USS Pearl Harbor (LSD 52) Grounding - PowerPoint PPT Presentation

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USS Pearl Harbor (LSD 52) Grounding

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USS Pearl Harbor (LSD 52) Grounding LTJG Ryan R. Downing Navigator USS DECATUR References Safety Message 271153Z OCT 08 Background On 20JULY an evolution brief ... – PowerPoint PPT presentation

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Title: USS Pearl Harbor (LSD 52) Grounding


1
USS Pearl Harbor (LSD 52) Grounding
  • LTJG Ryan R. Downing
  • Navigator USS DECATUR

2
References
  • Safety Message
  • 271153Z OCT 08

3
Background
  • On 20JULY an evolution brief and daily OPS/INTEL
    brief were conducted onboard USS PEARL HARBOR
    (PHB) in preparation for the second day of
    scheduled amphibious operation on 21 July.

4
Background
  • The AMPHIB OPS consisting of the backload of 15th
    MEU Assets, were constrained to inner and outer
    sea echelon areas (sea) located in Kuwaiti
    territorial water IVO Kuwaiti Naval Base (KNB).

5
Preparation
  • Sea boxes were plotted by both Navigation and
    Combat
  • Navigator reviewed both charts
  • Failed to notice Combats was incorrect
  • CO/XO did not review for approval
  • Charts were not brought to OPS/INTEL nor was a
    Navigation brief conducted

6
The Operating Box
  • The CO gave no direction and there was no
    discussion WRT location of operations in the
    inner sea box.
  • PHB has already operated in this box one month
    prior and on 20 JUL in support of Amphibious
    Backload Ops.
  • ORM was discussed, however grounding and
    navigational hazards were not specifically
    identified as risks!

7
21 JULY
  • PHB operating in prescribed inner sea box
  • The Western edge of the box contained a small
    section of shoal water, 250 yds in diameter and
    marked at 1.9m deep
  • IAW the CO standing orders, this is restricted
    waters
  • Within 2nm of shoal water or lt10 fathoms

8
Bridge Watch 0700-1200
  • The Navigator was the OOD with a U/I
  • Nav Dept LPO was the conning officer
  • Navigation detail was not manned
  • No deck log entry made when entering restricted
    waters (as required by CO SO)
  • QMOW taking 6min fixes IAW Nav Bill
  • Restricted waters requires 2min fix intervals
  • Combat and Bridge not comparing fixes

9
Bridge Watch (cont.)
  • The Conning Officer notice the ship not
    responding to commands
  • The OOD checked the chart and realized the latest
    fix to show the ship in shoal water
  • The ship was aground
  • Damage included a section of scraped paint from
    frames 55 to 70

10
Human Factors
  • Failure to Follow Procedure
  • Publish procedure for restricted waters not
    followed
  • CO SOs/Nav Bill IAW COMNAVSURFOR/COMNAVAIRFOR
    Surface Ship Dept. SORM
  • Nav Brief, Nav Detail, RMD not set
  • Formal chart review
  • DR, fix interval, fix comparisons, reporting
    procedures

11
Human Factors (cont)
  • Knowledge of Regulations Inadequate
  • CO SO define restricted waters as within 2nm of
  • shoal and/or depths lt10 fathoms
  • By definition the
  • OP BOX is rest. waters
  • Not recognized by CO,
  • XO, NAV/OOD
  • Know the Standing Orders

12
Human Factors (cont)
  • Lack of Attention to Detail/Unnecessary
    Distractions
  • Studying the chart before taking the watch
  • Analyzing and comparing fixes
  • Recognition of identical fixes and fixes plotted
    in shoal water
  • QMOW phone talker during LCAC Ops
  • Turnover (4 plotters in CIC within 1hr)

13
Human Factors (cont)
  • Complacency
  • Previous Ops, same box (4 weeks and day before)
  • Dangerously close to shore during amphibious
    operations
  • Watchstanders unfamiliar with SO, as it defines
    restricted waters

14
Human Factors (cont)
  • Inadequate Training
  • No formal Officer
  • training or plan onboard
  • Junior Officer training
  • not monitored closely

15
Human Factors (cont)
  • Inadequate Supervision
  • The CO failed in supervisory duties of safe
    navigation
  • His bridge and combat watch teams failed to
    operate IAW his Standing Orders
  • No direction, insufficient chart study, and
    failure to conduct a thorough ORM review
  • Watch not stood properly
  • CO, XO, NAV/OOD, OOD U/I, Conning Officer, CICWO,
    CICWS

16
Human Factors (cont)
  • Bridge/Combat Communication and Resource
    Management
  • Resource management for Bridge and Combat watch
    teams not incorporated
  • Communications ineffective
  • Combat not utilized as a useful resource
  • No forceful backup from Combat

17
Human Factors (cont)
  • Lack of Chain of Command Continuity
  • PHB served under 3 different ISICs from workups
    to deployment
  • Lack of continuous and dedicated squadron
    oversight
  • Identify potential problems, training cycle

18
Summary
  • Standing Orders alone could have prevented the
    mishap.
  • Know the Standing Orders!
  • Complacency/Distractions
  • Inadequate preparation, briefs, ORM
  • Poor watch standing
  • Know your watch team. Maintain SA and know your
    OP Area, identify hazards before assuming the
    watch
  • No formal training
  • Continue to train your watch teams

19
QUESTIONS?
Ship Shipmate Self
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