single afternoon was spent by one individual developing this outline. Because of the magnitude of this problem and the lives at stake, I would recommend a real TapRooT® Root Cause Analysis of at least the last four major accidents and a Generic Cause Analysis of those incidents before corrective actions are initiated.

Of course, the Navy is already initiating corrective actions that seem to put the burden of improvement on the Commanding Officers who don’t have additional resources to solve these problems. Perhaps the Navy can realize that inadequate root cause analysis can be determined by the observation of repeat accidents and learn to apply advanced root cause analysis and support it from the CNO to the Chiefs and Junior Officers throughout the fleet. Then senior Navy officials can stand up and request from Congress and the President the resources they need to keep our young men and women safe at sea.

Postscript

This wasn’t the first or the last analysis of the collisions that plagued the Navy. But I believe it is still fairly good advice based on the information that has been released…

NTSB Investigation Results

Comprehensive Review of Recent Surface Force Incidents

Press Coverage of NTSB Report

Defense News Coverage

2017 Strategic Readiness Review (US Navy)

USNI News Report

GAO Report

Readiness Reform Oversight Committee

Compendium of Readiness Articles and Reports