USS JOHN S MCCAIN COLLISION

Sumo

War Hero
All three - His relief was announced earlier this year with handover originally due for some time within the next few weeks, then into retirement.

Whilst it makes sense to get the new man in early he was definitely pushed:

<<... Adm. Scott Swift, commander of U.S. Pacific Fleet, dismissed Aucoin "due to a loss of confidence in his ability to command," the U.S. Pacific Fleet said in a statement.

It said Rear Adm. Phil Sawyer will assume command of the 7th Fleet immediately. Aucoin had expected to retire this year, but his superiors decided to push his departure date due to concerns over his leadership skills, the New York Times reported. Aucoin has commanded the Japan-based fleet since September 2015...>>
Yep read all that, in the link you provided
 
All three - His relief was announced earlier this year with handover originally due for some time within the next few weeks, then into retirement.

Whilst it makes sense to get the new man in early he was definitely pushed:

<<... Adm. Scott Swift, commander of U.S. Pacific Fleet, dismissed Aucoin "due to a loss of confidence in his ability to command," the U.S. Pacific Fleet said in a statement.

It said Rear Adm. Phil Sawyer will assume command of the 7th Fleet immediately. Aucoin had expected to retire this year, but his superiors decided to push his departure date due to concerns over his leadership skills, the New York Times reported. Aucoin has commanded the Japan-based fleet since September 2015...>>
Maybe he was too busy doing his EVTs to keep his eye on the day job?
 

Seadog

War Hero
Moderator
I seem to recall ATG having the following in his ARRSE ad or Navy Net signature. Maybe he still does.

"Generalship is about three things: character, competence, and communication. So do we select our generals on such criteria? Don’t be daft, of course we don’t. We pull them up through patronage, misplaced loyalty, self-promotion and a host of other rather tawdry reasons and, occasionally, on ability; but it is not always the brightest and the best that are selected for high office."

Lt Gen Sir Graeme Lamb.

I suggest that the same thing may happen with admirals.
 
https://news.usni.org/2018/03/08/singapore-safety-report-uss-john-s-mccain-aug-21-2017-collision

35 page report: Singapore Safety Report on USS John S. McCain Aug. 21, 2017 Collision March 8, 2018 7:46 AM

...The collision resulted in 10 fatalities on the USS John S McCain.

The safety investigation determined that the USS John S McCain made a sudden turn to Port (left) into the path of Alnic MC because of a series of missteps that took place after propulsion controls were transferred.

When the Bridge team of Alnic MC saw the USS John S McCain turning, it presumed that the USS John S McCain would be able to safely pass ahead. The collision happened within three minutes of the USS John S McCain turning to Port, and the actions taken by Alnic MC were insufficient to avoid the collision...


A fully comprehensive report describing those harrowing 3 minutes leading up to that dreadful incident.
 

Dredd

War Hero
Thought you chaps would be interested in this interpretation of the events, based upon the NTSB findings and applying a commercially available incident root cause process called TapRooT®:


The comments at the end regarding holding those actually responsible to account is an interesting one. Would the RN act any differently?
 

Sumo

War Hero
Thought you chaps would be interested in this interpretation of the events, based upon the NTSB findings and applying a commercially available incident root cause process called TapRooT®:


The comments at the end regarding holding those actually responsible to account is an interesting one. Would the RN act any differently?
Instead of blame culture I prefer to use systems failure analyses, where an holistic systems approach is used working backwards from the failure/incident, manning levels , training, etc will be included, the final report puts the cause on a or even multiple root causes.

For instance the Zeebrugge ferry disaster, studied as part of SE degree, the finale report showed that 18 practice, Bad/illegal or not with company policy, were broken every time the vessel sailed and became the norm, no issue if any one of the 18 didn’t line up. On the night of the disaster all 18 lined up in bad weather, with the known results.

Route cause was the vessels owners, who eventually ended up in court putting pressure on the crew Capt down to get to sea A.S.A.P, even though all acquitted it set a precedence in UK law of corporate manslaughter
 

Dredd

War Hero
I also look at this as similar to the 737-Max 8 issue. The constant pressure to design in tech that is being used to give the computer more control over what used to be the role of the meatware inevitably invokes the Law of Unintended Consequences when a "bug" in the programme does something (or does not do something) it was intended to do. Complex systems and sudden real-time situations needing prompt and certain action which does not pan out as expected do not mix well and are resulting in fatalities.

The Zeebrugge example is one where practical reality was being used to compensate for a series of poor processes and complacency, where lack of consequences were reinforcing poor behaviours. It is not the same as this incident as one aspect of the problem was the unfamiliarity with the design, compounded by inadequate manuals and training. In this case a simple error was not identified due to over-complexity of the system and the flash to bang not being immediate, so the course deviation could not be easily corrected and confirmed as effective until collision was imminent.
 
D

Deleted 493

Guest
I am reading 'Breaking the Covenant' at the moment by David Hill, which intricately opens out some eye popping failure in MoD oversight which leads directly to what Sumo alludes to - the 'Swiss Cheese Effect' whereby for one reason of another, the holes in cheese slices figuratively live up to allow a clear path through. This happens on too many occasions, and the big blame is 'political correctness' or overweening regulation. The book focuses on the Sea King collision off AKR in the last decade in the Gulf and highlights other accidents such as the Nimrod and the Scampton Hawk ejector seat incident which Martin Baker seemed to be leaned on to take the rap for.

There's an interesting parallel also with the near loss of HMS Endurance, itself the subject of an excellent three part blog by former XO Tom Sharpe in 'Mayday In Magellan'.

levers
 

Sumo

War Hero
I am reading 'Breaking the Covenant' at the moment by David Hill, which intricately opens out some eye popping failure in MoD oversight which leads directly to what Sumo alludes to - the 'Swiss Cheese Effect' whereby for one reason of another, the holes in cheese slices figuratively live up to allow a clear path through. This happens on too many occasions, and the big blame is 'political correctness' or overweening regulation. The book focuses on the Sea King collision off AKR in the last decade in the Gulf and highlights other accidents such as the Nimrod and the Scampton Hawk ejector seat incident which Martin Baker seemed to be leaned on to take the rap for.

There's an interesting parallel also with the near loss of HMS Endurance, itself the subject of an excellent three part blog by former XO Tom Sharpe in 'Mayday In Magellan'.

levers
Didn't try to aloud to any Cheese, this is a different technique, it looks for single points of failure, Risk mitigation, FMEA analysis etc. Systems Failure analysis looks at a system after failure. the initial risk analysis, cheese if you like could be perfectly valid, but somebody no knowing the implications, changes the process and an incident happens.
The height of the Faslane sheds comes to mind. designed to be able to remove periscopes in the shed. orifer comes along and shows how many millions can be saved if the shed height is reduces? he gets his promotion and oops cannot remove periscopes in the shed. not a life issue but just shows what happens when someone plays with a process without sound follow up analysis to the change.
 
D

Deleted 493

Guest
Didn't try to aloud to any Cheese, this is a different technique, it looks for single points of failure, Risk mitigation, FMEA analysis etc. Systems Failure analysis looks at a system after failure. the initial risk analysis, cheese if you like could be perfectly valid, but somebody no knowing the implications, changes the process and an incident happens.
The height of the Faslane sheds comes to mind. designed to be able to remove periscopes in the shed. orifer comes along and shows how many millions can be saved if the shed height is reduces? he gets his promotion and oops cannot remove periscopes in the shed. not a life issue but just shows what happens when someone plays with a process without sound follow up analysis to the change.
The Swiss Cheese effect is relevant in all cases of FMEA. If you don't allow a slice to be moved into alignment (i.e. your nameless 'orifer' - I assume you mean 'officer' - having what you allude to an unmitigated input into the project with out design change analysis in this case) then the incident doesn't happen. It is the effect in most prominent accidents and incidents from Grenfell Tower, to the United 232 air disaster to Ladbrooke Grove to HMS Nottingham. In the cases highlighted in Hill's book, the scandal exists in MoD covering their tracks or rubbing out their fingerprints. The Nimrod crash was investigated by the Haddon-Cave inquiry, itself seemingly comprehensive but still not managing to root cause the actualities of the deaths of flyers. Removing difficult and onerous maintenance techniques and ensuring fuelling modifications were properly scrutinised would have prevented that, installing fire preventative foam in the Hercules fleet would have prevented one being brought down in the middle east and not overtorquing a Philadeas nut would have saved the life of an red Arrows pilot at Scampton when his ejector seat inadvertently operated and his chute failed to deploy, something for which Martin Baker wrongly took the can for. All of these were victims of slices of the cheese lining up. There are more and there will be more.

levers
 

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