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A lone seaman recommended the mine countermeasures ship Guardian avert course out of a restricted zone. Yet this warning was ignored and the crew soon smacked into a protected reef, destroying the ship and setting off an international incident.
This revelation is among the findings in a new report released Thursday that faults the commanding officer and his navigation team for the Jan. 17 grounding of the Guardian on a reef off the Philippines.
The 160-page report is the most detailed investigation yet released on the grounding and provides new details on the missteps leading up to the accident and more context on the decision to fire the ship's commanding officer, Lt. Cmdr. Mark Rice, and three shipboard leaders. It also coincides with the findings of a safety incident report that was reported in late April, which concluded that watchstanders dismissed electronic navigation alarms and troubling discrepancies between the chart and what they were seeing, which should have prompted them to reassess their situation.
The report characterized the grounding as "entirely preventable" and paints a picture of a warship where navigation was sloppy and watchstanders were lax. Rice was aware that the ship's track led right over a reef on a large-area general chart but decided that was OK since it was clear by a few miles on a coastal chart. Rice and his navigation team did not attempt to assess the discrepancy between the charts, as required.
Rice later explained his rationale to rely solely on the coastal chart, saying that "it is well known that general charts are inaccurate," according to the new report released by the Pacific Fleet.
But it was the coastal chart that proved inaccurate. Guardian ran aground at almost the exact position plotted on the general track: the south islet of the Tubbataha Reef, a national marine sanctuary. Had the Guardian somehow cleared these shoals, it was still on track to hit another navigation hazard, the report notes.
The report laid bare countless errors, but makes clear that these began with sloppy navigation planning. Neither Rice or his navigation team recognized the danger of entering a restricted area around the reef or followed rules that require warships to steer clear of territorial seas, either of which would have prevented the grounding, these reports said.
"There is nothing more fundamental to a professional mariner than the safe navigation of his or her vessel," the investigators wrote in their report, dated March 11. "As this investigation shows, the U.S. Navy is 'relearning' painful lessons taught by the grounding of USS Patriot (MCM 7) near Chinhae Bay, Korea on 19 March 2005 and the grounding of USS Port Royal (CG 73) on 5 February 2009."
Pacific Fleet estimates that the grounding has cost the Navy a running total of $44 million, a figure that does not include the total loss of the ship or expected claims by the Philippines.
In a sign that the errors were serious and widespread, the Navy in early April fired the skipper and much of his navigation team, including the second-in-command, Lt. Daniel Tyler, who double-hatted as the navigator; the lieutenant junior grade standing officer of the deck at the time of the grounding; and a chief quartermaster who served as the assistant navigator and was the quartermaster of the watch when the ship struck the reef.
"Further disciplinary and administrative action is under consideration," Adm. Cecil Haney, the head of the Pacific Fleet, wrote in his May 22 letter closing the report.
On Thursday, Pacific Fleet spokesman Lt. A.J. Falvo did not rule out more reprimands, stating via email that further administrative action is possible.
Rice, who has been reassigned to Expeditionary Strike Group 7 and was first contacted by Navy Times to comment on the safety investigation two months ago, said "I am still not in a position to provide a statement" in an email, citing ongoing legal issues.
Rice and his navigator had plotted the ship's track to skirt two atolls in the Sulu Sea, as the ship headed from the Philippines to Indonesia. The general chart, which displays the entire region in a small scale, displayed them running directly into the Tubbataha Reef. But the closer-in coastal chart incorrectly showed they could safely clear it.
Most watchstanders were unaware of this discrepancy and the night orders made no mention of the ship's closing within four miles of land, a distance that requires the ship to set a navigation detail to provide more precise plotting.
The coastal chart misplaced the reef by eight miles. That meant the bridge and combat watchstanders were navigating on the wrong chart and were literally in the dark about what they were steaming towards.
But crewmembers did not make required reports, like 'radar landfall' or 'unexpected sighting of a navigation aid,' that may have alerted the skipper in time that all was not what it seemed. They did not rigorously attempt to resolve the confusion. The investigators concluded that the watch teams often dismissed automated warnings on the electronic charting system without reviewing or reporting them and speculated that the volume of the audible alarms had been turned off.
One exception, however, was the 20-year old seaman who told the officer of the deck that the electronic charting Voyage Management System warned that the ship had entered a restricted zone and recommended leaving it. He also recommended setting the navigation detail, as required.
The officer of the deck, a lieutenant junior grade who also served as the ship's communications officer, relayed this to Tyler, the double-hatted XO and navigator then asleep in his stateroom.
The OOD later told investigators he told Tyler the distance to the reef and recommended setting the NAV detail. Tyler, however, recalled that the OOD didn't relay the distance, did not express any concern and did not suggest the detail.
Tyler considered this "a routine-albeit unnecessary report" and determined no NAV detail was needed.
Roughly an hour later at about 1:30 a.m., radar picked up a contact that appeared to be a white light off the bow. The combat information center reported it as a barely moving small boat or ship. Thinking it was a fishing boat, the OOD turned starboard to avoid it and also avoid calling the sleeping skipper.
Lookouts observed that the light flashed every five seconds, like a buoy or other navigation aid, and asked the OOD about it. Confusion persisted. As the light grew nearer over the next 50 minutes, some watchstanders began to think it may be a navigation light. The OOD, who had been expecting to see this light off the port beam, gradually came around to this thinking. But he did not stop immediately or notify the CO, as is the norm when the ship's position is in doubt. By then it was too late.
The helmsman, a mineman 3rd class, recalled "everyone on the bridge looking at the lighthouse," the report said. "This was the only thing that the remembers the bridge watch team doing before the ship ran aground" at 2:20 a.m.
The investigation, while thorough, was hampered by the loss of logs when the crew later abandoned ship, by the emergency destruction of some of the electronic charting logs, and was dependent on crewmember memories many days after the accident. In addition, two unnamed crewmen invoked their right against self-incrimination and declined to be interviewed.
Nonetheless, the report found plenty of room for improvement. Officials recommended that ships be "required to immediately report" digital chart discrepancies and ordered a thorough review of digital charting programs, with special attention to ways that the system can be more user-friendly.
One fix suggested: Piping navigation alarms into a speaker so they can't be ignored.