NTSB issues final report on USS Fitzgerald collision September 8, 2020
The US National Transport Safety Board (NTSB) has just released its final report on the June 17th 2017 collision between the USS Fitzgerald and containership ACX Crystal (IMO 9360611). The report determined that the probable cause of collision was the failure of the Fitzgerald’s bridge team to take early and substantial action to avoid collision as the give-way vessel in a crossing situation.
Contributory factors were ineffective communication and cooperation among the Fitzgerald crew on the bridge and in the combat information centre (CIC), and the Fitzgerald commanding officer’s insufficient planning for the hazards of the vessel’s intended transit.
Further factors were:
the Navy’s ineffective oversight of the Fitzgerald in the areas of operations scheduling, crew training, and fatigue mitigation.
the ACX Crystal watch officer’s lack of early detection of the Navy vessel and insufficient actions to avoid collision once in doubt as to the destroyer’s intentions.
The collision happened shortly after the US Navy destroyer 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
Containership ACX Crystal, about 40% longer than the Fitzgerald at 731ft, with 21 people on board, was traveling east-northeast at about 18.5 knots in the bay, headed to Tokyo, from Nagoya, Japan.
Neither vessel radioed the other as the distance between the ships continuously decreased. Actions taken by watch officers to avoid impact seconds before the collision were too late. The ships collided. Seven Fitzgerald sailors died in the accident, with three others suffering serious injuries.
No injuries were reported aboard the ACX Crystal. The destroyer sustained extensive damage to its forward starboard side and the ACX Crystal sustained damage to its bow.
The NTSB was the lead federal agency for the investigation and delegated its authority to the US Coast Guard to gather documents and perform interviews on behalf of the NTSB. The NTSB developed the analysis and probable cause based on evidence gathered by the Coast Guard and additional documentation provided by the Navy.
Marine Accident Report 20/02 contained 11 findings, seven identified safety issues, four safety recommendations and the probable cause of the accident.
Identified safety issues include:
the insufficient training of the Fitzgerald’s crew;
Fitzgerald crew fatigue;
the practice of U.S. Navy vessels of not broadcasting AIS signals;
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 US Navy;
the commanding officer’s inadequate assessment of the transit route’s hazards;
the commanding officer’s decision to not augment bridge watchstanding personnel with a more experienced officer.
As a result of its investigation the NTSB issued three safety recommendations to the Navy and one to Sea Quest Management Inc., the operator of the ACX Crystal.
Two safety recommendations issued to the Navy called for review and revision of fleetwide 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 recommendation to the Navy sought the broadcast of AIS information when in the vicinity of commercial vessel traffic, at all times, unless such broadcasts could compromise tactical operations.
“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.”
The safety recommendation issued to Sea Quest Management Inc sought additional training for navigation officers on collision avoidance regulations, radar and automatic radar plotting aids.
2008-built, Philippines-flagged, 29,060 gt ACX Crystal is owned by Olympic Steamship Co SA care of manager Sea Quest Management Inc of Manila, Philippines. It is entered with Japan Club (Tokyo Office In Charge) on behalf of Olympic Steamship Co SA.https://www.ntsb.gov/investigations/AccidentReports/Pages/mar2002.aspx