WASHINGTON
(Sept. 3, 2020) — The National Transportation
Safety Board
issued Thursday four safety recommendations in its final report on the agency’s investigation
of the fatal, June 17, 2017, collision between the USS Fitzgerald and the
container ship ACX Crystal.
The
collision happened shortly after the 504.5 foot-long, 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, while the 730
foot-long, Philippine-flag, container ship ACX Crystal 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 and the ships collided. Seven
Fitzgerald crewmembers died in the accident, and three others suffered 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 U.S. 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 contains 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 US Navy vessels to not broadcast automatic
identification system signals;
· insufficient oversight and directive by the U.S. Navy;
· the commanding officer’s inadequate assessment of the
transit route’s hazards; and
· the commanding officer’s decision to not augment bridge
watchstanding personnel with a more experienced officer.
(This
graphic depicts the reconstructed paths of the US Navy destroyer Fitzgerald,
the container ship ACX Crystal, the Maersk Evora and the Wan Hai 266 in the bay
of Sagami Nada the evening of June 17, 2017. The Fitzgerald and the ACX
Crystal collided and seven US sailors died and three others injured as a result
of the accident. NTSB graphic by Kevin Renze/Christy Spangler, background by
Google Earth)
In the report the NTSB says the Fitzgerald’s
bridge team’s failure to take early and substantial action to avoid collision,
as the give-way vessel in a crossing situation, is the probable cause for the
collision. The NTSB also says ineffective communication and cooperation among
the crew on the Fitzgerald’s bridge and combat information center, coupled with
the commanding officer’s insufficient planning for the hazards of the
destroyer’s intended transit, contributed to the collision. The ACX Crystal’s
watch officer’s lack of early detection of the Fitzgerald and insufficient
actions to avoid collision, once in doubt of the destroyer’s intentions, also
contributed to the collision.
“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.”
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 call 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 seeks the broadcast of automatic identification
system information when in the vicinity of commercial vessel traffic, at all
times, unless such broadcast could compromise tactical operations. The safety
recommendation issued to Sea Quest Management Inc., seeks additional training
for navigation officers on collision avoidance regulations, radar and automatic
radar plotting aids.
Marine Accident Report 20/02 and
the public docket for the investigation are available. Portions of
Marine Accident Report 20/02 were
designated as Controlled Unclassified Information by the US Navy and those
portions were edited to comply with information security standards.
To report an incident/accident or if you are a public safety agency, please call 1-844-373-9922 or 202-314-6290 to speak to a Watch Officer at the NTSB Response Operations Center (ROC) in Washington, DC (24/7).
