TOTAL PROFESSIONALISM Training MSI Norfolk VA 07 DEC

TOTAL PROFESSIONALISM Training MSI, Norfolk VA 07 DEC 00 The Grounding of USS LA MOURE COUNTY

TOTAL PROFESSIONALISM Overview • LMC participating in UNITAS 41 -00 • While operating with Chilean navy ships Valdivia and Galvarino, LMC was preparing to conduct an amphibious assault at Caleta Cifuncho, Chile • While proceeding to anchorage/marine debarkation point, LMC ran hard aground along rocky shoreline • LMC suffered significant hull and running gear damage, flooding in several spaces, and spilled fuel spill IVO Caleta Cifuncho • LMC was aground for approx 98 minutes until towed off rocks by GAL

References TOTAL PROFESSIONALISM • NAVSEA PMS 470 initial estimate repair cost • OPNAVINST 5100. 19 C NAVOSH Program Manual for Forces Afloat • Preliminary environmental impact report from NOAA office of response and restoration • OPNAVINST 3500. 39, (ORM) • CNSL/CNSP/SNAL/CNAP INST 3530. 4 A (NAVDORM) • LMC Standing Orders, Navigation Standards, CIC Doctrine, Restricted Maneuvering Doctrine • NSTM 079, Vol 1 (DC, Stability and Buoyancy) • NSTM 079, Vol 2 (Practical DC) • WRN-6 Tech Manual • LMC CART II Assessment Report

TOTAL PROFESSIONALISM Background • Time and date of mishap: 0517 (local), 12 SEP 00 • Geographic location: Caleta Cifuncho, Chile (25 -37. 1 s, 070 -38. 8 w) • Weather conditions: – – – – Visibility: 10 nm, no moonlight, slight coastal mist Temp: 60 O F Winds: 180 -200 t, 18 -22 kts Precipitation/lightning: none Seas: 5 -7 ft Current: negligible flood Tide: low at 0253, high at 0813 Sea state and direction: 2, from SW • Ship's employment: underway, participating in UNITAS 41 -00 Chilean Phase

Location IQUIQUE Caleta Cifuncho CALDERA PUERTO ALDEA VALPARAISO TALCAHUANO PUNTA ARENAS

Location Antofagasta Caleta Cifuncho (Cifuncho Bay) Town of Cifuncho (Population 42) Coquimbo / La Serena

The Capital city of the middle of freakin’ nowhere.

TOTAL PROFESSIONALISM Timeline Background • At UNITAS amphib planning meeting in Iquique, Chile, LMC and Chilean Navy personnel modified amphib plan to launch AAV’s from anchorage, requiring LMC to anchor one hour earlier (0530 Q) than original schedule to meet amphib timeline • LMC used NIMA chart 22225 and Chilean chart 206 for transit to intended anchorage. 22225 is WGS 84 compatible for use with GPS. Chart 206 is not WGS 84 compatible. LMC personnel were unaware that certain charts were not compatible with GPS. Lack of knowledge of GPS capabilities/ limitations, over-reliance on GPS as single source of determining ship's position, and loss of situational awareness were the principle factors in LMC's grounding.

A Recipe for Disaster Actual Track History Intended Track (Uncorrected) Intended Track (Corrected) GPS Chart Error: 191@1800 yds

TOTAL PROFESSIONALISM Timeline: 11 SEP 00 • 1500: NAV Brief. Not attended by 6 of 15 positions including: OOD, Conning Officer, Piloting Officer, and Shipping Officer/senior OS. There is no discussion of making CIC primary plot due to lack of visual nav aids. ORM was not briefed. • 1630: CO signs sea and anchor watchbill, posted on LAN at 1645. Several personnel do not realize they are assigned to watchbill until late that night. • 2200: Night orders direct LMC to loiter throughout the night, then proceed to anchorage, setting Nav detail 0430, and S+A detail at 0445.

TOTAL PROFESSIONALISM • • Timeline: 12 SEP 00 (1) 0247: 1 st lt assumes deck 0309: BM 1 takes conn 0430: Station navigation detail 0430: Nav on bridge. Plotting on chart 22225 with WRN-6. Nav observes RADAR video is not very clear. • 0430: BM 1’s relief never arrives on bridge • 0430: CO, on bridge, notes fuzzy land edge on RADAR. Leading QM 1 tells CO radar not cutting. CIC personnel indicated that radar picture was clear. CIC did note any instance of poor RADAR performance. Technicians for SPS-64 and SPS-67 never called to troubleshoot either bridge radar.

TOTAL PROFESSIONALISM Timeline: 12 SEP 00 (2) • 0445: OOD directs conning officer to follow Nav's recommendations unless specifically told not to. This is conning officer's first watch in restricted waters. • 0445: Station S+A detail • 0450: XO bridge • 0456: OPS assumes watch as CICWO • 0500: CO observes coastline obscured by fog. Distance to coastline approx 2000 yds. Cannot correlate coast view to ship's track. Ship appears parallel to coast. S+A detail stations report manned and ready. 11 positions had been changed without CO's authorization. Manned and ready checklist was not complete at time report given to CO. • 0500 Bridge shifts to chart 206. After first GPS fix on bridge, CIC shift charts.

Chilean Chart 206

TOTAL PROFESSIONALISM Timeline: 12 SEP 00 (3) • 0500: First position 600 yds left of track, 2300 yds from nearest shoal water • 0501: CICWO goes to signal bridge, recognizes LMC visually far left of track. CICWO returns to CIC to confirm observations based on CIC's plot. • 0507: GPS Fix in CIC 600 yds left of track. Piloting officer attempts to obtain radar fix, but misidentifies radar reference points. As result, radar fix does not cut. • 0507: CIC recommends course 180 via 21 MC. No action taken by bridge team. CIC does not give reason for recommendation. • 0508: CICWO comes to bridge to compare fixes and confirm left of track. CICWO confirms fixes, but is not overly concerned because “there is plenty of time to maneuver to starboard and regain track. ”

TOTAL PROFESSIONALISM Timeline: 12 SEP 00 (4) • 0509: XO moves to bridgewing. Using NOD, observes close rocky coastline. Recognizes nod has no 3 -D capability. • 0509: OOD asks navigator for report. Navigator has no updated information. • 0510: CO notes junior QM 1 not on station. CO questions who authorized him not being on station. QMSN goes below to awaken him. • 0511: XO approaches CO and voices concern that shoreline looks awfully close in NOD. Recommends coming right to open distance, just to be safe. CO acknowledges recommendation. XO believes that ship is going to come right. • 0512: XO questions JA phone talker and learns CIC has no fix • 0513: CIC has no fix

TOTAL PROFESSIONALISM Timeline: 12 SEP 00 (5) • 0513: Coastline on beam, approx 1000 yds. CO directs XO to supervise nav team. • 0513: OOD checks bridgewings and sees nothing, returns to bridge. • 0513: XO questions NAV to determine ship's course. Based on response, XO believes ship is coming right. Nav recalls saying ship could come right to intercept track, but Nav recommends maintaining course 150. Ship does not alter course. • 0514: CIC reports no fix, recommends bare steerageway. Nav notes recommendation, recommends maintaining course and speed. CO hears report from CIC and navigator's response. • 0514: OOD checks RADAR, notes proximity to land, recommends slowing. CO concurs.

TOTAL PROFESSIONALISM Timeline: 12 SEP 00 (6) • 0515: CICWS/Shipping Officer comes to bridge, directs Nav's attention to situation, recommends coming right to 220. (several conflicting statements) • 0515: CIC recommends 200. OOD directs Conn to follow Nav's recommendations because bridge plot is primary nav plot. • 0516: CIC recommends 200. Unknown if recommendation was acknowledged. • 0516: Ordered speed change from 9 knots to 3 knots • 0516: OOD urgently calls CO to port bridgewing. Rocks jutting out from coast less than 200 yds dead ahead. CO orders "all back full, all back full emergency. " Speed over ground 9 -10 knots • 0516: CICWO comes to bridge, sees co ordering all back full, returns to CIC. RADAR display shows ship between 2 fingers of land. Ship misses first protrusion of rocks

TOTAL PROFESSIONALISM Timeline: 12 SEP 00 (7) • 0516: CO/OOD order right full rudder, then hard right rudder to open distance from rocks • 0517: Loss of steerageway. Rudder amidships. To check swing of stern into rocks, XO orders all ahead full, left full rudder. CO/XO believe ship is past danger. • 0517: Main control hears loud unusual noise along hull • 0517: Second protrusion of rocks appears forward of bow • 0517: LMC hard aground IVO Punta Artigas. Series of engine and rudder commands ordered to keep stern clear of rocks and avoid broaching. Wave action pounds LMC on rocks. • 0521: Forward fuel tanks crushed by rocks below, forcing fuel up vent piping on focsle • 0526: Flooding and ruptured fuel line in ATB. Space is evacuated. General Quarters sounded soon thereafter.

TOTAL PROFESSIONALISM Post-Grounding Timeline (1) • 0530: Stern anchor let go to prevent stern from swinging into rocks and broaching ship • 0533: Flooding in MOGAS pump room. • 0534: 1/2 to 1" water on deck in weight room. • 0535: Chilean naval officer onboard LMC requests assistance from Chilean ocean-going tug, Galvarino • 0544: Repair 3 combating flooding in weight room • 0545: 12" fuel on deck and level rising in ATB • 0545: Flooding in FTB • 0550: GAL standing by LMC stbd quarter • 0555: 2 ft of fuel/water in ATB. 6" rupture in port ATB deck. Box patch rigged and de-watering with a portable eductor begins. Level of fuel on deck restricts patching team efforts.

TOTAL PROFESSIONALISM • • • Post-Grounding Timeline (2) 0559: MOGAS pump room flooded solid, heavy fuel smell 0559: Flooding in ballast and fuel tanks 0620: Soundings are rising throughout forward part of ship 0628: LMC gives GAL permission to pass towing hawser 0635: Stern anchor dragging 0640: Rudder actuator in port aft steering punches through deck. Hydraulic oil leak in port after steering gear room. 0640: I-type shoring on aft manhole cover in weight room complete 0640: Shot line received from GAL to stern of LMC, GAL takes strain on towing hawser 0643: Sunrise. LMC begins moving off rocks 0647: De-watering of MOGAS pump room with portable eductors begins

TOTAL PROFESSIONALISM Post-Grounding Timeline (3) • 0651: Level in ballast tank rising. De-ballasting of ballast tank with installed ballast pumps begins. • 0655 LMC floats free of rocks • 0657 Secure de-ballasting of ballast tanks: ineffective. • 0748 Anchored in Cifuncho Bay

TOTAL PROFESSIONALISM • • Damage Keel severed and deformed between frames 101 -120 (40 feet) Damaged port CPP, missing one blade Damaged stbd CPP, missing one blade Damaged port and stbd OD boxes Damaged port and stbd struts and underwater shafting Damaged port and stbd stern tube seals Damaged port and stbd rudders to extent that entire assemblies must be replaced • Damaged stbd rudder to extent that entire assembly must be replaced • Damaged port steering gear • Potentially damaged bow thruster

TOTAL PROFESSIONALISM Damage (cont’d) • MOGAS pump room flooded solid with fuel/water mixture, requiring replacement of all equipment and electrical/electronic components in space • Damaged deck and racks in aft troop berthing (ATB), requiring replacement • Stress crack in ATB fan room • 2 holes (1/2" each) in fwd troop berthing (FTB) fan room deck • Flooded fwd CHT pump room, requiring replacement of 2 CHT pump motors, 4 controllers, lighting, alarm fixtures, and float switches • 20 fuel tanks ruptured and/or contaminated • 4 ballast tanks damaged • Six cracks in aluminum superstructure

TOTAL PROFESSIONALISM Cost • Estimated cost to repair or replace DOD property: – Original: $70 M+ (based on repairing in Norfolk area) – Final: $10 M+ to “sell” to Chile • Estimated cost of non-DOD property damage: – 120, 000 Gallon spill of F-76, JP-5, and MOGAS, damaging a 1/4 mile section of beach: approx 20, 000 dead sea urchins along surf zone. • Operating days lost: infinite (LMC decommissioned), deployed USS Tortuga to fill UNITAS gap • $30, 000+ per day for services • Travel costs for support teams: (NOAA, JAG, MIB, NAVSEA, MDSU, lodging for 300 Marines ashore for 30 days) • Undetermined cost of 45+ operating days for 2 Chilean Navy ships and Chilean dive team

TOTAL PROFESSIONALISM Qualifications All personnel involved in mishap were qualified with following exceptions: • Navigator: – Did not complete navigator PQS (NAVEDTRA 43492 -2 C, 316) – Did not complete required WRN-6 course – No waiver submitted • Leading QM did not complete required WRN-6 course – No waiver submitted • Port bearing taker did not complete required PQS (NAVEDTRA 43492 -2 C, 310) • Aft lookout did not complete required PQS (NAVEDTRA 434922 C, 302)

TOTAL PROFESSIONALISM Training • CO reported onboard MAY 00, XO JUL 99, 1 st LT (OOD) AUG 99, Navigator FEB 00, OPS (CICWO, SWO) AUG 99, CICWS JUN 00. • All major watchstanders had at least 1 yr onboard and were experienced, other than conning officer • No documentation of nav-related STT evolutions being conducted after 13 MAR 00. • Completed following major training milestones: – – – Nav check-ride 16 MAY 98 (3 personnel still onboard) RADAR nav team trainer 12 MAR 99 (3 attendees onboard) CART II 11 JUN 99 FEP 03 NOV 99 INDEX 05 -12 APR 00, 30 MAY-15 JUN 00 ORM training 12 MAY 00

TOTAL PROFESSIONALISM Damage Control • Exceptional! Simultaneously tracking and responding to all reports of structural damage, containing multiple fuel and seawater flooding incidents, and controlling stability of ship. Considering the magnitude and complexity of damage, overall DC efforts met or surpassed all standards. • DC lessons learned: – Firefighting boots had inadequate traction with fuel on deck – Firex Firewalker Ranger boots were more effective on fuel covered decks – De-watering of fuel/water deteriorated inner lining of fire hoses within 2 hours. CHT hoses were better suited for this purpose. – Hydraulic jacks proved very effective during shoring operations – Wet vacs especially effective during flooding cleanup – DC personnel assessed S-type eductors to be more effective in combating flooding from mishap than peri-jet eductors – Steel shoring not covered by PMS

TOTAL PROFESSIONALISM Probable Causes (1) • Unaware chart 206 not WGS 84 compatible. Chart 206 is unsuitable for GPS navigation using default datum. Chart 206 is valid only for radar and visual navigation. Unaware of "user defined datum” procedures in WRN-6 tech manual. • While ship recognized lack of visual nav aids prior to event, LMC failed to resolve ambiguity between GPS and RADAR fixes. Bridge failed to take into account CIC recommendations and relied on GPS as single source of navigation. • Navigator never recommended course to regain track. Navigator recommended courses based on bearings and ranges to a GPS waypoint on chart 206. • Despite known lack of visual nav aids, Navigator did not recommend, and CO did not direct, shift of primary plot to CIC (per NAVDORM).

TOTAL PROFESSIONALISM Probable Causes (2) • Employed SPS-67 almost exclusively. SPS-64 minimally employed, and 2 separate Furuno RADARS on bridge and CIC not used at all. • Following standards of navigation were not adhered to: – CIC and bridge nav teams failed to compute set and drift – Nav failed to provide standard position reports to CO/XO/OOD/CONN – Nav failed to relay CIC "no fix" reports to CO/OOD – CIC and bridge nav teams failed to synchronize fix "mark" times – Preparation of CIC and bridge charts did not include the addition of marked danger soundings and danger ranges • Junior QM 1, assigned by the watchbill, not on bridge. QM 1 knowingly violated the published watchbill

TOTAL PROFESSIONALISM Probable Causes (3) • CO/XO/OOD allowed improper nav team position reports. • SWO failed to ensure watchbill was adhered to and failed to ensure that watchstanders were manning proper watch stations. Following 11 changes to approved watchbill were made without authorized approval: Conning officer Navigation plotter Stbd bearing taker Nav bearing recorder/JW BMOW Master helmsman Master lee helmsman Status board/JL Forward lookout/JL CIC log keeper Stbd aft steering helm

TOTAL PROFESSIONALISM Probable Causes (4) • Nav plotter U/I was also performed duties as nav bearing recorder/JW. CIC nav plotter also assigned as piloting officer. • CIC did not effectively disseminate hazard to navigation information. Upon shifting to chart 206, CIC temporarily lost situational awareness. Upon resolving position ambiguity and reestablishing situational awareness, CIC failed to convey close proximity of hazard to navigation. • CICWO not proactive in performance of duties: did not maintain effective exchange of information between bridge and CIC or aid in resolving differences.

TOTAL PROFESSIONALISM Probable Causes (5) • Lack of situational awareness on part of CO, XO, Nav, OOD, CICWO to proximity of hazard to navigation. • Loss of situational awareness by piloting officer and leading QM 1. Due to initial inability to correlate RADAR nav reference points when bridge and CIC shifted to chart 206, nav team defaulted to uncorrected GPS plot. • Overconfidence in GPS created an atmosphere of complacency • Overconfidence by CO, XO, OOD Nav in abilities of bridge nav team. Despite 2 "no fix" reports from CIC, ship continued to proceed to anchorage at 11 kts based on bridge nav team recommendation.

TOTAL PROFESSIONALISM Probable Causes (6) • Ineffective coordination and communication between bridge and CIC nav teams. Lack of sea and anchor detail de-briefs perpetuated miscommunication and lack of coordination between bridge and CIC. • Ineffective S+A watchbill coordination and execution. Watchbill not promulgated until after nav brief. Numerous changes to watchbill not approved. • ORM ineffective. Nav brief contained ORM matrix. However, hazards associated with this evolution were not effectively assessed. • Command failed to ensure required personnel attended nav brief

TOTAL PROFESSIONALISM • • Recommendations to LMC (1) Increase emphasis on ORM Scheduled a navigation LTT Conduct STT events at every opportunity Promulgate watchbills in timely fashion with increased emphasis on ensuring qualified watchstanders at every station. Avoid dual tasking key watchstanders. Navigator and QM 1 complete required PQS and schools Review ship's policy for setting restricted maneuvering Review CNSL Howgozit regarding safe navigation Conduct log keeping training

TOTAL PROFESSIONALISM Recommendations to LMC (2) • Promote environment emphasizing teamwork, coordination, and communication between bridge and CIC nav teams • Include use of all systems onboard for determining hazards to navigation (i. e. SPS-64, Furuno) • Ensure required personnel attend nav briefs and are familiar with evolutions • Attend MSI coordinated nav team training at earliest opportunity • Conduct WRN-6 training for bridge and CIC personnel, emphasizing capabilities and limitations of GPS

TOTAL PROFESSIONALISM Other Recommendations For SWOS: • Continue to emphasize navigation practices/ procedures at every level of officer training • Develop ORM practical exercise for inclusion in PCO, PXO, department head, and division officer curricula For COMPHIBGRU TWO: • Conduct navigation check-ride onboard LMC at next available opportunity. For CNET: • Revise WRN-6 STEP CD-ROM course. Course in present form is not user friendly and needs to be reviewed if this is to be considered the equivalent of the school-house taught course.

TOTAL PROFESSIONALISM