In a remarkable news conference today, a group of Navy admirals led by Chief of Naval Operations (CNO) Admiral John Richardson briefed the public on the findings of three separate but related inquiries stemming from last summer’s collisions involving USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56). Included were Navy-produced summaries of the legally- privileged investigations conducted in the aftermath of the two collisions, and a detailed “Comprehensive Review” of “surface fleet operations and incidents at sea” conducted by a panel led by U.S. Fleet Forces Commander Admiral Philip Davidson and directed by the Vice Chief of Naval Operations, Admiral William Moran. The reports are public and worth reading in their entirety.

Seventeen sailors died in the two collisions, and costs to repair damage to the ships will likely exceed $500 million. In the aftermath of the accidents, almost ten once-sterling careers were summarily ended: The Pacific Fleet commander (a four-star admiral) will retire early, the Surface Force commander (a three-star admiral) will retire early, the Seventh Fleet commander (another three-star admiral) was relieved of command, the two-star Carrier Strike Group commander was relieved, and the captain in charge of the Japan-based destroyer squadron was fired. Both ship’s commanding officers and executive officers were also sacked. These accidents have raised questions of basic competence and readiness in what has traditionally been considered the Navy’s most competent and ready force, the Japan-based Seventh Fleet. These doubts have also not gone unnoticed (or unamplified) by the propaganda efforts of the Chinese government, who have opportunistically seized on the accidents to undercut confidence in American influence in the region.

Today’s news conference and the reports are the Navy’s attempt to do four things. They first aim to provide a detailed examination of the events onboard the ships that led to the collisions without contaminating ongoing admiralty investigations. Second, they hope to tell a straightforward story so that the reader can draw conclusions as to responsibility. Third, they seek to lay bare the deep and persistent readiness problems plaguing the Navy’s Forward Deployed Naval Force in Japan in the face of rising operational commitments. Fourth, they want to relate those persistent readiness problems to the circumstances that led to the collisions. The Navy’s effort successfully addresses the first three tasks, but is somewhat unsatisfying on the fourth.

The Collisions and the Issue of Responsibility

In the aftermath of the summer’s tragedies, the most often asked question was “How can something like this happen?” Given the size, maneuverability, and relatively slow speed at which seagoing traffic moves, it seemed incomprehensible to many that ships could collide. Yet they did, and the two public documents released by the Navy yesterday provide a detailed, meticulous understanding of those events. Some may wonder why the public is not provided with the actual investigations conducted by Rear Admiral Brian Fort (Fitzgerald) and Rear Admiral Richard Brown (John S. McCain), and conspiracy theorists are likely to suspect the Navy is hiding something. Yet a fair reading of the publicly-released reports leaves the reader with a clear understanding of events and more than sufficient information to understand what happened. Specific timelines are provided. Mistakes are clearly called out, and those mistakes are identified with the watch (or position) who made the mistake. Thought processes and motivations for actions are included. And clear and unambiguous assignment of responsibility is made. What readers are not privy to are the identities of the individuals involved and other information that might be considered prejudicial to ongoing legal cases. Irrespective of that level of detail, what we are provided with are two narratives of human failure with disastrous consequences.

As someone who commanded a ship very much like the two in question, I read these reports with great interest and profound regret. In the aftermath of the Fitzgerald collision, I wrote in these pages of past collisions that, “[i]n virtually every instance, decisions made by fallible human beings were contributing factors.” Reading the Navy’s report on the Fitzgerald, this conclusion is reinforced. The person in charge of the safe navigation of the ship (the officer of the deck — usually an officer in the rank of lieutenant, junior grade) failed on several critical occasions to make required reports to the commanding officer on ships that would pass close-by. The commanding officer was asleep following a busy day of operations, but his explicit orders to bridge watch-standers warranted his notification several times that night, orders that were not followed. One of the ships the captain was not notified about was the motor vessel ACX Crystal, the other ship involved in the collision, whose track that night required the FITZGERALD to give way. These failures were repeated, and obvious, and to the extent that blame can be discerned from this collision, this officer’s actions come under special scrutiny.

Those assisting the officer of the deck (the junior officer of the deck and the junior officer of the watch — usually both ensigns) failed also to do so, or to urge the officer of the deck to take proper action. While the ship was operating in the vicinity of heavy merchant vessel traffic, the situation that they were faced with was not in and of itself extraordinarily complex: Three ships were to the Fitzgerald’s starboard side (or right) proceeding left (across the Fitzgerald’s bow), and each one of them — by the nautical rules of the road — had the “right of way,” meaning that the Fitzgerald was required to take action to avoid collision, to include slowing, turning to the right, or both. The Fitzgerald did not do either and the collision was the result.

There were additional contributing factors to this collision other than the gross professional failures of the officer of the deck. There was a lack of communication between those on the bridge and those in the “combat information center” whose job it was to serve as support and forceful backup to the bridge. There were questions of equipment configuration (especially radars), the degree to which available technology was being used, and the level of utility of the information that was available. These other factors played a role, but had the officer of the deck done what he or she knew to be the right thing, there would have been no collision. The tragedy of the USS Fitzgerald will be remembered in the U.S. Navy as an abysmally low moment in professional competence.

The John S. McCain collision is no less a story of human failure. The facts associated are somewhat less egregious, but the outcome was even more tragic. Early in the morning of August 21, the John S. McCain collided with the Liberian Flagged ALNIC MC east of the Strait of Malacca on the way to a port visit later that day in Singapore. A series of events were put in motion the previous day by the commanding officer, who with the best of intent, showed questionable judgment at several key moments in this tragedy.

The collision can be traced back to the previous day, when the ship conducted a “navigation brief” for the next day’s transit into Singapore, as required by U.S. Navy Surface Force regulations. At this brief, the planned track is explained leg by leg, aids to navigation are discussed and described, and the listing of key personnel by position (“watch-bill”) is reviewed. Because of the special demands of navigating near land and major ports, it is customary to fill that watch-bill with the most experienced watch-standers. In the special case of entering or leaving port, the “sea and anchor detail” is that team of sailors and officers. One of the jobs on that team — the master helmsman — played a key role in what happened next. The master helmsman is someone whose expertise and experience in the physical act of steering the ship and operating its engines from a control console on the bridge is of the highest caliber. This person is required to be present at the navigation brief.

The navigator, the operations officer, and the executive officer agreed that the optimal time to set the sea and anchor detail would be 0500 the next morning, which would have put the more experienced team (including a master helmsman) on deck earlier during the demanding transit to Singapore. The cost of doing so would mean that the entire ship (including members of the sea and anchor detail) would have to wake earlier than normal so that the crew could be fed before what was projected to be a three-plus hour transit to Singapore. The benefit of setting the detail earlier was clear: the presence of more experienced team members during a busy transit. Concerned with ensuring his crew got the extra hour of sleep, the captain overruled his leadership team and ordered that the detail to be set at 0600. In addition to giving the crew that extra hour of sleep, he did not want to risk a possible man overboard in the darkness of the dawn hours as crewmembers proceeded to their stations. Finally, he explained that he would be present on the bridge (as he was in fact, for the four and a half hours leading up to the collision), a signal that he believed his presence there would be sufficient risk mitigation. As events transpired, this was not the case.

On the morning of the collision, about an hour before the sea and anchor detail would report on deck (around 0500), the captain noticed that the helmsman operating the ship control console was having difficulty responding to the numerous course and speed orders he was given. This sailor was not a master helmsman, as would be required were the ship at sea and anchor detail (which it would have been by this time if the captain had followed his leadership team’s advice). To remedy this, the captain ordered that the steering and engine control functions be split, which necessitated another sailor joining the helmsman; one would steer, and one would control the engines. For this split to occur, the ship control console must be reconfigured according to a validated procedure. As it turns out, neither sailor involved was proficient in that procedure (though their administrative files indicated that they were qualified).

Steaming ahead into an area of high traffic density, the botched equipment configuration led the bridge team to believe that they had “lost steering” and so the word was passed on the ship’s announcing system to “man after steering” (a secondary location from which steering can be accomplished). Steering had not been lost, but the watch-standers did not recognize their error, nor were they able to reconcile the physical movements of the ship with their understanding of what was happening with the ship’s rudders and engines. Then came the collision.

Two decisions by the commanding officer — both well-intentioned — contributed directly to the collision. The first was to delay setting the sea and anchor detail, which would have positioned a master helmsman on the ship control console. Remember, the Fitzgerald collision had occurred less than two months earlier. There were already stories in the press about the degree to which crew exhaustion might have contributed to that accident. Giving his crew an extra hour of sleep and delaying for additional daylight to promote top-side safety seemed like good ideas to him at the time, despite the recommendations of his leadership team. The second decision was that of splitting out the steering and engine control functions, something that was not discussed at the navigation brief the day before, and something in which it turns out the assigned helm operators were not proficient.

Like the Fitzgerald, there were myriad other contributing factors that led to this collision. But stripped to its essentials, the actions of fallible human beings were central to this accident. It is difficult to conceive of this accident happening if the commanding officer had set the sea and anchor detail when his leadership team advised, which would have meant the presence of a master helmsman on deck.

The Navy suffered two collisions, 17 dead sailors, over a half-billion dollars in damage, and two ships out of commission in an already thinly-stretched theater. These accidents, as well as a collision between a cruiser and a fishing boat earlier in the year, and the grounding of another cruiser off the coast of Japan, contributed to the rational conclusion that something was deeply amiss in the Western Pacific, and it was this sense that the CNO responded to in directing Admiral Davidson’s comprehensive inquiry into surface warfare operations. Ultimately, one of the questions facing that review would be the degree to which systemic issues — if they existed — helped bring about these avoidable tragedies.

The Comprehensive Review

The third document released yesterday was the Comprehensive Review of Surface Warfare compiled by a task force of naval officers, civilians, and members of the other armed services under the direction of Admiral Philip Davidson, the commander of U.S. Fleet Forces Command. In this 60-day review, the panel was directed to conduct

a Comprehensive Review of surface fleet operations and incidents at sea that have occurred over the past decade with emphasis on Seventh Fleet operational employment to inform improvements Navy-wide.

The review is notable for its direct and unsparing assessment of the state of training, readiness, and operations in the Seventh Fleet, and it is replete with substantial and important recommendations to address the systemic issues it did find.

The “elevator speech” summary of the nearly 170 pages goes something like this: The requirements of monitoring the rise of China’s navy and North Korean aggression dramatically increased the demand for available naval forces in the Seventh Fleet. A finite number of ships were available to accomplish these missions. To ensure that the growing number of missions could be accomplished, operational commanders began to task ships for these operational requirements with decreasing regard for the level of proficiency of the ships as measured by its certification status. In other words, the mission began to crowd out training.

This “can-do” dedication to mission accomplishment created what was at best, a more casual approach to the importance of basic training and readiness of assigned ships and crews. At worst, it created a more resigned approach to the perception of a “new normal.” The report does not lay out the specific objections made by officers able to object to the imbalance between readiness and mission accomplishment. Based on conversations I have had with officers with recent service in the Seventh Fleet, those objections were made.

Over a period of three years (2014 to 2016), more than one third of the required mission area certifications for the 12 cruisers and destroyers in Japan had been “mitigated” with a waiver, as the average number of days underway for the ships increased by nearly 50 percent. These mission area certifications (about 20 on each ship) consist of administrative, material, and operational assessments in proficiency in the missions assigned to the ship. These include anti-air warfare, anti-surface warfare, anti-submarine warfare, seamanship, and navigation. By the time of this summer’s accidents, ships in based in Japan that were not in a mandated maintenance or modernization period were virtually always considered available for a wide range of missions, including ballistic missile defense patrols, and freedom of navigation operations. Their level of training and proficiency (certification status) came to be viewed as a second order consideration.

The review also dug deeply into the four 2017 incidents (three collisions and a grounding) in the Western Pacific with the aim of assessing the state of individual, team, and unit level proficiency, with an eye to how that proficiency and readiness is supported (or not, as the case may be) by the larger system of training, manning, and maintenance. To its credit, the report pulls no punches. This includes acknowledging the fact that the effort to bring readiness and schedule regularity to U.S.-based forces may have come at the cost of readiness of the forces in Japan.

A final area where the report is dead-on and unsparing, is in its criticism of the technical and material support of the surface force. Specifically, the report states that the bridge equipment — surface search radars, displays, automated identification system (a system of identification that is mandated in the commercial world and which provides real-time location information), has not kept up with the technology found on even an average commercial ship. The Navy spends its money on combat systems and weapons. Bridge and ship control technology received short shrift. The bridge watch-standers on the two Navy ships that were involved in collisions were not suffering from a lack of information generated by electronic means. Rather, they suffered from unintegrated and unreliable information, and the humans onboard were not well-served by the technology available.

Most important of all in the Comprehensive Review is an exhaustive series of recommendations that will serve as a “work-list” for the Navy, each of which is designed to address a training, manning, maintenance, or technical deficiency. It would be useful for the Navy to provide an estimated cost to implement these recommendations, some of which are straightforward and some of which (such as altering the readiness production model for forces based in Japan) have expensive force structure implications. The Navy has done a good job of identifying its own deficiencies and providing itself with a path forward. That said, there were three areas I would like to have seen better evaluated in the Comprehensive Review.

Shortcomings in Self-Critique

First, it is not clear from the comprehensive review the extent to which the deficiencies noted in the Navy’s surface fleet are confined to ships based in Japan or are applicable across the entire fleet. If what was found in the Western Pacific exists to any degree elsewhere, the Navy’s readiness problem may be deeper than suspected.

Second, there is precious little discussion in this report given the degree to which the operational requirements had increased and, crucially, who it was that was driving the operational requirements. As the military is fond of saying, “shit rolls downhill,” and the operational requirements that are so thinly stretching the Navy in the Western Pacific are the purview of the secretary of defense and the commander of the Pacific Command. It is not enough for Secretary of Defense Jim Mattis and Admiral Harry Harris to create military requirements. It is also their responsibility to ensure the forces filling those requirements are sufficient and ready, and the report does not touch on the degree to which either this or the previous secretary of defense or the commander of Pacific Command were aware of the strain on the force or efforts that they took to remedy it.

My final point may not be a criticism per se, but an observation. America’s readiness issues in the Pacific are deep and critical. They existed before these collisions, and had the collisions never occurred, would still be worthy of the attention they are now receiving. But that is not how any of this happened. Two collisions and 17 deaths shined a spotlight on a dark area of naval readiness, but those who look to associate the larger readiness problems with the actual circumstances leading to the collisions are likely to be disappointed. There is no smoking gun here. The ships that collided were fully qualified for the activities they were undertaking when they collided, irrespective of the degree to which other mission areas were not fully certified. Connecting the dots backward from an officer of the deck who knowingly violated the commanding officer’s standing orders on when to call him, to an increase in Seventh Fleet operational tasking, is a tall order, and this report does not make that case.

While experienced naval officers may feel in their bones that the readiness issues in the Pacific are closely related to these accidents, the explicit case is not made in the Comprehensive Review, and is to some extent undercut by the reports supplied by the Navy on the collisions. What is apparent is that on these two ships, basic human errors led to catastrophic outcomes. And it is also apparent that the Japan-based surface force is insufficiently supported. A systemic approach demands that both issues be addressed, and it appears that the Navy is poised to do so.

Bryan McGrath is the Managing Director of The FerryBridge Group LLC and the Assistant Director of the Hudson Institute’s Center for American Seapower. He served in the Navy and commanded USS BULKELEY (DDG 84) from 2004-2006.

Image: U.S. Navy/Joshua Fulton