ProPublic has a fascinating look at the root causes of collisions involving the USS Fitzgerald and the USS John S. McCain in 2017. One of the interesting facts that was apparently a contributing factor in the USS McCain collision was that the same systems on different ships would often have different interfaces and operating procedures.
A third-generation Navy officer, Copeman fired off a couple more memos before retiring, hoping he might at last get the leadership’s attention.
The first warned of the fleet’s increasing “configuration variance” problem: The same systems operated in dozens of different ways on different ships, confusing sailors as the Navy shifted them from one vessel to another.
“I liken it to this,” Copeman told ProPublica. “You have a car with a steering wheel and a gas pedal and one day you walk out and get in your car and an iPad sits were your steering wheel used to be and the gas pedal is no longer there.”
Copeman enlisted a four-star admiral, Bill Gortney, to sign the memo and distribute it in the upper echelons of the Navy. His memo would prove prescient. Four years later, confusion over the McCain’s new steering system caused the ship to turn in front of an oil tanker.
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According to the investigative report, the McCain was steaming through the crowded Singapore Strait en route to a shipyard on the country’s northern coast, when the captain noticed that one of his sailors was having difficulty staying on course and maintaining the ship’s speed at the same time.
The captain ordered a second crew member at a different computer console to take control of the speed, but that only led to more confusion and eventually panic. No one fully understood how to use the new touchscreen navigation system. For several minutes, the crew mistakenly thought it had lost control of the steering. Then they accidentally slowed the propeller on only one side, forcing the McCain to turn sharply left.
