WASHINGTON — Two accidents that claimed the lives of 17 sailors and wounded dozens more resulted from complete breakdowns in standard Navy procedures and poor decision-making by officers and sailors on the bridge of the two warships, according to a Navy report obtained by Defense News.

The Navy plans to release on Wednesday its first official report on the specific causes of the two unrelated collisions this summer when both the destroyers Fitzgerald and John S. McCain struck commercial vessels in crowded sea lanes in the Pacific.

The report reveals that both collisions came after critical failures of officers and sailors on the bridge and raises troubling questions about the basic proficiency of the Japan-based 7th Fleet and the surface Navy as a whole.

In both incidents, sailors on the bridge failed to sound a ship-wide alarm notifying the crew of danger, which is a standard Navy procedure.

Ships at sea must sound five short blasts of the ship’s whistle to alert the crew and the other ship of a coming collision. That did not occur in either collision. Neither the crew members below deck nor the other ships involved had any warning from the Navy that their ships were headed for disaster, the reports found.

Also, neither bridge’s watch standers sought to make bridge-to-bridge radio communication with the approaching ship, which is also a standard Navy procedure.

Yet the specific failures that led to the collisions on each ship were unique.

The June 17 collision between the Fitzgerald and the motor vessel ACX Crystal off the coast of Japan was the result of a complete failure of safeguards put in place to prevent at-sea accidents, as well as clear violations of standing orders to inform the commanding officer when approaching ships pose a safety risk.

The McCain’s Aug. 21 collision with the oil and chemical tanker Alnic MC near the Strait of Malacca appeared to be the result of a series of mistakes by the ship’s bridge watch-standers and heavy risks assumed by the commanding officer in a busy shipping lane.

The reports issued to the public, while incomplete, put to rest a parade of wild theories that arose in the wake of the shocking accidents, which assigned responsibility for the incidents to everything from terrorism to Chinese or Russian cyber attacks.

The reports also shed new light on the full extent of the damage sustained by the destroyers, with no fewer than 14 spaces, lockers and escape trunks on McCain flooding completely, and 17 on Fitzgerald.

In the case of Fitzgerald, the officer of the deck failed to notify the ship’s captain that the destroyer was closing with the Crystal despite standing orders requiring it. On McCain, the captain was present on the bridge the whole time.

Both ships lost track of their situations completely, said Capt. Rick Hoffman, a retired cruiser captain who reviewed the documents for Defense News.

“The thing that stood out to me was in both situations they had minimal situational awareness,” said Hoffman. “In the case of Fitzgerald, nearly criminal negligence on the part of the bridge watch team. And in neither case did the ship sound five short blasts or raise the general alarm to let anyone know they were in danger.”

The Navy did not release the full investigations but only a summary of the findings, citing ongoing legal proceedings. The collisions led to the relief of both commanding officers and several other crew members, as well as the destroyer squadron commander, the Ronald Reagan Carrier Strike Group commander and the 7th Fleet Commander.

It was the first time a numbered fleet commander has been relieved since World War II.

The Navy tasked Fleet Forces Commander Adm. Phil Davidson with conducting a wide-reaching review of operations in 7th Fleet and the surface Navy more broadly. A 33-member panel conducted the review and the results are set to be rolled out later this week.

Davidson is set to recommend an admiral be appointed to oversee the implementation of his recommendations, according to a copy of the endorsement letter obtained by Defense News.


The probes into Fitzgerald and McCain discovered two very different sets of conditions with a common outcome.

As the Fitzgerald sailed into the busy waters near Japan it cut through a channel with specific rules for navigation known as a a traffic separation scheme. The ship did not have the navigation patterns on its charts and repeatedly drove across the bow of ships exiting the channel.

The Fitzgerald’s commanding officer was in his cabin prior to the collision, which took place at 1:30 a.m. The report documents numerous mistakes made by the officer of the deck, who is the main officer in charge of safe navigation while on watch.

At one point, the Fitz crossed the bow of an oncoming merchant ship at a range of less than 650 yards — fewer than four ship-lengths — but the officer of the deck never informed the captain, a violation of standing orders that requires the skipper to be summoned to help oversee hazardous conditions.

The CO, Cmdr. Bryce Benson, did not know the ship was headed for a collision until the bow of the ACX Crystal punched into his stateroom. He was ultimately rescued by crew-members as he clung to the outside of the ship. He had been in command for less than a month.

Also, at no point prior to the collision did the officer of the deck attempt to make contact with the Crystal on bridge-to-bridge radio, nor did the OOD try to maneuver to avoid Crystal until only a minute before the collision.

Meanwhile, down in the Fitzgerald’s combat information center, which displays inputs from the ship’s weapons systems and radars, the watch standers there failed to “tune and adjust their radars to maintain an accurate picture of other ships in the area,” the report found. That means CIC failed to track the multiple ships exiting the channel.

The Fitzgerald’s watch-standers also failed to use the Automated Identification System, a publicly accessible computer program that provides real-time updates on the location and speed of merchant ships in the area.

Fitzgerald’s lookouts failed as well, with the investigation indicating the sailor or sailors assigned to look out for hazards were literally looking the other way the whole time.

“Watch-standers performing lookout duties did so only on Fitzgerald’s port side, not on the starboard side where the three ships were present with the risk of collision,” the report reads.

The report also found that crew fatigue was likely a factor because the ship had a full day of inspections and qualifications prior to the accident.

With no warning, sailors below deck at the time of the collision had between 30 and 60 seconds to evacuate the rapidly flooding berthing. Some were jarred awake by seawater flooding their bunks.

Seven sailors died on Fitzgerald, all of them in and around the flooded berthing compartments.


The complete breakdown in Navy norms on Fitzgerald stands in sharp relief to the accident on McCain, where the commanding officer presided over the whole incident.

It was just before dawn when the McCain headed into the Strait of Malacca, one of the busiest waterways in the world. The ship’s commanding officer, Cmdr. Alfredo Sanchez, had been on the bridge overseeing navigation in the heavily trafficked area near Singapore for more than four hours when the accident occurred at 5:23 a.m.

The failures on McCain began hours before accident.

Sanchez had decided to give his crew some extra rest and delayed orders putting his crew on what is known as sea and anchor detail, which requires more sailors and puts the ship at a higher state of readiness. That includes a bulked up navigation team, a full suite of lookouts and a master ship driver on the bridge.

Sanchez ordered the crew to set sea and anchor detail at 6 a.m. instead of an hour prior, when the ship entered the shipping lane heading into the Strait of Malacca. The ship’s operations officer, executive office and navigator had all recommended the ship set sea and anchor at 5 a.m. for safety reasons.

The critical failure came when the current was pushing the ship left and Sanchez noticed the helmsman — usually a junior sailor charged controlling the ship’s steering and speed when ordered by the officer of the deck or conning officer — was having trouble keeping the ship on course.

The master helmsman who would perform these tasks during a sea and anchor detail was still in the chow line at the time.

At 5:20 a.m., Sanchez ordered a second watch-stander to help run the controls to steer the ship, letting the helmsman keep control of the rudder while giving the second watch-stander control of the speed and position of the ship’s two propellers — a position known as the lee helm.

Putting two sailors at the separate positions required changing the ship’s steering configuration and shifting control of engine propeller speed to another part of control console.

But changing the control mechanisms immediately led to confusion because they mistakenly shifted all of the controls — both rudder and engine speed — to the second console.

As a result, the helmsman could no longer control the steering. He initially believed he had lost steering due to a mechanical failure, when in fact, he was just confused about the configuration of the equipment.

Four minutes before the collision, confusion began to run wild on the bridge while watch-standers attempted to fix a nonexistent loss of steering.

Complicating the situation further, changing in steering configurations forced the rudder to revert to a center line position, releasing the previous position that was set to the right between one and four degrees to fight the current that was pushing the ship left.

With the rudder unintentionally set to center line, the current continued to push the ship left of track.

During the confusion, when the bridge thought they had lost control of steering, the commanding officer ordered the engine to slow the ship’s speed from 20 knots to five. But the sailor at the console controlling the speed of the two propellers only slowed the port shaft to five knots, while the starboard shaft was still turning at 20 knots, abruptly pushing the ship sharply to the left and into the track of the Alnic MC for more than a minute.

An officer on the bridge ordered the steering controls to be shifted to a space near the rear of the ship that can also control steering, known as aft steering. But that was not yet manned due to Sanchez’s decision to man sea and anchor at 6 instead of 5 a.m.

The McCain’s steering configuration was changed five times in the roughly three minutes before the collision, according to the Navy report.

By the time the aft steering was manned and the sailor on the bridge fixed the speed issue that was forcing McCain left of track, it was too late.

The collision with Alnic MC at 5:23 a.m. created a 28-foot hole in the side of McCain, flooding spaces within seconds and killing 10 sailors, most of whom appear to have been crushed to death or drowned in the berthing.

David B. Larter was the naval warfare reporter for Defense News.

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