NTSB Says Navy Bridge Team Failure Caused USS Fitzgerald Collision

NTSB Says Navy Bridge Team Failure Caused USS Fitzgerald Collision
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The U.S. National Transportation Safety Board has issued four safety recommendations in its 34-page final report from the agency’s years-long investigation into the 2017 collision between the guided missile destroyer USS Fitzgerald and a merchant containership.

The collision occurred shortly after the 504.5 foot-long Fitzgerald, with 315 people on board, departed its homeport of Yokosuka, Japan, bound for the Philippines. The Fitzgerald was traveling southbound at about 22 knots in the bay of Sagami Nada off Japan’s Honshu Island when it collided with the 730 foot-long container ship ACX Crystal with 21 people on board, according to the NTSB. No radio contact was made between the vessels, the NTSB said. The ACX Crystal sustained only minor damage to its bow and no injuries.

Seven sailors aboard the Fitzgerald died in the accident and three others suffered serious injuries.

The NTSB was the lead federal agency for the investigation and delegated its authority to the U.S. Coast Guard to gather documents and perform interviews on behalf of the NTSB.

Marine Accident Report 20/02 includes 11 findings, seven identified safety issues and four safety recommendations, as well as the probable cause of the accident.

Probable Cause
In the report, the NTSB stated the probable cause as the Fitzgerald’s bridge team’s failure to take early and substantial action to avoid collision as the give-way vessel in a crossing situation. Also contributing was the ineffective communication and cooperation among the crew on the Fitzgerald’s bridge and combat information center, coupled with the commanding officer’s insufficient planning for the hazards of the destroyer’s intended transit.

As for the ACX Crystal, the watch officer’s lack of early detection of the Fitzgerald and insufficient actions to avoid collision, once in doubt of the destroyer’s intentions, also contributed, the NTSB said.

“This tragedy highlights the importance of keeping a vigilant watch, determining the risk of collision, and the role of the Automatic Identification System,” said Morgan Turrell, Acting Director of the NTSB’s Office of Marine Safety. “If you are in doubt of another vessel’s intentions, you need to use proper sound and visual signals, and then take early and effective action to avoid a collision.”

Safety Issues
In addition insufficient training of the Fitzgerald’s crew and crew fatigue, the NTSB said the regular practice of U.S. Navy vessels not broadcasting automatic identification system (AIS) signals as one of the key safety issues in the accident. On the day of the accident, the Fitzgerald was not transmitting its data, although it was receiving information about other vessels in the area.

The NTSB’s report also highlighted the failure of both ships’ crews to take actions in accordance with the Convention on the International Regulations for Preventing Collisions at Sea; insufficient oversight and directive by the U.S. Navy; the commanding officer’s inadequate assessment of the transit route’s hazards; and the commanding officer’s decision to not augment bridge watchstanding personnel with a more experienced officer.

Safety Recommendations
As a result of the investigation, the NTSB issued a total of four safety recommendations, including three to the Navy and one to Sea Quest Management Inc., the operator of the ACX Crystal.

For the Navy, two safety recommendation call for review and revision of fleet-wide training and qualification requirements for officers of the deck related to the collision regulations, as well as review and revision of bridge resource management training. The third seeks to broadcast of automatic identification system information when in the vicinity of commercial vessel traffic, at all times, unless such broadcast could compromise tactical operations.

The safety recommendation issued to Sea Quest Management Inc., meanwhile, seeks additional training for navigation officers on collision avoidance regulations, radar and automatic radar plotting aids.