COMPREHENSIVE REVIEW OF RECENT SURFACE FORCE INCIDENTS

26 OCT 2017
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Table of Contents

1. EXECUTIVE SUMMARY.......................................................................................................................................... 5

1.1 Introduction ............................................................................................................................................................ 5

1.2 Summary of 2017 Mishaps ..........................................................................................................................11

1.3 Summary of Findings and Actions ...........................................................................................................16

1.3.1 Poor seamanship and failure to follow safe navigational practices ....................................16

1.3.2 Degraded watchteam performance.....................................................................................................16

1.3.3 Erosion of crew readiness, planning and safety practices ......................................................17

1.3.4 Headquarters processes inadequately identified, assessed, and managed 

operational risks...............................................................................................................................................................17

1.3.5 Assessments do not reinforce effective learning .........................................................................18

1.3.6 “Can-do” culture undermined basic watchstanding and safety standards ......................19

1.3.7 Surface ship Bridges not modernized as an integrated control room................................19

1.4 Conclusion............................................................................................................................................................20

2. METHOD OF REVIEW............................................................................................................................................23

2.1 Scope......................................................................................................................................................................23

2.2 Comprehensive Review Team membership.......................................................................................26

2.3 Structure of the Report...................................................................................................................................26

2.4 Areas for Further Study .................................................................................................................................27

3. SUMMARY AND ANALYSIS OF MISHAPS.................................................................................................29

3.1 Introduction ..........................................................................................................................................................29

3.2 USS John S. McCain (DDG 56) Collision with ALNIC MC ..........................................................29

3.3 USS Fitzgerald (DDG 62) Collision with ACX CRYSTAL.............................................................31

3.4 USS Lake Champlain (CG 57) Collision with Nam Yang 502....................................................32

3.5 USS Antietam (CG 54) Grounding...........................................................................................................33

3.6 Analysis of Past Incidents.............................................................................................................................34

3.6.1 Common Causal and Contributing Factors.....................................................................................35

3.6.2 Additional Important Factors...................................................................................................................39

3.7 Summary Findings ...........................................................................................................................................40

3.7.1 Fundamentals ...........................................................................................................................................41

3.7.2 Teamwork ...................................................................................................................................................41

3.7.3 Operational Safety..................................................................................................................................41

3.7.4 Assessment................................................................................................................................................42
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3.7.5 Culture ..........................................................................................................................................................42

4. INDIVIDUAL TRAINING..........................................................................................................................................43

4.1 Introduction ..........................................................................................................................................................43

4.2 Findings .................................................................................................................................................................46

4.2.1 Officer Training..............................................................................................................................................47

4.2.2 Officer Career Path .....................................................................................................................................49

4.2.3 Enlisted Training...........................................................................................................................................52

4.3 Recommendations ...........................................................................................................................................54

4.3.1 Individual Training........................................................................................................................................54

4.3.2 Officer Career Path .....................................................................................................................................56

5. UNIT TRAINING..........................................................................................................................................................57

5.1 Introduction ..........................................................................................................................................................57

5.2 Findings .................................................................................................................................................................59

5.3 Recommendations ...........................................................................................................................................63

6. GENERATION AND EMPLOYMENT OF OPERATIONAL FORCES..............................................65

6.1 Introduction ..........................................................................................................................................................65

6.1.1 Force Generation .........................................................................................................................................65

6.1.2 Force Employment ......................................................................................................................................67

6.2 Findings .................................................................................................................................................................69

6.2.1 Force Generation .........................................................................................................................................70

6.2.2 Force Employment ......................................................................................................................................73

6.3 Recommendations ...........................................................................................................................................75

6.3.1 Force Generation .........................................................................................................................................75

6.3.2 Force Employment ......................................................................................................................................75

7. SEAMANSHIP AND NAVIGATION EQUIPMENT READINESS AND UTILITY.........................77

7.1 Introduction ..........................................................................................................................................................77

7.2 Findings .................................................................................................................................................................78

7.2.1 Inspection, Certification, and Assist Visits (ICAV).......................................................................78

7.2.2 Bridge System Modernization and Training....................................................................................81

7.2.3 Human Systems Integration (HSI) and Human Factors Engineering (HFE)..................87

7.3 Recommendations ...........................................................................................................................................89

8. SYSTEMIC PROBLEMS ........................................................................................................................................93

8.1 Introduction ..........................................................................................................................................................93
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8.2 Findings .................................................................................................................................................................94

8.2.1 Critical Assessment and Learning.......................................................................................................94

8.2.2 Human Performance Factors.................................................................................................................97

8.2.3 “Can do” Culture........................................................................................................................................101

8.2.4 Sustaining Change...................................................................................................................................103

8.3 Recommendations ........................................................................................................................................105

8.3.1 Critical Assessment .................................................................................................................................105

8.3.2 Human performance factors................................................................................................................105

8.3.3 “Can do” culture .........................................................................................................................................105

8.3.4 Sustaining change....................................................................................................................................106

9. APPENDICES...........................................................................................................................................................107

9.1 Summary of Recommendations.............................................................................................................107

9.2 Matrix of Mishap Attributes........................................................................................................................115

9.3 Commands and Organizations Visited by CRT..............................................................................117

9.4 Comprehensive Review Team Members...........................................................................................120

9.4.1 Independent Advisors .............................................................................................................................121

9.5 References........................................................................................................................................................122

9.6 Acronyms ...........................................................................................................................................................127

9.7 VADM (Ret) Balisle Fleet Review Panel Summary and Recommendations ...................131

9.8 Government Accountability Office and the Center for Naval Analyses Reports and 

Summary of Actions....................................................................................................................................................148

9.9 History of Surface Warfare Officer School ........................................................................................162

9.10 Classified Appendix ......................................................................................................................................173
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1. EXECUTIVE SUMMARY

1.1 Introduction

The U.S. Navy’s surface force responds daily to rigorous operational demands. 

In areas like the Western Pacific, the U.S. Navy has assured peace and stability in the 

region for over 70 years. During this time, skillful commanders at all levels have taken

surface ships through all manners of difficult situations: through dangerous weather, 

multi-national search and rescue efforts, major combat operations, complex 

humanitarian support missions, theater security cooperation exercises with allies and 

partners, and all in accordance with international laws. The overall effect has assured 

freedom for all nations to use the seas to thrive and prosper. For the vast majority of all 

operational tasking, the surface force executes its missions safely and professionally. 

The improvements in technology on U.S. Navy ships over the decades, 

particularly in propulsion, navigation and combat systems, have been met with more 

training, more qualifications, and a smarter, more able force of officers and Sailors. 

However, good seamanship and navigation practice still requires each surface ship to 

make paramount the requisites of good judgment, leadership, and teamwork, and to a 

very high degree, superior planning and execution of the fundamentals. 

Standing together on the Bridge, the Commanding Officer (CO) and the Officer of 

the Deck (OOD), along with many other watchstanders, have to meet their challenges 

as a team. They have to voyage plan carefully, anticipate dangerous conditions, and 

combine their collective skills to effectively use the methods and techniques best suited 

to their ship, its equipment, and the conditions at hand. To be an effective team, all 

watchstanders have to learn to recognize the adequacy of their actions and provide 

forceful backup to correct potential hazards before a mishap occurs. 

This is true at all levels of command. All watchstanders, from the most junior 

Sailor to the CO, have an obligation to use their voice to provide forceful backup when 

they see a deviation from procedure or dangerous situation developing. Command 

leadership, regardless of experience and rank, must have the humility to constantly 

encourage their subordinates to do the same. Corrective actions will be most effective 

when a culture of safety matures to the point where knowledge meets capability, and all 
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levels of command are operating interdependently, with greater teamwork, and with a 

heightened awareness of the adequacies of their actions. 

Today, proficiency in seamanship and navigation competes for time and attention 

with the expanding tactical duties of our naval professionals at sea. Missions such as 

long range surface fires and land strike, air and missile defense of ships, allies and the 

homeland, anti-submarine warfare, and amphibious and mine operations are more 

complex than ever before, and require extensive training and focus. Further, the 

operational demands for surface ships to perform these missions continue to increase, 

even as the size of the surface force and the Navy has decreased.

This year, there have been three collisions and one grounding involving U.S. 

Navy ships in the Western Pacific. The two most recent mishaps involved separate 

incidents of a Japan-based U.S. Navy destroyer colliding with a commercial merchant 

vessel, resulting in the combined loss of 17 U.S. Sailors. Each of these accidents was 

investigated to determine specific causes, identify accountability, and disseminate 

lessons learned.

In their wake, the Vice Chief of Naval Operations (VCNO) assigned Commander 

United States Fleet Forces Command to lead a comprehensive review of these mishaps 

to determine the improvements or changes needed to make the surface force safer and 

more effective. As directed, this review addresses the following areas: individual 

training and professional development; unit level training and operational performance; 

development and certification of deployed operational and mission standards with 

particular emphasis on ships based in Japan; deployed operational employment and 

risk management; material readiness of electronic systems to include navigation 

equipment, surface search radars, propulsion and steering systems; and the practical 

utility and certification of current navigation and combat systems equipment including 

sensors, tracking systems, displays and internal communication systems. This 60-day 

review was undertaken by a diverse cross-section of talent from the surface force, as 

well as other services, warfare communities, industry, civilian maritime experts, 

academia, and other professions.

This review evaluated the aforementioned matters using a solution-oriented 

approach to identify gaps in Doctrine, Organization, Training, Material, Leadership and 
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Education, Personnel, and Facilities (DOTMLPF). The review found weaknesses in 

each of these areas. As examples: in Doctrine, the review found weaknesses in the 

way operational tasking is prioritized and issued to Japan-based ships; in Organization, 

variances were identified in headquarter staffs and the manner by which they execute 

command and control and manage the readiness of assigned forces; in Training, gaps

were noted in the way seamanship and navigation skills are provided and assessed for 

individuals and teams on surface ships; for Material, inconsistencies and gaps were 

found in the configuration control and oversight of Bridge navigation systems; in 

Leadership and Education, deficiencies were noted in the leader’s ability to identify, 

mitigate, and accept risks, and then learn rapidly from near-miss events and other 

hazards; in Personnel, gaps were identified in the qualification and proficiency of the 

surface force in seamanship and navigation; and in Facilities, gaps were identified in the 

shiphandling trainers and associated shore-based infrastructure in place to support 

training for safe seamanship and navigation at sea.

In the recent incidents, the U.S. Navy ships sustained catastrophic flooding, loss 

of critical systems, and 17 Sailors were killed. Yet, in periods of chaos and extreme 

conditions, Sailors rushed in to take emergency actions to save the ship, their 

shipmates, and restore critical systems. This does not happen without effective training, 

proficiency, discipline and toughness. 

In each incident, there were fundamental failures to responsibly plan, prepare 

and execute ship activities to avoid undue operational risk. These ships failed as a team 

to use available information to build and sustain situational awareness on the Bridge 

and prevent hazardous conditions from developing. Moreover, leaders and teams failed 

as maritime professionals by not adhering to safe navigational practices.

Further, the recent series of mishaps revealed weaknesses in the command 

structures in-place to oversee readiness and manage operational risk for forces forward 

deployed in Japan. In each of the four mishaps there were decisions at headquarters 

that stemmed from a culturally engrained “can do” attitude, and an unrecognized 

accumulation of risk that resulted in ships not ready to safely operate at sea.
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The recommendations to correct the weaknesses across the DOTMLPF 

addressed in this report are intended to instill the needed capabilities and proficiencies 

to make the surface force safer and more effective in the following five areas:

(1) Fundamentals. Basic skills such as seamanship and navigation, rigor in 

individual qualification processes, proficiency, and adherence to existing standards; 

(2) Teamwork. The extent to which the surface force deliberately builds and 

sustains teams, and whether they are tested with realistic and challenging scenarios; 

(3) Operational safety. The process and tools by which ships are made ready 

for tasking, ships are employed, and technology is used to safely operate at sea;

(4) Assessment. The extent to which ships and headquarters plan, critically 

self-assess, generate actionable lessons learned, and share knowledge across the 

force;

(5) Culture. The sum of the values, goals, attitudes, customs and beliefs of the 

surface force that defines its identity.

The recommendations described in this report address the skills, knowledge, 

capabilities, and processes needed to correct the abnormal conditions found in these 

five areas, which led to an accumulation of risk in the Western Pacific. The pressure to 

meet rising operational demand over time caused Commanders, staff and crew to 

rationalize shortcuts under pressure. The mishap reports support the assertion that 

there was insufficient rigor in seeking and solving problems at three critical stages: 

during planning in anticipation of increased tasking, during practice/rehearsal for 

abnormal or emergency situations in the mishap ships, and in execution of the actual 

events. This is important, because it is at these stages where knowledge and skills are 

built and tested. Evidence of skill proficiency (on ships) and readiness problems (at 

headquarters) were missed, and over time, even normalized to the point that more time 

could be spent on operational missions. Headquarters were trying to manage the 

imbalance, and up to the point of the mishaps, the ships had been performing 

operationally with good outcomes, which ultimately reinforced the rightness of trusting 

past decisions. This rationalized the continued deviation from the sound training and 

maintenance practices that set the conditions for safe operations. 
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 The findings in chapters four through eight and appendix 9.10 underscore the 

imbalance between the number of ships in the Navy today and the increasing number of 

operational missions assigned to them. The Navy can supply a finite amount of forces 

for operations from the combined force of ships operating from CONUS and based

abroad; this finite supply is based both on the size of the force as well as the readiness 

funding available to man, train, equip and sustain that force. Headquarters are working 

to manage the imbalance. U.S. Navy ships homeported in the continental United States 

(CONUS) balance maintenance, training and availability for operations (deployments 

and/or surge); the Pacific Fleet is re-examining its ability to maintain this balance for 

ships based in Japan as well. Under the Budget Control Act of 2011 and extended 

Continuing Resolutions, the ability to supply forces to the full demand is – and will 

remain – limited. 

The demand for ready and certified ships to support operations required in the 

Western Pacific ultimately exceeded the quantity that could be generated from surface 

forces based in Yokosuka, and without an effective process to clearly define available 

supply and the associated readiness, risks were taken to provide these ships for 

dynamic and short notice tasking. With the exception of manpower, direct readiness 

funding to Japan-based ships was not a contributing factor, but funding shortfalls for 

capacity and readiness Navy-wide did have an impact in putting more pressure to meet 

increasing demand for Japan-based assets without additional support from CONUSbased ships. Additionally, with finite resources, the capacity and readiness of CONUS 

forces was also inadequate to help offset the deficit.

The risks that were taken in the Western Pacific accumulated over time, and did 

so insidiously. The dynamic environment normalized to the point where individuals and 

groups of individuals could no longer recognize that the processes in place to identify, 

communicate and assess readiness were no longer working at the ship and 

headquarters level. 

Culturally, operating requirements around the globe will cause the surface Navy 

to remain biased toward mission execution. While that “can-do” culture has served us 

well in crisis and combat for decades, it does not relieve our commanders of the need to 

continuously assess, mitigate and accept risk. We should be careful about how we 
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make change to that culture. Recommendations in this report include actions that the 

Navy can take immediately to improve surface force safety and effectiveness, followed 

by near-term actions that the Navy can take in the next 30-150 days, as well as longterm actions to study for their potential ability to mitigate the risk of further mishaps. 

Additionally, the Navy should ensure the development of processes to enforce 

predictive standards of performance, improve collection of objective measures of human 

and unit performance, conduct assessments, and monitor predictive and leading trends 

so corrective actions are taken preemptively. 

The primacy of efficiency over effectiveness and the impact that it has on 

readiness is not a new phenomenon. In 2009, after a decade of taking measures to 

increase efficiency in the surface Navy and other Navy programs an assessment of 

surface force readiness (commonly known as the Balisle report) was completed. It 

concluded that the totality of efficiency measures and efforts to reduce costs, such as 

the optimal manning initiative, increases to the Navy standard work week, and 

decreases in new Surface Warfare Officer (SWO) candidate training course lengths, 

directly contributed to a decline in surface force readiness. 

The surface force embraced this finding and has deliberately tried to restore 

effective readiness to the force by increasing the number of people aboard ship, 

incrementally restoring SWO candidate training and implementing better maintenance 

management and training, among other improvements. While resources were restored, 

the restoration still had to be done in balance with modernization and force structure 

requirements. In many cases, deferred modernization has delayed the installation of 

modern integrated Bridge systems. Sailors from one ship cannot simply cross to 

another ship of the same class and expect familiar equipment or lay-outs. Low cost 

simulators do not sufficiently provide the fidelity to fully replicate the stresses of complex 

operations in high traffic areas.

Going forward, the Navy must develop and formalize “firebreaks” into our force 

generation and employment systems to guard against a slide in standards. We must 

continue to build a culture – from the most junior Sailor to the most senior Commander 

– that values achieving and maintaining high operational and warfighting standards of 

performance. These standards must be manifest in our approach to the fundamentals, 
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teamwork, operational safety, and assessment. These standards must be enforced in 

our equipment, our individuals, our unit teams, and our fleets. This Comprehensive 

Review aims to define the problems with specificity, and offers several general and 

specific recommendations to get started on making improvements to instilling those 

standards and strengthen that culture. 

1.2 Summary of 2017 Mishaps

USS John S. McCain (DDG 56) Collision with ALNIC MC

On the morning of 21 August 2017 USS John S. McCain was preparing to enter 

the Singapore Strait for transit to Sembawang, Singapore. The ship completed a full 

Navigation Brief the day before that included the estimated time of 0500 to enter the 

Traffic Separation Scheme (TSS) and subsequent passage in close proximity to shoal 

water. Although the Executive Officer (XO) and Navigator recommended setting the 

Sea and Anchor Detail at 0500, the CO decided to delay stationing the detail until 0600 

in order to give the crew more time to rest and to minimize the chance of a man 

overboard during hours of darkness. As mitigation, the CO planned to be on the Bridge 

for the entire transit and in fact arrived on the Bridge at 0115 and remained there until 

after the collision. 

Of the Bridge watchstanders, the Junior Officer of the Deck (JOOD), the 

Boatswain’s Mate of the Watch (BMOW), and the eventual Lee Helmsman (Lee Helm) 

were on temporary duty from the USS Antietam (CG 54) to provide these Sailors 

underway time for qualifications while USS Antietam was under-going repairs. Although 

the watchbill listed the USS Antietam Sailors as qualified, the BMOW and JOOD 

qualification dates coincided with the day they reported to USS John S. McCain, and 

they conducted no requalification events. The Lee Helm qualified as Helm/Lee Helm 

within a few weeks of reporting to USS John S. McCain.

After entering the TSS, the CO noticed that the Helmsman was having difficulty 

both steering the ship and adjusting the ship’s speed due to prevailing environmental 

conditions. The CO ordered the OOD to separate the control of steering and thrust to 

two separate stations: the Helm and Lee Helm. While attempting to execute this order, 

the Bridge watchstanders unintentionally transferred steering control to the Lee Helm 
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console and “un-ganged” the throttles (i.e., separated the port and starboard throttle 

controls from a coupled control to individual throttle control). Complicating the 

execution of the order was a series of watch reliefs for meals then in progress among 

the various watchstations and a lack of posted procedures for transfer of throttle and 

steering control. Recognizing that he no longer had control of steering, the Helmsman 

announced a loss of steering (system) casualty (malfunction). The After Steering 

station was manned in short order and attempted to take emergency control. Due to 

confusion on the Bridge about the nature of the casualty and the operation of the Ship’s 

Control Console (SCC), steering control would be inadvertently transferred among 

various controlling stations four times within the two minutes leading up to the collision. 

As a result of this perceived lack of steering control, the ship began a slow turn to port. 

After hearing the Loss of Steering casualty the CO directed the OOD to slow the 

ship. The OOD ordered 10 knots and the Conning Officer duly gave the order. The Lee 

Helm executed the order and slowed the port shaft, but did not recognize that the 

throttles were not linked and that he had control only of the port shaft. Unrecognized by 

the watchteam, control of the starboard shaft remained at the Helm station for more 

than 60 seconds after control of the port shaft was taken by the Lee Helm. The speed 

change to the port shaft slowed the ship but also increased USS John S. McCain’s rate 

of turn to port as the starboard engines and shaft remained ordered to 20 knots. The 

CO then ordered a speed of 5 knots, but the Lee Helm’s actions only reduced power to 

the port shaft due to the individual throttle control. The starboard shaft still remained at 

20 knots, exaggerating the rate of turn even further. About three minutes after the 

reported Loss of Steering casualty began, USS John S. McCain regained positive 

steering control in After Steering and answered Right 15 degrees rudder. About this 

same time throttles were matched at the Lee Helm and the starboard engine and shaft 

slowed to 5 knots. These actions were too late to avoid collision with the ALNIC. At 

about 0524, and because of the port turn induced by the loss of steering control and 

thrust control actions, the USS John S. McCain crossed in front of ALNIC, whom the 

USS John S. McCain had just passed ahead of, and USS John S. McCain was struck 

on her port quarter. Despite what the watchstanders believed, there never was a loss of 

steering casualty.
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Primary causes of the collision were leaderships’ loss of situational awareness in 

a high traffic area and failure to follow safe navigational practices, coupled with 

watchstanders who were not proficient with steering control operations or engineering 

casualty response procedures. Contributing to the collision were failures in basic 

watchstanding and seamanship among the Bridge and Combat Information Center 

(CIC) teams; a failure by these same watchteams to take clear and decisive action to 

avoid collision when in extremis; and the failure of the Commanding Officer in assigning 

and changing watchstanders, in ordering equipment configuration changes in the TSS, 

and in failing to take prudent measures to mitigate these risks. This critique of USS 

John S. McCain does not imply that ALNIC mistakes and deficiencies were not 

contributing causal factors in the collision. 

USS Fitzgerald (DDG 62) Collision with ACX CRYSTAL

On 17 June 2017, USS Fitzgerald was attempting to cross a highly congested 

sea lane at night. While maneuvering to pass merchant and fishing vessels and 

complete the crossing, watchstanders failed to visually differentiate between two 

vessels in close proximity and did not calculate the closest point of approach using all 

available means before making a final crossing maneuver. Watchstanders in CIC were 

inattentive, disengaged in developments on the Bridge, and unaware of several nearby 

vessels, specifically, a Philippines-flagged commercial containership named the ACX 

CRYSTAL.

As the CRYSTAL and USS Fitzgerald approached each other, the OOD became 

aware of the ships’ relative positions and realized action was necessary. The OOD first 

decided to alter course to starboard, but then evaluated there was insufficient sea room 

to turn to starboard without colliding. The OOD then ordered the Conning Officer to 

come to full speed, and then flank speed ahead, and then ordered a full, and then hard 

left rudder. The actions were delayed as the Conning Officer “froze” in the moment. 

The OOD and the Conning Officer both began to shout orders to the helm. Eventually, 

the Boatswain’s Mate of the Watch put the rudder over hard left and pushed the ship’s 

throttles forward. These actions occurred just 30 seconds prior to the impact, and the 
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USS Fitzgerald had briefly started coming left and increasing speed by the time of 

impact. 

The merchant vessel's port bow (left front) impacted USS Fitzgerald's starboard 

side amidships (right middle). At no time leading up to the collision did the USS 

Fitzgerald or CRYSTAL watchstanders attempt to communicate over radio, or take 

decisive action to avoid collision. 

The collision resulted from a compilation of failures by leadership and 

watchstanders to plan for safety, appropriately adhere to sound navigation practices, 

execute basic watchstanding principles, properly use navigation tools, and deliberately 

and effectively respond when in extremis. This critique of USS Fitzgerald does not 

imply that CRYSTAL mistakes and deficiencies were not contributing causal factors in 

the collision.

USS Lake Champlain (CG 57) Collision with Nam Yang 502

On 9 May 2017, USS Lake Champlain was escorting an aircraft carrier. A 

Republic of Korea fishing vessel, Nam Yang 502 was operating in the same area, with 

USS Lake Champlain watchstanders intermittently tracking Nam Yang 502 for over an 

hour on a constant course and speed. USS Lake Champlain watchstander awareness 

of the vessel was inconsistent due to their poor RADAR operating technique and some 

inoperable commercial radar (backup) equipment. The Bridge and CIC watchteams 

were undisciplined in their communications and failed to coordinate common situational 

awareness and agreement on the safety of planned maneuvers. While changing course 

to maintain relative position with the escorted aircraft carrier, the USS Lake Champlain 

turned in front of the fishing vessel without realizing the risk of collision. The Bridge 

watchteam was slow to react and executed improper and untimely maneuvers in an 

attempt to avoid collision, and the Nam Yang 502 struck USS Lake Champlain 

amidships on the port side.

Minutes before the collision, USS Lake Champlain’s Bridge watchstanders 

attempted to contact Nam Yang 502 on the radio and simultaneously signaled the 

fishing vessel using the ship whistle. Nam Yang’s global positioning system and radio 
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were not working properly. Further, Nam Yang did not attempt to communicate with 

USS Lake Champlain or take immediate action to avoid collision. 

The collision occurred because an inexperienced Bridge team failed to follow

safe navigational practices and take proper actions to avoid collision. This critique of 

USS Lake Champlain does not imply that Nam Yang mistakes and deficiencies were 

not contributing causal factors in the collision. 

USS Antietam (CG 54) Grounding

On 31 January, 2017, USS Antietam moved from her berth in Yokosuka to an 

anchorage in Tokyo Bay to take on supplies before a planned transit to conduct local 

area training. The navigation plan and brief noted the prevailing environmental 

conditions (high wind and current) but did not account for them during the approach to 

anchorage. After maneuvering to avoid shipping, USS Antietam turned to its anchorage 

using a different approach course than planned. Wind and current pushed USS 

Antietam south of the intended anchorage point, toward the nearest charted shoal. 

USS Antietam was 114 yards away from the planned anchorage point when the order to 

“let go the anchor” was given, however, the CO believed the ship was only 50-75 yards 

away from the planned anchorage. 

The dropping of the anchor was delayed because a retaining pin had been 

inserted backwards, making it difficult for deck personnel to remove it. When the 

anchor was finally released, the ship used less than half the amount of chain required to 

hold the ship in place under that day’s conditions. Recognizing continued wind-induced 

drift toward the shoal, the CO decided to bring up the anchor and reposition to the 

planned anchorage point. Internal miscommunication delayed anchor retrieval. As 

USS Antietam continued to drift toward the shoal, the CO delayed adding power or 

maneuvering into the wind until the anchor was retrieved, believing the greatest risk was 

damaging the ship’s SONAR dome by increasing speed while the anchor was 

underfoot. Once the anchor was retrieved and as power was added, the blades of both 

propellers struck bottom. 

The grounding was a result of the Bridge watchteam’s failure to counter USS 

Antietam’s movement towards shoal water, poor seamanship while anchoring, 
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leadership’s delayed response when steering into danger, and the watchteams inability 

to provide forceful backup in an extremis situation. 

1.3 Summary of Findings and Actions

1.3.1 Poor seamanship and failure to follow safe navigational practices

In each case, Bridge and CIC watchstanders did not maintain situational 

awareness and recognize that a significant error chain was in motion. Once confronted 

with an extreme situation, watchstander actions failed to comply with procedures as 

outlined in governing directives, as well as common customs of service, such as 

standard commands. Additionally, watchstanders did not take emergency actions, to 

include sounding alarms, signaling to the other ship, or warning the crew. In every 

mishap, departures from procedures or approved customary practices were deemed to 

have directly contributed to the mishap.

Action: Improve seamanship and navigation individual skills training for Surface 

Warfare Officer candidates, Surface Warfare Officers, Quartermasters and 

Operations Specialists.

Action: Create an objective, standardized assessment program to periodically 

assess individual seamanship and navigation skills over the course of a Surface 

Warfare Officer’s career. 

Action: Numbered Fleet Commanders establish appropriate policies for surface 

ships to actively transmit and use Automatic Identification System (AIS) when 

transiting high traffic areas. 

1.3.2 Degraded watchteam performance

Each of the four Bridge and CIC teams involved in the mishaps did not work with 

each other to solve problems as an effective team. Command leadership on these 

ships failed in their absolute responsibility to develop and properly balance their 

watchteams with depth and experience to foster consistent superior performance. 

Bridge and other CIC watchstanders did not perform their duties as primary advisors to 

the OOD for the safe navigation of the ship as required by Commanding Officer’s 

Standing Orders and higher level instructions. 
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Action: Improve current seamanship and navigation team training and 

certifications to include assessment in emergency and in extremis environments.

Action: Improve shore-based Bridge trainers and add CIC functionality to team 

training facilities.

Action: Integrate Bridge and CIC evaluations for unit level seamanship and 

navigation training scenarios in shore-based team trainers, and during at sea 

training and certifications events.

1.3.3 Erosion of crew readiness, planning and safety practices

The readiness generation model for ships based in Japan does not support the 

training needs for these ships. The increase in operating tempo in the Western Pacific 

combined with longer and more complex maintenance and modernization periods, has 

effectively reduced the amount of time Yokosuka-based ships have to train and certify in 

the existing Forward Deployed Naval Force (FDNF) – Japan readiness generation 

model. FDNF-Japan surface forces must be committed to a new model tailored to 

supporting operational requirements while preserving time for maintenance and training. 

This review endorses COMPACFLT’s actions to conduct a hull-by-hull material review 

of FDNF-Japan ships’ material condition, review the certifications of each FDNF- Japan 

ship, and implement a zero-based readiness review of the FDNF Japan continuous 

readiness generation cycle. 

Action: Conduct comprehensive Ready for Sea Assessments to determine the 

material and operating readiness for all Japan-based ships.

Action: Develop a force generation model for ships based in Japan that 

addresses the increasing operational requirements, preserves sufficient 

maintenance and training time, and improves certification accomplishment.

1.3.4 Headquarters processes inadequately identified, assessed, and managed 

operational risks

Higher headquarters readiness processes were not rigorously executed to 

provide leadership appropriate information to make employment decisions. The 

mitigation plans developed for expired training certifications for Yokosuka-based ships 

almost universally identified insufficient training time to complete the certifications as a 

cause, and rescheduling of training as the mitigation. As a result, employment 
18

decisions were made without adequate assessment of the readiness risk of reduced 

training. Additionally, no independent organization was providing oversight to the 

certification process to ensure standards were maintained. 

Action: Permanently establish Naval Surface Group Western Pacific as an 

echelon 4, Immediate Superior in Command administrative headquarters 

responsible for maintaining, training and certifying FDNF Japan ships.

Action: Restore the SEVENTH FLEET deliberate employment scheduling process

to improve operational planning and risk management.

Action: Cancel all existing Risk Assessment Mitigation Plans (RAMP) until all 

Ready for Sea Assessments (RFSA) are complete.

Action: Establish a single Echelon 2 higher headquarters responsible for the 

readiness generation of all Navy forces.

1.3.5 Assessments do not reinforce effective learning

Surface ships, Type Commanders headquarters, and safety organizations have 

not all instituted a culture of critical assessment and continuous improvement. Unit 

evaluation processes are mainly focused on analyzing specific events and do not 

provide a broader view of performance over time. Additionally, the numerous external 

assessments that are performed do not always provide sufficient critical examination of 

a crew’s performance to drive learning and improvement. Safety programs and safety 

reporting and analysis systems to develop and promulgate lessons learned and 

feedback from significant events are also inadequate. The lack of objective 

performance measures prevents the identification of trends so action can be taken on 

problems before they become hazardous.

Action: Perform a baseline review of all inspection, certification, assessment and 

assist visit requirements to ensure and reinforce unit readiness, unit selfsufficiency, and a culture of improvement.

Action: Establish and utilize near miss reporting processes to share lessons 

across the surface force.

Action: Improve Naval Safety Center and fleet and force headquarters safety 

programs and data analysis to provide predictive operational safety and risk 

information.
19

1.3.6 “Can-do” culture undermined basic watchstanding and safety standards

Historically, our can-do culture has often differentiated us from our adversaries 

and has been pivotal in bringing victory against overwhelming odds. A can-do culture, 

when self-inspired, is a virtue that the Navy relies on to be successful. The can-do 

culture becomes a barrier to success only when directed from the top down or when 

feedback is limited or missed. We want that can-do culture and must build the

experience and temperament in our Commanders and crews that will reinforce its virtue. 

The prevailing belief of Japan-based ships and higher headquarters was that a high 

pace of operations equates to a high state of proficiency. In part, this belief led to an 

undervaluing of human performance factors, such as fatigue. When combined with an 

absence of foundational training and critical assessment, this attitude induced a slow 

erosion of standards, and organizational drift from the deliberate processes used to 

manage time, resources, rest and a commitment to safety as a way of operating.

Action: Improve Operational Risk Management training and education at all 

Surface Warfare Officer School milestone courses.

Action: Establish a comprehensive fatigue and endurance management policy to 

implement fatigue recovery standards and codify a circadian ship and watch 

rotation routine for surface ships.

Action: Establish human performance expertise at all Type Commander staffs.

1.3.7 Surface ship Bridges not modernized as an integrated control room

U.S. Navy Bridge equipment modernization has occurred without centralized 

oversight of the cumulative effect of equipment and configuration changes on the 

Bridge. Technology intended to simplify navigation, improve situational awareness for 

smaller watchteams, and increase flexibility for ship control is complex, and in some 

cases, more difficult to operate. Force wide, the transition from legacy to modern 

systems has been slowed due to lack of funding and has resulted in unique Bridge 

configurations and wide variances in configurations from ship-to-ship, even within the 

same ship class. However, from the perspective of individual ships, technological 

change can appear rapid and disjointed. Gaps between the foundational training 

provided to enlisted crewmembers, and the complexity of the technology used in 
20

modern ship control consoles, make it difficult for ships’ personnel to retrain and 

requalify for operating and technical proficiency.

Action: Consolidate responsibility and authority for Bridge system modernization

and improve methods for human systems integration. 

Action: Establish formal policy for requalification requirements for personnel 

temporarily assigned to ships and when changes in equipment configuration 

occur.

Action: Accelerate plans to replace aging military surface search radars and 

electronic navigation systems.

Action: Improve stand-alone commercial radar and situational awareness piloting 

equipment through rapid fleet acquisition for safe navigation.

1.4 Conclusion

The U.S. Navy operates in an environment constantly subject to change. Amidst 

these changes, the Navy is expected to adapt quickly and operate effectively. Many of 

its leaders resourcefully find ways to generate strong teams in this environment and use 

resources effectively to succeed. However, continued success is not guaranteed. The 

surface force must seek and trend precursors that lead to significant mishaps at sea. 

The commonalities among the four mishaps discussed in this document originated in a 

failure to properly plan and prepare, and ultimately manifested in unnecessarily 

pressurized execution of these important seamanship evolutions. Systemic issues at 

higher levels also adversely affected organizational processes at the unit level. Even

when presented with information that indicated standards of readiness were not met, 

rather than taking pause and determining what was needed to correct the problem, the 

force was conditioned to mitigate the risk only through the delay of some training action 

that would ultimately lessen the impact on operational missions, and then proceed on 

those same missions without real risk mitigation. 

All levels of command must evaluate the sufficiency of internal programs and 

processes to self-assess, trend problems, and develop and follow-through on corrective 

actions. This kind of assessment must be an integral part of our everyday culture, as it 

is an essential aspect of ensuring the Navy’s ability to safely and effectively perform its 

missions at sea. Continuous improvement processes must account for human factors 
21

in individual and team performance, to include individual and operational fatigue. These 

factors may determine mission outcomes regardless of other readiness indicators. 

Knowing that human induced errors are part of any system, we must account for them 

as risks to be mitigated for overall mission accomplishment, whether the team is a 

division, a ship, or a Fleet, System Command or Type Command headquarters. 

Effective internal and external assessments that document these tendencies reduce 

vulnerabilities, and will improve Navy’s surface force operational effectiveness at all 

levels.

Some of the challenges identified by this comprehensive review are not unique to 

the surface force. The increasing demand for forces, ever-pressurized maintenance 

cycles, and understanding the human performance elements of operational safety cut 

across all Navy communities. As such, each community leader should examine the 

results of this comprehensive review and assess the principles of the findings for 

broader applicability.

Accordingly, there must be more consistent and disciplined processes at the 

Fleet and Type Commander staffs, with clear guidance, responsibility, authority, and 

accountability for readiness, training and operations. This will set the conditions for our 

ships to maintain the highest levels of readiness and superior performance in the 

missions the Navy asks of them. Similarly, effective improvements to surface force 

operations and training can also be made at the command level so that ships, 

squadrons and crews are trained, certified, rested, responsive, and ready to go.
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23

2. METHOD OF REVIEW

2.1 Scope

Over the past decade U.S. Navy ships have been involved in 12 major at-sea 

mishaps (collisions, allisions, or groundings), including four incidents this year in the 

Western Pacific. Each of these mishaps was followed by in-depth investigations into 

the root causes leading to the incidents. These individual investigations were 

accompanied by recommendations intended to provide lessons to be learned and to 

prevent a singular causal or contributing condition from reoccurring in the future. These 

lessons and other changes were meant to instill individual unit improvements and did 

not examine the institutional Doctrine, Organization, Training, Material, Leadership and 

Education, Personnel, and Facilities (DOTMLPF) conditions that might be external 

factors in these mishaps.

Learning involves recognizing the adequacy of our actions and correcting 

potential hazards before a mishap occurs. Corrective actions will be most effective 

when a culture of safety matures to the point where knowledge meets capability, and all 

levels of command are operating interdependently, with greater teamwork at their 

respective levels, and a heightened awareness of the adequacies of their actions with 

respect to the Navy’s goals. 

Leadership typically goes through several phases following a major mishap: 

ordering an operational pause or safety stand down; assembling a team to determine 

what happened and why; and developing a list of discrete actions for improvement.

Causes are identified, meaningful actions taken, and there has been repeated nearterm success in instilling improved performance. However, these improvements may 

only have marginal effect in the absence of programs and processes to ensure lessons 

are not forgotten. Still, all levels of command must evaluate the sufficiency of internal 

programs and processes to self-assess, trend problems, and develop and follow 

through on corrective actions in the wake of mishaps. 

In August 2017, the Vice Chief of Naval Operations (VCNO) assigned 

Commander United States Fleet Forces Command to lead a comprehensive review of 

surface ship operations and incidents at sea to determine improvements or changes 
24

needed to make the surface force safer and more effective. The Comprehensive 

Review Team (CRT) examined the significant surface mishap investigation reports over 

the past ten years, conducted field observation, interviews, and focus group discussions 

at various echelon levels from individual units to the Fleet Commander, and reviewed 

source documentation defining requirements for and execution of force generation and 

force employment models, as well as training curricula and equipment design criteria 

and utilization. The areas specified in the VCNO memorandum directing the 

comprehensive review of recent surface ship incidents include:

a. Individual training and professional development to include seamanship, 

navigation, voyage planning, leadership development, and officer and enlisted 

tactical training in formal schools and on the job.

b. Unit level training and operational performance, to include manning, personnel 

management, watch bill management, Bridge (and CIC) team resource 

management, contact management, contact avoidance, leadership oversight,

and risk assessment/mitigation at all levels of the chain of command.

c. Development and certification of deployed operational and mission standards 

(Force Generation) with particular emphasis on Forward Deployed Naval 

Forces (FDNF), to include validation of required certification standards, gaps 

between required standards and actual employment practices, effectiveness of 

leadership and oversight at all levels of the administration and operational 

chains of command, maintaining and enforcing standards throughout FDNF 

assignment including self-assessment practices, external inspection 

reinforcement, and remedial action mitigation plans.

d. Deployed Operational Employment and Risk Management (force 

employment), to include Combatant Commander mission requirements, theater 

security cooperation requirements, maintenance impacts, other competing 

priorities (experimentation, concept development), and their corresponding 

impact to operational tempo (OPTEMPO) and fundamental navigation and 

seamanship proficiency.
25

e. Material readiness of electronic systems to include navigation equipment (e.g. 

AIS, radars, ECDIS, VMS, WSNs), propulsion and machinery to include steering 

systems, combat system modernization, and material availability.

f. Practical utility of current navigation equipment and combat systems including 

sensors, tracking systems, displays, and internal communications networks to 

evaluate their effectiveness at integrating tactical data and providing situational 

awareness to our people. 

This review evaluated the aforementioned matters using a solution-oriented 

approach to identify gaps in DOTMLPF. The review found weaknesses in each of these 

areas and as a result makes recommendations for DOTMLPF improvements to make 

the surface force safer and more effective.

The cumulative results of the findings and recommendations in this report go a 

step beyond the individual and collective actions that are needed. The recommended 

changes, i.e., the things the Navy must go and do, are based on the conclusion that the 

actions taken in the wake of these mishaps can help instill the knowledge, capabilities 

and proficiencies necessary for improvements in these five areas:

(1) Fundamentals. Basic skills such as seamanship and navigation, rigor in 

individual qualification processes, proficiency, and adherence to existing standards; 

(2) Teamwork. The extent to which the surface force deliberately builds and 

sustains teams, and tests them with realistic and challenging scenarios; 

(3) Operational safety. The process and tools by which ships are made ready 

for tasking, ships are employed, and technology is used to safely operate at sea;

(4) Assessment. The extent to which headquarters plan, critically self-assess, 

generate actionable lessons learned, and share knowledge across the force;

(5) Culture. The sum of the values, goals, attitudes, customs and beliefs of the 

surface force that defines its identity.
26

2.2 Comprehensive Review Team membership

The Comprehensive Review Team (CRT) consisted of 34 servicemen and 

women and civilians. The team consisted of a range of subject matter experts, to 

include personnel with extensive experience in afloat leadership; underway operations, 

including the Western Pacific operating area; institutional training; equipment and 

systems research, development, and acquisition; and ship maintenance. It included 

civilian experts, and military members from other Navy warfare communities and from 

other services. Multiple members also had substantial experience in conducting major 

inquiries and audits. A complete roster of team members is included in Appendix 9.4. 

The VCNO also directed U.S. Fleet Forces Command to seek input and insight 

from other services, industry and highly qualified experts outside the Services as the 

comprehensive review of surface ship incidents was conducted. Several distinguished 

individuals were appointed to advise the CRT during the course of the review, and are 

included in Appendix 9.4.1.

2.3 Structure of the Report

This report is organized in chapters that analyze the major elements of the 

VCNO’s Memorandum. Chapter three provides a summary of the four 2017 mishap 

events involving USS John S. McCain, USS Fitzgerald, USS Antietam, and USS Lake 

Champlain. This section also describes common causal factors among these mishaps, 

and was informed by other mishap events that have occurred over the past ten years. 

All four 2017 mishaps illustrated a breakdown in fundamentals, teamwork, operational 

safety, assessment, and culture. Chapters four through eight provide detailed findings 

and recommendations related to the following areas, respectively: individual training; 

unit level training; development and certification of operational forces, mission 

employment and operational safety; seamanship and navigation equipment readiness 

and utility; and systemic problems and recommendations to improve the mission culture 

in the surface force. The appendices contain supporting documentation, including a 

matrix of factors in each of the four mishaps; a list of commands visited or personnel 

interviewed as part of this review.
27

2.4 Areas for Further Study

The following areas were identified by the review, but were not considered in 

depth due to time constraints and/or security needs. These should be considered for 

additional review and analysis: force structure, to include Navy Integrated Air and 

Missile Defense capacity; improving acquisition processes to fully account for training 

and integrated logistics support; improving processes that support learning across the 

Navy (i.e., between warfare communities); and improvements in damage control 

Finally, while the Navy concluded cyber-attack was not a factor in either the USS John 

S. McCain-ALNIC collision or the USS Fitzgerald-ACX CRYSTAL collision, continued 

study is recommended on cyber vulnerabilities of surface ship propulsion and navigation 

systems. 
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3. SUMMARY AND ANALYSIS OF MISHAPS

3.1 Introduction

This review examined each of the major mishaps that occurred since 2007. 

Below are summaries of each of the four mishaps that occurred in 2017 beginning with 

the most recent, and a listing of mishaps from the previous ten years. This chapter 

summarizes the causal, contributing, and additional important factors common among 

the events. Causal factors are those elements or events that, if corrected, would have 

interrupted the chain of events and prevented the incidents from occurring. Contributing 

factors are elements or events that, if corrected, might have prevented the incident from 

occurring. Additional important factors are germane to these incidents and related 

incidents at sea but are not a direct contributor to the event. This critique of U.S. Navy 

vessels does not imply that other vessels’ mistakes and deficiencies were not 

contributing causal factors in the collision.

3.2 USS John S. McCain (DDG 56) Collision with ALNIC MC

On the morning of 21 August 2017 USS John S. McCain was preparing to enter 

the Singapore Strait for transit to Sembawang, Singapore. The ship completed a full 

Navigation Brief the day before that included an estimated time of 0500 to enter the 

Traffic Separation Scheme (TSS) and passage in close proximity to shoal water. 

Although the Executive Officer (XO) and Navigator recommended setting the Sea and 

Anchor Detail at 0500, the CO decided to delay stationing the detail until 0600 in order 

to give the crew more time to rest and to minimize the chance of a man overboard 

during hours of darkness. As mitigation, the CO planned to be on the Bridge for the 

entire transit and in fact arrived on the Bridge at 0115 and remained there until after the 

collision. 

Of the Bridge watchstanders, the Junior Officer of the Deck (JOOD), the 

Boatswain’s Mate of the Watch (BMOW), and the eventual Lee Helmsman (Lee Helm) 

were on temporary duty from the USS Antietam (CG 54) to provide these Sailors 

underway time for qualifications while USS Antietam was undergoing repairs. Although 

the watchbill listed the USS Antietam Sailors as qualified, the BMOW and JOOD 

qualification dates coincided with the day they reported to USS John S. McCain, and 
30

they conducted no requalification events. The Lee Helm qualified as Helm/Lee Helm 

within a few weeks of reporting to USS John S. McCain. The Conning Officer was a 

new ensign who joined the ship two months before the collision and had not attended 

the Basic Division Officer Course.

After entering the TSS, the CO noticed that the Helmsman was having difficulty 

both steering the ship and adjusting the ship’s speed due to prevailing environmental 

conditions. He ordered the OOD to split the steering and throttle control between two 

stations, the Helm and Lee Helm. While attempting to execute this order, the Bridge 

watchstanders unintentionally transferred steering control to the Lee Helm console and 

“un-ganged” the throttles (uncoupled the throttle control so the left throttle controls the 

port propulsion shaft and the right throttle controls the starboard shaft). Complicating 

the execution of the order was a series of watch reliefs for meals then in progress 

among the various watchstations and a lack of posted procedures for transfer of throttle 

and steering control. Recognizing that he no longer had control of steering, the 

Helmsman announced a loss of steering (system) casualty (malfunction). The After 

Steering station was then manned in short order and attempted to take control. Due to 

confusion on the Bridge about the nature of the casualty and the operation of the Ship’s 

Control Console (SCC), steering control was inadvertently transferred among various 

controlling stations four times within the two minutes leading up to the collision. During 

this time the ship began a slow turn to port. After hearing the Loss of Steering casualty 

the CO directed the OOD to slow the ship. The OOD ordered 10 knots and the Conning 

Officer duly gave the order. The Lee Helm executed the order and slowed the port 

shaft, but did not recognize that the throttles were not linked and that he had control 

only of the port shaft. Unrecognized by the watchteam, control of the starboard shaft 

remained at the Helm station for more than 60 seconds after control of the port shaft 

was taken by the Lee Helm. The speed change to the port shaft slowed the ship but 

also increased USS John S. McCain’s rate of turn to port as the starboard engines and 

shaft remained ordered to 20 knots. The CO then ordered a speed of 5 knots, but the 

Lee Helm’s actions only reduced power to the port shaft due to the individual throttle 

control. The starboard shaft still remained at 20 knots, exaggerating the rate of turn 

even further. About three minutes after the reported Loss of Steering casualty began, 
31

USS John S. McCain regained positive steering control in After Steering and answered 

Right 15 degrees rudder. About this same time throttles were matched at the Lee Helm 

and the starboard engine and shaft slowed to 5 knots. These actions were too late to 

avoid collision with the ALNIC. At about 0524, and because of the port turn induced by 

the loss of steering control and thrust control actions, the USS John S. McCain crossed 

in front of ALNIC, whom the USS John S. McCain had just passed ahead of, and USS 

John S. McCain was struck on her port quarter. Technically, there never was a loss of 

steering casualty.

Primary causes of the collision were leaderships’ loss of situational awareness in 

a high traffic area and failure to follow safe navigational practices, coupled with 

watchstanders who were not proficient with ship control console operations (steering 

and throttle control) or associated casualty response procedures. Contributing to the 

collision were failures in basic watchstanding and seamanship among the Bridge and 

CIC teams; a failure by these same watchteams to take clear and decisive action to 

avoid collision when in extremis; the failure of the Commanding Officer to properly 

assess risk in setting Sea and Anchor detail, changing watchstanders and equipment 

configurations in the Traffic Separation Scheme (TSS), the presence of nearby 

shipping, and to take prudent measures to mitigate said risks. This critique of USS 

John S. McCain does not imply that ALNIC mistakes and deficiencies were not 

contributing causal factors in the collision.

3.3 USS Fitzgerald (DDG 62) Collision with ACX CRYSTAL

On 17 June 2017, USS Fitzgerald, based in Yokosuka, Japan, was transiting in 

calm seas with clear visibility from a near-Japan shore training area to conduct routine 

operations in the Western Pacific. Her planned navigation track required her to transit a 

highly trafficked area known as the Sagami-Wan at relatively high speed. After 

midnight, with traffic increasing, USS Fitzgerald maneuvered to pass and avoid several 

merchant and fishing vessels. At the time, Bridge and CIC watchstanders were not 

employing all sensors to maintain a clear picture of ships in their area, did not calculate 

predicted closest-points-of-approach for traffic, and did not share information and 

intentions among the team on watch and with the Commanding Officer.
32

As USS Fitzgerald approached the point of collision, Bridge and CIC 

watchstanders were poorly monitoring surface traffic and as a result were unaware of 

multiple contacts within ten miles of the ship. Shortly after 0100, a crossing situation 

developed between USS Fitzgerald and three large on-coming merchant vessels, all of 

which were transmitting on AIS. The merchant ships were traveling in close proximity to 

each other on similar courses with two overtaking the third. The OOD decided to 

maintain course and speed, predicting that USS Fitzgerald would cross 1500 yards 

ahead of what she recognized as a crossing vessel with the right of way, and began to 

prepare a contact report to inform the CO. Shortly before the collision, the JOOD 

sighted visually, and informed the OOD of a closer than anticipated contact, the ACX 

CRYSTAL to starboard and recommended slowing. The OOD, confused between what 

she saw and what she intended with the crossing situation, ordered right full rudder in 

order to pass behind the merchant. However, before that order was executed, in an 

attempt to turn away from the merchant, the OOD reassessed and improperly ordered 

the conning officer to come to full speed, and then flank speed ahead, and then ordered 

a full, and then hard left rudder. Simultaneously, the ACX CRYSTAL began to turn to 

the right. Neither the USS Fitzgerald’s or ACX CRYSTAL’s final maneuvers were 

effective to steer clear of danger. At 0130, the merchant vessel's port bow (left front 

quarter) impacted USS Fitzgerald's starboard side amidships (right middle) and caused 

significant damage above and below the waterline. Seven U.S. Sailors were killed, and 

three were injured. This critique of USS Fitzgerald does not imply that CRYSTAL 

mistakes and deficiencies were not contributing causal factors in the collision.

3.4 USS Lake Champlain (CG 57) Collision with Nam Yang 502

On 9 May 2017, USS Lake Champlain, homeported in San Diego, was underway 

on deployment in the Sea of Japan and assigned to operate in a positon to screen a 

nearby aircraft carrier on a clear, relatively calm day. The CO had departed the ship via 

helicopter for a meeting on the aircraft carrier, the XO was in her stateroom, and the 

ship was conducting maintenance on one of its four engines. 

A fishing vessel in the area, the Nam Yang 502, had been on a constant course 

and speed for over an hour, and was transmitting its unique identification, position, 
33

course and speed on its Automatic Identification System (AIS). Both USS Lake 

Champlain and the aircraft carrier had positive radar and AIS contact on the fishing 

vessel, had correlated the Nam Yang 502 in the tactical link between ships, and the 

vessel had been visually spotted by USS Lake Champlain lookouts. However, USS 

Lake Champlain radar and AIS contacts, and the crew’s awareness of them, were 

intermittent due to incorrect radar operator techniques and an inoperable backup 

commercial radar system. USS Lake Champlain, over a series of maneuvers to remain 

in their assigned position relative to the aircraft carrier, did not follow standard 

procedures for lookouts, for communications between the Bridge and CIC, and for 

maneuvering requirements for stand-on versus give way vessels.

At 1145, USS Lake Champlain reversed its own course in front of the fishing 

vessel. Upon recognizing the possibility of collision, the OOD initially and improperly 

delayed maneuvering. At 1150, the OOD ordered right full rudder and engines to 

maximum speed (which was limited by some approved maintenance in progress). The 

OOD reassessed and ordered left full rudder (in an attempt to turn away from the fishing 

vessel) - these orders were carried out, and eventually turned left with available power. 

The fishing vessel did not maneuver, and struck USS Lake Champlain amidships on the 

port beam at 1151. Due to the small size of the fishing vessel, damage to both ships 

was relatively minor. This critique of USS Lake Champlain does not imply that Nam 

Yang mistakes and deficiencies were not contributing causal factors in the collision. 

3.5 USS Antietam (CG 54) Grounding

On 31 January 2017, USS Antietam moved from her Yokosuka base to an 

anchorage in Tokyo Bay to take on supplies before a planned transit to conduct local 

area training. The navigation plan and brief noted the prevailing environmental 

conditions (high wind and current) but did not account for them during the approach to 

anchorage. After maneuvering to avoid shipping, USS Antietam turned to their 

anchorage using a different approach course than planned. Wind and current pushed 

USS Antietam south of the intended anchorage point, toward the nearest charted shoal. 

USS Antietam was 114 yards away from the planned anchorage point when the order to 
34

“let go the anchor” was given. However, the CO believed the ship was only 50-75 yards 

away from the planned anchorage. 

The dropping of the anchor was delayed because a retaining pin had been 

inserted backwards, making it difficult for deck personnel to remove it. When the 

anchor was finally released, the ship used less than half the amount of chain required to 

hold the ship in place under that day’s conditions. Recognizing continued wind-induced 

drift toward the shoal, the CO decided to bring up the anchor and reposition to the 

planned anchorage point. Internal miscommunication delayed anchor retrieval. As 

USS Antietam continued to drift toward the shoal, the CO delayed adding power or 

maneuvering into the wind until the anchor was retrieved, believing the greatest risk was 

damaging the ship’s SONAR dome by increasing speed while the anchor was 

underfoot. Once the anchor was retrieved and as power was added, the blades of both 

propellers struck bottom. 

The grounding was a result of the Bridge watchteam’s failure to counter USS 

Antietam’s movement towards shoal water, poor seamanship while anchoring, 

leadership’s delayed response when steering into danger, and the watchteam’s inability 

to provide forceful backup in an extremis situation. 

3.6 Analysis of Past Incidents

There are commonalities between the grounding and collisions that occurred this 

year, and several groundings, allisions, and collisions that occurred in the previous ten 

years. Past mishaps also considered included:

 06 Oct 2014, USS Tortuga (LSD 46) allided with a buoy at the entrance to 

Chesapeake Bay while inbound to anchorage.

 12 Feb 2014, USS Taylor (FFG 56) grounded in a harbor while pulling into port in 

Samsun, Turkey.

 17 Jan 2013, USS Guardian (MCM 5) grounded on a reef in the Philippines.

 12 Aug 2012, USS Porter (DDG 78) collided with a tanker near the Strait of 

Hormuz and sustained major hull damage above the waterline.

 16 May 2012, USS Essex (LHD 2) collided with a fleet replenishment oiler while 

conducting an approach alongside the oiler for underway replenishment.
35

 21 Jun 2011, USS Emory S. Land (AS 39) allided with a channel buoy after 

experiencing a loss of rudder control while heading into Bahrain.

 05 Feb 2009, USS Port Royal (CG 73) grounded off the coast of Oahu, HI, while 

off-loading personnel into a small boat.

 19 Sep 2007 USS Halyburton (FFG 40) sustained damage to the sonar dome 

when dropping anchor off the coast of Central America.

This review considered the factors present in the above collisions, allisions and 

groundings from 2007-2016 in order to build an awareness of the possible common 

factors that may have existed during past events that perhaps also existed during the 

four mishaps in 2017. 

3.6.1 Common Causal and Contributing Factors

Non-compliance with safe navigational practices (fundamentals). In each of the 

four mishaps, the ships failed to take sufficient action. Multiple watchstations failed to 

comply with safe navigational practices and prescribed U.S Navy maneuvering and 

communications requirements. These failures were a causal factor to the chain of 

errors that resulted in these incidents.

Incorrect action in extremis (fundamentals). Once confronted with an extreme 

situation, each of the four ships delayed action, to include sounding alarms, signaling to 

the others ship, or warning the crew. All four ships failed to take action in ample time to 

avoid danger. Incorrect actions in extremis were a contributing factor to the chain of 

errors that resulted in the incident. 

Substandard proficiency of Bridge and CIC watchstanders (fundamentals). In 

each of the four mishaps, the qualification of individuals for specific watchstations did 

not translate to proficiency to safely execute the mission. In USS John S. McCain, three 

key mishap watchstanders on the Bridge were temporarily assigned from another ship 

and had been qualified without adequate training on equipment differences between the 

two ships. In all four mishaps there was a gap in watchstander training, their 

experience, and/or their proficiency, and their ability to conduct the tasks they were 

assigned to perform. Beyond initial qualification and certification, the Bridge and CIC 
36

watchstanders in each of the four incidents failed to respond to degraded conditions, 

and did not take associated controlling actions when approaching situations of extremis.

Substandard risk management and planning (operational safety, assessment). 

In each of the four mishaps, the U.S. Navy ships involved failed to take into account 

relevant planning considerations such as weather, background lighting, hazards to 

navigation, traffic separation schemes, patterns and density of nearby shipping, and the 

capabilities of their own people and equipment. Three of the mishaps occurred during 

or shortly after transitions from one operation to another: USS Antietam was 

transitioning from underway to anchoring, USS Fitzgerald was moving from training 

evolutions to operational tasking, and USS John S. McCain was entering a busy TSS 

and preparing to enter port. Flawed planning was a contributing factor to the chain of 

errors that resulted in the incident. 

Substandard Bridge and CIC coordination (teamwork). In each of the four 

incidents the TAO, Surface Warfare Console operator (SUWC), Shipping Officer and 

other CIC watchstanders did not perform their duties as primary advisors to the OOD for 

the safe navigation of the ship as required by Commanding Officer’s Standing Orders 

and higher level instructions. CIC did not use readily available tools or information such 

as AIS, radar, correlated link tracks, or lookout reports, to build situational awareness. 

CIC watchstanders also failed to translate that information into action or 

recommendations to avoid grounding or collision. None of the Bridge watchstanders 

(e.g., OOD, JOOD, CONN) requested information from CIC to confirm position and 

course of nearby shipping, estimated CPAs, and agreement with recommended course 

maneuvers. Inadequate teamwork was a contributing factor to the chain of errors that 

resulted in these incidents. 

Substandard CIC performance (fundamentals). Each of the four incidents 

involved unsatisfactory performance of the enlisted and officers on watch in CIC. Basic 

watchstanding fundamentals were not applied. For example, CIC Surface 

watchstanders did not conduct manual maneuvering boards (MOBOARD) or

subsequently make recommendations to the Bridge to assist with safe contact 

avoidance. In addition, the senior OSs and the officers on watch in CIC failed to 
37

observe and correct watchstander performance standards. Substandard CIC officer 

and enlisted (OS) performance was a contributing factor to the chain of errors that 

resulted in the incident.

Inadequate use and understanding of technology (fundamentals). In each of the 

four mishaps, watchstanders did not demonstrate proficiency in their abilities to use all 

resources available on the Bridge to gain situational awareness about their 

surroundings. For example, RADAR operators consistently failed to use the correct 

range scale or tune the RADAR to the appropriate settings based on the environmental 

conditions. In addition, navigation teams improperly interpreted information displayed 

on VMS; and did not use AIS to correlate information from other sources. Additionally, 

watchstanders did not have a complete understanding of their ship’s integrated 

navigation systems, which gave effect to a false reliance on configurations that were 

perceived to work more efficiently.

Practice of not using AIS (operational safety, assessment). In each of the three 

collisions, the U.S. Navy ships involved had an AIS receiver and transmitter, but 

maintained their AIS in receive mode only. This removed one of the primary awareness 

and collision avoidance tools used on board most commercial vessels around the world. 

Further, they generally failed to use AIS information to improve their situational 

awareness. Inadequate use of AIS was a contributing factor to the chain of errors that 

resulted in the incident. 

Substandard use of lookouts (fundamentals, operational safety). With the 

exception of USS Antietam’s grounding, all mishaps involved unsatisfactory 

performance by lookouts, including the Bridge watch officers that also serve as 

lookouts. In each collision, one or more of those with lookout responsibilities did not 

report the closing contact and did not determine whether a constant bearing/decreasing 

range situation existed using tools such as MOBOARDs, alidades, or bearing circles. 

Lookout performance was a contributing factor to the chain of errors that resulted in the 

incident.

Watchbill Execution (culture). In each of the four mishaps, some of the 

personnel on watch at the time of the incident, or shortly before, were not on the 
38

approved watchbill, and some of the personnel were not at their assigned 

watchstations. For example, the anchor windlass operator on USS Antietam was 

replaced with a different watchstander without approval; just before the USS Lake 

Champlain collided with Nam Yang, two junior OSs relieved four more senior OSs on 

the Surface Watch Station (SWS) so the more senior OSs could take a meal break; and 

on USS Fitzgerald, the SUWC departed for a restroom break without first obtaining a 

relief, and returned minutes prior to the collision. In each case, this was not the first 

time such substitutions were made without the required formal command permission. 

Poor watchbill management was a contributing factor to the chain of errors that resulted 

in the incident.

Poor logkeeping (fundamentals). In every mishap, Bridge and CIC 

watchstanders failed to keep proper navigation, position and surface contact logs. 

There was a lack of required entries, inconsistent times noted on entries, non-standard 

entries or phraseology customary to the service, lack of formal review, and significant 

numbers of missing logs, particularly missing surface contact logs. Poor log taking was 

a contributing factor to the chain of errors that resulted in the incident.

Ineffective shipboard training programs (operational safety, assessment). In 

each of the four incidents, there was inadequate training on the Nautical Rules for 

officers and watchstanders. In USS John S. McCain three key mishap watchstanders 

were temporarily assigned from another ship and had been qualified without training on 

equipment differences between the two ships. Training programs on these ships also 

contained training not relevant to upcoming operations; unapproved training plans; lack 

of records of attendance at training; lack of makeup training; and leadership was often 

not present at training. Training was a contributing factor to the chain of errors that 

resulted in the incident.

Inadequate fatigue management (culture). Fatigue was evaluated as a 

contributing factor in the USS Fitzgerald and USS John S. McCain collisions. Based on 

the reported sleep of the watchstanders at the time of the mishap, and referencing the 

validated expert data on deployed U.S. Navy crew performance when fatigued, USS 

Antietam watchstanders, including the navigator and the OOD, experienced the effects 
39

of fatigue as they transitioned from an ashore watch rotation to an at-sea watch rotation. 

In the case of USS Lake Champlain, while the ship was using a circadian watchbill, it 

did not support that watchbill with an effective ship’s routine, necessitating relief for 

meals at critical times leading up to the mishap. 

3.6.2 Additional Important Factors

Lack of supporting documentation on ship’s steering systems (operational 

safety). Watchstanders on USS John S. McCain did not have the training or knowledge 

on the modes of operation of the Integrated Bridge and Navigation System, particularly 

relating to the modes of operation for the ship’s steering controls. They unknowingly 

transferred control of steering away from the Helmsman while shifting modes of 

operation. The designed responses of the IBNS when shifting modes also creates 

known vulnerabilities that have not been clearly communicated to the operators on 

ships with these systems.

Environment (operational safety, assessment). The environmental conditions 

present in each incident were manageable with proper Operational Risk Management 

(ORM), which henceforth in this report will be covered under operational safety. With 

the slight exception of the environmental conditions leading up to the USS John S. 

McCain mishap, which included mostly cloudy skies with isolated thunderstorms and 

moonlit illumination of less than one percent, the visibility during these incidents was 

unrestricted, seas were calm, and winds were moderate yet average for the regional 

climate. By all accounts, the ambient environment surrounding each of these events 

posed no significant challenges, nor did it presage the mishaps that would later occur. 

In only one mishap, that of the USS Antietam’s grounding was weather (winds) a direct 

causal factor. 

Routine operations (operational safety, assessment). Three of four mishaps 

involved ships that were independent deployers, and occurred during standard Bridge 

and CIC team evolutions common to all Navy ships. Except in the case of USS Lake 

Champlain, which was maneuvering to take a new station relative to the aircraft carrier 

when it collided with Nam Yang, there were no external warfare or defense obligations 
40

that pressurized these situations. Each of these evolutions involved some risk, but each 

had been previously accomplished by the same crew with safe and effective outcomes.

Certification in Navigation and Seamanship (fundamentals, teamwork). All four 

U.S. Navy ships passed their navigation certifications. Each had successfully passed a 

navigation check ride by their ISIC, though in the case of USS Antietam and USS Lake 

Champlain, the certification had been accomplished by the Afloat Training Group (ATG) 

on behalf of their ISIC due to their ISIC not having qualified representatives available to 

conduct the assessment. Though qualified, the mishaps indicate the teams onboard 

these four ships were not proficient.

Positive control by the Commanding Officer (fundamentals, operational safety). 

In two of the four incidents the CO was on the Bridge at the time of the mishap. There 

was a lack of formality in the COs taking the conn while directing specific action, 

coupled with a lack of formal declaration that they had done so by the OOD led to 

confusion and delays in executing critical ship control actions by the OOD, Conning 

Officer and Helmsmen. The CO was not on the Bridge at the time of the USS 

Fitzgerald’s collision with ACX CRYSTAL and USS Lake Champlain’s collision with 

Nam Yang. In each case, the OODs did not call the CO to the Bridge, or the CO’s 

representative in the CO’s absence in a situation when they were required to do so by 

the Commanding Officer’s Standing Orders.

3.7 Summary Findings 

Findings were developed through examination of the significant surface mishaps 

above, field observation, interviews, and focus group discussions at various echelon

levels from individual units to the Fleet Commander. In addition, the Review Team 

examined source documentation defining requirements for and execution of force 

generation and force employment models, as well as training curricula and equipment 

design criteria and utilization and a variety of primary references from industry and 

academia. The Review Team identified the gaps in doctrine, organization, training, 

material, leadership and education, personnel, and facilities that point to actions needed

to improve in the areas of fundamentals, teamwork, operational safety, assessment, 
41

and culture. Each of the findings below is discussed in detail in chapters four through 

eight.

3.7.1 Fundamentals

 The training continuum for Surface Warfare Officers (and candidates), 

Quartermasters, and Operational Specialists does not provide sufficient 

seamanship and navigation knowledge in advance of milestone assignments. 

(Sections 4.2.1, 4.2.2, 4.2.3)

 The individual qualification proficiency of Surface Warfare Officers is not 

periodically assessed against objective qualification standards or in high traffic, 

emergency or extremis situations. (Section 4.2.2)

 Unit seamanship and navigation training, assessments, and certifications do not 

adequately test or measure performance in high traffic, emergency, or extremis 

conditions. (Section 5.2)

3.7.2 Teamwork

 Unit seamanship and navigation training, assessment, and certifications do not 

adequately test or measure total Bridge and Combat Information Center team 

performance and effectiveness. (Section 5.2)

 Navigation and Seamanship Shiphandling Training (NSST) facilities do not 

adequately train the unique seamanship and navigation requirements for Navy 

Bridge and Combat Information Center teams. (Section 5.2)

 The watchstation requirements for proper surface contact management have not 

been reevaluated and established for the restoration of manning on surface ships 

after the “optimal manning” era. (Section 7.2.2)

3.7.3 Operational Safety

 Administrative and operational headquarters processes inadequately identified, 

communicated, and mitigated operational risks for ships based in Japan. (Section 

6.2.2)

 Mishap units inadequately identified, communicated, and mitigated readiness 

risks within their units for the assigned tasking. (Sections 6.2.2 and 8.2.1)

 Increasing operational tempo and longer maintenance periods reduced the 

amount of time for Yokosuka-based ships to train. (Sections 6.2.1 and 6.2.2)
42

 There is insufficient administrative organizational oversight for the training and 

certification of Yokosuka-based ships. (Section 6.2.1 and 6.2.2)

 The demand for ready and certified ships to support operations in the Western 

Pacific exceeds the quantity that can be generated from Japan-based ships with 

adequate training and maintenance. (Sections 6.2.1 and 6.2.2)

3.7.4 Assessment

 The RAMP process did not adequately address or mitigate operational and 

training risk for Yokosuka-based ships. (Sections 6.2.1 and 6.2.2)

 Navy technical authority (NAVSEA) and type commander (COMNAVSURFOR) 

did not provided sufficient guidance on how to man, train, qualify, and operate 

modernized surface ship Bridge systems. (Section 7.2)

 Outdated modernization and acquisition design guidance has led to delivery of 

safety-critical Bridge equipment without effective human machine interface 

review. (Sections 7.2.2 and 7.2.3)

 The high number of inspections, certifications, assessments, and visits by 

external organizations create a burden on ships’ crews and do not provide an 

objective validation of crew proficiency and self-sufficiency. (Section 8.2.1)

3.7.5 Culture

 The surface force requires an improved assessment process that utilizes 

objective data on performance, including near miss data, to detect and reverse 

organizational drift and institutionalize improvements. (Sections 8.2.1 and 8.2.4)

 The surface community does not have a comprehensive fatigue and endurance 

management plan to implement fatigue recovery standards and to codify a 

circadian watch and ship routine. (Section 8.2.2)

 The surface force does not have adequate training at all levels on human 

performance factors including fatigue, diet, and stress management. (Section 

8.2.3)
43

4. INDIVIDUAL TRAINING

4.1 Introduction

Seamanship and navigation are hallmarks of the naval profession. Seamanship 

is the skill to operate, navigate and handle a ship at sea. Navigation is the process of 

planning, recording, and controlling the movement of a vessel from one place to another 

on the sea. Developing seamanship and navigation skills requires a solid foundation of 

mathematics, geometry, physics, oceanography and meteorology, as well as an 

understanding of the forces that affect a ship’s movement on water. Becoming 

proficient in these fundamentals takes education and practice. Naval professionals 

develop practical experience by applying what they learn in the classroom with the tasks 

they perform at sea. Over time, they become proficient in gaging weather and ocean 

currents, using RADARs, alidades, and bearing circles, and doing so through repetition 

in a wide variety of routine and challenging environments. 

Part of safe navigation at sea involves understanding and applying the navigation 

rules to be followed by vessels at sea to prevent collisions. These rules were 

developed over many years and are based upon conventions established by maritime 

nations. The introduction of powered propulsion systems and increases in international 

maritime trade necessitated the codification of these traditions and informal rules. The 

Nautical Rules are defined by the International Regulations for Preventing Collisions at 

Sea (COLREGS) published by the International Maritime Organization (IMO), and 

remain an outgrowth of the same informal rules and customs that naval professionals 

have followed for over a century. In other words, a U.S. Sailor in the 1940s would have 

largely been subject to the same general regulations designed to prevent collisions at 

sea as would a Sailor operating a modern U.S. warship today. 

These Rules have stood the test of time, and are buoyed from centuries of 

maritime custom, and learned through hundreds of accidents at sea worldwide in order 

to make passage on the seas safer and more efficient. The necessity for such a 

standard for safety is even greater today. In the last 25 years alone, the amount of 

maritime traffic on the sea has increased by 400 percent, demanding even more 
44

attention to adherence to the Rules and the customs of good seamanship and safe 

navigation. 

Because risks are high in the maritime environment, there are widely accepted 

standards for safe seamanship and navigation. The International Maritime Organization 

(IMO) prescribes standards to safely and efficiently conduct commerce on the seas and 

prevent damage to the environment in accordance with international maritime law. In 

the U.S., the International Convention on Standards of Training, Certification and 

Watchkeeping (STCW) for Seafarers, standardizes the skills and foundational 

knowledge a maritime professional must have in seamanship and navigation, such as 

taking electronic fixes, celestial navigation, plotting, and voyage planning; and use of 

equipment such as AIS, RADAR, echo sounders (fathometers), global positioning 

system devices, steering gear, and weather measurement tools; as well as 

understanding and application of the Nautical Rules, identifying shapes, sound signals, 

lights and safe maneuvering. 

Civilian maritime professionals are required to demonstrate that they have the 

knowledge and skills to be able to do all these things before advancing to the next level 

of the merchant marine industry. Many aspiring and current merchant marine 

professionals have some difficulty navigating the U.S. Coast Guard regulations, which 

enforce the STCW standards, but there are programs and individual courses to facilitate 

their training. Some programs include courses for those already in the maritime 

profession to provide education and application through ship simulators that facilitate 

building and assessing the skills necessary to meet regulatory and industry demand.

One example of this training can be found at the Maritime Institute of Technology 

and Advanced Studies (MITAGS), which developed a program to objectively assess 

civilian seamanship and navigation skills and provide recommendations for focused 

training and improvement. This program (the Navigation Skills Assessment Program 

(NSAP) assesses the performance of individuals in a one or two day scenario to 

measure performance in five areas: ship handling, communications, Bridge equipment

use, Bridge Resource Management (BRM) and application of the Nautical Rules. BRM 

is the process by which Bridge watch officers make use of all available human, 

equipment and information resources to safely and effectively navigate a ship. 
45

In order to meet the Navy’s missions, surface forces must, at a minimum, 

perform in all five of the above areas for safe and effective seamanship and navigation. 

The U.S. Navy’s fundamental purpose is to control the sea at the time and place 

necessary to accomplish its objectives in war. To do this, the Navy maintains, trains 

and equips combat ready naval forces capable of winning wars, deterring aggression 

and maintaining freedom of the seas. Surface warships are designed, manned, trained 

and equipped for this purpose. They are less detectable by RADAR, and their systems 

are designed to be less susceptible to an adversary’s intelligence collections, anti-ship 

missiles, and torpedoes to make themselves harder for an adversary to find, and harder 

for an adversary to kill. Still, the surface force must safely operate across the globe and 

through all manners of difficult situations 

While the STCW standards are intended as a regulatory reference of 

fundamental proficiencies required of civilian mariners, U.S. Navy Surface Warfare 

Officers (SWO) must be capable of demonstrating seamanship and navigation 

competence in more stressing and challenging operating environments, from benign 

situations in which their warship is able to use all available IMO/SCTW resources and 

tools, to much more complex environments that account for a warship’s unique 

characteristics and operations. In short, the Navy’s mission demands that the surface 

force must have the knowledge and skills to navigate safely and effectively without the 

use of sensors, to include electronic navigation, RADAR and AIS when it is required.

Further, the technology used on U.S. Navy warships to lower detection from 

RADAR means warships must be particularly prepared to react to routine and 

emergency situations at sea when risk of collision may exist. While specific technology 

improvements such as reduction in RADAR detectability of a U.S. warship’s external 

hull has lessened their own vulnerability to an adversary, the second order effect is that 

a warship that is more difficult to detect on RADAR by commercially configured 

merchant vessels may lessen the time, distance or understanding for which ample and 

safe actions can be taken to avoid collision. This underscores the need for close 

coordination between the Bridge and CIC. 

The need for safe seamanship and navigation in order to carry out the ship’s 

principal purpose in warfighting drives a watch organization and equipment 
46

configuration that goes beyond the IMO standards prescribed for the maritime industry. 

A warship’s CIC possesses the capability to collect, organize and display information to 

decision makers who direct, control and coordinate individual ship and multiple ship 

actions. CIC is the ship’s nerve center, where RADAR and communications are 

combined to coordinate the warfighting mission. In the course of carrying out naval 

missions and tasks, CIC also generates information that is critical to the safe navigation 

of a ship. 

To navigate a warship safely and effectively, the Commanding Officer must 

ensure Bridge and CIC personnel conduct prudent voyage planning carefully, anticipate 

dangerous conditions, and combine their collective skills to effectively use the methods 

and techniques best suited to their ship, its equipment, and the conditions at hand. 

Warfighting capabilities necessary to gain and maintain sea-control through the 

employment of combat power may be distributed over vast distances, multiple domains, 

and a wide array of platforms. While other seagoing professions must be proficient in 

seamanship and navigation, in the Navy these skills are also needed to establish, 

anticipate and react to conditions the ship might encounter both in peace and in combat. 

The causal factors in these four mishaps are linked directly to a failure to take 

sufficient action in accordance with the rules of good seamanship. In addition, the 

ships’ Bridge and CIC personnel did not use readily available tools or information such 

as AIS, RADAR, correlated link tracks, or lookout reports, to help build situational 

awareness. Bridge and CIC watchstanders also failed to translate that information into 

action or recommendations to avoid grounding or collision. As a result, the Review 

Team identified a number of findings that made improvements in the development, 

training and assessment of seamanship and navigation skills for Navy personnel 

involved in the safe navigation of U.S. Navy vessels critically important.

4.2 Findings

The Surface Warfare Officer community consists of nearly 9,000 officers 

stationed in 10 homeports throughout the world, and assigned to a variety of ship types 

such as Aircraft Carriers, Destroyers, Cruisers, Mine Countermeasure ships, Littoral 

Combat Ships, and Amphibious ships. In recent years, SWO career development 
47

placed greater emphasis on breadth of experience in a broad variety of professional 

competencies than on reinforcing superior seamanship in navigation. Additionally, the 

Review Team found that Surface Warfare Officer candidate training is too dependent 

upon on the job training (OJT). Further, enlisted rating training for QM, OS and 

Electronic Technicians (ET) is overly dependent in OJT as well. The Review Team also 

found that throughout their career path, the simulated training SWOs receive does not 

include a rigorous assessment of seamanship and navigation knowledge and skills, 

including in emergency and extremis scenarios, in preparation for their next milestone 

assignment (i.e., Conning Officer, OOD; TAO, Commanding Officer).

4.2.1 Officer Training

Surface Warfare Officer candidates receive their first dedicated period of formal 

training before or shortly after reporting to their first ship, depending on classroom 

availability. Currently, initial formal training for SWO candidates consists of a nine week 

course taught in Norfolk or San Diego early in an officer’s career with specific focus in 

the development of individual skill sets and knowledge in a number of topics, including 

navigation and seamanship, engineering, damage control, maritime warfare and 

leadership. Seamanship and navigation instruction includes Nautical Rules instruction 

and examination, and simulator time focused on the development of an individual’s 

basic skills in handling a ship under power. A five week course is taught at the 

conclusion of a SWO candidate’s first assignment at sea, totaling 14-weeks of a 

combined initial accession program. 

During this training, SWO candidates receive instruction that is based on the 

Surface Warfare Officer Personnel Qualification Standards (PQS). All watchstations 

that are listed on the ship’s watchbill are required to use PQS for qualification. PQS 

delineates a list of minimum knowledge, skills, and abilities that an individual must 

demonstrate before standing watches or performing other specific duties, and it is 

divided into distinct parts: fundamentals, which include the basic knowledge that can be 

learned through lectures and OJT such as understanding definitions and describing 

basic naval customs and practices; systems, which include understanding the operating 

parameters of systems associated with the watchstation, such as the functions of fire 
48

pumps, Bridge equipment, anchoring systems, or combat systems equipment; and 

actions that must be demonstrated for qualification, such as mooring to a buoy, towing 

operations, underway replenishment, or getting underway and mooring to a pier. 

All three levels of the PQS for a watchstation provide the foundational work 

necessary for the safe, secure, and proper operation of a ship. Commanding Officers 

are authorized to tailor PQS to best suit their ship and equipment. In this way, the 

training programs on each ship and PQS are fundamentally linked. The OJT that 

qualified watchstanders provide to under instruction watchstanders is tied directly to the 

tasks that an individual is required to demonstrate. 

The Review Team found that the current SWOS Basic Division Officer Course 

(BDOC) teaches about half of the required fundamentals and systems theory included 

in the Surface Warfare Officer Personnel Qualification System (PQS). This is purely a 

function of the length of the course. The remaining fundamentals and understanding of 

systems associated with their ships, as well as the watchstation demonstrations that are 

required by PQS for qualifying, is the responsibility of the ship’s training programs to 

meet their unique requirements. The classroom training provides standardized lessons 

in the form of lectures and activities to support the OJT that SWO candidates receive on 

their ships as they work through PQS to describe and demonstrate tasks before 

qualifying. 

The first major Bridge watchstation that a new SWO candidate stands is Conning 

Officer, yet the individual is not arriving to the ship with the foundational knowledge and 

skills to perform in the duty. In fact, Conning Officers, Junior Officers of the Deck, and 

prospective Officers of the Deck (OOD) receive the majority of their foundational training 

through OJT. The quality of that OJT is largely dependent upon the ship, its 

Commanding Officer, and the level of knowledge of the individuals assigned to that 

ship. The result is the development of our SWO corps lacks objective and consistent 

qualifying standards and knowledge. 

This review found that in each of the four mishaps, the ships failed to take 

sufficient action. Multiple watchstations failed to properly apply safe navigation and 

seamanship practices was causal to the chain of errors that resulted in these incidents. 

Further, in each of the four incidents the TAO, and multiple watchstations in CIC failed 
49

in the performance of their duties as primary advisors to the OOD for the safe 

navigation of the ship, and failed to use readily available tools or information such as 

AIS, radar, correlated link tracks, or lookout reports, as required by Commanding 

Officer’s Standing Orders and higher level instructions. 

The failure of qualified, trained and certified personnel and watch teams to 

execute their duties safely and professionally, while unacceptable, is not uncommon. 

For example, the Review Team observed instruction at MITAGS, which has performed 

over 1,600 assessments on merchant marine professionals using the NSAP model 

described above, and noted a number of characteristics of poor seamanship and 

navigation skills in the merchant marine community. As examples: 36 percent of 

individuals turned to port in extremis; 35 percent were unable to properly tune their 

navigation RADAR; 30 percent did not make proper use of electronic chart system 

safety features; and, overall, there was an overreliance on electronic chart systems as a 

single source of navigation information, as well as a broader neglect of visual and 

RADAR equipment.

The Review Team found that SWO navigation and seamanship training, while 

incorporating improvements in schoolhouse training, lacks a comprehensive 

assessment of an officer’s navigation and seamanship proficiency at each career 

milestone. The results of this are two-fold: first, the officer returns to a ship at each 

milestone having only minimal refresher training in Nautical Rules and BRM, and 

second, that officer has not been objectively evaluated in the application of these skills 

in routine, emergency or extremis scenarios to determine the adequacy of the training 

the officer received or the degree to which the officer has learned or relearned the 

fundamentals provided during training. Most importantly, the Commanding Officers that 

receive these officers aboard for assignment do not know what to expect of their officers 

since they have received no standardized, objective evaluation.

4.2.2 Officer Career Path

Over the past ten years, the SWO community has accessed and assigned new 

SWO candidates above the billeted needs on surface ships, taking into account officer 

retention in order to meet sufficient numbers of Department Heads required to man the 
50

force. As a result, more SWO candidates must share opportunities to conduct the 

necessary tasks and evolutions necessary to qualify for a particular watchstation. 

Considering the number of first tour division officers (SWO candidates), the pattern of 

arrival from initial training, the number of prerequisites required for SWO qualification

(such as damage control, maintenance management, and CIC Watch Officer) and the 

requirement to complete the surface warfare qualification within 18-months, there is little 

time to build experience and demonstrate proficiency. The policies and practices 

related to first tour division officer assignment and SWO qualification force SWO 

candidates to place greater value on qualification rather than experience and 

proficiency. 

In addition, the Review Team found that foundational standards for professional 

core competencies are not consistent among all accession sources. The team found 

that the U.S. Naval Academy and Naval Service Training Command have jointly 

promulgated an Officer Professional Core Competencies (PCC) manual to delineate the 

knowledge, skills and abilities requirements for basic trained naval officers to possess, 

but the competencies actually taught are not consistent across all accession sources.

The current SWO career path specifies two division officer tours, each two years 

in length. Every SWO candidate must complete their SWO qualification during their first 

tour, which includes qualification as OOD. The experience gained during these two 

division officer assignments is highly dependent upon ship’s operational schedule. If 

assigned to a U.S. port a new SWO candidate might see a ship tour dominated by 

shipyard maintenance, training and certification, or operational deployment, all to a

varying degree. Forward deployed ships operate under different operating cycles and 

notionally operate with a higher operating tempo. Two year division officer assignments 

are not synchronized to these operating cycles. As a result, individual experience 

varies widely depending upon when a SWO candidate joins the ship. Given the large 

number of first tour division officers and the variances in operational experience, these 

officers may complete their initial sea duty assignment having completed the minimum 

tasks and experience to complete the Surface Warfare Officer qualification. In other 

words, they transfer to a second sea tour just as they are poised to gain proficiency and 

experience following qualification in their first ship 
51

Further, there is no standard for the quality or quantity of time spent as a 

watchstander, nor the tasks performed on watch. Civilian navigation and seamanship 

standards for qualification include a time component that is tracked and must be 

presented as part of the certification and qualification process. In 2015, the surface 

force instituted a requirement that three of a SWO’s first four sea tours must be 

assignments to commissioned ships in an effort to increase the operating experience for 

SWOs. However, SWOs do not define or track currency or proficiency throughout an 

officer’s career, to include a basic accounting for number of days at sea and number of 

qualified watches at sea.

Following these first two sea duty assignments and generally after a tour ashore, 

SWOs selected for Department Head receive 27-weeks of instruction at the Department 

Head course prior to their next and more senior assignment aboard ship. The training 

during this period of instruction covers a broad array of topics, but is primarily focused 

on maritime warfare and developing officers’ tactical proficiency to qualify as Tactical 

Action Officers. As part of this course officers receive instruction in tactics, engineering, 

damage control, leadership, and navigation and seamanship, which includes Nautical 

Rules instruction and a practical assessment in shiphandling in a Bridge simulator. 

They also receive the USCG certified BRM course, but do not receive simulated training 

on emergency or extremis situations.

Prior to assignment as an Executive Officer (XO) or Commanding Officer (CO), 

officers attend a ten week Surface Commanders Course. The course opens with 

engineering and damage control material, and then continues with maritime warfare, 

command management programs, the Senior Officer Ship Maintenance and Repair 

Course (SOSMRC), seamanship and navigation, and leadership instruction. During 

navigation instruction, prospective XOs receive the USCG-certified BRM course, 

Nautical Rules instruction and examination, and complete a shiphandling refresher 

training and receive a practical shiphandling assessment. Officers who “fleet up” from 

Executive Officer to Commanding Officer aboard the same ship return to Newport for a 

two week period before assuming command. The training conducted during this two 

week period is specifically tailored to the projected operational schedule for the ship 

during the officer’s command tour, with input from the ship’s Immediate Superior in 
52

Command. The Review Team found that seamanship and navigation may be a part of 

this process, but is not mandatory.

Prior to returning to sea as a Major Commander (paygrade O-6), officers attend a 

three week Major Commanders Course in Newport, Rhode Island. The course includes 

a refresher practical exercise in BRM, Nautical Rules instruction and examination, as 

well as a shiphandling assessment. The Review Team found that this course does not 

include instruction on the role of an Immediate Superior in Command (ISIC) in 

assessing the ship’s navigation skills during the ISIC navigation check ride, or methods 

to provide appropriate oversight to shipboard navigation and seamanship.

4.2.3 Enlisted Training

Quartermasters (QMs) and Operations Specialists (OSs) are the primary enlisted 

members responsible for the support of navigation tasks on Navy ships. QMs are 

responsible for maintaining the navigation plot on the Bridge and fixing the ships 

position, and OSs, among other duties, are responsible for performing RADAR plotting 

and surface contact management support to the Bridge watchteam. Another key 

member of the seamanship and navigation team is the Electronics Technician (ET). 

The ET provides the maintenance support for Bridge and CIC navigation equipment. 

The QM training continuum consists of both schoolhouse training and OJT. Prior 

to 2015, formal QM training in the school house was limited. The apprentice-level 

course (“A” school) was not mandatory and there were no journeyman or masters-level 

courses. In 2015, A-school courses became mandatory, and they taught applicable 

sections of Nautical Rules, fundamentals of navigation aids, and other information 

needed to maintain a proper navigation plot. The Nautical Rules exam is based on a 

tailored, locally produced test bank that does not utilize the United States Coast Guard 

test bank. Plotting skills are first learned and tested on paper navigation charts, then on 

VMS. The VMS Operator Course for version 9 will be taught to all QM “A” school 

graduates starting in October 2017. Additionally, prior to 2013, Sailors that transitioned 

into the QM rating (vice joining the Navy with QM as an assigned rating), completely 

relied upon OJT in order to build their skills. As a result, existing junior Sailors that 

transitioned into the QM rating did not receive any initial training on navigation 
53

fundamentals, relying entirely on OJT for their skill training. In October 2016, a QM 

Journeyman course was established in San Diego and Norfolk homeports. This course 

provides for the development of skills prior to a second sea duty assignment. 

Successful completion of this course results in awarding the 0203 NEC. The Review 

Team found that as a whole the QM Journeyman course has appropriate rigor, but 

needs improved emphasis on RADAR theory and operation and log keeping 

requirements. 

Senior QMs were recently admitted to the Surface Navigator course in Newport, 

RI, which is also taught for all prospective Navigation Officers. Successful completion 

of the course results in the award of the 0202 NEC for enlisted members. This critical 

NEC is in high demand in the surface force. The QM attrition rate in this course 

currently stands at 45 percent. This five week course is the first time QM’s are exposed 

to the same Nautical Rules instruction and examination process that SWOs receive, 

including the requirement to pass a 50-question test generated from the USCG Nautical 

Rules test bank. Basic navigation chart plotting fundamentals are also significant 

factors in the high QM attrition rate. This course is the capstone (final achievement) for 

the QM training continuum. 

The Review Team also found that the OS rating does not have an established 

continuum of formal training for the rating, and relies too heavily on OJT. There is an 

apprentice course that teaches the required occupational standards, but without 

sufficient rigor in RADAR theory. There is no OS masters course, or school for midlevel Petty Officers. Given the degree of responsibilities these Sailors carry for 

supporting Bridge watchstanders in safe navigation, the absence of an OS continuum of 

training makes OJT the primary method these Sailors must use to develop their 

navigation plotting, RADAR operation and surface contact management skills. 

The Review Team also found that level of knowledge of navigation systems 

maintenance in the surface force needs improvement. The apprentice school for ETs is 

focused on basic electrical theory and the development of occupational standards. The 

apprentice school does not address the depth of knowledge and skills needed to 

properly maintain complex electronic navigation systems on ships, specifically the 

Integrated Bridge Navigation System (IBNS), the Electronic Chart Display and 
54

Information System (ECDIS), and Voyage Management System (VMS). These skills 

are developed in the ET Navigation Systems Maintenance Training course, which 

produces the critical skill defined in the Navy under the Navy’s Enlisted Classification 

(NEC) 9617. This course was first introduced in October 2016. The Review Team

found this course provides needed improvements to instruction on electronics systems 

maintenance. 

The Review Team found that QMs and OSs have insufficient knowledge to 

properly use the tools provided for navigation and surface contact management to fulfill 

CIC’s fundamental role in supporting safe and effective navigation. Just like the 

Conning Officer must arrive with a solid understanding of navigation and seamanship to 

effectively perform, QMs and OSs must also arrive at their command with solid 

foundation and skills in operating RADAR, AIS, ARPA and the duties of their 

watchstation. Further, the Review Team found there is no formal training on Aegis 

consoles provided to OSs for surface contact management on Aegis equipped ships. 

All Aegis console operator knowledge for OSs in CIC that stand the Surface Warfare 

Coordinator (SUWC) watchstation gain knowledge and qualify via OJT. The SUWC is a 

key watchstander in CIC that supports the Bridge in surface contact management and 

effective contact avoidance. 

QM and OS schools do not teach the appropriate level of knowledge in operating 

and tuning surface search radars, and the OJT onboard ships is not meeting the need. 

OJT alone does not produce the required level of knowledge to build sufficiency as a 

foundation for these critical watchteam support qualifications; reductions in formal 

schools have contributed to an observed decline in the knowledge base across the 

surface force. The Review Team also found that training and examination for these 

watchstanders on the Nautical Rules during OJT is insufficient to deliver a consistent 

and appropriate understanding and application of the Rules. 

4.3 Recommendations

4.3.1 Individual Training

1. Create an objective, standardized assessment program to periodically assess 

individual seamanship and navigation skills over the course of a Surface 
55

Warfare Officer’s career. This process should be informed by the MITAGS 

Navigation Skills Assessment Program (NSAP) principles to assess Surface Warfare 

Officer seamanship and navigation skills at every career milestone, including an 

objective assessment by SWOS prior to initial qualification as Officer of the Deck. 

[NETC, 31Mar2018]

2. Improve seamanship and navigation individual skills training for Surface 

Warfare Officer candidates, Surface Warfare Officers, Quartermasters and 

Operations Specialists. This effort should include at a minimum updating the 

curricula (content and durations) for Surface Warfare Officers, Quartermasters, 

Operations Specialists, and Electronics Technicians, for all career milestones from 

new accession to major command (for officers) or master-level (for enlisted). [NETC, 

31Mar2018]

3. Improve Operational Risk Management training and education at all Surface 

Warfare Officer School milestone courses. [NETC, 31Mar2018]

4. Provide additional fundamentals training for officers who qualified SWO without 

initial classroom training (e.g., SWOSDOC or B/ADOC) covering Automated RADAR 

Plotting Aid (ARPA), Electronic Chart Display and Information System (ECDIS), and 

Automatic Information System (AIS). [NETC/CNSF, 31Mar2018]

5. Update the Surface Warfare Officer Requirements Document to capture the metrics 

used to evaluate seamanship and navigation skills in Surface Warfare seamanship 

safety assessments. [CNSF, 31Mar2018]

6. Incorporate fatigue, crew endurance, and stress management into appropriate 

career milestone Surface Warfare Officer training and enlisted leadership courses. 

[NETC, 31Mar2018]

7. Evaluate use of Yard Patrol craft in all officer accession programs. The study should 

include the feasibility of expanding Yard Patrol craft use, and other training methods, 

so that every naval officer receives core competencies as articulated in the Officer 

Professional Core Competencies Manual. [USNA/NETC/CNSF, 30Sep2018]

8. Update Personnel Qualification Standards for Bridge and CIC watchstations 

including actions to address current navigation tools, surface search radars, ship 

control systems, and team performance related to navigation and contact 

management and avoidance. [NETC, 31Dec2017]
56

9. Revise the Surface Force Readiness Manual to define the Officer of the Deck 

requalification process and circumstances under which watchstanders requalify on 

their current platform due to configuration changes. [CNSF, 31Mar2018]

4.3.2 Officer Career Path

1. Align the number of SWO candidates assigned to ships with the billet requirements. 

[CNP, 31Mar2018]

2. Evaluate the SWO career path from accession to major command including the 

scope and timing of formal training, sea/shore assignments, and Executive Officer 

and Commanding Officer sequence and timing. This evaluation should also 

incorporate a process to ensure an appropriate talent distribution of SWO 

candidates to the fleet in their first sea duty assignment. [CNP, 30Sep2018]

3. Establish a single, longer division officer tour as the standard, with allowances for 

specific billet requirements. Emphasize that the focus of division officer tours should 

be building proficiency, especially in seamanship and navigation. [CNP, 31Mar2018]

4. Establish policy to define, maintain, and reestablish SWO currency (e.g., a Bridge 

log) that accounts for Surface Warfare Officer OOD, JOOD, and Conning Officer 

watchstations. [CNSF, 31Dec2017]
57

5. UNIT TRAINING

5.1 Introduction

Effective teams must be built on a solid understanding and execution of the 

fundamentals. Teams become proficient through frequent reinforcement, repetition and 

understanding of the importance of each individual's contribution, as well as the roles of 

their teammates, to the safe and effective accomplishment of the mission. As 

discussed in Chapter four, the surface force is required to be well versed in a variety of 

warfare missions as well as seamanship and navigation. The nature of military 

operations, and the unique ship handling and reduced detectability characteristics of 

warships puts a greater burden on its crew to safely navigate. As such, the 

cohesiveness of the Bridge and CIC team is the keystone for safe operations at sea. 

Some of our most junior personnel are assigned to duties involving the safe 

navigation of the ship within the Bridge and CIC team. As such, they are relied upon to 

provide immediate, relevant input to our operations at sea. Given the importance of 

their contribution, OJT should be limited to honing their skill as a member of a team vice 

building their individual skills fundamentals. Watchstanders must arrive on their ship 

with a solid foundation for their seamanship and navigation duties including the use of 

equipment. After all, the Conning Officer is charged with driving the ship with careful 

consideration of the ship’s engines, rudder, lines, ground tackle, as well as 

environmental conditions. Our QMs and OSs plot the ship’s position, use sensors to 

detect shipping and must routinely report seamanship and navigation hazards to ensure 

the safety of the ship. The fundamental training they receive is the foundation on which 

successful ships execute their mission at sea. 

In accordance with the Surface Force Readiness Manual (SFRM), and the 

Navigation Department Organization and Regulations Manual (NAVDORM), Navigation 

and Seamanship assessments and exercises should occur after maintenance periods 

and during the Basic Phase of a ship’s training cycle. The first step in a ship’s 

navigation certification is the Immediate Superior in Command (ISIC) navigation check 

ride. Typically held during sea trials, the ISIC check ride verifies ships leaving major 

maintenance availabilities are safe for basic navigation operations. Once a ship is in 
58

the Basic Phase, Afloat Training Group (ATG) navigation training and certification 

exercises are conducted in a building block approach with a final certification exercise 

that qualifies the ship for unrestricted operations at sea.

The ATG is Commander Naval Surface Force’s (CNSF’s) executive agent for 

training and assessment. As part of the SFRM, ships perform ATG-monitored exercises 

to demonstrate readiness. Exercises are prescribed by CNSF in the Surface Force 

Exercise Manual (SFEM), and build from basic operations, to include demonstrating 

mobility and navigation, to more advanced operations involving warfighting. 

Certification in a mission area is granted by a ship completing all of the certification 

exercises (CE) for that mission over a specified period of time. 

Three of the critical mission areas that comprise the full unit certification include 

Mobility Seamanship (MOB-S), Mobility Navigation (MOB-N) and Surface Warfare 

(SW). Each mission certification is designed to implement an incremental approach to 

certification throughout the various stages (1.1 through 1.4) of the certification. 

Specifically, phase 1.1 is designed to validate equipment required for the respective 

mission area. All equipment should be operational and maintained to standards prior to 

advancing to the next phase. During phase 1.2, ATG introduces and reviews core 

competencies which are further enhanced with hands on training during phase 1.3. 

Assuming the unit has demonstrated adequate knowledge in fundamentals and 

equipment utilization, with the recommendation of ATG, the unit will proceed to phase 

1.4, the formal certification event. During the certification event, the unit will 

demonstrate specific tasks relevant to specific core competencies of the mission area. 

For example, MOB-S requires man overboard drills with shipboard and rigid hull 

inflatable boat (RHIB) recovery as well as safe and successful execution of mooring to a 

buoy, and MOB-N requires a precision anchorage. By design, simulator opportunities 

are interspersed throughout the training and certification process to allow more time to 

practice shipboard procedures, while enhancing their seamanship and navigation skills. 

Simulator training requirements, including hours needed in coursework and evolutions, 

are specified in the Navigation Seamanship and Shiphandling Training instruction.

During a Commanding Officer’s (CO) tour, their ship is expected to conduct forty 

hours of Bridge Resource Management (BRM) training. Ships are required to send 
59

three watch teams to BRM training to include three teams each consisting of an Officer 

of the Deck (OOD), a Conning Officer, and an Officer of the Deck under instruction. All 

classes will be attended by a senior observer (CO, XO, or Senior Watch Officer. 

Similarly, Special Evolutions Training (SET) is required every calendar year with 28 

hours of instruction. Each ship is allocated an additional 32 SET hours per year for use 

at the CO’s discretion. Basic Ship Handling is designed for newly commissioned and 

novice Bridge watchstanders, but can also be tailored for more experienced 

shiphandlers. 

A fundamental tenet of the SFRM is to train the watchstander, watchteam, and 

maintainer with the goal of Sailors deploying at their peak readiness and properly 

prepared to overcome the challenges presented on deployment. The current structure 

of the SFEM in combination with the specific exercise grading criteria in place at ATGs

are insufficient to accomplish that goal. The individual watchstanders that comprise the 

Bridge and CIC teams each serve a critical role in overall functionality of the unit. 

However, with the exception of low-visibility operations (where CIC maintains the 

surface picture for the Bridge), none of the mission area certification metrics for MOB-S, 

MOB-N and SW evaluate the Bridge and CIC team performance regarding coordinated 

surface contact management, and casualty control team processes, especially in

complex, tactical, or rigorous emergency and in extremis scenarios.

5.2 Findings

All four ships involved in 2017 mishaps were certified in MOB-N, which was 

preceded by a successful ISIC navigation check ride. The Review Team found these 

assessments inadequate in validating the team performance between CICs and Bridges 

in predictable operational situations. Further, the ISIC navigation check ride evaluates 

scenarios that do not require observation of Bridge watchteams where the Commanding 

Officer and Executive Officer are not on the Bridge and only evaluates Restricted 

Waters Navigation and Low Visibility Piloting. 

ISICs are not properly manned or qualified to effectively execute their 

responsibilities as prescribed in the NAVDORM. For example, there is no requirement 

for a senior QM assessor to be trained on the specific navigation, piloting and ship 
60

control systems on the ship being observed. Similarly, Destroyer Squadrons do not 

currently have the NEC 0202, Assistant Navigator codified as a requirement for the QM 

billets on staff. There are similar mismatches in OS staff requirements to support 

navigation check rides. Of note, ensuring sufficient expertise exists in squadron staff 

becomes increasingly difficult with the numerous configurations of navigation 

equipment, RADAR sensor and ship control systems. 

In addition to the manning shortfalls associated with the navigation check ride, 

the detailed navigation assessment checklist grading criteria is comprised of “yes” or 

“no” answers and consequently, does not provide in-depth guidance on how to use 

those grades to make the final assessment useful for the crew. Likewise, neither 

command leaders nor their composite teams are assessed for proficiency as part of the 

checklist. There are no criteria for proficiency with equipment (e.g., AIS, ARPA, ECDISN, and RADAR piloting). As discussed earlier, these are some of the fundamental tools 

that junior watchstanders must be able to utilize and extrapolate from in order to support 

the Bridge and CIC team synthesis.

In order for Yokosuka-based destroyers to maximize operational availability, the 

ISIC navigation check ride is conducted on the first day of sea trials and the navigation 

watchteam training and final navigation certification event is conducted at the end of the 

same underway. The Review Team found this process to be ineffective. As a corollary, 

three of the four ships involved in the four representative mishaps had recently 

completed major maintenance availabilities with truncated navigation training and 

certification (ISIC navigation) check rides.

There is insufficient formal training on the roles and responsibilities of CIC in safe 

navigation and contact management during the MOB-N certification. Each course is 

taught as a microcosm of the overall navigation and contact management process with 

no emphasis on teamwork, information dissemination, or effective communication. 

ATG’s MOB-N 1.2 training events are targeted solely at Quartermasters and there is no 

integration with CIC or other Bridge watchstanders (e.g., OODs). Additionally, contact 

management and avoidance is not included in the MOB-N curriculum.

The review found that the navigation and seamanship certification exercises 

used by ATG are not providing a critical validation of the true proficiency of Bridge and 
61

CIC watch teams. ATG’s navigation certification exercises, prescribed by the SFRM, do 

not place sufficient rigor on the knowledge, skills, and abilities of individual watches and 

teams. The certification exercises do not include contact management, Bridge casualty 

control scenarios, effective use of RADARs, or watchbill management. Additionally, 

navigation training presentations are not tailored to ships’ individual navigation suites. 

Subsequently, a Bridge team can receive satisfactory grades even when the Bridge and 

CIC fail to work as an effective team, or a Bridge watch officer fails to demonstrate the 

required skills with maneuvering boards or the use of RADAR in open ocean navigation. 

Further, certification exercises are largely checklist-based and do not provide holistic 

assessments of watchteam effectiveness or readiness. This was evident in the USS 

Antietam mishap as the ship was certified in MOB-S at the time of the mishap.

The Review Team found that there is no venue away from a ship for Bridge and 

CIC teams to conduct navigation and surface track management exercises on ship’s 

representative equipment. The existing shore-based Bridge trainers do not incorporate 

a CIC component, either by live interaction or by instructor role play. Specifically, 

Navigation, Seamanship, and Shiphandling Training (NSST) simulators and facilities do 

not have the capability or capacity to include CIC watchteams into navigation, contact 

management, and contact avoidance scenario training. While the simulators are 

effective for ship handling (driving) training, they do not currently have the capability to 

emulate or simulate the various ship control systems that are resident in the surface 

force. Thus it is not possible to run through evolutions or casualties relating to rudder 

and throttle control. Likewise, Surface Warfare Officer School (SWOS) Bridge 

simulators do not have a CIC component.

The Review Team found BRM and basic shiphandling course periodicity 

requirements do not ensure watchteams receive the training as part of a logical workup 

prior to operations. The course curriculum and lesson plans for each of the mandated 

courses are dated and need to be reviewed for currency and relevancy. None of the 

NSST-required courses require enlisted Bridge watch standers, and thus the actual 

crew members who stand watch as teams while the ship is underway do not benefit 

from this simulator. These simulators are capable tools but, by instruction, the 

mandated courses emphasize individual officer training vice team training. Further, this 
62

training is not in all cases graded and is not used to inform officer watch qualifications. 

Additionally, the USCG certification for BRM training at fleet concentration area NSST 

sites was not included in conjunction with the award of a new contract.

The Review Team found that the RADAR Navigation Team Trainer is not 

updated and is not required for individuals that are on ECDIS on certified ships – all but 

approximately ten ships in service. The RADAR Navigation Team Trainer course 

includes Voyage Management System (VMS) instruction, classroom instruction and 

practical exercises in paper chart work, terrestrial and coastal navigation, celestial 

navigation, and navigation team exercises in a Bridge simulator, but there is no interplay 

or simulation of interaction with the CIC navigation team during these Bridge team 

trainers. Additionally, there is no mechanism for ATG to tailor training to the widely 

variable and fast-evolving navigation and ship control suites, especially in a tactical 

environment. As a result, there is no rigorous training for casualty control drills involving 

actual or perceived loss of steering or loss of throttle control. 

While a review of grade-sheets used by ATG shows the SW exercises do not 

explicitly evaluate CIC-Bridge teamwork, the more tactically advanced demonstrations 

implicitly require some degree of CIC-Bridge teaming to be successful. However, in the 

four mishaps the ships were not certified in SW. The SW certification expiration lag 

time ranged from nine to seventeen months, which eliminated its usefulness in 

mitigating weaknesses inherent in the more fundamental MOB exercises.

A review of completed ATG MOB-N grade sheets for ships involved in these 

mishaps indicates an overreliance on checklists by ATG assessors and an inadequate 

assessment of the watchteams as a whole. As an example, each evolution conducted 

includes a specific score of effective interior communications between controlling 

stations. The ATG MOB-N assessment of USS Fitzgerald in February of 2017 included 

handwritten comments in most individual events pointing to problems with Bridge

communications with other stations, but there were no summary comments highlighting 

that trend. Additionally, problems in taking timely and accurate fixes and bearings in a 

number of the exercises were not highlighted. The administrative reviews by the ATG 

team also identified a number of deficiencies in day-to-day performance of the crew. 

For example, they noted that crews spent insufficient time in NSST doing special 
63

evolutions, standing orders and night orders were not reviewed, and there was a lack of 

compliance with requirements from a list of NAVDORM appendices. The ATG 

comments indicate they were corrected on the spot or were to be corrected in future 

training. While in aggregate these indicate a lack of rigor in ensuring current knowledge 

by watchstanders, and upholding basic standards of readiness for navigation, there 

were no references to these issues in the summary of comments provided in the ATG 

report.

5.3 Recommendations

1. Improve current seamanship and navigation team training and certifications to 

include assessment in high shipping density, emergency and in extremis 

environments. This action should include establishing the curriculum to evaluate 

Bridge and CIC teams’ ability to respond to navigation and shiphandling scenarios in 

accordance with the Nautical Rules for non-standard and emergency situations, 

including in extremis. [NETC/CNSF, 31Mar2018]

2. Improve shore-based Bridge trainers and add CIC functionality to team 

training facilities. Establish the requirement to include all watchstations associated 

with safe navigation in team trainers and determine any facility modifications or 

upgrades necessary to accomplish the integrated training. Leverage outside expert 

organizations (e.g., NASA Langley Research Laboratory, Crew Systems and 

Aviation Branch) to independently assess and recommend improvements to the

simulator training strategy. [CNSF/NETC/OPNAV, 31Mar2018]

3. Integrate Bridge and CIC evaluations for unit level seamanship and navigation 

training in shore-based team trainers, and during at sea training and 

certifications events. Commanding Officers shall be required to attend, and 

scenarios shall focus on high-density traffic transits. [CNSF/NETC, 31Mar2018]

4. Improve current seamanship (MOB-S) and navigation (MOB-N) team training and 

certifications to include assessment of Bridge-CIC team performance up to and 

including the Commanding Officer. [CNSF, 31Mar2018]

5. Recertify Bridge Resource Management training in the fleet concentration areas’ 

Navigation Seamanship and Shiphandling Trainers to USCG standards. [NETC, 

31Mar2018]

6. Implement a plan for all ISICs to evaluate the proficiency of the ships and crews to 

safely navigate in high-density traffic transits in the NSST as part of their ISIC 
64

navigation check ride after extended maintenance and before deployment. [CNSF, 

31Dec2017]

7. Revise the NAVDORM to establish the SUWC as the primary surface contact 

management and contact avoidance watch station in CIC and establish formal 

SUWC training. [CNSP/CNSL/CNAP/CNAL/NETC, 31Mar2018]
65

6. GENERATION AND EMPLOYMENT OF OPERATIONAL FORCES

6.1 Introduction

6.1.1 Force Generation

The Navy executes a rigorous process to prepare and certify warfighting units as 

ready for operational tasking. This process of force generation is executed through a 

cycle that provides time for maintenance of the ship, execution of appropriate crew 

training, validation of crew proficiency through a demanding certification process, and 

sustainment of readiness throughout a period of operational availability. Once certified 

and available for operations, the unit will be assigned tasking by the operational 

commander (called force employment). The execution of this force generation and 

force employment process must be balanced to ensure that the maintenance, training 

and certification efforts support and align with operations, operational plans and the long 

term readiness of the force.

The Optimized Fleet Response Plan (OFRP) is the dominant Navy force 

generation model that outlines a predictable cycle to maximize a ship’s employability 

while preserving the appropriate time for maintenance, modernization and training. The 

OFRP’s guiding principles are to align and synchronize all the processes that prepare 

units for deployment. This includes distribution of manpower to operational 

requirements; scheduling maintenance and modernization; improving the overall quality 

of work and life for personnel; and ensuring forces are deployed with the right 

capabilities, trained and certified to a single high-end standard, and equipped to meet 

the Navy’s missions. 

Based on the OFRP guiding principles, force generation for ships that are 

homeported in the U.S. involves a building block approach that consists of four major 

phases: maintenance (major shipyard repairs, upgrades and platform modernization), 

basic phase (core capability/skills achieved by individual units to Type Commander 

standards), integrated or advanced training (advanced capability/skills to build individual 

units and staffs into aggregated, coordinated strike groups certified by the Fleet 

commander) and a sustainment phase (deployment or sustainment readiness as 
66

resourced), all accomplished in series. After completing unit certifications, the 

Commanding Officer must sustain the readiness of the ship using internal training 

processes. Each readiness cycle is 36-months, as outlined in Figure 6.1. All unit 

certifications reset at the beginning of the ship’s maintenance phase, requiring a 

recertification within each cycle.

Figure 6.1. OFRP-based CONUS readiness generation model.

Forward-deployed naval forces execute a tailored force generation model that 

should follow the same principles as the OFRP but uses different cycle duration than in 

CONUS to align with the mission tasks to be executed. 

The readiness generation model for ships forward-deployed to Japan (FDNF-J) is 

aligned with a 24-month cycle for mission area certifications as prescribed by the 

SFRM. During that 24-month cycle ships are in a continuous period of sustainment, 

treated as ready for operational tasking when they are not in depot-level maintenance 

and modernization. During this sustainment phase, routine maintenance and training, 

and certification when required, are scheduled in windows interwoven with operations. 

Added requirements in any area put stress on the system; for example, longer than 

planned maintenance periods can serve to reduce the time available for training and 

certification or limit the opportunity to service higher operational demand. The force 

generation process must balance these demands while ensuring the ships are 

maintained in a high state of readiness. 

Figure 6.2: Japan-based readiness generation model.

Included in the FDNF-J force generation model is a process to adjudicate any 

mission area certifications that expire but cannot be recertified because either (1) an 

operational demand supersedes the time needed to re-certify a particular mission area, 

or (2) a maintenance, training, or manning deficiency exists that prevents successful 

completion of a certification. These lapses in certification that cannot be quickly 

Months

CVN

CRUDES Maintenance Basic Advanced Int.

Maintenance Basic Advanced Int. LV Deployment LV

LV Deployment LV Sustainment Maint

Sustainment

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 Months

CRUDES Maintenance Sustainment

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
67

regained should be rare; and in these circumstances, a Risk Assessment Mitigation 

Plan (RAMP) is produced by the ship to delineate the condition that prevents 

certification, the risks associated with operating without that certification, any actions 

(such as additional oversight or temporarily assigned personnel) to mitigate those risks, 

and a plan to complete the certification. The RAMP is the mechanism by which the unit 

Commanding Officer communicates the potential risks to his or her unit performance 

associated with expired mission area certifications, and the actions to be taken to 

mitigate those risks. Headquarters in the chain of command should then ensure an 

informed decision on unit employment is made. Rigorous execution of the RAMP 

process would result in appropriate risk mitigation measures to ensure a ship was ready 

for tasking.

The Review Team found that the increasing demand in the Western Pacific, 

driven by increased BMD and presence missions and increased dynamic tasking to 

support exercises and experimentation (further details provided in the Classified Annex, 

Appendix 9.10), exceeded the capacity that can be reasonably generated from Japanbased ships under their existing readiness generation model cycle. The time available 

for training was also impacted by maintenance periods extending beyond nominal 

durations due to an increased scope of work and number of ships based in Yokosuka. 

As a result of this increased demand and delays in maintenance execution training 

opportunities were reduced and completed warfare area certifications across FDNF-J 

declined from 93 percent in 2014 to 62 percent in 2016. 

This data indicates the assumptions underpinning the Yokosuka-based ships 

force generation model, such as duration of maintenance periods, had changed to the 

point that the intended model could not be executed. Additionally, execution of the 

RAMP process for these expired certifications had become an administrative 

acknowledgement of the expired certifications without true evaluation of the associated 

risk or development of meaningful mitigating actions.

6.1.2 Force Employment

Upon completion of the force generation process, a unit is ready and available to 

the operational commander. Effective force employment requires that the capacity of 
68

the force generation model be balanced with the mission requirements as defined, and 

prioritized, by higher authority (such as the Geographic Combatant Commander). 

Higher headquarters often must adjudicate shortfalls in forces available for mission 

requirements based on the priority provided, including an evaluation of additional 

capacity that may be available using CONUS-based forces. The Joint Staff’s Global 

Force Management process is used to resolve these capacity shortages taking into 

consideration the priority of requirements across all combatant commander areas of 

responsibility.

Surface ships based outside the continental U.S. (OCONUS), particularly in 

Japan, are employed to support operational commitments nearly every day. Many of 

these operational tasks have strategic and tactical importance. Annually, there are over 

20 joint exercises identified by Commander, U.S. Pacific Command, and nearly 150 

exercises identified by Commander, U.S. Pacific Fleet. At least ten of these exercises 

involve a high level of ship participation. Additionally, there are requirements levied on 

the ships that operate in the Western Pacific by the SEVENTH Fleet Commander to 

support various requirements such as carrier escort missions and theater security 

cooperation. In 2015, the average number of days underway for the Cruisers and 

Destroyers, assigned to Commander, SEVENTH Fleet was 116 days. In 2016, it 

increased to 162 days as shown in figures 6.3 and 6.4 below.

Figure 6.3: No. of days spent in major availabilities, regular maintenance, 

inport and underway for Japan-based ships in calendar year 2015.

0

50

100

150

200

250

300

350

SHI ANT CHV CDW JSM FTZ STE BEN LAS MCB MUS

SRA Maint Inpt U/W
69

Figure 6.4: No. of days spent in major availabilities, regular maintenance, 

inport and underway for Japan-based ships in calendar year 2016.

Since 2015, operational requirements for the Western Pacific have increased 

dramatically. The Review Team found that these operational requirements were 

coming from multiple sources and were not always prioritized to allow proper 

adjudication based on the readiness of forces available – every task was a priority. As 

a result, additional forces were generally not requested or assigned. This led to an 

increase in operational tasking for Yokosuka-based ships at the expense of planned 

CNO Maintenance Availabilities (CMAV) and training. As data was indicating a decline 

in readiness, higher headquarters did not recognize the aggregate risk of the pace of 

operations and did not take action to correct the imbalance between the generation and 

employment of Japan-based forces. Finally, having a single commander balance the 

risk of readiness generation and force employment requirements from multiple sources 

may complicate responsibility and accountability for both aspects. 

6.2 Findings

U.S. Navy ships have been based in Yokosuka, Japan, since the Korean War. In 

1973, the Navy established the first forward deployment of a Navy aircraft carrier and 

her escorts with the USS Midway (CV 41) Carrier Battle Group. From that point on, the 

U.S. Navy has routinely based a carrier and multiple surface combatants in Yokosuka. 

The U.S. Navy has also based ships in Sasebo, Japan, since 1980. These ships are 

amphibious ships and minesweepers. The advantages of homeporting naval forces in 

Japan include the ability to provide immediate presence and response in support of 

0

50

100

150

200

250

300

SHI ANT CHV CDW JSM FTZ STE BEN LAS MCB MUS BAR

SRA Maint Inpt U/W
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national objectives. Additionally, these forces routinely operate alongside allied and 

partner navies, and become expert in the operating environment in the areas of the 

Western Pacific important to America’s interests.

 The Review Team found the increasing demand for ready and certified ships to 

support operations in the Western Pacific exceeds the quantity that can be reasonably 

generated from Japan-based ships under their existing readiness generation model 

cycle. In their attempt to meet this demand, SEVENTH FLEET reduced the amount of 

time set aside to train Yokosuka-based ships. These factors are contributing to the 

erosion of training and material readiness of ships based in Japan, and have resulted in 

an increase to the operational risk to mission accomplishment.

6.2.1 Force Generation

The cruisers and destroyers (CRUDES) based in Japan are among the most 

capable in the surface force, and they are also among the oldest ships in the inventory. 

The average age of the Cruisers based in Japan is 28 years and the average age of the 

Destroyers is 21 years. As a result, the time required to modernize and maintain these 

ships has also increased, which directly impacts their overall operational availability. 

Maintenance availabilities conducted by the U.S. Naval Ship Repair Facility and 

Japan Regional Maintenance Center (SRF) in Yokosuka, Japan, are getting longer due 

to growth in scope of maintenance required during depot-level maintenance periods and 

an increased number of ships based in Yokosuka. Further, the decision to execute 

more complex modernization periods, meant to refresh and upgrade ships’ hull, 

propulsion, navigation and combat systems, has also required longer-than-planned 

maintenance periods. Compounding the problem, the growth in maintenance and 

modernization workload has grown faster than SRF can add capacity; since 2012 SRF 

workload has increased by over 15 percent while capacity has grown by ten percent. 

As with many industrial enterprises, there is a lag between SRF hiring an individual and 

full productivity from that individual that exacerbates the challenge. Additionally, past 

restrictions on the duration of overseas assignments resulted in higher turnover of those 

SRF positions filled by U.S. citizens. This reduced the experience level within the SRF 

workforce beginning in 2012.
71

The increase in required maintenance and modernization periods, compounded 

with operational tasking, has effectively limited time available for training on Japanbased ships. Without the necessary time to train, the required exercises to recertify in a 

particular mission area are compressed. Consequently, nearly 100 percent of Japanbased ships have one or more expired certifications, and in each case, a Risk 

Assessment Mitigation Plan (RAMP) is in place. As discussed in Section 6.1.1, the

RAMP should include meaningful mitigation measures and a plan to attain the mission 

area certification. The RAMP is intended to ensure that the training risk is accurately 

identified by the ship and headquarters, and that the headquarters have assessed the 

mitigation plans as adequate. 

The Review Team found that rather than providing an adequate plan to define 

and mitigate operating risks until completing the necessary actions to recertify, the 

RAMP process was largely used to communicate missed training or personnel 

shortages and the schedule to recover. These reports gave the appearance that ships 

were persistently available even without full certification. Compressed time between 

missions and required in port maintenance limited the CO’s ability to establish training 

time and focus on improvements to weak areas identified through operations and 

exercises. Further, there was limited time for ships to implement lessons learned during 

training opportunities or repeat exercises in order to gain proficiency and/or maintain 

standards. 

The Review Team found that manning distribution is not fully aligned and 

synchronized with the readiness generation and force employment needs of Yokosukabased ships. Surface force ship manning levels declined Navy-wide during the 2009-

2013 time period as a result of downsizing initiatives, the implementation of optimal 

manning (reduced manning) standards on ships, and other cost saving programs. 

Investments were then made from 2014 to 2016 to increase fleet manning and 

reduce surface ship gaps; further, all FDNF and CONUS ships and squadrons had their 

fill and fit adjusted so that all FDNF ships and other deploying ships could deploy with 

the same level of manpower readiness. This resulted in a decrease for FDNF-Japan 

ships from 95 percent fit / 95 percent fill to 92 percent fit / 95 percent fill (meaning 7-8 

crewmembers on a DDG may be “fit” to the ship from outside the apprentice, 
72

journeyman or supervisor ranks, but the total number of sailors aboard ship would 

remain the same); this action helped enable an increase for FDNF-Rota ships and all 

CONUS deployers from 90 percent fit / 90 percent fill to 92 percent / 95 percent. 

Surface ship manning levels began declining below these 92 percent fit / 95 

percent fill standards for deployers across the Navy in 2016 and continue today, 

primarily caused by underfunded manpower total ownership costs, a high number of 

apprentice level enlisted rolling ashore after increased manning of sea duty 

assignments in 2013-2014, a lower number of accessions in 2016 (and for all FDNFJapan, Rota, and Bahrain ships) due to unaccompanied/accompanied tour length 

policies and sea duty and overseas screening processes.

Figure 6.5: Manning fit/fill for Japan-based surface ships.

Temporary assignment of personnel is one mechanism that can be used tomitigate a critical-skill shortage (e.g., search-and-rescue swimmer). Often this process 

is accomplished by taking sailors from a ship in maintenance and sending them on 

temporary duty to operating ships. There are benefits of executing this process: sailors 

from ships in maintenance can maintain or gain proficiency aboard a more frequently 

operating ship, and in turn, operating ships can close critical skill gaps in their ship’s 

complement when underway for operations. This practice can also impact the 

temporarily assigned sailor by reducing the opportunity to complete school or training 

while in port. Additionally, this practice reduces the overall number of sailors remaining 

on the in-port ship to complete daily tasks while in maintenance and places additional 

stress on affected sailors and families. Manning shortfalls contributed to overall 
73

degrading quality of work and life for ships’ personnel based in Yokosuka, a key tenet of 

a functional readiness cycle. This gap, coupled with high operational tempo, impacted 

some ships’ ability to sustain individual tempo for the Sailors while still trying to meet 

operational and training expectations of a fully manned ship. 

On the whole, a judicious and targeted use of temporary assignments can 

provide benefit to both the individual involved and the ships if the challenges are 

properly mitigated for the sailor and for both units. In many instances, these temporary 

fills did not take into consideration the specific qualifications required for a ship’s 

specific configuration. Further, the Review Team found no formal ISIC or Type 

Commander policy exists that specifically addresses the temporary assignment of the 

right personnel or manage their qualification process for the (temporary) gaining ship for 

Yokosuka-based ships.

Prior to 2015, the resources available from Japan-based ships were adequate to 

meet the operational demands in the Western Pacific using a deliberate employment 

scheduling process. Since 2015, operational demand has increased significantly in the 

Western Pacific to support high-priority national tasking including BMD and presence 

missions, in addition to dynamic tasking to support exercises and experimentation 

(further details provided in Appendix 8.10). The shift from deliberate planning to 

dynamic tasking placed a burden on the ships trying to recertify because of the 

unpredictability of schedules. The increase in BMD mission requirements is not unique 

to SEVENTH Fleet (see Appendix 9.10). The Navy should evaluate overall BMD 

capacity in the fleet to determine the necessary force structure (platforms and 

capabilities) to support the expected near and long-term mission requirements.

6.2.2 Force Employment

The Review Team found that having a single commander balance the risk of 

readiness generation and force employment requirements from multiple sources often 

sub-optimizes the foundational maintenance, modernization and training needed to 

develop the readiness necessary to meet the Navy’s statutory responsibility to organize, 

train, and equip the force. The current Force readiness generation structure for 

Yokosuka-based ships has complicated accountability and responsibility for training and 
74

certification, as well as force employment. The Review Team found that without a 

command and control structure that clearly delineates the responsibility, authority, and 

accountability for force generation and force employment, the tendency to employ 

forces without proper maintenance and training will likely remain. 

With the increased demand for ships in the Western Pacific, the rigor of 

executing employment scheduling conferences was not maintained by SEVENTH Fleet. 

This led to a greater reliance on “dynamic tasking.” No scheduling conferences have 

been held since November 2016. Additionally, the SEVENTH Fleet headquarters had 

not executed a disciplined process to prioritize the tasks and missions assigned to 

Japan-based ships, resulting in escalating requirements for operations. Operational 

requirements gradually took precedence over training and maintenance, and resulted in 

decisions to employ ships that have not been given the time to train and certify in all 

required mission areas. For example, in FY16 and FY17, 10 of 18 and 6 of 16 CMAVs 

were rescheduled, canceled, or shortened. Some of the deferred maintenance is 

executed in Windows of Opportunity (WOO) periods, but the execution in a WOO is less 

efficient because of ship schedule uncertainty. 

The decision to employ forces that were not certified in one or more mission 

areas was effectively made under the SEVENTH Fleet Commander’s authority for 

operational control of its assigned forces and is inherent in the responsibility to assign 

tasks, designate objectives, and give authoritative direction necessary to accomplish the 

mission. However, these decisions were made without full understanding of the true 

readiness of the ships, and the decisions relied too heavily on acceptance of a RAMP. 

The Review Team found that the RAMP process was not an effective tool for accurately 

assessing and mitigating risk. Force employment decisions were often made without 

regard to the cumulative fatigue that near constant operations potentially have on a 

crew as well. Consequently, the resultant risk was left to individual Commanding 

Officers to execute assigned missions with whatever mitigations they thought 

appropriate. 
75

6.3 Recommendations

6.3.1 Force Generation

1. Develop a force generation model for ships based in Japan that addresses the 

increasing operational requirements, preserves sufficient maintenance and 

training time, and improves certification accomplishment. [CPF, 31Dec2017]

2. Conduct comprehensive Ready for Sea Assessments to determine the 

material and operating readiness for all Japan-based ships. [CNSF, on-going]

3. Permanently establish Naval Surface Group Western Pacific as an Echelon IV, 

Immediate Superior in Command administrative headquarters responsible for 

maintaining, training, and certifying FDNF Japan ships. Evaluate establishing a 

similar activity in Rota, Spain and Everett, Washington. 

[CPF/USFF/CNSF/CNSL/C6F, ongoing]

4. Cancel all existing Risk Assessment Mitigation Plans until all Ready for Sea 

Assessments are complete. [CPF Immediate]

5. Evaluate the utility of the RAMP process as a risk management tool and make 

changes as appropriate. [CPF, 31Dec2017]

6. Evaluate and recommend a maintenance and modernization scheme for all 

Yokosuka-based ships that takes into account the operational requirements, the 

training, SRF&JRMC and industrial base capacity and make recommendations for 

improvement. [OPNAV/USFF/CPF/NAVSEA, 30Jun2018]

7. Evaluate the OPTEMPO requirements applicable for forward-deployed units and 

revise control measures to account for the unique operational cycles for FDNF. 

[OPNAV, 31Dec2017] 

8. Evaluate the current alignment of SRF and JRMC to Commander, U.S. Pacific Fleet 

and determine if changes in owner/operator structure are needed. 

[OPNAV/CPF/NAVSEA, 31Dec2017]

6.3.2 Force Employment

1. Restore the SEVENTH FLEET deliberate employment scheduling process to 

improve operational planning and risk management. [C7F/CPF, immediate]
76

2. Establish formal policy for requalification requirements for personnel 

temporarily assigned to ships and when changes in equipment configuration 

occur. [CNSF/CSF/CNAF, 30Nov2017]

3. Establish a single Echelon II higher headquarters responsible for the 

readiness generation of all Navy forces. [OPNAV/USFF/CPF, 30Sep2018]

4. Evaluate existing “redlines” policy with respect to navigation, RADAR, steering, and 

propulsion systems. [CNSF, 30Nov2017].

5. Improve the overseas and sea duty screening process to more rapidly identify those 

who will not screen for overseas and/or sea duty and to accelerate the process to 

identify replacement candidates. [CNP, 31Mar2018]

6. Evaluate all current operational requirements in the Western Pacific and prioritize 

operations with available resources. If assigned forces capacity is not sufficient to 

source the requirement utilize the Global Force Management process to request 

additional support. [C7F/CPF, 30Nov2017]
77

7. SEAMANSHIP AND NAVIGATION EQUIPMENT READINESS AND UTILITY

7.1 Introduction

Ensuring the utility of ship equipment needed to safely navigate begins with the 

Chief of Naval Operations staff codifying concepts of operations into requirements to be 

used as the basis for ship design. These operational requirements become the basis 

for acquisition and cradle-to-grave life-cycle support by Program Managers within the 

Program Executive Offices (PEOs). Some of those high-level requirements are 

translated into concrete models for Bridge watchteam structures, to include the type of 

individuals selected to operate consoles and the desired foundational training. Then, 

engineering organizations design, certify, integrate, and test the equipment matched to 

those watchteams, and they develop documentation and training to prepare operators 

and technicians to use and maintain those systems. Once the surface force Type 

Commander accepts new equipment and certifies it ready to operate, ships and 

supporting maintenance activities maintain equipment readiness to established 

standards to ensure capability and redundancy at sea or in battle. These standards for 

material condition are also enforced for at-sea training to ensure normal system 

configurations and procedures and to build proficiency through training.

There are no causal factors in the four representative mishaps linked to material 

readiness of equipment needed to safely operate at sea. The Review Team identified a 

number of findings that made getting ready and staying ready more difficult. First, the 

Navy should improve the ability of Commanding Officers to validate their self-assessed 

material condition and the proficiency of their technicians and operators with less timedemanding engagements on their ships. Second, the Navy should consolidate 

responsibility for all Bridge system operational and technical requirements to improve 

management of ship Bridges as integrated control rooms. Lastly, the Navy should 

improve the application of modern human factors engineering to the Bridge, and Bridge 

consoles, during modernization.
78

7.2 Findings

7.2.1 Inspection, Certification, and Assist Visits (ICAV) 

As outlined in the Surface Force Readiness Manual, the goal of ICAV is to 

ensure Sailors deploy with their ship at peak readiness and they are properly prepared 

to overcome equipment challenges at sea. ICAV was created to consolidate and 

optimally manage shore-to-ship assistance with minimal burden to the ship. Currently, 

the sheer number of visits by external organizations often creates a burden on ship’s 

crews and they do not provide an objective validation of crew proficiency and selfsufficiency. Examples of visits include navigation system certification, preventative 

maintenance assessments, Afloat Training Group events, and the series of material 

condition assessments collectively called the Total Ship Readiness Assessment 

(TSRA). Ships can be subjected to as many as 238 separate inspection, certification,

and assist visits in a 36-month period. The ICAV process should be better planned and 

executed to eliminate duplication of effort and better support Sailors and the consistent 

readiness of their equipment. Each visit can be made more effective if deficiencies 

found were summarized and provided to ship Commanding Officers with objective 

measures of performance and candid comments on weaknesses to allow for focused 

improvement. Further, it should come in a format that supports both Type Commander 

and Systems Commander trend analysis. Related visits should be combined by 

planning them from a ship’s perspective; sending teams to assess equipment 

supporting ship functional areas (e.g., Bridge systems) or ship divisions instead of 

planning visits around the responsibilities of shore organizations. The scope and scale 

of assistance Sailors receive from outside organizations costs them valuable training 

time and often does not directly address their manning, training, or equipment needs. 

The lack of objective executive level feedback following ICAV visits is preventing 

meaningful improvement as Commanding Officers have to carefully mine voluminous, 

detailed reports gathered by specialists and presented in a variety of formats to 

ascertain where they need focused improvement. The most candid feedback on 

problem areas is currently provided expert-to-expert (e.g., at the Chief Petty Officer or 

Leading Divisional Petty Officer level). While visiting teams intend to be helpful, many 
79

team members indicate they want to avoid “putting Sailors on report” without giving 

them an opportunity to improve. So the lack of objective grading and candid feedback 

in out briefs and reports prevents trending on ships, across ships and by Commanding 

Officers. Additionally, the scope of each visit tends to be defined by the responsibility of 

the ashore sponsoring organization without consideration of what is most effective from 

the crew’s perspective. 

As an example, Naval Sea Systems Command (NAVSEA) conducts navigation 

certifications (NAVCERT) for all surface ships. (This is not to be confused with either 

the ATG navigation certification, which focuses on crew proficiency, or the ship’s ISIC

navigation check-ride, which validates that a ship is safe to go to sea for testing and 

training following extended availabilities.) The NAVSEA NAVCERT focuses on the 

material readiness of navigation systems to support safe operations at sea, primarily in 

time-keeping and geo-positioning the ship. The NAVCERT process also assesses 

Sailor proficiency in maintaining equipment on their own, between certifications, and 

while operating at sea. 

Review of navigation equipment discrepancies data from ships involved in the 

mishaps led to broader analysis across the Navy. Although provided with the same 

basic navigation equipment, NAVCERT surface ship performance is consistently lower 

than submarines. Figure 7.1 shows the average number of deficiencies found through 

NAVCERT by ship class over the past two years. Deficiencies found are reported to 

ships in real-time for tracking. High-Risk deficiencies are certification-limiting, and 

prevent NAVCERT close-out. If ship operations are needed prior to resolution, a 

departure from specification is required. When asked to explain the differences in 

performance among platform classes certifying authorities, experts noted that unlike 

surface ships, submarines technicians are both operators and maintainers and tend to 

demonstrate higher proficiency and standards.

Figure 7.1: Average no. of navigation equipment discrepancies past two years

Ship Class (sample size) Total at Start (High Risk) Total at End (High Risk)

CRUDES and MCM (40) 35 (6) 18 (0)

AMPHIB and CVN (20) 68 (12) 23 (0)

SSN and SSBN (24) 6 (2) 1 (0)
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When reviewed in aggregate, the metrics collected through the training and 

certification processes show consistent inaccuracy in ship’s self-assessment of their 

material condition overall. As an example, analysis of Board of Inspection and Survey 

(INSURV) reports indicate that on their own, surface ships only captured an average of 

18 percent of the material deficiencies that INSURV finds when observing ships 

performing the same maintenance. Other ICAV visits such as the 3M certification and 

TSRA confirm a steady trend of low-accuracy in surface ships Current Ships 

Maintenance Plans (CSMP), which capture and track all material deficiencies onboard a 

surface ship. This impedes effective planning for maintenance and impacts the ability of 

ships and their chains of command to assess readiness and mitigate operational risk. 

While there are no equivalent objective measures for operator and technician 

level-of-knowledge and proficiency in interacting with their equipment, the magnitude of 

inaccuracy in ship self-assessment suggests substantial gaps in crew level of 

knowledge in system design and maintenance procedures. When visit reports include 

raw data that suggests poor crew performance, the reports do not convey any executive 

level perspective so that Commanding Officers or higher authorities can focus efforts on 

improving readiness and self-sufficiency. Additionally, inaccurate material condition 

data leads to growth in maintenance periods which ultimately takes away from time 

dedicated to training and operations. Surface Maintenance Engineering Planning 

Program (SURFMEPP) data confirms the undefined backlog of ships’ force material 

deficiencies as a principal cause of unacceptable growth between planning and 

execution, which prevents ships from returning to sea on time. 

Visiting certification teams respond to the demand for readiness and operations 

by helping ships as much as possible, to include entering deficiencies into ships’ 

maintenance systems, ordering material, and performing direct corrective actions. 

While well intentioned, and helpful in the short term, this can undermine certification of 

self-sufficiency and technical proficiency. The existence of persistent, moderate 

deficiencies at the time of certification also increases the risks of operationally impacting 

failures at sea. With adjustments in scope and the quality and candidness of feedback 

in out-briefs and reports, current engagements such as NAVCERT could provide ships 

better insights in where improvement is needed to maintain readiness on their own and 
81

operate safely. Multiple additional opportunities within the ICAV set of engagements for 

similar adjustments to scope, consolidation of related visits, and cessation of redundant 

or low-value visits were identified anecdotally and merit further review.

7.2.2 Bridge System Modernization and Training 

There is sufficient sensor data available in Navy combatant Bridges and CICs to 

clarify and amplify what can be seen by eye and allow safe ship maneuvering and 

navigation. However, the Navy should improve the clarity and consistency of guidance 

to ships on how to man and operate Bridge systems. Additionally, the Navy lacks clear 

accountability for delivering effective training to ships undergoing modernization. 

When integrated by watchteams as designed, Navy ships are equipped with a 

navigation “system-of-systems” that exceeds IMO standards. Yet, in recent mishaps, 

some ships did not use all available sensors to amplify direct observations (e.g., 

enhanced optical sensors, RADAR, and AIS), did not use installed tools to assist 

integrating the CIC surface contact picture for Bridge watches (e.g., Bright Bridge), and 

were unfamiliar with ship control systems. Unlike modern civilian ship Bridges, 

designed to routinely operate with two (cargo ships) or four (cruise ships) licensed and 

unlicensed watchstanders, most Navy ship Bridges remain laid out in a manner tied to 

their history and they still rely on relatively large Bridge and CIC watchteams to safely 

operate in dynamic, tactical conditions by design. 

At present, modernization of ship Bridge arrangements and systems is not 

engineered and managed holistically as an integrated control room over its lifetime. 

Without centralized ownership and tight alignment between changes in high-level 

operational requirements, intent and timelines for modernizing Bridge systems, and 

oversight of the capabilities and training needs for ship operators has resulted in: (1) 

increasing complexity with suboptimal human factors engineering, (2) inconsistent 

configuration control and gaps in equipment specific training, and (3) declining support 

for navigation RADAR systems. 

The large number of different Bridge system configurations, with increasingly 

complex and ship-specific guidance on how to make them work together, increases the 

burden on ships in achieving technical and operational proficiency. The variability and 
82

complexity from ship to ship makes managing individual qualification on specific 

equipment more important; but it also makes it more difficult. Ships require better 

support from Systems Commands and technical support functions ashore in merging 

the influx of operational and technical guidance and clarifying steps needed to 

requalifying their Sailors following periods of modernization. 

Because the Navy is warfare oriented, the design of a ship’s CIC receives 

significant rigor and undergoes a disciplined and cohesive process at the SYSCOMs. 

Surface ship CICs are well laid out ergonomically and their design is sustained between 

concepts of operation, technology design, and training through a ship’s life cycle. The 

same level of rigor is not in place for the design of the Bridge. With the exception of 

newly designed platforms, the sensors and sub-systems relied on by surface ship 

Bridge watchteams are independently designed, certified, and modernized by distinct 

technical and program management organizations responsible to field, maintain, and 

modernize their systems in support of distinct operational functions and not the Bridgeas-control-room. In general, ship operational requirement documents have not driven 

more effective Bridge equipment integration and management by NAVSEA and 

acquisition offices inside the Navy. The exceptions include LCS and DDG-1000, where 

the design of the Bridge around a “cockpit” model forces tighter control and up-front 

integration. Each organization remains motivated by sound, but different objectives, 

and there is not a strong unifying force to drive collaboration and coordination during 

modernization cycles. Some of these issues were self-identified by NAVSEA and 

Program Executive Offices (PEOs), which are responsible for acquisition in the Navy, 

during the introspective assessments performed as part of the CNO-directed 

operational pause.

Although coordination of a team is inherent in the ship design, the Navy requires 

clearer integrated guidance for ships to consistently man and operate Bridge support 

systems in the context of that design. The NAVDORM describes watch positions 

primarily related to navigation, but does not prescribe when those positions are to be 

set. Commanding Officers generally model their watchteams after those in place before 

they took command or based on expectations they developed from firsthand experience 

on prior ships. No one interviewed could identify a resource available to them to learn 
83

how installed equipment was intended for use together in various operational scenarios. 

Not surprisingly, practices vary substantially. 

From the 1990s to today, the Navy has been through periods of substantial 

change in policy and technology that eroded collective oversight and control of Bridge 

systems. As described below, long standing watchstanding practices were changed 

between 2001 and 2004 to reduce manning. In 2013, after completion of the Fleet 

Review by Vice Admiral (ret.) Balisle, Navy leadership returned to past manning 

practices. However, clear corrective guidance was not issued to inform ships how to 

respond operationally after nine years of functioning in the context of (reduced) optimal 

manning on surface ships. Similarly, although modernization was underway to support 

optimal manning concepts, no revised guidance was issued to NAVSEA, leading to 

confusion about the design basis and intended use of newly fielded equipment. 

During the optimal manning era, the Navy invested in smart ship programs to 

field “bolt-on” systems to help accommodate smaller watchteam sizes through 

automation and use of commercial-off-the-shelf (COTS) tools that are also employed by 

civilian merchant vessels. Bridge concepts mirrored that of merchant ships, with two to 

four person Bridge teams. At that time, modernization occurred in a piecemeal fashion, 

typically in-stride with new sensors and upgraded computer-based tools added 

incrementally as the Navy was able to deliver them. From 2003 to 2005 the Navy 

sought approval to use DDG 51 Class acquisition funding for the development of a more 

fully integrated Bridge under the optimal manning experiment model, with the design 

basis of three persons on the Bridge. Cost savings would be achieved over the life of 

the ship through reduced manning. The focus of that development was an integrated 

Bridge system allowing the helmsman to shift forward to a position where the JOOD 

could lookout and directly drive the ship under the supervision of the OOD. RADAR, 

AIS data, and electronic charting data would be integrated to adjacent consoles for use 

by the OOD with minimal support from CIC. 

Progress in executing modernization plans has been slow. Integrating data from 

commercially available navigation systems into those systems used for combat 

operations has proven complex, expensive, and challenged by cyber security risks that 

have to be judiciously addressed and readdressed as environments and risk-
84

assessments change. The Navy delivered the first truly integrated Bridge control and 

navigation system hardware in USS John Paul Jones (DDG 53) and USS Michael 

Murphy (DDG 112) in 2011. The Navy did not initially permit integration of tools such as 

AIS, citing unmitigated cyber security risks to the ship. Since then, technical challenges 

which vary from ship-to-ship have impeded selective integration of AIS by Commanding 

Officers when desired and tactically permissible. 

In parallel with continued modernization of Bridges for reduced manning, 

problems with supportability of legacy navigation systems were identified in 2011. As 

geo-positioning and timing equipment is integral and necessary for warfighting 

capabilities, a task force was initiated to bring “navigation wholeness” to in-service 

surface navigation systems. The task force’s findings in 2012 led to substantial urgent 

investment (approximately $458 million budgeted over a five-year span) in modernizing 

some Bridge systems. Over this same period of investment, support and operational 

availability of the surface force’s primary navigation RADARs have declined. As an 

example, both SPS-73 and SPS-67 RADARs on forward deployed Cruisers and 

Destroyers are reported as consistently below operational availability thresholds for the 

last two years. Their replacement, Next Generation Surface Search RADAR (NGSSR), 

has been delayed due to underfunding. 

In two of the mishaps, interoperability between SPS-73 and other Bridge 

systems, particularly AIS and ECDIS-N, remains problematic. AIS data was unable to 

be pulled into USS Fitzgerald’s SPS-73 console for improved situational awareness. In 

USS John S. McCain, a different problem that causes SPS-73 data to overload some 

versions of ECDIS-N when in heavy traffic, caused watchstanders to disable that 

interface. Similarly, ships with older versions of ECDIS-N cannot import AIS data in 

high traffic areas as it causes the ECDIS-N to overload and malfunction. While all 

sensor data remains available at separate consoles, it is not integrated into a single 

display. In response to declining support for repairs and challenges integrating systems 

as designed, some ships independently procure and install commercial RADARs that 

provide ARPA, AIS, and ECDIS on a single console. This practice adds to the 

complexity of Bridge system configuration control. Some commercial RADARs degrade 

other installed sensors and none have logistics or training support. A high pace of 
85

modernization of interrelated Bridge systems along several independent paths 

continues today. Management by different technical organizations with different 

sponsorship, unstable funding, and the aforementioned security risks have disrupted 

plans and left the Navy in a period of continuous technological transition. 

Gaps among Navy headquarters organizations that define and execute 

modernization strategies, and the Type Commander who issues operational guidance, 

impact the ability of ships to train, use, and maintain new equipment. The documents 

delivered to ships receiving the Integrated Bridge and Navigation System (IBNS), which 

includes extensive electronic control modifications to the legacy ship control consoles 

(helms), still retain optimal manning as their design basis, and those practices are 

included in training for the ships. 

Of note, in USS John S. McCain, which had recently received the IBNS upgrade, 

the consolidated manning and training impact assessment provided to the ship ahead of 

her last modernization period omitted training requirements for enlisted rates that stand 

watch at the helm. While the guidance to USS John S. McCain was extensive, it was 

ambiguous in terms of impact to operator qualification and actions needed to prepare 

for certification; leaving much to the judgment of the ship only three months before 

installation began. In comparing that guidance with recent direction for a submarine 

entering modernization, the submarine is simply informed: “Installation of new tactical 

systems invalidates the following watchstander qualifications: Officer of the Deck (OOD) 

(Surfaced and Submerged); Contact Manager (Surfaced and Submerged); ... ; and 

Sonar Supervisor;” and so on. This direction also provided a clear phased plan for 

requalification with specific accountability for monitoring progress and updating 

readiness reporting systems throughout that process. There is not an equivalent 

assessment of qualification impact and direction for surface ships entering 

modernization periods. Of note, three of the four ships involved in the 2017 mishaps 

recently underwent maintenance periods with modernization.

Following the Fleet Review in 2010, which highlighted gaps in training, PMS 339 

was established within NAVSEA to serve as a single point of contact to coordinate the 

complex interactions of “a standing committee [the Surface and Expeditionary Warfare 

Training Committee (SEWTC)] of knowledgeable and accountable representatives who 
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actively participate in the development and assessment of manpower and training 

requirements and resourcing solutions.” Commander, Naval Surface Forces (CNSF), 

as the Navy's lead for the Surface Warfare Enterprise, chairs the SEWTC, and PMS 

339 is assigned its execution agent. Although SEWTC was modelled after its 

equivalent in undersea warfare, in practice, these committees behave differently. For 

the submarine force, Commander Submarine Force (CSF) representatives are the 

dominant voice in developing plans for approval, with a strong focus at the unit level; in

the SEWTC the dominant voice is the Surface Warfare resource sponsor (OPNAV N96) 

with a focus on balancing competing fiscal requirements. 

Since NAVSEA’s PMS 339 branch was established, it has been effective at 

identifying the magnitude of the training system problems and has been effective at 

advocating for training needs through budget requests. However, as implied by 

instruction and discussed above, there is a committee involved in setting training 

priorities and “cut lines” for unfilled requirements; and following SEWTC action, it is 

unclear who is ultimately accountable for failures in providing training to the surface 

force. As a recent example, training developed for DDG-1000 systems and equipment 

as part of acquisition was delivered late and determined inadequate for use on a ship. 

Commander Naval Education and Training refused to accept the training delivered for 

use in Navy schools. Remaining acquisition funding was insufficient to bring the training 

up to Navy standards, and the reduction in the forecast size of the DDG-1000 Class 

reduced the calculated benefit for the significant projected cost. Ultimately, PMS 339 

was assigned responsibility for managing this as a training gap. Currently, the PMS 339 

staff is developing interim training plans to support DDG-1000 replacement crews.

Coordination between organizations involved in Bridge system modernization will 

benefit from improved and unambiguous governance. Extant policy documents and 

written instructions do not establish clear organizational responsibility and technical 

authority for life-cycle management of a ship’s Bridge, to include assessing operational 

impacts of control and sensor modernization which lead to short term thinking. Most 

examples identified occurred when new acquisition Program Managers were under 

pressure to reduce costs and viewed “program-of-record” equipment as “too expensive” 

or “high risk.” As an example, RADAR systems with no responsible life-cycle manager 
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have been acquired and installed in ships (e.g., LPD-17 amphibious Class ships) and 

replaced shortly after delivery. In some cases, non-program-of-record RADARs have 

been installed by ships with support of acquisition dollars that are found to degrade 

performance of other sensors. Poor coordination and weak technical authority 

ultimately undermine efforts to establish strong configuration control and commonality 

on surface ship Bridge systems which are intended to reduce training and life-cycle 

support costs over the long term.

7.2.3 Human Systems Integration (HSI) and Human Factors Engineering (HFE)

HSI and HFE are complex topics that are broad in scope and generally mean 

different things to different people. For the purposes of this review, HSI includes 

assessing the Bridge layout, with emphasis on visibility and accessibility of critical 

information and controls needed in emergencies, watchstation ergonomics, as well as 

detailed assessments of the design of human machine interfaces. Recent design 

guidance used in surface ship modernization and acquisition contracts led to safetycritical equipment delivery without effective human machine interface reviews. Most 

ships and ship systems acquisition and modernization professionals have a limited 

understanding of HSI methods appropriate for use in ensuring delivered systems are 

sufficiently designed for both normal and emergency operating conditions. In IBNS, the 

selection of control types (e.g., discrete controls, such as physical levers, buttons, and 

knobs, versus touch screen controls), their spatial arrangement and density, as well as 

use of color schemes to clearly indicate out-of-normal conditions were inconsistent with 

best practices in industry for safety critical control panels. 

As an example, the touch screen controls and displays for ship control consoles 

are sufficiently dense that most watchstanders interviewed use the back-up method 

(track-ball and button input) as the touch screen for throttle control is considered 

unusable. As another example, review of recent problem history identified that following 

installation of the integrated Bridge system (IBS), eight of the first 12 ships receiving the 

installation immediately reported intermittently losing throttle control when changing 

speed quickly. The underlying problem was determined to be differences in how 

network operating systems manage messages between control stations. Ultimately, it 
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took nine months to resolve the issue throughout the surface force. For safety critical 

controls interfaces, issues like these should be prevented through upfront analysis of 

human-machine-interface requirements and validated through qualification testing in 

advance of equipment delivery. If thorough human factors assessments, land-based 

testing, and design qualification are considered too expensive or time consuming, then 

modernization of these controls systems should not be undertaken.

There is a gap between the enlisted operator and maintainer foundational 

training and the procedures and control systems delivered today by the in-service 

Engineering Agent (ISEA). Some ships recognize the complexity and compensate with 

the presence of technicians assigned to the Bridge during special evolutions. During 

casualties affecting steering, thrust control, or navigation systems it is crucial that 

officers and other Bridge operators not become focused on equipment casualty 

response as their attention is needed to understand shipping and navigation hazards 

and communicating with other ships through signals and radios. 

Beyond the potential inability of operators to diagnose an equipment casualty 

and take immediate actions in time to prevent mishaps, as occurred in USS John S. 

McCain, limited understanding of how automated systems function has been shown to 

increase the frequency of operator errors. In this context, unnecessary complexity in 

equipment or inadequate training for operators creates a latent hazard that may not be 

revealed during training or assessment of proficiency in conducting normal operations. 

There is a tendency of designers to add automation based on economic benefits (e.g., 

reducing manning, consolidating discrete controls, using networked systems to manage 

obsolescence) without considering the effect to operators who are trained and proficient 

in operating legacy equipment. Similarly, attempts to add flexibility with alternate modes 

of control demands operator attention to track modes of operation and stay aware of 

differences in system behavior. When considering the effects on operator cognitive 

loading, ability to make decisions with an uncalibrated degree of trust in automation, 

and potential increases in frequency of error, even modernization only intended to 

improve reliability can have the opposite effect when the whole human-machine system 

is assessed. Surface force IBNS operators interviewed noted the densely packed 
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display areas dedicated to errors and faults indicating that it is hard to interpret and the 

frequency of faults is distracting leading to normalization over time.

As an example, when Boeing introduced fly-by-wire in their 777, they deliberately 

retained conventional controls and went to lengths to ensure control system response 

felt the same to pilots to prevent impacts to proficiency. Reviewing controls in civilian 

ships, as well as United States Naval Ships (USNS, such as replenishment ships), show 

similar retention of discrete and familiar ship controls even as Bridge systems are 

modernized for electronic navigation. Naval Surface Warfare Center Dahlgren was 

identified as a center of excellence for human factors engineering within the Navy 

design community. Discussions with their leading experts revealed they had not been 

involved in specific reviews during modernization of Bridge system. The discussions 

also highlighted some gaps in their expertise specifically related to modern industrial 

standards for assessing HMIs in safety-critical controls systems. 

Although the NAVSEA critical design review of the ship control consoles and 

integrated Bridge and navigation system (IBNS, a later variant of IBS) installed on USS 

John S. McCain was ongoing during this comprehensive review, some of the interim 

findings include gaps in operating procedures governing the transfer of control that was 

attempted by USS John S. McCain crew, gaps in recommended and required training 

and procedures for Bridge watchstanders operating new consoles, and unclear 

guidance for each ship on the setup and operation of AIS, SPS-73, and electronic chart 

systems together for maximum situational awareness. 

7.3 Recommendations

1. Consolidate responsibility and authority for Bridge system modernization and 

improve methods for human systems integration. Establish a single authority 

responsible for all Bridge system operational requirements aligned with a single 

engineering authority responsible to the Navy for management of the Bridge and 

Combat Information Center systems as an integrated control room over the life of 

each ship class. [OPNAV/NAVSEA/PEO IWS, 31Mar2018]

2. Accelerate plans to replace aging military surface search RADARs and 

electronic navigation systems. Fully fund development and implementation of 

Next Generation Surface Search RADAR. [NAVSEA, 31Mar2018]
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3. Improve stand-alone commercial RADAR and situational awareness piloting 

equipment through rapid fleet acquisition for safe navigation. Identify, acquire, 

install and provide the maintenance and training support, for an appropriately 

positioned common commercial RADAR system on all surface ships. Remove 

existing non-supported commercial RADARs and establish policy preventing 

installation of commercial sensors without authorization. [NAVSEA/CNSF, 

31Mar2018]

4. Perform a baseline review of all inspection, certification, assessment and 

assist visit requirements to ensure and reinforce unit readiness, unit selfsufficiency, and a culture of improvement. The goal of this review should be to 

reduce the overall burden on ships by eliminating low value engagements and 

refocus remaining actions on validating unit readiness, unit self-sufficiency, and 

improvement. [CNSF/NAVSEA, 31Mar2018]

5. Numbered Fleet Commanders establish appropriate policies for surface ships 

to actively transmit and use Automatic Identification Systems (AIS) when 

transiting high traffic areas. Consider if similar guidance is needed for 

submarines. [C3F/C4F/C5F/C6F/C7F/CTF80, immediate]

6. Share lessons learned and operational guidance from the on-going technical review 

of USS John S. McCain systems and procedures. [NAVSEA, 30Nov2017]

7. Immediately develop and release a fleet advisory on safe and effective operation for 

all variants of ship’s steering systems in all modes of operation. [NAVSEA, 

immediate]

8. As an immediate aid to navigation, update AIS laptops or equip ships with hand-held 

electronic tools such as portable pilot units with independent ECDIS and AIS. 

[CNSP/CNSL, 31Mar2018] 

9. Accelerate plans to transition to ECDIS-N versions 9.4 and greater on all ships with 

hardware that secures its connection and allows full AIS integration. In the interim, 

NAVSEA and Type Commanders should jointly develop ship specific guidance on 

how to configure and operate ECDIS-N, RADARs, and AIS to maximize reliable 

situational awareness, reduce cyber vulnerability, and best meet the intent of IMO 

standards. [NAVSEA/PEO IWS, 30Nov2017]

10.Survey ships with integrated Bridge systems for feedback and lessons learned. 

[NAVSEA, 31Mar2018]
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11.Conduct design and procedural reviews to reassess all variations of Bridge control 

systems in the fleet with focus on the complexity, suitability of human machine 

interfaces, and reliability of the underlying safety-critical control systems for thrust 

and steering. [NAVSEA, 31Mar2018]

12.Assess the alignment between foundational training for enlisted operators and 

technicians and the technology used in integrated Bridge system consoles to ensure 

operators can take appropriate actions in response to equipment casualties. 

[NAVSEA, 31Dec2017]

13.Develop standards for including human performance factors in reliability predictions 

for equipment modernization that increases automation. [NAVSEA, 31Mar2018]

14.Update and define the Bridge and CIC watchstation requirements during all 

operating conditions in the SORM, NAVDORM, and EDORM. [CNSF, 31Mar2018]
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8. SYSTEMIC PROBLEMS

8.1 Introduction

The surface force is operating under difficult external conditions. Globally and 

domestically, the Navy is expected to adapt quickly and operate amidst uncertainty and 

change. Many of its leaders resourcefully find ways to generate strong teams in that 

environment with sufficient resiliency to succeed; however, even within those 

commands, continued success is not guaranteed, and culturally the surface force is not 

actively seeking identifying and trending precursors that could lead to mishaps. Even 

when presented with information that indicates standards of readiness are not met, 

rather than pausing and aggressively determining what is needed to correct the 

problem, the surface force is conditioned to mitigate the risk through some action that 

lessens the severity of the problem, and then proceed on with the mission. This 

tendency does not prevent problems from occurring in the future. 

Without the benefit of objective data to trend precursors to mishaps, leaders will 

not have the knowledge to make institutional corrections to prevent future incidents from 

occurring. Leading up to 2017, the raw number of mishaps had been on a slow, but 

steady decline, which helped to instill a false sense of safety and security. While flaws 

in that assessment are easily seen retrospectively, the surface force did not have robust 

methods for objectively measuring leading indicators of decline, nor trained people in 

place to proactively find gaps in existing safety analyses to effectively drive change. To 

improve the predictability of team and unit performance, judiciously applied evaluations 

must properly grade and calibrate the ship's internal programs and processes including 

planning, preparation and execution.

The common causal factors identified in the majority of the mishaps center on 

individual and team performance. Understanding the human performance factors 

involved is important to determine appropriate long-term corrective actions. Elements 

such as endurance, fatigue, team dynamics, and models of learning must be 

considered.
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8.2 Findings

8.2.1 Critical Assessment and Learning

Surface ships may receive over 200 Inspections, Certifications, and Assist Visits 

(ICAV) every 36 month cycle. The Review Team found that, collectively, the large effort 

expended does not consistently result in crews, Commanding Officers, or their ISICs

developing accurate or meaningful information on capability, nor does it drive a culture 

of learning and improvement. Recently, the Surface Type Commanders have 

implemented a reporting requirement for near-miss events with specific guidance on 

“cultural breakdowns.” This effort is a step in the right direction because it is a nonpunitive process that can capture near real-time data that can be meaningfully 

incorporated into training curricula and processes. 

This process of developing near-miss learning must ensure appropriate focus on 

precursors, instead of reactive details of an actual mishap in order to increase the 

margin and learning for operating safely at sea. The right data and trend analysis 

enables decision makers at any level to make systemic improvements before a problem 

occurs. Furthermore, extensive trend analysis will reveal more areas or periods of 

vulnerability. For example, three of the four ships had just come out of an extensive 

SRA and had been dynamically tasked to support continuous operations. In retrospect, 

ships immediately operating after an extended maintenance period are more vulnerable 

when it comes to proficiency and basic safe operations at sea. Some would counter 

that historical data does not support a relationship between ship employment following 

long periods of upkeep and an increased risk of mishaps at sea; however, recent events 

demonstrate that the lack of previous mishaps may have been a function of other 

factors or mitigations. 

Poor analytics and data visualization leads to wrong conclusions. For example, a 

2013 safety briefing to senior leadership concluded that there is “no apparent correlation 

between training or lack of training opportunity to increase in mishap rate.” However, a 

revisit of the raw data revealed elementary analytic techniques that resulted in 

misleading macroscopic trends, thus disarming the decision makers and diluting the risk 

management process. 
95

The Naval Safety Center has a broad mission that includes responsibility for 

evaluating operational risk as well as occupational health and safety. Driven by

regulatory requirements (and enhanced by the relative ease in collecting injury 

statistics), the safety center’s most effective trending tools capture information important 

to occupational safety and health. The data available to guide understanding of 

operational safety risks is limited to what can be derived from mishap and hazard 

reports provided to them. As such, their analysis has seldom yielded unique insights or 

recommendations applicable to particular mishaps or to broader performance 

improvements. Recommendations typically echo solutions captured singly in 

investigations without addressing systemic or human factors problems as they are 

understood by the scientific community. Similar conditions were present within BP and 

in the government regulatory agencies responsible for oversight in advance of the 

catastrophic events surrounding the loss of the Deep Water Horizon in the Gulf of 

Mexico.

The rigorous application of critical self-assessment can reduce the deviation from 

expected standards. Processes such as the Plan, Brief, Execute, Debrief (PBED) focus 

on specific evolutions or events, and are useful at the unit level. However, a more 

holistic assessment to understand performance trends and identify systemic issues is 

needed for all levels of command. Corrective actions will be most effective when a 

culture of safety matures to the point where knowledge meets capability, and all levels 

of command are operating interdependently, with greater teamwork at their respective 

levels, and a heightened awareness of the adequacies of their actions with respect to 

the Navy’s goals. 

The cumulative effect of poor critical assessment resulted in three principle 

modes of failure, which are highlighted in each of the four incidents that occurred this 

year: failure to plan, failure to practice, and failure in execution. With planning: our 

Commander's options to accomplish a greater number of missions have incrementally 

placed a greater emphasis on rationalizing deviations where planning did not reinforce 

challenging the assumptions. On practice: well before the Bridge watchstanders 

assumed the watch, they had not rehearsed emergency or extremis situations; in 
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execution: ships and headquarters failed to question if what they were doing was 

adequate to what they needed to do, and make corrections.

Figure 8.1: Conditions of Failure Matrix

Additionally, as discussed in more detail in Chapter six, higher headquarters did 

not have sufficient data to understand the true risk based on the actual readiness state 

of the ships when making employment decisions. Without the backstop of a strong 

assessment program, the surface force is susceptible to the impact of cultural drift 

within a command and in the force as a whole. Not having a process in place to assess 

instances of organizational drift allows for an accumulation of accident risk over time 

that is generally unrecognized by individuals both inside and outside of the command.

Non-compliant actions or inactions were not unique to the day of the respective 

mishaps. Several existing, accepted practices did not conform with written standards. 

For example, in the mishap involving USS Lake Champlain, some watchstanders in CIC 

believed that a surface contact log was maintained throughout their watch, but a 

Surface Contact Log was, in fact, not maintained for several days prior to the collision. 
97

Furthermore, the Digital Dead Reckoning Trace plot was not in use at the time of the 

collision. In every mishap, a combination of seemingly minor departures from 

procedures or practices was deemed to have been contributory or directly causal to the 

final mishap chain. These departures constitute organizational drift and reflect the long 

cultivation period of the mishaps. 

8.2.2 Human Performance Factors

With a high pace of operations, forward leaning teams can fail to recognize when 

human performance limits are reached. Outward focus on mission can stifle 

acknowledgement of fatigue preventing good decision making by individuals or teams. 

The mishaps highlighted the belief that operating at a high pace builds the proficiency 

that will overcome attendant risks and ignored four other critical factors: fatigue, crew 

endurance, performance and feedback.

Fatigue

Fatigue or ineffective fatigue/rest management was embedded in the four key 

mishaps that occurred in the Western Pacific. For example, in the mishap involving 

USS Fitzgerald, liberty expired at 0600 for all hands, followed by a full schedule of 

demanding evolutions that left the 2200-0200 watch section fatigued and without 

adequate rest. Similarly, USS Antietam watchstanders on the Bridge and Forecastle 

reported “fair” to “poor” sleep quality as they transitioned from an ashore to at-sea watch 

scheme. Witnesses on USS John S. McCain cited fatigue, even exhaustion, as having 

a negative impact on morale. This ship did not use a static, circadian rhythm watchbill. 

On the other hand, in the case of USS Lake Champlain, the ship did employ a circadian 

rhythm-conducive watchbill, but they did not support that watchbill with an effective 

ship’s routine.

Recent surface forces guidance on fatigue management requires further 

refinement and expansion to all ships at all times. Circadian rhythm watchbills alone 

are not enough (e.g., 12 on 12 off is circadian, but does not account for administrative 

work after watch), and any circadian rhythm watchbill scheme without a supporting 

ship’s routine is also ineffective. The crew will not experience the long term benefits 
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(improved crew endurance) of the concept unless the ship’s routine supports the static 

watch rotation. For example, the inherent value of the 3-and-9, 4-and-8 or 6-and-18 

watch rotations supports fatigue recovery (e.g., sleep quality with the opportunity for 8 

hours of uninterrupted sleep) and crew endurance. Crew endurance is the ability to 

maintain optimal warfighting performance while enduring job-related physical, 

psychological, and environmental challenges. 

Endurance

Operational effectiveness depends on crew endurance. If crewmembers are 

overly fatigued, mission accomplishment, performance, and safety are in jeopardy. 

Chronic sleep debt has long-term physical and mental health consequences and 

degrades human performance. Overall, the command’s ability to identify fatigue factors 

early, effectively implement a circadian rhythm watch bill with corresponding special 

evolution watch bills, and a supporting ship routine will optimize fatigue recovery and 

crew endurance.

The USCG has developed the Crew Endurance Management System (CEMS) 

which is a set of tools and practices maritime operators can use to manage productivity 

and safety levels in their operations. CEMS specifically helps operators identify the 

operational risk factors affecting crew endurance in particular situations, and to control 

these risk factors by means of proven practices and procedures. This guide is 

specifically intended to help maritime operators maximize crew performance and safety 

by identifying and controlling factors affecting crew endurance in normal operations.

Performance

Additionally, with respect to watchteam performance, resilience, and operational 

safety, there is strong Defense Equal Opportunity Management Institute (DEOMI) 

survey evidence that forward deployed operational readiness overall is affected by 

fatigue and stress. DEOMI survey results from forward deployed ships showed relevant 

recurrent themes regarding exhaustion, high stress, and lack of sleep. These negative 

indicators appear on 21 of the 22 ships based in Japan. 
99

Manning shortfalls can contribute to crew fatigue and crew endurance. For 

example, manning shortfalls of 15-20 percent exist within particular enlisted ratings on 

some classes of ships. This gap, coupled with high operational tempo, impacts the 

command’s ability to train and sustain individual tempo for the Sailors if they are still 

trying to meet operational and training expectations of a fully manned ship, often at the 

expense of sleep. Consistent with civilian requirements, the Navy Standard Work Week 

assumes 13 hours per day for Sailors on operational ships. However, survey data 

indicates personnel working significantly longer hours. 

As evident in the recent analysis of the Navy Standard Work Week (NSWW), 

typical on-duty hours exceeded the planning threshold factor of 15 percent. In other 

words, Service Diversion (e.g. quarters, inspections, sick call or non-training-related 

assemblies) exceeded the NSWW planning factor by 64 percent, training and drills 

exceeded by 58 percent and watchstanding exceeded by 29 percent. Naturally all 

categories of Off-Duty Hours were under the NSWW planning factors. Time spent 

eating was under executed by 37 percent, personal and Sunday time was short by 51 

percent and sleep was short by 28 percent. The execution of the NSWW, especially in 

the lens of manning shortfalls, stifles fatigue recovery and crew endurance.

In light of the above, the Navy has recently completed the first part of a DDG 

Class inport work week study. Because there are multiple variants of the DDG Class 

destroyer, there are seven different Ship Manpower Documents (SMD) that display the 

minimum manpower required to achieve readiness and meet ships’ anticipated 

workloads. As of October 2017, the Navy has completed review of one of seven DDG 

Class SMDs. The initial results indicate more enlisted Sailors will be needed to achieve 

minimum readiness standards.

Some solutions to manning shortfalls cause their own secondary problems. 

Since 1 May 2017, 49 Sailors in certain ratings on ships executing a maintenance 

period (e.g., Operations Specialist, Search and Rescue swimmer) have been 

temporarily assigned to other deploying Japan-based ships. Many of these deploying 

ships would not have met the requirements to deploy without the temporarily assigned 

critical skill sailor. Pulling Sailors from inport ships and placing them on deploying ones 

reduces or eliminates time to complete school or training for that Sailor, and denies 
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opportunities for longer term fatigue recovery. Additionally, this practice reduces the 

overall number of Sailors remaining on the inport ship to complete daily tasks and 

places additional stress on affected Sailors and families.

Human performance in service of the Navy mission is rich in inherent complexity, 

due to the nature of operations and the extreme environments and conditions in which 

work is performed. High-stakes, high-demand, high-tempo operations in a challenging 

maritime environment provide various opportunities for errors and undesirable 

outcomes which can manifest themselves in many different ways, but the driving forces 

behind these incidents are rarely unique. Error is a result of some causal factor, or 

more likely factors that impeded human performance. These factors could be:

environmental, like fog that degraded visual perception or a noisy workspace that 

muddled communication; cultural, like poor housekeeping practices or low 

watchstanding standards; team-related, like inadequate team communication or a lack 

of a shared mental model; or individual, like a lack of a questioning attitude, physical or 

cognitive fatigue, or poor risk assessment. The confluence of factors produces an error, 

which in turn may have consequences in the form of an incident or near miss event. It 

is important to look at the causal factors that contribute to near miss events, as they are 

likely to be the same factors that could have contributed to more serious accidents.

Improved training can help overcome human performance weaknesses. Previous 

successes with the legacy approach for simulator employment should be leveraged with 

emerging and innovative strategies in order to learn more effectively as part of a 

deliberate learning curriculum. Further, a need exists to ensure training and operational 

interfaces are consistent to support better transfer of training and more valid 

assessments in simulator environments. 

Feedback

The Review Team met with experts in the field of training and simulation,

including government and contract providers, and NASA Langley Research Laboratory 

Crew Systems and Aviation Branch scientists (developing new ways to sense and 

categorize psycho-physiological responses to improve human performance). 

Simulations can directly improve two observed shortcomings in current surface training: 

team effectiveness; and individual performance in the use of specific equipment such as 
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VMS, Surface Search Radars, and AIS to build situational awareness. Current training 

programs are ineffective in addressing either shortcoming. To become effective, the 

Navy must develop training models in a structured way, and then deliberately develop 

simulators and task-trainers to match that model.

The realism, rapidity, and immediate feedback of the technology discussed 

above will further enhance the implementation of the PBED process in line with central 

tenets of learning. This will improve the surface community’s approach to analyze 

discrete events and discuss improvements among the watchstanders and the team in 

real time. This will also normalize the inherent variability associated with inconsistent 

shipboard operational experiences. 

Experiences in this training environment must include effective assessment of 

performance to build confidence and a willingness of junior officers and sailors to 

provide forceful backup to the team. Watch teams must continually apply the best 

concepts, techniques and technologies to accelerate learning as individuals, teams and 

organizations. 

8.2.3 “Can do” Culture

Whether called “can do” or “mission first,” the surface force is culturally oriented 

to accomplish whatever task it is given. When this attitude is self-inspired, remarkable 

results can be, and have been, achieved. We value this culture, because the Navy

needs leaders who can confidently manage their ships and crews as well as their 

operational risks. But can-do should never mean must-do. So, we must continue to 

encourage our Commanders to accept the risks when the benefit to be gained is worth 

the potential risk of failure. The manifestation of that culture in a unit, or headquarters, 

is highly dependent on the experience and temperament of individual leaders. And, as 

outlined in this report’s analysis of managing the supply and demand of surface forces, 

the effectiveness of systems in place to prevent overstressing of individuals or units 

varies. 

Under pressure to perform, and feeling ill-equipped to succeed, some leaders 

can stop listening to their team when feedback appears to detract from their immediate 

goals. Interviews revealed that, particularly among ships based in Japan, crews 
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perceived their Commanding Officer was unable to say "no" regardless of unit-level 

consequence. Tight directive control can result in a command climate intolerant of 

dissenting views or questions that prevents effective teamwork and forceful feedback in 

planning, preparations, and execution.

The perceived uniqueness of Japan-based ships is significant in two ways: (1) 

the formalized and approved model for the training and certification of forces in Japan 

was overtaken by the increases in operating tempo; and (2) there was no separation 

between responsibilities for producing ready forces and employing those forces to meet 

mission demands. These differences made Japan-based ships fragile relative to other 

fleets where there are structural checks in place against unidentified drifts in training 

and certification readiness. By routinely employing forces that do not meet full 

readiness standards (e.g., 84 training events for Japan-based ships were cancelled due 

to operational demands), leadership marginalized the standard, and in turn degraded 

the training and certification process, resulting in increased risk to the FDNF-Japan

surface force. Consequently, the rigor in conducting risk-to-force assessments was 

overshadowed by operational primacy, and led to only partially informed assessments, 

poor mitigation identification, and reduced ability to meet the mission. 

Sailors take great pride in a “can do” attitude. Crews are safety conscious, but 

when it comes to assessing their own fatigue their perceptions tend to be reactive, often 

complacent and dominated by unsubstantiated optimism that motivation on caffeine can 

replicate the cognitive and physical prowess of a well-rested crew. While many 

warfighters believe and assert that fatigue can be overcome by motivation, adequate 

motivation can only moderate the deleterious effects of fatigue to a limited degree. 

Motivation alone cannot compensate for the impact of sleep debt on performance 

levels, which have been found to decline as much as 30 percent after the first night of 

sleep deprivation, and up to 60 percent during the second night when sleep deprivation 

was combined with continuous cognitive tasks. When fatigue can impact operator 

performance and ship safety, sailors need to know when they must succumb to their 

own fatigue, be proactive about their fatigue management plan, and reach out to 

leadership. 
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8.2.4 Sustaining Change

Historically, the surface force unintentionally and unknowingly stopped short of 

institutionalizing changes or going after force-wide cultural issues that were resident in 

nearly all mishaps. A singularly focused program, such as the Fleet-wide Improvement 

and Operational Safety (FIOS) program, would have the bandwidth to build resilience by 

harvesting lessons learned across Navy platforms, sustaining improvement, and serving 

as an authoritative platform from which to drive widespread cultural change. One of the 

goals of this program would be to end the cycle leadership typically goes through 

following a major mishap: order an operational pause or safety stand down; assemble a 

team to determine what happened and why; and develop a list of discrete actions to get 

better. Like many times before, following this review, many causes will be identified, 

many meaningful actions will be taken, and there will likely be near-term success in 

getting things back on track. In reality, however, this may be chipping away at the 

margins. In the absence of an enduring program in place to prevent forgetting important 

lessons, systemic change and long lasting improvements may not occur. 

The assessment of relevant risks in advance so that mitigations can be put in 

place to eliminate or minimize the hazard is essential to avoid major incidents. While it 

is, of course, critical to learn lessons from near-miss and mishap events with the aim of 

preventing future incidents, this approach is reactive and has the disadvantage that 

preventative measures may not be identified or taken until some mishap has occurred. 

A proactive approach using innovative analytic techniques that is responsive to 

identified trends in close calls supports the implementation of strategies, mitigations, 

and solutions without waiting for a precipitating untoward event.

Finally, each of the four Bridge and CIC teams involved in the mishaps did not 

work with each other to solve problems as an effective team. Standing on the Bridge 

together, all the watchstanders, and the CO, face the same problem. Successful teams 

will use their collective skills as a team to effectively use the methods and techniques 

best suited to their ship and the conditions at hand. A principle attribute of teamwork is 

forceful backup. The surface force must work to embrace a culture where the CO is not 

perceived as the single source for all answers. Watchstanders that are well trained, 

knowledgeable and proficient, each have a contribution to the success of the team. 
104

Throughout their careers, Commanders and subordinates need to understand, develop 

and foster a climate which empowers all individuals to provide forceful backup. 

The surface force has taken some positive steps in this regard, particularly with 

the development of the Naval Surface and Mine Warfighting Development Center 

(NSMWDC), a model that was adopted from effective programs in other communities.

The Warfare Tactics Instructor (WTI) program trains officers in warfighting doctrine and 

tactics to help crews achieve tactical superiority, and as part of this, empowers its WTIs 

with the knowledge and courage to be assertive with the crews they are training. Most 

of all, this program empowers junior officers with the knowledge and courage to provide 

forceful feedback to senior officers in order to help them learn how to become better 

tacticians and more effective warfighters and leaders. 

This idea has broader applicability to watchstanders on the Bridge and in CIC. 

All watchstanders, from the most junior Sailor to the CO, have an obligation to use their 

voice to provide forceful backup when they see a deviation from procedure or 

dangerous situation developing. Command leadership, regardless of experience and 

rank, must have the humility to listen to the backup and consider it in their decisions. By 

example, this will encourage their subordinates to do the same. 

Corrective actions in the surface force will be most effective when a culture of 

safety is backed by a culture of teamwork. When subordinates are routinely 

empowered to speak-up, they are also developing the courage that will be needed in 

situations of extremis, and when all levels of command are operating interdependently, 

with greater teamwork, and with a heightened awareness of the adequacies of their 

actions. 
105

8.3 Recommendations

8.3.1 Critical Assessment

1. Establish and utilize near miss reporting processes to share lessons across 

the surface force. Implement a near miss/close call critique process to support 

identification and mitigation of underlying hazards and vulnerabilities that contribute 

to operational risk, including Human Factors analysis. [CNSF, on-going]

2. Improve Navy Safety Center and fleet and force headquarters safety programs 

and data analysis to provide predictive operational safety and risk information. 

[USFF/CPF/NSC/CNSF/CNAF/CSF/CNIF/NECC, 31Mar2018]

8.3.2 Human performance factors

1. Develop a plan to deliberately train and assess units under stress and fatigue 

conditions that implements risk controls during execution, and allows for recovery 

time afterward. [CNSF, 31Mar2018]

2. Leverage the Navy Leader Development Framework (NLDF) competency and 

character development continuum similar to reinforce team building, team leadership 

and team effectiveness in support of the six sound shipboard operating principles. 

[OPNAV, 31Mar2018]

3. Based on the results to date from the study of DDG manning requirements, conduct 

a pilot to supplement manning on one unit in basic phase and validate expected 

improvements in individual workloads. A unit in a similar basic-phase schedule 

should be used for comparison. [CNP/CNSF, 31Mar2018]

8.3.3 “Can do” culture

1. Establish a comprehensive fatigue and endurance management policy to 

implement fatigue recovery standards and codify a circadian ship and watch 

rotation routine for surface ships. Include in this policy an implementation plan 

(similar to the USCG Crew Endurance Management Program) which considers 

human factors and delineates operational restrictions to include “Go-No-Go” criteria 

for hours on task, and task limitations. [CNSF, 30Nov2017]

2. Establish mental health evaluation support at the waterfront in all fleet concentration 

areas. [CNSF, 31Mar2018]
106

8.3.4 Sustaining change

1. Establish human performance expertise at all Type Commander staffs. 

Incorporate a human factors expert permanently on Echelon III staffs to 

institutionalize the Fleet Improvement and Operational Safety (FIOS) program and 

integrate it with the existing Afloat Safety Program. [OPNAV/USFF/CPF, 

30Sep2018]

2. Establish Commanding Officer mentors in surface ship homeports. Assign senior 

mentors with proven at sea leadership experience to develop leadership skills and 

improve organizational capacity. The key components of this mentorship program 

will focus on seamanship and navigation, team building and operational safety. 

[CNSF, 31Mar2018]

3. Review the Overseas Screening, Sea Duty Screening, Overseas Tours Extension 

Incentives Program (OTEIP) and Exceptional Family Member programs to improve 

mitigation to manning assignments for all forward-deployed ships and squadrons. 

[CNP, 31Mar2018]
107

9. APPENDICES

9.1 Summary of Recommendations

4.3.1 Individual Training

1. Create an objective, standardized assessment program to periodically assess 

individual seamanship and navigation skills over the course of a Surface 

Warfare Officer’s career. This process should be informed by the MITAGS 

Navigation Skills Assessment Program (NSAP) principles to assess Surface Warfare 

Officer seamanship and navigation skills at every career milestone, including an 

objective assessment by SWOS prior to initial qualification as Officer of the Deck. 

[NETC, 31Mar2018]

2. Improve seamanship and navigation individual skills training for Surface 

Warfare Officer candidates, Surface Warfare Officers, Quartermasters and 

Operations Specialists. This effort should include at a minimum updating the 

curricula (content and durations) for Surface Warfare Officers, Quartermasters, 

Operations Specialists, and Electronics Technicians, for all career milestones from 

new accession to major command (for officers) or master-level (for enlisted). [NETC, 

31Mar2018]

3. Improve Operational Risk Management training and education at all Surface 

Warfare Officer School milestone courses. [NETC, 31Mar2018]

4. Provide additional fundamentals training for officers who qualified SWO without 

initial classroom training (e.g., SWOSDOC or B/ADOC) covering Automated RADAR 

Plotting Aid (ARPA), Electronic Chart Display and Information System (ECDIS), and 

Automatic Information System (AIS). [NETC/CNSF, 31Mar2018]

5. Update the Surface Warfare Officer Requirements Document to capture the metrics 

used to evaluate seamanship and navigation skills in Surface Warfare seamanship 

safety assessments. [CNSF, 31Mar2018]

6. Incorporate fatigue, crew endurance, and stress management into appropriate 

career milestone Surface Warfare Officer training and enlisted leadership courses. 

[NETC, 31Mar2018]

7. Evaluate use of Yard Patrol craft in all officer accession programs. The study should 

include the feasibility of expanding Yard Patrol craft use, and other training methods, 

so that every naval officer receives core competencies as articulated in the Officer 

Professional Core Competencies Manual. [USNA/NETC/CNSF, 30Sep2018]
108

8. Update Personnel Qualification Standards for Bridge and CIC watchstations 

including actions to address current navigation tools, surface search radars, ship 

control systems, and team performance related to navigation and contact 

management and avoidance. [NETC, 31Dec2017]

9. Revise the Surface Force Readiness Manual to define the Officer of the Deck 

requalification process and circumstances under which watchstanders requalify on

their current platform due to configuration changes. [CNSF, 31Mar2018]

4.3.2 Officer Career Path

1. Align the number of SWO candidates assigned to ships with the billet requirements. 

[CNP, 31Mar2018]

2. Evaluate the SWO career path from accession to major command including the 

scope and timing of formal training, sea/shore assignments, and Executive Officer 

and Commanding Officer sequence and timing. This evaluation should also 

incorporate a process to ensure an appropriate talent distribution of SWO 

candidates to the fleet in their first sea duty assignment. [CNP, 30Sep2018]

3. Establish a single, longer division officer tour as the standard, with allowances for 

specific billet requirements. Emphasize that the focus of division officer tours should 

be building proficiency, especially in seamanship and navigation. [CNP, 31Mar2018]

4. Establish policy to define, maintain, and reestablish SWO currency (e.g., a Bridge 

log) that accounts for Surface Warfare Officer OOD, JOOD, and Conning Officer 

watchstations. [CNSF, 31Dec2017]

5.3 Unit Training

1. Improve current seamanship and navigation team training and certifications to 

include assessment in high shipping density, emergency and in extremis 

environments. This action should include establishing the curriculum to evaluate 

Bridge and CIC teams’ ability to respond to navigation and shiphandling scenarios in 

accordance with the Nautical Rules for non-standard and emergency situations, 

including in extremis. [NETC/CNSF, 31Mar2018]

2. Improve shore-based Bridge trainers and add CIC functionality to team 

training facilities. Establish the requirement to include all watchstations associated 

with safe navigation in team trainers and determine any facility modifications or 

upgrades necessary to accomplish the integrated training. Leverage outside expert 

organizations (e.g., NASA Langley Research Laboratory, Crew Systems and 
109

Aviation Branch) to independently assess and recommend improvements to the 

simulator training strategy. [CNSF/NETC/OPNAV, 31Mar2018]

3. Improve current seamanship (MOB-S) and navigation (MOB-N) team training and 

certifications to include assessment of Bridge-CIC team performance up to and 

including the Commanding Officer. [CNSF, 31Mar2018]

4. Integrate Bridge and CIC evaluations for unit level seamanship and navigation 

training in shore-based team trainers, and during at sea training and 

certifications events. Commanding Officers shall be required to attend, and 

scenarios shall focus on high-density traffic transits. [CNSF/NETC, 31Mar2018]

5. Recertify Bridge Resource Management training in the fleet concentration areas’ 

Navigation Seamanship and Shiphandling Trainers to USCG standards. [NETC, 

31Mar2018]

6. Implement a plan for all ISICs to evaluate the proficiency of the ships and crews to 

safely navigate in high-density traffic transits in the NSST as part of their ISIC 

navigation check ride after extended maintenance and before deployment. [CNSF, 

31Dec2017]

7. Revise the NAVDORM to establish the SUWC as the primary surface contact 

management and contact avoidance watch station in CIC and establish formal 

SUWC training. [CNSP/CNSL/CNAP/CNAL/NETC, 31Mar2018]

6.3.1 Force Generation

1. Develop a force generation model for ships based in Japan that addresses the 

increasing operational requirements, preserves sufficient maintenance and 

training time, and improves certification accomplishment. [CPF, 31Dec2017]

2. Conduct comprehensive Ready for Sea Assessments to determine the 

material and operating readiness for all Japan-based ships. [CNSF, on-going]

3. Permanently establish Naval Surface Group Western Pacific as an Echelon IV, 

Immediate Superior in Command administrative headquarters responsible for 

maintaining, training, and certifying FDNF Japan ships. Evaluate establishing a 

similar activity in Rota, Spain and Everett, Washington. 

[CPF/USFF/CNSF/CNSL/C6F, ongoing]

4. Cancel all existing Risk Assessment Mitigation Plans until all Ready for Sea 

Assessments are complete. [CPF Immediate]
110

5. Evaluate the utility of the RAMP process as a risk management tool and make 

changes as appropriate. [CPF, 31Dec2017]

6. Evaluate and recommend a maintenance and modernization scheme for all 

Yokosuka-based ships that takes into account the operational requirements, the 

training, SRF&JRMC and industrial base capacity and make recommendations for 

improvement. [OPNAV/USFF/CPF/NAVSEA, 30Jun2018]

7. Evaluate the OPTEMPO requirements applicable for forward-deployed units and 

revise control measures to account for the unique operational cycles for FDNF. 

[OPNAV, 31Dec2017] 

8. Evaluate the current alignment of SRF and JRMC to Commander, U.S. Pacific Fleet 

and determine if changes in owner/operator structure are needed. 

[OPNAV/CPF/NAVSEA, 31Dec2017]

6.3.2 Force Employment

1. Restore the SEVENTH FLEET deliberate employment scheduling process to 

improve operational planning and risk management. [C7F/CPF, immediate]

2. Establish formal policy for requalification requirements for personnel 

temporarily assigned to ships and when changes in equipment configuration 

occur. [CNSF/CSF/CNAF, 30Nov2017]

3. Establish a single Echelon II higher headquarters responsible for the 

readiness generation of all Navy forces. [OPNAV/USFF/CPF, 30Sep2018]

4. Evaluate existing “redlines” policy with respect to navigation, RADAR, steering, and 

propulsion systems. [CNSF, 30Nov2017].

5. Improve the overseas and sea duty screening process to more rapidly identify those 

who will not screen for overseas and/or sea duty and to accelerate the process to 

identify replacement candidates. [CNP, 31Mar2018]

6. Evaluate all current operational requirements in the Western Pacific and prioritize 

operations with available resources. If assigned forces capacity is not sufficient to 

source the requirement utilize the Global Force Management process to request 

additional support. [C7F/CPF, 30Nov2017]
111

7.3 Seamanship and Navigation Equipment Readiness and Utility

1. Consolidate responsibility and authority for Bridge system modernization and 

improve methods for human systems integration. Establish a single authority 

responsible for all Bridge system operational requirements aligned with a single 

engineering authority responsible to the Navy for management of the Bridge and 

Combat Information Center systems as an integrated control room over the life of 

each ship class. [OPNAV/NAVSEA/PEO IWS, 31Mar2018]

2. Accelerate plans to replace aging military surface search RADARs and 

electronic navigation systems. Fully fund development and implementation of 

Next Generation Surface Search RADAR. [NAVSEA, 31Mar2018]

3. Improve stand-alone commercial RADAR and situational awareness piloting 

equipment through rapid fleet acquisition for safe navigation. Identify, acquire, 

install and provide the maintenance and training support, for an appropriately 

positioned common commercial RADAR system on all surface ships. Remove 

existing non-supported commercial RADARs and establish policy preventing 

installation of commercial sensors without authorization. [NAVSEA/CNSF, 

31Mar2018]

4. Perform a baseline review of all inspection, certification, assessment and 

assist visit requirements to ensure and reinforce unit readiness, unit selfsufficiency, and a culture of improvement. The goal of this review should be to 

reduce the overall burden on ships by eliminating low value engagements and 

refocus remaining actions on validating unit readiness, unit self-sufficiency, and 

improvement. [CNSF/NAVSEA, 31Mar2018]

5. Numbered Fleet Commanders establish appropriate policies for surface ships 

to actively transmit and use Automatic Identification Systems (AIS) when 

transiting high traffic areas. Consider if similar guidance is needed for 

submarines. [C3F/C4F/C5F/C6F/C7F/CT80, immediate]

6. Share lessons learned and operational guidance from the on-going technical review 

of USS John S. McCain systems and procedures. [NAVSEA, 30Nov2017]

7. Immediately develop and release a fleet advisory on safe and effective operation for 

all variants of ship’s steering systems in all modes of operation. [NAVSEA, 

immediate]
112

8. As an immediate aid to navigation, update AIS laptops or equip ships with hand-held 

electronic tools such as portable pilot units with independent ECDIS and AIS. 

[CNSP/CNSL, 31Mar2018] 

9. Accelerate plans to transition to ECDIS-N versions 9.4 and greater on all ships with 

hardware that secures its connection and allows full AIS integration. In the interim, 

NAVSEA and Type Commanders should jointly develop ship specific guidance on 

how to configure and operate ECDIS-N, RADARs, and AIS to maximize reliable 

situational awareness, reduce cyber vulnerability, and best meet the intent of IMO 

standards. [NAVSEA/PEO IWS, 30Nov2017]

10.Survey ships with integrated Bridge systems for feedback and lessons learned. 

[NAVSEA, 31Mar2018]

11.Conduct design and procedural reviews to reassess all variations of Bridge control 

systems in the fleet with focus on the complexity, suitability of human machine 

interfaces, and reliability of the underlying safety-critical control systems for thrust 

and steering. [NAVSEA, 31Mar2018]

12.Assess the alignment between foundational training for enlisted operators and 

technicians and the technology used in integrated Bridge system consoles to ensure 

operators can take appropriate actions in response to equipment casualties. 

[NAVSEA, 31Dec2017]

13.Develop standards for including human performance factors in reliability predictions 

for equipment modernization that increases automation. [NAVSEA, 31Mar2018]

14.Update and define the Bridge and CIC watchstation requirements during all 

operating conditions in the SORM, NAVDORM, and EDORM. [CNSF, 31Mar2018]

8.3.1 Critical Assessment

1. Establish and utilize near miss reporting processes to share lessons across 

the surface force. Implement a near miss/close call critique process to support 

identification and mitigation of underlying hazards and vulnerabilities that contribute 

to operational risk, including Human Factors analysis. [CNSF, on-going]

2. Improve Navy Safety Center and fleet and force headquarters safety programs 

and data analysis to provide predictive operational safety and risk information. 

[USFF/CPF/NSC/CNSF/CNAF/CSF/CNIF/NECC, 31Mar2018]
113

8.3.2 Human performance factors

1. Develop a plan to deliberately train and assess units under stress and fatigue 

conditions that implements risk controls during execution, and allows for recovery 

time afterward. [CNSF, 31Mar2018]

2. Leverage the Navy Leader Development Framework (NLDF) competency and 

character development continuum similar to reinforce team building, team leadership 

and team effectiveness in support of the six sound shipboard operating principles. 

[OPNAV, 31Mar2018]

3. Based on the results to date from the study of DDG manning requirements, conduct 

a pilot to supplement manning on one unit in basic phase and validate expected 

improvements in individual workloads. A unit in a similar basic-phase schedule 

should be used for comparison. [CNP/CNSF, 31Mar2018]

8.3.3 “Can do” culture

1. Establish a comprehensive fatigue and endurance management policy to 

implement fatigue recovery standards and codify a circadian ship and watch 

rotation routine for surface ships. Include in this policy an implementation plan 

(similar to the USCG Crew Endurance Management Program) which considers 

human factors and delineates operational restrictions to include “Go-No-Go” criteria 

for hours on task, and task limitations. [CNSF, 30Nov2017]

2. Establish mental health evaluation support at the waterfront in all fleet concentration 

areas. [CNSF, 31Mar2018]

8.3.4 Sustaining change

1. Establish human performance expertise at all Type Commander staffs. 

Incorporate a human factors expert permanently on Echelon III staffs to 

institutionalize the Fleet Improvement and Operational Safety (FIOS) program and 

integrate it with the existing Afloat Safety Program. [OPNAV/USFF/CPF, 

30Sep2018]

2. Establish Commanding Officer mentors in surface ship homeports. Assign senior 

mentors with proven at sea leadership experience to develop leadership skills and 

improve organizational capacity. The key components of this mentorship program 

will focus on seamanship and navigation, team building and operational safety. 

[CNSF, 31Mar2018]
114

3. Review the Overseas Screening, Sea Duty Screening, Overseas Tours Extension 

Incentives Program (OTEIP) and Exceptional Family Member programs to improve 

mitigation to manning assignments for all forward-deployed ships and squadrons. 

[CNP, 31Mar2018]
115

9.2 Matrix of Mishap Attributes

USS John 

S. McCain

(DDG 56)

USS 

Fitzgerald 

(DDG 62)

USS Lake 

Champlain 

(CG 57)

USS 

Antietam 

(CG 54)

Underway Time X

NOT Fully Certified X X X

Weather as Predicted X X X X

Entering/Leaving Port within 

prior 24 Hours X X X

Poor Planning X X X X

CO/XO on Bridge X X

Bridge/CIC Comms Failure X X X X

Bridge-to-Bridge Comms Failure X X X N/A

Radar Improperly Tuned X X X X

SPY Radar Off X X X

Lack of Training on VMS X X

Only Bridge using VMS X X X

AIS Secondary System/Not 

Integrated X X X N/A

Formal Commands NOT 

Adhered to X X X X

Subpar Watchstanders 

(qualified, not proficient) X X X

No EXTREMIS Call X X X X

Tripwires Ignored/Not Realized X X X X

Quals: Sufficient vs. Proficient 

(watchbills) X X X

Plan Responsibility NOT 

Properly Known X

Special Evolution X X

Lost Situational 

Awareness/Bubble X X X X

Significant Gap in Seamanship 

(CO) X X

Training Programs Ineffective X X X X
116

USS John 

S. McCain

(DDG 56)

USS 

Fitzgerald 

(DDG 62)

USS Lake 

Champlain 

(CG 57)

USS 

Antietam 

(CG 54)

NAV Team Proficiency X X X

Fatigue/fatigue Management X X X X

Outdated CO Guidance X X X

Failure to follow CO Standing 

Orders X X X X

Poor Watch Team Continuity X X X

Poor Log Keeping X X X X

Primary Cause: Human Error X X X X

PBED not adhered to X X X X

Lack of Communication 

between Bridge / CIC X X X X

Poor Self-Assessment and 

training X X X X
117

9.3 Commands and Organizations Visited by CRT

The Review Team visited the following locations or interviewed personnel assigned to 

the following commands: 

 Baltimore, MD

Maritime Institute for Training and Graduate Studies

 Bremerton, WA

Afloat Training Group Pacific Northwest

 Dahlgren, VA

Center for Surface Combat Systems

 Great Lakes, IL

Center for Surface Combat Systems Unit

Surface Warfare Officers School Command Unit

 Manama, Bahrain

Commander, FIFTH Fleet

 Naples, Italy

Commander, SIXTH Fleet

 Newport, RI

Naval Leadership and Ethics Center

Surface Warfare Officers School Command

 Norfolk, VA

Antech Systems

Commander, United States Fleet Forces Command

Commander, Naval Surface Force Atlantic

President, Board of Inspection and Survey

Commander, Carrier Strike Group FOUR

Commander, Destroyer Squadron TWO TWO

Huntington Ingalls Industry

Naval Seamanship Shiphandling Trainer

Naval Surface Warfare Center – Corona

USS ARLEIGH BURKE (DDG 51)

USS MAHAN (DDG 72)

USS BULKELEY (DDG 84)

USS FORREST SHERMAN (DDG 98)
118

USS JASON S DUNHAM (DDG 109)

USS RAMAGE (DDG 61)

USS SAN JACINTO (CG 56)

USS TRUXTON (DDG 103)

USS GRAVELY (DDG 107)

USS WHIDBEY ISLAND (LSD 41)

USS FORT McHENRY (LSD 43)

Virginia Pilots Association

Commander, Afloat Training Group Atlantic

Afloat Training Group Norfolk

Center for Surface Combat Systems Detachment

Surface Warfare Officers School Command Detachment

Space and Naval Warfare Systems Center Atlantic

 Pearl Harbor, HI

Afloat Training Group Mid-Pacific

Commander, Destroyer Squadron THIRTY ONE

Commander, U.S. Pacific Fleet

Commander, Naval Surface Group Mid Pacific

 Philadelphia, PA

Naval Sea Systems Command

 San Diego, CA

Commander, THIRD Fleet

Commander, Naval Surface Force Pacific

Commander, Carrier Strike Group ONE

Commander, Carrier Strike Group ONE FIVE

Commander, Expeditionary Strike Group THREE

Commander, Destroyer Squadron ONE

Naval Seamanship Shiphandling Trainer

USS WAYNE E MEYER (DDG 108)

USS SOMERSET (LPD 25)

Commander, Afloat Training Group Pacific

Afloat Training Group San Diego

Center for Surface Combat Systems Detachment

 Sasebo, Japan

Commander, Expeditionary Strike Group SEVEN

Commander, Amphibious Squadron 11

Commander, Fleet Activities Sasebo

Commander, Mine Countermeasures Squadron SEVEN

Commander, Naval Ship Repair Facility
119

Naval Seamanship Shiphandling Trainer

USS BONHOMME RICHARD (LHD 6)

USS GREEN BAY (LPD 20)

USS PIONEER (MCM 9)

Afloat Training Group Western Pacific Detachment

 Washington, DC

Naval Sea Systems Command

Office of the Navigator of the Navy

Program Executive Office Integrated Warfare Systems

Space and Naval Warfare Systems Command

 Yokosuka, Japan

Commander, SEVENTH Fleet

Commander, Carrier Strike Group FIVE

Commander, Destroyer Squadron ONE FIVE

USS CHANCELLORSVILLE (CG 62)

USS STETHEM (DDG 63)

USS BARRY (DDG 52)

Afloat Training Group Western Pacific

U.S. Naval Ship Repair Facility, Yokosuka

Naval Surface Group Western Pacific
120

9.4 Comprehensive Review Team Members

Admiral Philip S. Davidson, Commander U.S. Fleet Forces Command 

Name Affiliation

VADM Richard P. Breckenridge, USN U.S. Fleet Forces Command (USFF)

RADM Peter A. Gumataotao, USN USFF/Naval Surface Force, Atlantic

CAPT Christopher W. Brunett, USN USFF 

CAPT Chris J. Bushnell, USN Surface and Mine Warfare Development Center

CAPT David S. Deuel, USCG Atlantic Area Command

CAPT Joseph Ring, USN Destroyer Squadron THREE ONE

CAPT Kurt M. Sellerberg, USN Naval Surface Force, Pacific

CAPT Melvin H. Underwood, CHC, USN Submarine Force, Atlantic

CAPT David A. Welch, USN OPNAV N3/N5

CDR H. Brendan Burke, JAGC, USN Office of the Judge Advocate General

CDR Brent K. Faulkner, JAGC, USN USFF

CDR Charles E. Hampton, USN USFF

LtCol William D. Shannon, USMC Marine Corps Forces Command

LCDR Owen B. Morrissey, SC, USN USFF

LCDR Shelby M. Nikitin, USN Navy Personnel Command

LCDR David C. Sandomir, USN Naval Surface Force, Pacific

LT Heather P. Steele, USN Afloat Training Group, Norfolk

LTJG Brian M. Herbert, USN USS LABOON (DDG 58)

LTJG Trenton R. Layne, USN USS TRUXTUN (DDG 103)

QMCM(SW) John C. Eskridge, USN Transient Personnel Unit, Norfolk

OSC(SW) Terry P. Dehollander, USN USFF

GSMC(SW) Tacito R. Reyes, USN Assault Craft Unit FOUR

Dr. Jon A. Jones Naval Sea Systems Command 08 (NAVSEA 08)

Mr. Stephen E. Fisher NAVSEA 08

Mr. Russell T. Williams USFF

Mr. William A. Walsh NAVSEA

Mr. Peter W. D. Morford, PMP, CPLP Afloat Training Group, Atlantic

Mr. Kevin J. Couch Naval Surface Force, Pacific

Dr. Kimberly Culley Submarine Force, Atlantic

Mr. Steven W. Holland USFF

Captain David K. Murrin USNS COMFORT (T-AH 20)

Mr. Mark E. Morrison USFF

Dr. Daniel J. Whiteneck Center for Naval Analyses
121

9.4.1 Independent Advisors

Name Affiliation

ADM Bill Gortney, USN (Ret) Highly Qualified Expert, Naval War College

GEN Carter Ham, USA (Ret) Special Government Employee

LtGen. John Sattler, USMC (Ret) Special Government Employee

VADM Mike Connor, USN (Ret) Consultant, ThayerMahan, Inc.

Captain Eric Nielson Special Government Employee,

President of the Association of Maryland Pilots 

Dr. Steven J. Spear Association Consultant, High Velocity Edge, LLC
122

9.5 References

American Bureau of Shipping, Guidance Notes on Ergonomic Design of Navigation 

Bridges, October 2003

Articles of the Convention on the International Regulations for Preventing Collisions at 

Sea (COLREGS), 1972

Button, R., Martin, B., Sollinger, J., & Tidwell, A., Assessment of Surface Ship 

Maintenance Requirements, Santa Monica, CA, RAND Corporation (2015)

Clark, B. & Sloman, J., Deploying Beyond Their Means: America’s Navy and Marine 

Corps at a Tipping Point, Center for Strategic and Budgetary Assessments

COMNAVSEASYSCOM message 171339Z August 2016, SEA 21 Ship Program 

Manager (SPM) Policy for Chief of Naval Operations Availabilities for CRUDES and 

Amphibious Ships

COMNAVSEASYSCOM message 281449Z June 2016, SEA 21 Ship Program Manager 

(SPM) Policy for the Late Add Process in CNO Availabilities for CRUDES and 

Amphibious Ships

COMNAVSURFOR Instruction 1412.4, Surface Warfare Officer Requirements 

Document, 23 March 2017

COMNAVSURFOR message 160050Z September 2017, COMNAVSURFOR 

Warfighting Serial 13-Confidence and Competence

COMNAVSURFPAC Instruction 4700.lB/COMNAVSURFLANT Instruction 

4700.lB/CNRMC Instruction 4700.7A, Total Ship Readiness Assessment Visit Program

COMNAVSURFPAC Instruction 5450.37F, Mission, Functions and Tasks of 

Commander, Naval Surface Group, Middle Pacific, 23 January 2017

COMNAVSURFPAC Instruction/COMNAVSURFLNAT Instruction 3505.1A, Navigation 

Seamanship and Ship-Handling Training, 12 December 2016

COMNAVSURFPAC/COMNAVAIRPAC/COMNAVAIRLANT/COMNAVSURFLANT 

Instruction 3530.4E, Surface Ship Navigation Department Organization and Regulations 

Manual, 31 October 2016

COMNAVSURFPAC/COMNAVAIRPAC/COMNAVAIRLANT/COMNAVSURLANT 

Instruction 3530.4D Appendix A, Squadron/Group Staff Navigation Assessment, 19 July 

2013

COMNAVSURFPAC/COMNAVSURFLANT Instruction 3500.11A, Surface Force 

Exercise Manual, 30 November 2016
123

COMNAVSURFPAC/COMNAVSURFLANT Instruction 3502.3, Surface Force 

Readiness Manual, 9 March 2012

COMNAVSURFPAC/COMNAVSURFLANT Instruction 3502.3, Surface Force 

Readiness Manual, 30 November 2016 

COMPACFLT/COMUSFLTFORCOM Instruction 3501.3D, Fleet Training Continuum 

Instruction, 1 October 2012

COMSC Instruction 3121.9C, Standard Operating Manual, 12 September 2012

COMSC Instruction 3501.4A, T-AO Single Hull Tanker Risk Mitigation Program

COMSC Instruction 3530.1, Military Sealift Command Navigation Policy, 18 October 

2016

COMSC Instruction 4490.1, Original Equipment Manufacturers and Non-Original 

Equipment Manufacturers Use Policy, 10 April 2017

COMSC Instruction 9670.1G, Allowance of Electronic Equipment for MSC Ships, 6 

March 1995

COMSEVENTHFLT Instruction 3501.1B, Seventh Fleet Training Program, 11 October 

2012 

COMTHIRDFLT Instruction 3501.1, Integrated and Advanced Fleet Training Instruction, 

25 September 2013

COMTHIRDFLT Instruction/I MEFO 3502.1, Amphibious Ready Group Fleet Response 

Training Plan and Marine Expeditionary Unit Pre-Deployment Training Program

COMUSFLTFORCOM message 051931Z August 2010, CSG-ESG Commander and 

Type Commander Command relationships

COMUSFLTFORCOM/COMPACFLT Instruction 3000.15A, Optimized Fleet Response 

Plan, 8 December 2014

COMUSFLTFORCOM/COMPACFLT Instruction 3000.16, Fleet Inspections, 

Certifications, Assessments and Visits Program and Processes, 17 February 2016

COMUSFLTFORCOM/COMPACFLT Instruction 3501.3D, Fleet Training Continuum

Culley, K. & Madhavan P., Trust in automation and automation designers: Implications 

for HCI and HMI. COMPUTERS IN HUMAN BEHAVIOR, 29, 2208–2210, (2013)

Department of Defense Design Criteria Standard: Human Engineering, MIL-STD1472G, 11 January 12

Det Norske Veritas Part 4 Chapter 11: Safety of Navigation
124

Germanischer Lloyd Rules for Classification and Construction Ship Technology: 

Seagoing Ships – Bridge Arrangement and Equipment on Seagoing Ships 2012

IMO Maritime Safety Committee Resolution A.817 (19), Performance Standards for 

Electronic Chart Display and Information Systems

IMO Resolution A.819 (19), Performance Standards for Shipborne Global Positioning 

System Receiver Equipment, 15 December 95

IMO Resolution A.893 (21), Guidelines for Voyage Planning, 4 February 00

IMO Resolution A.916 (22), Guidelines for the Recording of Events Related to 

Navigation, 22 January 02

MITAGS-PMI Quick Reference Guide to the Implementation of the STCW Manila 

Amendments, 2010 and the USCG Final Rules

MITAGS-PMI Simulation Capabilities and Facilities Guide, April 2017

MITAGS-PMI Training Requirements for Various Merchant Mariner Billets, 25 

September 17

NAVEDTRA 43101-3F, Personnel Qualification Standards, Surface Warfare Officer 

Engineering

NAVEDTRA 43101-4F, Personnel Qualification Standards, Surface Warfare Officer 

Combat Information Center Watch Officer, Officer Of The Deck Underway, Officer Of 

The Deck Underway Platform Endorsement, 

NAVEDTRA 43304-E, Personnel Qualification Standards, Tactical Action Officer

NAVEDTRA 43398-13B, Personnel Qualification Standards, Aegis Combat Information 

Center Supervisor, Aegis Piloting Officer, Aegis Shipping Officer, Aegis Surface 

Detector/Tracker and Radar Controller, Aegis Surface Subsurface Supervisor/Surface 

Subsurface Warfare Supervisor, 

NAVEDTRA 43398-14B, Personnel Qualification Standards, Aegis Surface Warfare 

Coordinator, Aegis Weapons System Warfare Coordinator

NAVEDTRA 43492-2J, Personnel Qualification Standards, Ship’s Control and 

Navigation

NAVMED P-6410, Performance Maintenance during Continuous Flight Operations, 1 

January 2000

NAVPERS 18068-32J CH-64, CHAPTER 32: Electronics Technician (ET), October 

2015 
125

NAVPERS 18068-59G CH-68, CHAPTER 59: Operations Specialist (OS), October 2016

NAVPERS 18068-66E CH-67, CHAPTER 66: Quartermaster (QM), July 2016

NAVSEA INSTRUCTION 2319.2, NAVSEA Advisory Program, 17 Ju1 2015

NAVSEA INSTRUCTION 5400.1F, Naval Sea Systems Command Organization 

Manual, 26 August 2013

NAVSEA Instruction 9420.4A, Certification of Navigation Systems, 2 October 2009

Norris, G., & Wagner, M., Boeing 777: The Technological Marvel, Minneapolis, MN, MBI 

Publishing (2001)

OPNAV Instruction 1500.57C, Surface and Expeditionary Warfare Training Strategy, 19 

February 2013

OPNAV Instruction 1500.76C, Naval Training Systems Requirements, Acquisition, and 

Management, 14 August 2013

OPNAV Instruction 3000.15A, Optimized Fleet Response Plan, 10 November 2014

OPNAV Instruction 3120.32D, Standard Organization and Regulations Manual, 16 July 

2012

OPNAV Instruction 4700.7L, Maintenance Policy for United States Navy Ships, 25 May 

2010

OPNAV Instruction 5400.45, Standard Navy Distribution List, 1 October 2017 

OPNAV Instruction 9420.1B, Positioning, Navigation and Timing Policy; Administration 

and Planning, 29 June 2007

OPNAV Instruction 9420.2, Implementation of the Electronic Chart Display and 

Information System-Navy (ECDIS-N) Certification Process, 15 February 2001

OPNAV Instruction 9420.2A, Navy Electronic Chart Display and Information System 

Policy and Standards, 31 October 2014

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error and awareness in supervisory control, HUMAN FACTORS, 37(1), 5-19 (1995)
126

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Development, Acquisition, Associated Life-Cycle Management, and Logistics 

Responsibilities and Accountability, 2 December 2011

U.S. Coast Guard, COMDTINST M3530.2E, Coast Guard Navigation Standards 

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U.S. Coast Guard, Navigation and Vessel Inspection Circular No. 02-03, Carriage of 

Navigation Equipment by Ships on International Voyages, 4 June 2003

U.S. Coast Guard, Navigation and Vessel Inspection Circular No. 4-89, Introduction to 

Human Factors Engineering, 27 November 1989

U.S. Coast Guard, Navigation Rules and Regulations Handbook, August 2014

U.S. Naval Academy, Naval Service Training Command, Officer Professional Core 

Competencies Manual, August 2015

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and Human Factors Review Guidance, March 2000

U.S. Nuclear Regulatory Commission, NUREG-0700 Rev 2, Human-Systems Interface 

Design Review Guidelines, May 2002
127

9.6 Acronyms

1/AE First Assistant Engineer

1/O First Officer

2/AE Second Assistant Engineer

2/O Second Officer

3/AE Third Assistant Engineer

3/O Third Officer

3M Maintenance and Material Management

ABS Able Bodied Seaman

ADOC Advanced Division Officer Course

ASA Afloat Safety Assessment

AIS Automatic Identification System

AMHS Automated Message Handling System

ARPA Automatic Radar Plotting Aid

ASTAC Anti-Submarine Warfare Tactical Air Controller

ATD Aviation Training Devices

ATFP Anti-Terrorism, Force Protection

ATG Afloat Training Group

ATO Anti-Terrorism Officer

ATP Airline Transport Pilot

BDOC Basic Division Officer Course

BMOW Boatswain’s Mate of the Watch

BRM Bridge Resource Management

BTB Bridge-to-Bridge

C4I Command, Control, Communications, Computers and Intelligence

CASREP Casualty Report

CAST Computer Aided Submode Training

CBT Computer Based Training

CDO Command Duty Officer

CE Certification Event

CEM Crew Endurance Management

CFR Code of Federal Regulations

CHENG Chief Engineer

CIC Combat Information Center

CICO Combat Information Center Officer

CICWO Combat Information Center Watch Officer

CICWS Combat Information Center Watch Supervisor

CMAV Continuous Maintenance Availability

CNRMC Commander, Naval Regional Maintenance Center

CNSL Commander, Naval Surface Atlantic

CNSP Commander, Naval Surface Pacific

CM Continuous Maintenance

CMC Command Master Chief

CNO Chief of Naval Operations

CO Commanding Officer
128

CONN Conning Officer

CONM Conning Officer Mentor

CONUS Continental United States

COVE Conning Officer virtual Environment

CPT Cockpit Procedures Trainer

CTOS Commercial, Over the Shelf

CPO Chief Petty Officer

CSC Combat Systems Coordinator

CSCS Center for Surface Combat Systems

CSMP Current Ship Maintenance Plan

CSO Combat Systems Officer

CV Certification Validation

DDRT Digital Dead Reckoning Tracer

DFS Departure from Specification

DRRS-N Defense Readiness Reporting System-Navy

DWO Deck Watch Officer

ECDIS Electronic Chart Display and Information System

EOCC Engineering Operator Casualty Control

EOOW Engineering Officer of the Watch

EOT Engine Order Telegraph

ET Electrician’s Mate 

F2S Forced to Source

FDNF Forward Deployed Naval Forces

FFS Full Flight Simulators

FN Fireman

FOS Feasibility of Support

FOST Flag Officer Sea Training

FTA Fleet Technical Assistance

FTD Flight Training Devices

HELM SAFETY Helm Safety Officer

HM&E Hull, Mechanical, and Electrical

IAW In Accordance With

IBS Integrated Bridge Systems

ICAV Inspection, Certification, and Assist Visit

IETM Interactive Electronic Technical Manuals

IMO International Maritime Organization

INSURV Board of Inspection and Survey

IOMM&P International Organization of Masters, Masters and Pilots

ISEA In Service Engineering Activity

ISIC Immediate Superior in Command

IVO In Vicinity Of

JOOD Junior Office of the Deck

JRMC Japan Regional Maintenance Center

LCU Landing Craft Unit

LCAC Landing Craft Air Cushion

LEE HELM Lee Helmsman
129

LOK Level-of-Knowledge

LOS Loss of Steering

LPO Leading Petty Officer

MASTER Ship’s Master

MASTER HELM Master Helmsman

MITAGS Maritime Institute of Technology and Advanced Studies

MLC Master Labor Contract

MOC Maritime Operations Center

MOQ Mate of the Watch

MSC Military Sealift Command

MSFSC Military Sealift Fleet Support Command

MTE Man, Train and Equip

NATO North American treaty Organization

NAV Navigator

NAVCERT Navigation Certification

NAVIC Navigation and Vessel Inspection Circular

NAVMAC Navy Manpower and Analysis Center

NEC Navy Enlisted Classification Code

NETC Naval Education and training Command

NOBC Naval Officer Billet Code

NSAP Navigation Skills Assessment Program

NSTM Naval Ship’s Technical Manual

NSST Navigation Seamanship and Shiphandling Trainer

NSSTRD Navigation, Seamanship, and Shiphandling Training Requirements 

Document

NSWC Naval Surface Warfare Center

NTTP Navy Tactics, Techniques, and Procedures

NTSP Navy Training System Plans

NUC Not Under Command

NVG Night Vision Goggles

OCNW Officer in Charge of a Navigation Watch

OCONUS Outside Continental United States

OFRP Optimized Fleet Response Plan

OIC Officer in Charge

OJT On the Job Training

OOD Officer of the Deck

OPS/INTEL Operations/Intelligence

OPTEMPO Operational Tempo

OS Operations Specialist

OSS Optical Sight System

PCC Post Command Commander

PCO Prospective Commanding Officer

PMS Planned Maintenance System

POA&M Plan of Action and Milestones

POT Propeller Order Telegraph

PQS Personnel Qualification Standard
130

PXO Prospective Executive Officer

QM Quartermaster

QMOW Quartermaster of the Watch

RAS Replenishment at Sea

R-COP Readiness Common Operating Picture

RDZV Rendezvous

RMC Regional Maintenance Center

RMD Restricted Maneuvering Doctrine

ROR Rules of the Road (COMDTINST M16672.2D)

RSC RADAR System Controller

S2E Sailor to Engineer

SAB Standard Answer Books

SITREP Safety Investigation Report

SME Subject Matter Expert

SMWDC Naval Surface and Mine Warfare Development Center

SN Seaman

SRA Selected Restricted Availability

SOP Standard Operating Procedure

SSDS Ships Self Defense System

SSOP Sound Shipboard Operating Procedures

STCW Standards of Training, Certification and Watchkeeping

SUBFOR Submarine Force

SURFOR Surface Force

SUWC Surface Warfare Coordinator

SWO Surface Warfare Officer

SWOS Surface Warfare Officer School

TACCOM Tactical Communicator

TAO Tactical Actions Officer

TASKORD Task Order

TLO Training Liaison Officer

TMI The Type Commander Material Inspection

TRAV Training Availability

TSC Theater Security Cooperation

TSO Temporary Standing Order

TSRA Total Ship Readiness Assessment

TYCOM Type Commander

UIC Unit Identification Code

U/I Under Instruction

UNK Unknown

USCG U.S. Coast Guard

USN United States Navy

USSF U.S. Fleet Forces

VMS Voyage Management System

WOO Windows of Opportunity

WTI Warfare Tactics Instructor

XO Executive Officer
131

9.7 VADM (Ret) Balisle Fleet Review Panel Summary and Recommendations

In support of this comprehensive review, the Navy provided an update on actions 

taken as a result of other reviews performed over the past eight years related to Navy 

readiness. The matrices in this enclosure supply the update for actions related to the 

2009 Fleet Review. The Review Team concludes the actions described herein have at 

least been partially effective in creating a lasting change. While many factors affect the 

ability to sustain improvements, including budgetary constraints and world events 

affecting the demand for Naval forces, this Review Team did not attempt to perform a 

more detailed review of the specific actions related to previous reports. Some findings 

and recommendations for improvement detailed in this report align with previous 

reviews.
Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

.3.2(a)-Implement a recurring, 

notional third party 

assessment, audit, and 

certification process integrated 

into the FRTP cycle as 

presented in Figure 3.3-5. See 

Section 5.2 of this report for a 

detailed explanation of a 

newer-term assessment 

process to quickly improve 

INSURV performance

Figure 3.3-5 is dated. FRTP (27-32 month) has been 

replaced by 36 month OFRP. CSG and ESG are the 

"readiness ISIC" referred to in the Balisle Report

The Balisle Report notes the number of failed 

INSURV inspections as a metric. The Board 

no longer provides Pass/Fail grading criteria, 

using instead IFOM as a more granular 

measurement. In order to conduct a better 

comparison to the metrics in the Balisle 

Report, the percentage of Satisfactory (>0.80) 

scores in INSURV Functional Area EOCs is a 

reasonable substitute. For the period FY2007 

to FY2010, only 55% of the nineteen (19) 

Functional Areas were graded as 

Satisfactory. For the period FY2011 to 

FY2016, 75% of Functional Areas were 

graded as Satisfactory 

-Results of third party assessments from 

FY2011 to FY2016 demonstrate that surface 

force material condition, as measured by 

INSURV Figure of Merit (IFOM), is essentially 

steady. IFOM is a number between 0.00 and 

1.00 generated by taking a weighted average 

of INSURV Functional Area Equipment 

Operational Capability (EOC) scores. Hull 

Structure assessment compliance. Simply 

put, INSURV audits whether or not class 

maintenance tasks and assessments are 

properly conducted and appropriately 

documented in accordance with established 

periodicities.

3.3.2(b)-Increase ATG 

manning to support their 

portion of recommended third 

party assessments. ATG 

manning is addressed 

separately in this report in 

Section 3.4 (Manpower and 

Training)

USFF established minimum ATG manning target of 

80% Fill

ATG Fill/Fit increased from 75% Fill in 2012 to 

84% Fill as of Sep 2017
133

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.3.2(c)-Use in-service 

engineering agent (ISEA) and 

multi-ship multi-option (MSMO) 

contractor assets to augment 

assessment teams. Use of 

MSMO in assessments 

including pre-INSURV 

assessments is also included 

in Section 5.2

ISEA and MSMO (Firm Fixed Pricing) requirements to 

supply the services of qualified on-site technical 

representatives and resources to accomplish Ship 

Assessments/Inspections have been added to the 

NAVSEA Standard Items

Continuous Maintenance Plan Task Backlog 

trend reflects an improving trend. A reduction 

from the highest level of approximately 6000 

backlogged tasks (January 2014) to 

approximately 2000 backlogged tasks 

(February 2017) has been recognized

3.3.2(d)-Increase CMAV 

funding to optimize work 

loading during these critical, 

dedicated maintenance 

periods

Balisle Report surmised that the Navy had been 

underfunding and understated requirement for many 

years:

Began fully recognizing ship maintenance 

requirements 

- 2010 - $200M in buy down of 2011 requirement 

- 2011 ~$400M in buy down of 2012 requirement) 

- ~$500M increase in ship maintenance funding from 

FY10 to FY12

Increased Programmed requirements 

Increased execution year growth 

Based on IFRR trend analysis from 2009 to 

2017: 

- While the percentage of on-cost availabilities 

shows a steady decline since 2011, the most 

recent availability data indicates this decline 

may have been arrested 

- As of November 2015, decline in onschedule availability completions appears to 

have bottomed out and the number of onschedule completions has risen since March 

2016

3.3.2(e)-Require certification of 

work completion for all 

availabilities: SURFMEPP for 

CNO availabilities and 

TYCOM/R-ISIC for CMAVs. 

Use availability completion 

certifications in concert with an 

expanded version of CNSF 

"redline" initiative

Per the JFFM REV C, CH-5, 3.6.8.1.2 (h), dated 11 

Aug 16, the NSA Chief Engineer must certify all work 

tied to the Availability Completion Key Event per the 

Availability Work Certification process

The JFFM REV C, CH-5, 3.6.8.1.2 (i), dated 11 Aug 

16, incorporates the requirement for Minimum 

Equipment (Redlines) to be met and maintained for 

all Mission Areas at the End of Maintenance Phase 

as part of Availability Work Certification and 

Completion Requirements

JFFM Requirements have been established 

to ensure availability completion certifications 

are used with redline requirements.
134

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.3.2(f)-Extend CNO 

Availability lengths as 

recommended by CNSF letter 

dtd 25 August 2009

As recommended by the CNSF letter dtd 25 AUG 

2009, the set restriction of 9 week pier and 12 week 

docking availabilities has been removed leading to 

increased availability time as reflected in the annual 

OPNAVNOTE 4700

Availability lengths vary today depending on 

Class Maintenance Plan (CMP) status. The 

lengths are generally set by the requirements 

in the SURFMEPP managed planning 

process

3.4.2(a)-Increase manpower of 

optimum manned ships and 

ATG immediately to 110% of 

current BA to compensate for 

the 8.4% perpetual loss of 

personnel

USFF advocated to restore end strength to ATG's 

and ships impacted by Optimal Manning shortfalls

Approximately 2200 End Strength restored to 

Optimal Manning shortfalls in POM-12 (DDG 

+1313, LHD +249, CG +375, LPD 17 +108, 

LSD 41 +168). Approximately 320 End 

Strength restored to ATGs in POM-12/ 13

3.4.2(b)-Initiate a study 

immediately to determine 

actual shipboard manning 

requirements based on 

"maintaining" the ship, in 

addition to watch standing and 

operational requirements. See 

more details and rough 

estimates in paragraph 3.4.1

NAVMAC's Fleet Manpower Requirements 

Determination (FMRD) model for developing Ship 

Manpower Documents (SMDs) has always included 

workload for "maintaining" the ship. The ship 

workload includes not only the Operational Manning 

(OM) (i.e. Watches), but Planned Maintenance (PM), 

Corrective Maintenance (CM), Facility Maintenance 

(FM), and the support/administrative workload 

assigned to the Own Unit Support (OUS) variable

NAVMAC continues to access and update 

Ship Manpower Documents on a periodic and 

regular basis. Additionally, OFRP has 

established manning requirements of 92% Fit 

and 95% Fill prior to beginning Basic Phase 

training

3.4.2(c)-Establish a 

coordinated Sea/Shore rotation 

strategy which provides 

targeted, career enhancing 

shore duty opportunities where 

craftsman's skills can be grown 

and developed. Leverage 

shore maintenance 

organizations, assessment 

teams, and advanced skills 

training staffs to size and 

shape technical skills 

capabilities across the Navy

USFF advocated for Investments in manpower at 

RMC's and other shore activities to provide warfighter 

support 

Investments in manpower at RMC's have 

increased military end strength by 1,188 since 

2010. Warfighting development centers were 

also implemented in 2014 that provided 

career enhancing opportunities across all 

warfare domains for enlisted personnel in 

operational and tactical expertise (Note: 

RMC Manning a topic at October FCRC)
135

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.4.2(d)-Approve and provide 

85% DNEC Fit 

requirement/Review Top Six 

Roll-Down criteria with surface 

technical ratings as first 

priority. Determine NEC 

attainment barriers (e.g. 

unrealistic rate requirement for 

attendance) and for each 

barrier, provide plan to 

mitigate. Include within the 

review the particular role and 

needs of ATGs

USFF Requested Review of Top Six Roll down. 

USFF directed Critical NEC (CNEC) thresholds in 

MCAF Directive 15-1 that correlated to the TYCOM 

DRRS-N requirements

Top Six Roll down reversed for earmarked 

supervisors at sea. Surface ship CNEC Fit 

increased from an average of 72% in 2012 to 

81% in Sep 2017. Additionally, OFRP has 

established manning requirements of 92% Fit 

and 95% Fill prior to beginning Basic Phase 

training
136

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.4.2(e)-Expand skills level 

training in the A schools or 

create an augmenting training 

capability and capacity on the 

waterfront to improve A school 

graduate repair expertise. 

Either approach must enhance 

Sailor initial skill sets to allow 

apprentice level Sailors to 

participate sooner in activities 

supporting material readiness

Since inception of the Surface and Expeditionary 

Warfare Training Committee in 2010, $280M has 

been invested in the restoration and modernization of 

Enlisted engineering training with the vast majority of 

investments targeting substantial improvements to 

Accession engineering training at Great Lakes and 

Journeyman-level maintenance training at both Great 

Lakes and at the Fleet Concentration Areas. To date 

(15 Sept 17), 45 new or substantially modernized 

engineering courses have been fielded with another 

75 in development or planning with scheduled 

delivery dates by 2019. Fielded training has been 

dramatically modernized by the infusion of virtual 

world technology balanced by hands-on, live skill 

application. The NAVSEA PMS-339 sponsored 

Technical Training Audit program (TTAP) has audited 

over 60 HM&E courses of instruction and with PMS339 resourcing has ensured current maintenance 

training matches current fleet systems configurations 

and remains technically accurate. Following the 

Balisle Report, NETC and its Learning Centers began 

an initiative to improve Accession Training by 

updating A and C school content and increasing the 

number of practical, lab-based learning objectives to 

achieve a better ratio of knowledge-based learning to 

performance-based learning. USFF N1 is 

coordinating with NETC to get specific actions and 

results at the individual learning centers over the 

2010-present time period in response to the Balisle 

Report. Additionally, the Navy has recently initiated 

RRL in order to modernize existing Enlisted 

Accession training; this process will eventually 

expand to journeyman and supervisory level training

Engineering maintenance training has been 

substantially improved. When engineering 

training was assessed in 2012, or 43 of 134 

existing courses of instruction or 32% fully 

met training objectives and fleet 

requirements. Today (Sep 17), with 21 new 

courses added, 88 of 155 courses of 

instruction or 58% now fully meet the 

mandated requirements. By 2020, the 

number will increase to 160 of 191 

engineering courses or 84%. In 2010, only 

one engineering course employed simulation 

to help deliver skill sets. Today, ALL 

engineering courses employ multiple virtual 

software applications / simulators. 88 HM&E 

systems have been modeled to date and 

employed predominantly in engineering 

maintenance training. Eight (8) new 

maintenance NECs have been added, 53 

have been substantially revised and updated, 

and 14 new NECs are in development / 

routing. In 2011, only 3,341 apprentice and 

journeyman level engineering billets out of 

7,706 or 43% had any formal training 

associated with the billet. By 2020, it is 

projected that there will be 6,081 apprentice 

and journeyman billets out of an expanded 

base of 9,468 billets or 64% with formal 

training, equating to having an additional 

2,740 engineers with formal training, a 82% 

increase from 2011 
137

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.5.2(a)-Conduct a 

comprehensive review of 

occupational standards for 

surface technical ratings to 

support improvement of 

apprentice level training

At the direction of NETC, SWOS conducted a 

comprehensive review of Surface Engineering 

Training Wholeness in 2011 assessing the 

effectiveness / robustness of the schoolhouse training 

for some 714 individual shipboard engineering billets 

in the Fleet followed by a comprehensive curriculum 

health assessment in 2012 focusing on some 134 

engineering courses of instruction. The results of 

both efforts informed the design and implementation 

of a comprehensive Surface Enlisted Engineering 

Training Restoration (and Modernization) Plan in 

2012. This plan informed some $280M in 

investments through the Surface and Expeditionary 

Warfare Training Committee (SEWTC) since POM-13

The analysis supported the design and 

implementation of a comprehensive plan and 

investment strategy to restore and modernize 

Enlisted Engineering training. To date, 

$280M have been invested by the SEWTC 

towards this effort

3.5.2(b)-Relocate more C 

schools to fleet concentration 

areas to provide additional 

opportunities for advanced 

skills development. This 

approach may require 

traditional lengthy C schools to 

be modularized for 

accomplishment in yearly 

increments and for delivery in 

fleet concentration areas

Of the 21 new courses of instruction fielded since 

2013, the vast majority of which were NEC producing 

C-Schools, 14 or 66% were established at the Fleet 

Concentration Areas. Of the 24 revised courses of 

instruction updated since 2013, again the majority of 

which were Fleet schools or NEC producing CSchools, 20 or 83% were established at the FCA

More training is slated to be fielded to the 

FCAs over the next few years as part of the 

comprehensive Surface Enlisted Engineering 

Training Restoration Plan

3.5.2(c)-Develop formal afloat 

technical training program. 

See also section 5.3

Self-Assessment Groom Training (SAGT) put in place 

to develop technical training. Additionally, CNSF 

developed the Continuous Training Instruction to 

ensure that ships have guidance for the development 

and implementation of a technical training program

CNSF has put the SFRM in place which 

incorporates the SFEM, TSRA, and RE 

manuals to improve technical training 

onboard the ship. Additionally, during the RE3 process, PQS tailoring is specifically 

reviewed to ensure ship technical training is in 

place
138

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.5.2(d)-Incorporate into all 

surface warfare officer training 

curricula a foundation and 

understanding of the material 

readiness standards of the 

surface force as developed in 

response to section 3.8

All SWO training curricula as well as all Enlisted 

Engineering training curricula provides a foundation 

and understanding of the material readiness 

standards of the surface force. Proper watch 

standing and procedural compliance are emphasized 

in all SWOS courses of instruction from Accession 

training through O-6 Major Command

BDOC, ADOC, and 3MU have been 

established with readiness standards 

incorporated into the COIs. Additionally, all 

other SWO courses have incorporated 

material readiness into the COIs. 

Additionally, Standard Ship Operating 

Procedures (SSOP) are tested in every COI

3.5.2 (e)-Concur with the 

restart of the SOSMRC course 

of instruction for prospective 

executive officer and 

prospective commanding 

officers. See also section 

5.4.1

SOSMRC has been restarted. Command 

Qualification Process modified, now includes 

engineering examination at SWOS as pre-requisite 

for command at sea

No assessment criteria or process has been 

established

3.5.2(f)-Move RMCs to the 

waterfront to improve 

intermediate level maintenance 

responsiveness and increase 

potential Sailor technical 

training opportunities

The physical location of the RMCs has not changed; 

however, the Navy Afloat Maintenance Training 

Strategy (NAMTS) program management 

responsibilities were transferred to CNRMC on 1 OCT 

2010 per CNRMCINST 4700.10, NAVY AFLOT 

MAINTENANCE TRAINING STRATEGY (NAMTS) 

PROGRAM in response to findings and 

recommendations.

- The NAMTS Program was established to improve 

battle group organic maintenance capability and 

material self- sufficiency. Sailor knowledge and 

proficiency in performing shipboard repairs are 

essential to these efforts. The NAMTS Program

provides formal shipboard systems and equipment 

repair training for Sailors assigned to intermediate 

and depot level maintenance activities and selected 

afloat commands

CNRMC has been monitoring MILPERS 

assignments/annual funding levels. CNRMC 

will update the FCRC in October on the 

proposed MILPERS cuts
139

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.6.2(a)-Interrupt the current 

downsizing of RMC Sailors 

now until the optimum mix of 

sea-shore rotation and ship 

repair needs can be 

determined. RMC manning 

estimates in section 3.4 of this 

report consider maintenance 

needs only and not those of 

sea-shore rotation

USFF advocated to halt downsizing of the RMC's and 

requested additional investments in manpower

RMC downsizing was halted and starting in 

2010, investments meant to improve seashore rotation were instituted. Since 2010, 

1,188 additional billets have been funded. 

3.6.2(b)-Establish core 

capabilities for each RMC 

similar to those in San Diego. 

These do not have to be 

identical and in fact, some 

differences will provide Sailors 

even more technical 

opportunities and experience 

on shore duty

RMC Core Capabilities are provided in Appendix A of 

COMUSFLTFORCOMINST 4790.3 REV C CH-2, 

VOL VI CH 35, REGIONAL MAINTENANCE 

CENTER I-LEVEL MAINTENANCE CAPABILITIES. 

Appendix A is the Capability Matrix and establishes 

the capabilities of each RMC (MARMC, SERMC, 

SWRMC, MWRMC, HRMC)

N/A

3.6.2 (c)-Shift control of RMCs 

to the surface Type 

Commanders

CNRMC was established 15 DEC 2010 as a NAVSEA 

managed activity

NAVSEA retains control of RMCs
140

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.6.2(d)-Establish common 

focus among RMCs to 

reinforce material readiness 

goals and training of Sailors, 

creating a culture of proactive 

maintenance and development 

of force-wide technical 

expertise

The establishment of a common focus among RMCs 

was provided in COMSUFLTFORCOMINST 4790.3 C 

CH-2, VOL VI CH 35. This chapter outlined the 

responsibilities of the Fleet Commanders, RMC 

Commanders, RMCs, and provided RMC 

Performance Measures.

-Additionally, the Navy Afloat Maintenance Training 

Strategy (NAMTS) program management 

responsibilities were transferred to CNRMC on 1 OCT 

2010 to create a common focus among RMCs and 

strengthen their ability to provide intermediate level 

maintenance support and selective maintenance 

training to surface ships, submarines, shore activities 

and other commands, per CNRMCINST 4700.10, 

NAVY AFLOT MAINTENANCE TRAINING 

STRATEGY (NAMTS) PROGRAM in response to 

findings and recommendations.

-The NAMTS Program was established to improve 

battle group organic maintenance capability and 

material self-sufficiency. Sailor knowledge and 

proficiency in performing shipboard repairs are 

essential to these efforts. The NAMTS Program 

provides formal shipboard systems and equipment 

repair training for Sailors assigned to intermediate 

and depot level maintenance activities and selected 

afloat commands

CNRMC has been monitoring MILPERS 

assignments/annual funding levels. CNRMC 

will update the FCRC in October on the 

proposed MILPERS cuts
141

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.6.2 (e)-Expand SSLCMA to a 

SURFMEPP organization 

mirroring SUBMEPP in 

responsibilities, resources, and 

authority. The accelerated 

plan proffered by SEA 21 in 

Appendix 012 is considered a 

great start but not considered 

comprehensive enough or fast 

enough

SSLCMA was expanded to a SURFMEPP 

organization mirroring SUBMEPP per NAVSEAINST 

5450.142B MISSION, FUNCTIONS AND TASKS OF 

THE SURFACE MAINTENANCE ENGINEERING 

PLANNING PROGRAM ACTIVITY, PORTSMOUTH, 

VIRGINIA dtd 17 AUG 2016

SURFMEPP provides centralized surface ship 

life cycle maintenance engineering, class 

maintenance and modernization planning and 

management of maintenance strategies 

aligned with and responsive to national, fleet, 

Surface Type Commander and Naval Sea 

Systems Command (NAVSEA) requirements 

and priorities

3.6.2(f)-Create from current 

waterfront manning resources 

a readiness ISIC

Material condition assessments are staffed through 

the CSG/ESG/TYCOM who has the responsibility of 

the R-ISIC and has the full authority to complete 

assessments in the form of Material Inspections 

performed through the FRP to assess ship's material 

and training readiness to ensure the ship is ready to 

meet mission requirements. 

Readiness Evaluations (READ-Es) are designed to 

assess a ship's readiness across the full spectrum of 

manning, material, and training, and to provide 

periodic feedback to the appropriate Immediate 

Superior in Command (ISIC) and Type Commander 

(TYCOM) per 

COMNAVSURFPAC/COMNAVSURFLANT 

INSTURCTION 3502.3, SURFACE FORCE 

READINESS MANUAL

N/A

3.7.2 (a)-Retain the SWE as a 

collaborative body but only so 

long as it does no encroach 

upon the chain of command

SWE utilizes RKC methodology to document and 

assess the health of current and readiness issues of 

each ship class annually. Inputs provided across the 

PESTONI readiness domain, including waterfront 

inputs

SWE develops: Future Warfighting Priorities 

to influence POM deliberations; Current 

Readiness Top Concerns, to focus PESTONI 

pillars' resource prioritization; and examines 

maintenance and modernization alignment 

with OFRP via Surface Master Plan, providing 

inputs to MOPP
142

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.7.2 (b)-Promulgate a clear 

message on standards 

promoting the importance of 

ownership and self-sufficiency. 

Near term: Rebalance ships' 

daily work routine to permit 

attaching the TA4 backlog 

(appendix 007) and improve 

damage control closure 

readiness to "Satisfactory" 

(appendix 010). The 

recognized initiatives to 

improve readiness will require 

more effort and more time on 

the part of our crews 

Back to Basics message, CNSF Warfighting serials, 

and Sound Shipboard Operating Principles (SSOP) 

have been promulgated to ensure standards are 

understood. Additionally, the RE-4, 5, 6, and 7 also 

assess self-assessment

Self-assessment scores have been increasing
143

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.8.2(a)The incongruence 

between the oft-stated need for 

resources and requirements at 

the shipboard level and the 

physical observations of ships' 

current workday suggests 

consideration should be given 

to daily work routine changes 

for accomplishing more ships 

maintenance

While no formal guidance has been promulgated 

providing guidance on daily work routines, work 

studies/assessments have been conducted to 

determine proper manning levels on ships and 

impacts to crew work hours, in particular, the impacts 

to crews when RRL is implemented and personnel 

are TDY attending training courses. Note that work 

routines are set by the individual unit based on 

requirements and priorities. Some actions have 

been taken to better focus ship activities: 

1. Reduction of administrative burden 

MESSAGE/initiative

2. Reinstituting the SOSMRC course

3. Total Ship's Readiness Assessment (TSRA) 

process 

4. In 2012 the Surface TYCOM revamped the 3-M 

certification process TYCOMINST 4790.1G

5. From a resource perspective, manning numbers 

continue to drop across the Force. High accession 

numbers in FY13 gave a temporary spike in Fleet 

manning, raising them to historical levels, but as 

those Sailors complete their sea tours and rotate to 

shore, manning will continue to decrease. There 

were 1,546 billet gaps at sea in MAR 2016, and that 

number increased to 6,592 gaps by MAR 2017. The 

numbers will continue to drop into 2018 and not start 

to improve again until sometime in 2019

Results of steps taken: 

1. More time for daily work routine

2. Leadership realigned on maintenance 

focus

3. Brought RMC experts to the ship to assist 

in materiel assessments

4. Added even more weight to the selfassessment and CSMP management scoring 

process 

- Although Enlisted Community Managers 

advertise being manned to 100% or higher 

across the majority of Navy ratings, a 

historical friction (LIMDU, Screening failures, 

Legal issues, etc) that averages around 15% 

causes sea duty to have a relatively high 

number of gapped billets in certain ratings
144

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.8.2(b)-Insert on the 

waterfront, a command and 

staff (nominally a readiness 

ISIC), responsible for 

communicating, inspecting, 

and maintaining material 

standards on the assigned 

ships. This staff should be 

accountable, responsible, and 

have the authority to fully 

complete these tasks

Material condition assessments are staffed through 

the CSG/ESG/TYCOM and have the full authority to 

complete assessments in the form of Material 

Inspections performed through the FRP to assess 

ship's material and training readiness to ensure the 

ship is ready to meet mission requirements per 

COMNAVSURFPAC/COMNAVSURFLANT 

INSTURCTION 3502.3, SURFACE FORCE 

READINESS MANUAL

Surface Force Readiness Manual Events:

-Engineering Readiness Assist Team (ERAT) 

- Subject Matter Experts conduct on-site 

assistance/training on identifying and 

correcting material/operational discrepancies

-INSURV Readiness Assist Team (IRAT) -

INSURV Preparations

-READ-E 2 - TYCOM-led assessment of 

material condition executed during the 

Sustainment Phase completed before the 

Maintenance Phase. Demonstrations are 

conducted during this period to identify any 

material condition degradations that occurred 

during the course of deployment and ensure 

that the ship maintains a constant focus on 

material assessments and standards

3.8.2(c)-Adjust the curricula of 

all A schools, C schools, and 

officer schools to include a 

clear and unequivocal 

message on standards, 

ownership, and self-sufficiency

Back to Basics message, CNSF Warfighting serials, 

and Sound Shipboard Operating Principles (SSOP) 

have been promulgated to ensure standards are 

understood. All SWO training curricula as well as all 

Enlisted Engineering training curricula includes a 

clear and unequivocal message on standards, 

ownership, and self-sufficiency. Proper watch 

standing and procedural compliance are emphasized 

in all SWOS courses of instruction from Accession 

training through O-6 Major Command

All curricula enforce and re-enforce standard 

of ownership. SSOPs are tested in all COIs

3.8.2(d)-Use the proposed 2 

FRTP cycle assessment 

proposal recommended in 

Section 3.3 to reinforce the 

new standards at all levels of 

ships assessed

OFRP established in 2014 and surface force following 

OFRP FRTP guidelines based on Master OFRP 

Production Plan

Recommendation superseded by OFRP
145

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.8.2(e)-Expand the current 

CNSF readiness initiative to 

quantify and qualify the new 

message on standards where 

compliance is critical to safety, 

life and operations. Consider 

completion redlines and formal 

certification for CMAVs 

(TYCOM), CNO availabilities 

(SURFMEPP) and readiness 

for sea (TYCOM)

SFTM replaced with SFRM, SFEM, TSRA Manual 

and Readiness Evaluation Manual. SFRM defined 

exit criterion across all PESTO pillars in each phase 

of OFRP (MP, BP, IP, SP) to ensure readiness for 

transition to next phase. SSOP, focused on 6 

standard operating procedures and PBED process, 

developed, promulgated to all schoolhouse for 

curriculum use, and issued to all CNSF Sailors for 

implementation and training. SSOP taught and 

tested in SWOS and CSCS COIs

SFRM defined rigor in training, material 

readiness, and assessment processes well 

beyond SFTM. SFEM, established a 

repeatable and predictable training process to 

ensure all ship's establish baseline level of 

knowledge and proficiency (Note: SFRM 

published in 2012 prior to OFRP 

implementation/execution)

3.8.2(f)-Include in 

assessments, inspections, 

audits, and certifications by 

third party teams a formal 

review of ship compliance with 

established new standards. 

The R-ISIC should be the 

Chief Assessor for each 

activity and oversee this review

The CSG/ESG/TYCOM has the responsibilities of the 

R-ISIC. To ensure readiness for scheduled 

deployments, external assessments and inspections 

through the TYCOM will validate proficiency and 

satisfactory material condition as the ship progresses 

through the FRTP per 

COMNAVSURFPAC/COMNAVSURFLANT 

INSTRUCTION 3502.3, SURFACE FORCE 

READINESS MANUAL

N/A
146

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.8.2(g)-Initiate a review to 

determine means of reducing 

TYCOM fluctuating execution 

year maintenance funding for 

surface ships. The inquiry 

should include the related 

costs associated with late 

planning or late cancellation of 

maintenance

The following steps have been implemented: 

1. Revised CMAV Milestone in JFMM (interim 

guidance published Oct 2017) 

2. Improve Understanding of Ship's Material 

Condition and CSMP Quality (COMNAVSURFOR 

CSMP BEST PRACTICES MESSAGE R 192145Z 

JUL)

3. Front Load Reservation Task Requests (RTR) on 

known HM&E work items that are prone to growth as 

a standard practice for planning/funding CNO avails

4. Transition to Firm-Fixed Price Contracting

5. CNSL/P expanded Maintenance University to 

enhanced deck plate training and CNO Availability 

Planning and Execution Briefs for every ship

Continuous Maintenance Availabilities are 

allowing work to be planned and screened to 

support availabilities in a timely fashion. 

CMAV milestones revision will be signed and 

published in Oct 2017. 

- Improved CSMP quality will allow more 

accurate work specifications which in turn 

reduces the need for costly rework and 

improves the availability planning process

- Reduces RCC cycle time by front loading 

work that can be initiated without time 

consuming process of contract changes

- Has reduced the amount awarded for CNO 

availabilities but has also shifted much of the 

schedule, performance responsibility from the 

Gov't to the Contractors

- Maintenance University focuses on 

maintenance management and incorporates 

many of the issues addressed in the report at 

all levels of SWOS from DIVO to Major 

Command

3.9.2(a,b)-Fund corrosion 

control audits and ABS 

surveys to the fullest extent 

possible in order to accelerate 

identification of the deep 

maintenance requirement

Per COMUSFLTFORCOMINST 4790.3 REV C, CH-5, 

3.5.1.2.1, dated 11 AUG 2016, The Corrosion 

Planning Conference: SUFMEPP, TYCOM 

representatives, RMC, CNRMC, Ship Repair Facility 

(Japan only) and Ship's Project Team, reviews 

current FRP cycle corrosion requirements. Per 

NAVSEAINST 5450.142B corrosion control is part of 

SURFMEPP mission functions and tasks

Example: In FY11 only approximately 60% of 

the tanks in the Fleet had reliable data in the 

Corrosion Control Information Management 

System. Through aggressive and disciplined 

execution of surveys and repairs the Fleet 

has increased the know conditions of tanks to 

98%. Corrosion control process status is an 

element of the quarterly SURFMEPP briefs to 

FFC N43
147

Recommendations Steps/Actions taken (e.g. policies implemented, 

signed instructions, etc.)

Results and/or impacts of steps/actions 

taken (where applicable)

3.9.2(c)-Increase CMAV 

planning window to decrease 

premium time costs and 

improve maintenance 

accomplishment

Planning requirements are established in JFMM REV 

C CH-5 VOL II CH 2 dated 11 AUG 2016

No assessment criteria has been established

3.9.2(d)-Define and fully fund 

continuous maintenance and 

depot maintenance 

requirements

Depot Maintenance requirements are defined using 

Technical Foundations Papers as a baseline. Ship 

Sheets are used to updated requirements for deferred 

or unanticipated work per NAVSEAINST A36 and 

OPNAV LTR 4700 SER N83/137005. However, 

OPNAV N83 continues to validate the requirement at 

some level less than 100% based on several factors 

such as ship class and remaining service life. Note: 

Balisle Report surmised that the Navy had been 

underfunding and understated requirement for many 

years:

We began fully recognizing ship maintenance 

requirements: 

- 2010 - $200M in buy down of 2011 requirement 

- 2011 ~$400M in buy down of 2012 requirement 

~$500M increase in ship maintenance funding from 

FY10 to FY12

- Increased Programmed requirements 

- Increased execution year growth 

Note: DON-19 ship depot maintenance funding 

between 97% to 100% of requirement across the 

FYDP

SURFMEPP's Class Maintenance Plans are 

adjusted as more data on the effects of partial 

funding is gained. The hidden costs are in 

growth in avail costs and longer term ESL 

affects. These hidden costs are coming to 

light as SURFMEPP's processes mature. We 

also have to note that the unpredictability of 

funding, given we have been operating under 

CRs, is also a contributing factor in properly 

funding maintenance execution
9.8 Government Accountability Office and the Center for Naval Analyses Reports 

and Summary of Actions

In support of this comprehensive review, the Navy provided an update on actions 

taken as a result of other reviews performed over the past eight years related to Navy 

readiness. The matrices in this enclosure supply the update for actions related to 

various reports issued by the Government Accountability Office and Center for Naval 

Analyses (CNA). The Review Team concludes the actions described herein have not 

been fully effective in creating a lasting change. While many factors affect the ability to 

sustain improvements, including budgetary constraints and world events affecting the 

demand for Naval forces, this Review Team did not attempt to perform a more detailed 

review of the specific actions related to previous reports. Some findings and 

recommendations for improvement detailed in this report align with previous reviews.
Report/Study Overview Recommendations Actions taken

Report 1: Improved 

strategic planning 

needed to ensure 

that Navy depots 

can meet future 

maintenance 

requirements (GAO 

report-June 2010)

Report provides an 

assessment of the 

Navy's 2007 Depot 

Maintenance 

Strategic Plan. 

GAO assessed the 

strategic plan by 

looking at:

(1) elements of a 

results-oriented 

management 

framework 

(2) OSD's direction 

for the plan's 

content

Recommend SECDEF direct 

SECNAV to take the following 

actions: 

1. Fully and explicitly address 

all elements needed for a 

comprehensive resultsoriented management 

framework, including those 

elements that we have 

identified as partially 

addressed or not addressing 

the current plan 

2. Demonstrate clear linkages 

among plans should the Navy 

continue to submit individual 

depot maintenance strategic 

plans instead of a single Navywide plan 

3. Fully and explicitly address 

the four critical areas of 

logistics transformation, core 

logistics capability assurance, 

workforce revitalization, and 

capital investment, consistent 

with OUSD (AT&L) criteria 

4. Develop and implement 

procedures to review revisions 

of the depot maintenance 

strategic plan to ensure they 

fully address all key elements 

of a results-oriented 

management framework, 

explicitly address an OUSD 

(AT&L) direction for the plans, 

and periodically assess 

progress and corrective 

Assistant Secretary of Defense noted: Navy will be 

directed to be more results-oriented in their next 

depot maintenance strategic plan and be required 

to more clearly demonstrate the linkages of their 

depot maintenance strategy to DOD's depot 

maintenance strategic plan 

GAO's four recommendations:

1. Fully and explicitly address all elements needed for 

a comprehensive results-oriented management 

framework, including those elements that we have 

identified as partially addressed or not addressed in the

current plan:

 * Current status: GAO -10-585 caused the Navy to 

write the comprehensive Depot Strategic Plan that was 

issued in October 2013. While this Plan reflects 

several of the elements of a comprehensive resultsoriented management framework, there is no specific 

mention of the intent to use that methodology in 

preparation of the Report

2. Demonstrate clear linkages among plans should the 

Navy continue to submit individual depot maintenance 

strategic plans instead of a single Navy-wide plan:

 * From Page 9 of the United States Navy Depot 

Maintenance Strategic Plan (Oct 2013): OPNAV N4 

and N9, NAVSEA , NAVAIR), COMFRC, SPAWAR, 

NAVFAC, NAVSUP, and the warfare enterprises (i.e., 

USE, NAE, SWE, and NECE) are listed as 

stakeholders in the Plan

3. Fully and explicitly address the four critical areas of 

logistics transformation, core logistics capability 

assurance, workforce revitalization, and capital 

investment, consistent with OUSD (AT&L) criteria. 

DoD's Response in the Report: The department 

concurred with GAO's recommendation to direct 

SECNAV to revise the Navy’s depot maintenance 

strategic plan to fully and explicitly address all 
150

Report/Study Overview Recommendations Actions taken

actions to the extent needed in 

meeting the plans' goals 

elements needed for a comprehensive results-oriented 

management framework:

 * From Page 11 specifically and throughout the 

United States Navy Depot Maintenance Strategic Plan 

(Oct 2013): The Navy Depot Maintenance Strategic 

Plan is structured on the DoD depot maintenance 

strategic elements: 

 - Logistics transformation 

 - Core logistics capability assurance

 - Workforce revitalization 

 - Capital investment

4., Develop and implement procedures to review 

revisions of the depot maintenance strategic plan to 

ensure they fully address all key elements of a resultsoriented management framework, explicitly address 

any OUSD (AT&L) direction for the plans, and 

periodically assess progress and corrective actions to 

the extent needed in meeting the plans’ goals:

 * Current status: There have been no efforts made 

to revise the October 2013 Strategic Plan since it was 

issued, and hence no need to develop and implement 

procedures to address the elements of a resultsoriented management framework

Report 2: Analyzing 

the Individual Level 

Training Continuum 

within the Surface 

Force: A 

Framework (CNA 

report-April 2011)

Policy decisions 

made outside of 

Navy training 

enterprise severely 

impact the ability of 

Navy to properly 

train to perform 

expected missions. 

To address this 

issue CNA 

developed a 

theoretical 

framework for the 

Refine and focus data 

collection analysis to provide 

information on training 

progression against desired 

proficiency, effectiveness and 

system utilization: 

1. Formalize and standardize 

OJT and grading criteria 

2. Improve tie between 

qualification and training 

3. Train the trainers of OJT 

4. Increase waterfront training 

presence to enable more 

PMS 339 (Surface Training Systems) conducts data 

collection (from current sources) and analysis to 

support the effectiveness of Navy schoolhouses and 

Self-Assessment Groom and Training (SAGT). 

1. CNSF developed the Continuous Training Instruction 

(CNSP/L 1500.1) to ensure that ships have guidance 

for the development and implementation of a technical 

training program. Lesson Topic Guides on ship and in 

each division. Shipboard trainers tailor training to the 

specific audience, to include the proficiency in the topic

2. READ-E (Readiness Evaluation) 3 reviews PQS 

program. New Continuous Training Instruction requires 

LOK Quizzes based on Divisional Training, but those 
151

Report/Study Overview Recommendations Actions taken

training continuum 

to analyze and 

mitigate the 

possible impacts of 

policy decisions 

impacting Navy 

training

hands on training and align 

training equipment to the 

systems in use

do not follow the Sailor to assess an individual Sailor's 

career-spanning level of knowledge

3. As part of Basic Phase, ATG trains the trainers and 

the Sailors. SBTT, recently reinstated, resurrected 

emphasis on training the training teams.

4. ATG, CSCS, NSMWDC, CSG-4, and TYCOM 

onboard throughout OFRP to train ships. SAGTs 

provide Sailors with direct training on their shipboard 

systems. Gives the Sailors skills to train:

 - ATG manning increased significantly after Balisle 

Report

 - Enable more hands on training with systems in 

use 

 - Establishment of NSMWDC specifically funded 

training and trainers to improve ships for integrated 

training

 - Increased number of billets at Intermediate-Level 

Maintenance facilities has led to Sailors being better 

educated in the systems to then train as part of ship's 

company

Report 3: Navy 

Needs to Assess 

Risks to Its Strategy 

to Improve Ship 

Readiness (GAO 

report-September 

2012)

Assessed: 

1. How Navy 

evaluates material 

readiness of its 

surface combatant 

and amphibious 

warfare ships and 

the extent to which 

data indicate trends 

or patterns in 

material readiness 

of these ships 

2. Extent to which 

Navy has taken 

steps to improve 

readiness of its 

Recommend SECDEF direct 

SECNAV to take the following 

actions: 

1. Develop a comprehensive 

assessment of the risks Navy 

faces in implementing its 

Surface Force Readiness 

Manual strategy, and 

alternatives to mitigate risks. 

Specifically, a comprehensive 

risk assessment should 

include an assessment of risks 

such as high operational 

tempos and availability of 

personnel 

2. Use the results of this 

Under Secretary of Defense responded that: 

1. Comprehensive risk assessment associated 

with implementation of Navy's Surface Force

Readiness strategy is neither necessary nor 

desirable 

2. Navy's existing assessment processes are 

sufficient to enable necessary adjustments to their 

Surface Force Readiness strategy 

* Concur with USD Assessment. Since the inception of 

the Surface Force Readiness Strategy the Navy has

adapted and expanded its assessment processes. The 

following actions have been taken since 2011-2012 

with the publication of the Surface Force Readiness 

Manual (SFRM):

 - TSRA (Total Ship Readiness Assessment) 

Alignment. Instituted to execute shipboard 
152

Report/Study Overview Recommendations Actions taken

surface combatant 

and amphibious 

warfare ships, 

including 

implementing its 

new readiness 

strategy

assessment to make any 

necessary adjustments to its 

implementation plan

assessments to improve current readiness and assist 

with maintenance availability planning via an over-theshoulder approach to training ships force maintenance 

personnel

 - Readiness Evaluations (READ-E). Designed to 

assess a ship's readiness across manning, materiel, 

and training, and to provide periodic feedback to ISICs 

and TYCOM. READ-Es (1-7) provide assessments at 

different phases of the ships OFRP 

Report 4: Navy 

Training Whitespace 

Limitations (CNA 

report- June 2013)

CNA undertook a 

small-scoped effort 

to understand if and 

why Naval 

personnel are 

facing whitespace 

limitations. The 

study established 

whitespace 

constraints for both 

officer and enlisted 

personnel, 

identifying “day job” 

responsibilities, 

manpower policies 

and equipment 

deficiencies as 

possible causal 

factors

Thorough study of regularly 

recurring job and operational 

requirements during interdeployment period with 

particular emphasis on 

whether the time burden of 

these requirements is tied to 

ship variables like ship age or 

condition, fit/fill of personnel or 

inter-deployment length

* This is a NAVMAC function and has already been 

implemented. The SNWW was adjusted about 2 years 

ago and they have begun conducting in-port workload 

studies by Class. DDG 51 Class was the first and that 

study has not been released as of yet

Report 5: 

Sustainable Plan 

and Comprehensive 

Assessment Needed 

to Mitigate LongTerm Risks to Ships 

Assigned to 

Overseas 

Addresses:

(1) the operational 

benefits, costs, and 

readiness effects 

associated with 

assigning ships to 

U.S. or overseas 

homeports and; 

Recommend SECNAV take 

the following actions:

1. To fully implement its 

optimized fleet response plan, 

develop and implement a 

sustainable operational 

schedule for all ships based

overseas

ASN-RDA memo dated 18 May 2015:

1. Navy implementing OFRP for all FDNF forces 

(schedule piece)

2. Navy will conduct assessment of long-term 

costs and risks of overseas homeporting and 

incorporate into future homeporting decisions 

* OFRP implemented as the operational framework 

delivering rotational and FDNF units and strike groups 
153

Report/Study Overview Recommendations Actions taken

Homeports 

(GAO report-May 

2015)

(2) the extent to 

which the Navy has 

identified and 

mitigated risks from 

homeporting ships 

overseas

2. Develop a comprehensive 

assessment of the long-term 

costs and risks to the Navy’s 

surface and amphibious fleet 

associated with its increasing 

reliance on overseas 

homeporting to meet presence 

requirements, make any 

necessary adjustments to its 

overseas presence based on 

this assessment, and reassess 

these risks when making 

future overseas homeporting 

decisions and developing 

future strategic laydown plans

to fulfill GFMAP commitments, while continuing to 

provide surge capability. OFRP improves the fleet’s 

readiness generation process by providing a balanced, 

sustainable, and predictable force generation cycle –

maximizing force employability. The resulting 

readiness generation cycle operationally and 

administratively aligns forces while stabilizing manning, 

optimizing maintenance/modernization, consolidating 

and streamlining inspections and evaluations, training 

to a single high-end standard, and improving and 

enhancing Quality of Service for our Sailors. Also in 

2014, C7F, C6F, & C5F in coordination with the 

applicable TYCOMs, (CNSP and CNSL) developed 

and implemented a sustainable OFRP model (e.g., 

operational schedule) for all ships based overseas. 

FDNF OFRP cycle lengths vary across the Navy and 

provide a balance between maintenance and 

modernization, training requirements, and operational 

availability. 

 - FDNF Japan based ships execute a 24 month 

cycle

 - FDNF Europe ships execute a 32-month cycle 

 - FDNF Bahrain PCs execute a 36 month cycle and 

MCMs execute a 24 months cycle 

* Although FDNF units are continuously deployed and 

therefore operate in a perpetual sustainment phase, 

required inspections, certifications, assist visits, and 

personnel, equipment, supply, training, and ordnance 

readiness requirements are conducted on a repetitive 

schedule throughout their cycle (e.g., a sustainable 

operational schedule) to ensure proficiency and 

readiness for forward deployed operations does not 

atrophy. The Navy’s established and enduring 

Strategic Laydown and Dispersal (SLD) process 

provides strategic rationale, guidance, and direction to 

approve and implement individual homeport, home 
154

Report/Study Overview Recommendations Actions taken

base, and hub shifts, to include forward deployed 

forces 

* SECNAV, based on recommendations from the CNO, 

disperses CONUS and FDNF units of the Navy’s 

operating forces to worldwide locations in a deliberate 

manner that directly supports DoD guidance and 

policy. The annual SLD plan is CNO’s expression of 

DoD guidance and policy, as well as Navy-specific 

guidance. This plan forecasts 10 years for the purpose 

of PPBE unit moves, and presents for approval the 

projected homeports, home bases, and hubs of the 

Navy’s operating forces and staffs for a 5-year period. 

The SLD process consists of two major phases: a 

design phase followed by an assessment phase. The 

design and assessment phases are aligned to support 

and inform the Navy’s POM submission, provide CNO 

a comprehensive plan for approval, and precede the 

Congressional testimony of senior Navy leadership

* OPNAV N46 is responsible for assessing the annual 

SLD plan. OPNAV N46 leads a cross-functional 

working group that determines SLD plan execution; 

recommends program changes, adjustments to its 

overseas presence, or mitigations; assesses 

responsibilities to organize, man, train, maintain, equip, 

and sustain naval forces to meet combatant 

commander and NCC warfighting capability and 

operational readiness requirements. OPNAV N4 will 

subsequently recommend to the CNO mitigations for 

any impacts caused by operational, support, and 

readiness factors to include submission of planning 

and programming input to the PPBE process. Upon 

the conclusion of the assessment phase, OPNAV N4 

coordinates with OPNAV N3/N5 to produce a 

comprehensive SLD plan for briefing to CNO and 

SECNAV, highlighting key findings and actions for 

decision and approval
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Report/Study Overview Recommendations Actions taken

Report 6: Progress 

and Challenges in 

Implementing the 

Navy's Optimized 

Fleet Response Plan 

(GAO report-May 

2016)

Review matters 

related to the Navy 

Optimized Fleet 

Response Plan. 

Report describes: 

(1) the extent of 

maintenance 

overruns and their 

impact on the Navy; 

(2) the Navy’s goals 

and progress in 

implementing the 

OFRP; and (3) 

challenges faced by 

public and private 

shipyards 

supporting the 

implementation of 

OFRP

No recommendations madefor information only 

(challenges identified)

* Fleet understands that maintenance delays impact 

the entire OFRP cycle and reduce overall force 

employability. More specifically, maintenance 

delays/overruns impact the unit's ability to effectively 

complete its FRTP and deploy with sufficient "reps and 

sets" to meet high-end standards. Providing sufficient 

and predictable ship maintenance funding, increasing 

the number of shipyard workers, improving shipyard 

infrastructure and training programs, and 

improvements in maintenance planning will improve 

shipyard performance overtime and reduce the number 

of maintenance overruns 

* USFFC and OPNAV N4 advocacy for aviation spares 

funding (APN-6) has resulted in improved funding 

posture through the FYDP (FY19-23). APN-6 is funded 

at 89% (BAM-19 BLIII) through the FYDP, which is 

above the 85% minimum threshold required to prevent 

backlog growth. Current APN-6 backlog is [NM: $32M / 

NA: $421M] down from [NM: $82M / NA: $586M] one 

year prior. USFFC continues to advocate for maritime 

spares outfitting funding (OPN-8); funding trends 

indicate OPN-8 will remain well below the minimum 

85% threshold; sitting at 69% through the FYDP 

(FY19-23). Current OPN-8 backlog sits at [NM: $33M / 

NA: $33M] which constitutes a significant increase from 

one year prior [NM: $8M / NA: $28M]. Absent 

additional OPN-8 funding, USFFC urges the 

prioritization of the 'outfitting' accounts over 'interim' 

within the OPN-8 program; 'outfitting' maintains high 

execution rates and fills storeroom 'holes; on inservices ships. USFFC, in conjunction with OPNAV N4 

and NAVSUP also recommend funding the change to 

the price-sensitive FLSIP COSAL model to improve 

maritime spares posture and resiliency at reasonable 

cost 

* Delayed Maintenance Days are reported quarterly in 
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Report/Study Overview Recommendations Actions taken

the IFRR. This metric is showing a performance 

improvement (decreasing trend) in FY17 when 

compared with FYs 14 - 16. The three CVN 

availabilities completed at the Naval Shipyards in 2017 

were on time or early. This measurement is part of a 

larger process of measuring CSG OFRP schedule 

compliance as each CSG completes an OFRP cycle. 

Specific to Growth and New Work (G/NW) in the 

shipyards, ensuring Surface Ships reach their 

Expected Service Life is being addressed under 

processes implemented at SURFMEPP over the last 

several years. As these processes mature, we expect 

that Growth and/or New Work percentages to decline. 

However, uncertain budgeting processes 

(Sequestration and Continuing Resolutions in 

particular) lead to deferred maintenance actions that 

become G/NW in subsequent availabilities. Navy and 

private shipyard officials agree that the personnel 

security protocols, procedures, and policy issues 

affecting contractor personnel performing ship 

maintenance has improved and are no longer a major 

concern

* Hiring challenges: Currently civilian hiring is taking a 

hit for backlogs and getting quality candidates to fill 

jobs. OPM/DOD/SECNAV have provided many 

flexibilities for hiring with Direct Hire Authority however 

due to current OCHR manpower shortages, it is difficult 

at best to get the jobs filled. On average it is taking 

four months to get an assessment initiated to begin 

preparation for announcing vacancies. This is 

systemic OCHR wide and in some ways a result of the MHA requirements for which OCHR had to take a 

major hit. Until HR is able to move forward with hiring, 

this challenge will continue. Recommend SECNAV 

provide authorization and funding for additional hires 

within the HR community
157

Report/Study Overview Recommendations Actions taken

Report 7: Surface 

TYCOM 

Organizational 

Analysis

(CNA report- July 

2016)

Study provides 

insight into the 

current command 

structure, and 

provides options to 

improve the ability 

of CNSF, CNSP 

and CNSL to meet 

assigned missions 

and responsibilities 

to effectively man, 

train, and equip the 

surface force. CNA 

focuses on three 

issues: 

1) re-examination of 

the status of the 

lead/follow concept 

2) effectiveness of 

executive agents 

acting on their 

TYCOMs behalf at 

locations outside 

Fleet concentration 

areas 

3) a case study of 

forces based in 

Bahrain

1. CNSF should take steps to 

increase the overlap of the 

SWE with the TYCOMs by 

setting the agenda for the 

SWE

2. Identify specific objectives 

for desired capabilities or 

processes to allow further 

analysis of reorganization 

options to mitigate disruptive 

effects in manning, training 

and equipping to meet these 

options

3. Define the changes to 

TYCOM man, train and equip 

processes brought by OFRP 

implementation. Consider the 

roles of EA and supporting 

commands

* CNSF sets the agenda/focus of the SWE based on 

Fleet Commander priorities. Studies are ongoing (BSO 

60/70, CNIC/NAVFAC, etc.) to examine how changing 

organizational alignments could improve both mission 

effectiveness and our overall efficiency of operations. 

Regarding TYCOM OFRP implementation, a significant 

change was establishing increased manning 

requirements (92% Fit and 95% Fill) for our units as 

they enter basic phase training. This has increased the 

stress on our ability to man our platforms given 

distributable inventory shortfalls. Another aspect, 

which was also present under FRP, is ensuring 

maintenance/modernization performance is improved 

so units can execute their planned FRTPs and not be 

faced with compressed pre-deployment training

Report 8: 

Optimized Fleet 

Response Plan 

Implementation 

Issues (CNA report–

Feb 2017)

Study provides and 

assessment of the 

achievability and 

longevity of OFRP 

implementation with 

focus on three 

major areas: 

1) Maintenance and 

1. Pursue a common 

dashboard for the OFRP 

scheduling process, building 

on the Surface Master Plan 

and the Master Aviation Plan 

2. Study the robustness of 

OFRP in meeting emergent 

demands for additional forces 

* Fleet Training Continuum and OFRP instructions are 

under review / revision. Both of these Fleet-wide policy 

documents delineate Fleet training (e.g., high-end) and 

establish notional training durations. The Fleet-wide 

revision for both of these instructions incorporates 

changes that will ensure Navy forces have adequate 

time and resources to execute high-end training. For 

example, USFF / CPF expanded notional training 
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Report/Study Overview Recommendations Actions taken

scheduling 

2) Manning 

3) Training 

3. Train an additional 6600 

personnel in NECs needed to 

meet OFRP NEC targets 

4. Increase VAW and VFA 

manning by approximately 150 

personnel – train 

approximately 340 additional 

personnel in core VAW and 

VFA NECs 

5. Incorporate and regularly 

test CNA planning framework 

to ensure rapid, standardized 

mitigation of unplanned 

schedule changes 

6. Targeted NMETL, 

CBTRM,SFRM and SFEM 

revisions to reflect high-end 

training standards and 

adequate resourcing for 

expanding training 

entitlements 

7. Further analysis of optimal 

means to maintain CSG 

integrity and meet desired 

deployment dates at a high 

level of proficiency

durations for CSG training in order to execute the 

recently established Advanced Phase. In the 

Advanced phase, WDCs conduct advanced tactical 

training in all warfighting required operating 

capabilities. The recently established SWATT is an 

example. Included in the Fleet Training Continuum 

revision is the Fleet-wide LVC Training Capability 

Policy Statement which states that an integrated live, 

virtual, constructive training capability will be used to 

train Navy forces to high-end threat conditions. The 

focus is on live training augmented by virtual and / or 

constructive where necessary and appropriate without 

detracting from the Fleet Synthetic Training (FST) 

program. As examples, this includes adding virtual / 

constructive effects to COMPTUEX as well as 

maintaining the FST family of exercises while allowing 

those programs to change over time to accommodate 

new technologies and new realities. Once the Fleetwide policy documents (e.g., FTC, OFRP) are 

promulgated, subordinate policy documents (e.g., 

CVTRM, SFRM, and SFEM) will be revised to reflect 

higher level guidance. It would be premature to update 

these subordinate policy documents until higher-level 

guidance is promulgated. The Fleet Training 

Continuum directs TYCOMs to conduct review of 

NMETLs annually and update as required to ensure 

inclusion of mission essential tasks, near-peer 

conditions, and high-end performance standards 

required for mission success 

* USFF leads the OFRP CFT in coordination with CPF 

that generates a common dashboard, the Master 

OFRP Plan (MOPP) for CSG/CRUDES, ARG, SSN, 

MPRA, NECC, MSC and LCS that covers 9 years into 

the future. The MOPP incorporates inputs from the 

Surface and Aviation Master Plans which includes 

force schedules, analysis of schedules/employment, 
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Report/Study Overview Recommendations Actions taken

force updates (assumptions, limiting factors, and 

environment), force PESTO review and commanders 

recommendations. The process provides cross 

community participation to ensure OFRP lessons 

learned are shared across the fleet. USFF also 

implemented a Strike Group Baseline Configuration 

Change Plan (BCCP) to improve coordination and 

planning for future Strike Group deployment planning 

based on planned equipment/systems for future 

deployments.

* Under OFRP, all units train to a high end 

performance standard for all required operational 

capabilities, resulting in all units deploying certified to 

conduct full scale operations. OFRP maximizes 

periods of employability for sustainment, deployments 

and surge capacity providing a more robust force 

available to respond. As OFRP achieves steady state 

with steady predictable schedules, more ships will be 

available for emergent response 

* To attain OFRP NEC Fit targets Fleet-wide, we 

recommend that the Navy train an additional 6,600 

personnel in the appropriate NECs. More specifically, 

in order to simultaneously man five CSGs at OFRP 

manning levels, thereby supporting OPNAV Ao and 

OFRP LOE 9, we recommend that the Navy increase 

VAW and VFA manning by approximately 150 

personnel. In doing so, it should focus specifically on 

Chief Petty Officer manning and core maintenance 

ratings. In addition, to meet this Ao target, we 

recommend that the Navy train roughly 340 additional 

personnel in core VAW and VFA NECs

* Prior to OFRP, training and certification of 

independent deployers was based on planned 

deployment instead of a full range of missions to 

support the high end, near peer. Once deployed, these 

units could be reassigned to other mission areas that 
160

Report/Study Overview Recommendations Actions taken

were not certified. Under OFRP, training and 

certification of independent deployers are assigned to 

and train with carrier strike groups to the full range of 

missions. By training to the high end performance 

standards for all required operational capabilities, a 

ready force is provided to Combatant Commanders to 

mitigate unplanned schedule changes

* Strike Group schedules are optimized to align the 

required maintenance periods of CVN, CRUDES and 

aircraft. Strike Group composition is adjusted when 

one or more of these units do not align with the CVN 

maintenance periods. Aligning the maintenance, 

training and employment provides the best CSG 

integrity at a high level of proficiency

Report 9: Actions 

Needed to Ensure 

Proper Size and 

Composition of Ship 

Crews (GAO report 

– May 2017)

In 2001, the Navy 

began reducing 

crew sizes on 

surface ships 

through an initiative 

called optimal 

manning, which was 

intended to achieve 

workload 

efficiencies and 

reduce personnel 

costs. In 2010, the 

Navy concluded 

that this initiative 

had adversely 

affected ship 

readiness and 

began restoring 

crew sizes on its 

ships. This report 

examines (1) any 

trends in ship 

Conduct a comprehensive 

reassessment of the Navy 

standard workweek and make 

any necessary adjustments:

1. Update guidance to require 

examination of in-port 

workload and identify the 

manpower necessary to 

execute in-port workload for all 

surface ship classes;

2. Develop criteria and update 

guidance for reassessing the 

factors used to calculate 

manpower requirements 

periodically or when conditions 

change; and

3. Identify personnel needs 

and costs associated with the 

planned larger Navy fleet size, 

including consideration of the 

updated manpower factors 

and requirements

* This is a NAVMAC function and has already been 

implemented. The SNWW was adjusted ~ 2 years ago 

and they have begun conducting in-port workload 

studies by Class. DDG 51 Class was the first and 

study has not been released
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Report/Study Overview Recommendations Actions taken

operating and 

support costs and 

maintenance 

backlogs, (2) the 

extent to which the 

Navy’s manpower 

requirements 

process accounts 

for ship workload, 

and (3) any 

manning challenges 

and implications for 

the future
9.9 History of Surface Warfare Officer School

Evolution of Division Officer Training

From Ensign (O1) through Lieutenant (O3)

Chronology of major events in Division Officer Training:

1970: 6-week pilot course, known as the Surface Warfare Officer Basic Training, stood 

up at the Naval Destroyer School in Newport RI.

1974: SWO Basic Training expanded and renamed the Surface Warfare Officer

Division Officer Course or “SWOSDOC”; second course formally stood at SWOSPAC 

Coronado, CA. 

1975: SWOSDOC increased to 16 weeks in length. Naval Destroyer School renamed 

to the Surface Warfare Officers School Command (SWOSCOLCOM). Ship handling 

and navigation training provided through two 8-hour underway sessions on yard patrol 

craft (YPs) until 1993.

1993: SWOSPAC Coronado dis-established as part of BRAC; all SWOSDOC courses 

consolidated in Newport, RI.

2003: 16-week formal division officer training (SWOSDOC) dis-established and training 

shifted to the fleet. Accession officers sent directly to their ships and given the entirety 

of the SWOSDOC curriculum on a set of compact disks to be learned aboard the ship 

(“SWOS in a Box”). After approximately 1 year aboard ship, Ensigns required to return 

to SWOS Newport for a 3-week course (Advanced Ship handling and Tactics course 

/ASAT), as a pre-requisite for final SWO qualification. ASAT focused heavily on ship 

handling training - Conning Officer Virtual Environment (COVE) simulator / instructorfacilitated.

2008: SWOS in a Box recognized as inadequate to properly prepare accession officers. 

COMNAVSURFOR directed the creation of a 3-week Surface Warfare Introduction 

(SWO Intro) course at Afloat Training Groups San Diego and Norfolk and at SWOS 

Newport.

2012: SWO Intro and ASAT dis-established and replaced with an 8-week Basic Division 

Officer Course (BDOC) at SWOS Newport. Approx. 100 hours out of the total 320 hour 

course dedicated to Navigation, Seamanship and Ship handling (NSS) including 24 

hours in the COVE I simulators. 

2014: 4-week Advanced Division Officer Course (ADOC) established for Division 

Officers headed to their Second Division Officer Tours. Training includes 54-hours of 

additional NSS material including approximately 24 hours in the COVE simulators. The 

stand-up of ADOC marked the re-establishment of a critical formal schoolhouse 

continuum for Division Officers since 2003.
163

2016: BDOC expanded to 9 weeks and ADOC expanded to 5 weeks. The expansion of 

both courses included additional NSS training.
164

Division Officer Courses Defined: 

The Basic Division Officer Course (BDOC) is an intensive, 9-week course of 

instruction delivered in the Norfolk and San Diego fleet concentration areas and 

designed to provide foundational classroom training, augmented by hands-on training 

(ship handling simulators, practical application, ship visits, etc.) to prospective surface 

warfare officers. The course places emphasis on in-class instruction and the use of 

technology such as the Conning Officer Virtual Environment (COVE) simulators, which 

simulate every class of ship in the U.S. Navy and all their homeports, in addition to 

many routine ports of call around the world. COVE allows for the reinforcement of 

concepts in navigation, seamanship, and ship handling. The course also provides 

instruction on division officer fundamentals, maritime warfare, engineering, leadership, 

and damage control. BDOC training facilities in Norfolk and San Diego have been 

equipped with state-of-the-art electronic classrooms and ship handling simulators to 

deliver the required training. The course has an annual throughput of 800 to 900 

officers.

BDOC provides 81 hours of classroom instruction on Navigation Seamanship and Ship 

handling (NSS) topics plus 32 hours of COVE simulator training. Note: By November 

2017, additional training will be implemented including 1 hour of classroom instruction 

on Bridge-to-Bridge communications plus 2 hours of practice in the COVE simulator, 

and 6.5 hours of classroom training on ARPA plus an additional 4.5 hours of practice in 

the COVE simulator, bringing the total to 88.5 hours of classroom instruction and 37.5 

hours of COVE simulation for a total of 126 hours of NSS training. 

The Advanced Division Officer Course (ADOC) is an intensive, 5-week course of 

instruction in Newport, RI that is designed to reinforce and build on the core concepts 

introduced in the Basic Division Officer Course by pairing them with fleet experience 

through practical application, simulation, and discussion. This course advances the 

knowledge of the student through 200 hours of intensive professional military training. 

The objective of ADOC is to prepare juniors officers to effectively perform as a “Fleet 

Lieutenant”; a consummate special evolutions Officer of the Deck, expert trainer of 

watch standers “under instruction”, and an Officer ready to undertake qualification in 

advanced warfare and engineering watch stations. The course has an annual 

throughput of 800 to 900 officers.

ADOC provides 37 hours of NSS classroom instruction and 31 hours of COVE 

simulation training for a total of 68 hours of NSS training.
165

Evolution of LCS Training

Ship handling and Bridge training for LCS: 

In 2007 a 6-week Littoral Combat Ship Officer of the Deck (LCS OOD) course and an 8-

week LCS Junior Officer of the Deck (LCS JOOD) course were established at SWOS 

Newport using COVE simulators designed to the specific LCS-1 and LCS-2 Bridge

configurations. Training courses remain the same in 2017. 

In addition to ship handling and navigation training for the LCS class, SWOS also 

provides engineering training. Since 2009, SWOS has provided Readiness Control 

Officer (RCO/EOOW) training to prospective engineering officers assigned to LCS class 

ships. The training is delivered through the use of the Virtual Maintenance Performance 

Aid (VMPA) which enables the student to step away from the RCO console and move 

about the ship via the use of an avatar. 

In December 2016, SWOS fielded the 26-week Engineering Plant Technician (EPT) 

course for both LCS-1 and LCS-2 class ships. This course of instruction uses an 

Immersive Virtual Shipboard Environment (IVSE) to provide prospective EPTs detailed 

instruction on LCS engineering systems, operating procedures, and casualty control 

procedures. 

The first EPT student completed the entire course in 13 weeks. Feedback from the fleet 

on EPT graduates has been extremely positive. An updated RCO course, using the 

IVSE technology, and an engineering team trainer (ETT) is also under development with 

scheduled implementation in FY-18. EPT, RCO, and ETT courses also provide rapid 

refresh for LCS crews. 
166

Evolution of Department Head Training

From Lieutenant (O3) through Lieutenant Commander (O4)

Chronology of major changes to Department Head Training:

1961: The Naval Destroyer School established at Newport, RI; new program designed 

to train prospective destroyer department heads to perform in challenging at-sea billets. 

Course subsequently expanded to 24 weeks. 

1975: Various surface warfare officer courses of instruction, including SWOSDOC, DH, 

PXO, and PCO, consolidated under a single command known as the Surface Warfare 

Officers School Command (SWOSCOLCOM, but referred to as “SWOS”)

2013: As part of the Surface Warfare Command Qualification Process, a command 

assessment for post 1st tour Department Heads established at Newport.

2016: Department Head training pipeline realigned with other non SWOS delivered 

Department Head pipeline training courses. 

Note: Since its inception in 1961, the Department Head Course has remained a 

cornerstone and flagship training program for the Surface Warfare Officer community. 

Over the past 56 years, course length has remained relatively stable, averaging 24 to 

27 weeks in length.

Department Head Course Defined:

The Surface Warfare Officer Department Head Course is a highly intensive 27 week 

course of instruction taught at SWOS Newport. The course provides students the 

training needed to go on and fill Department Head assignments aboard Surface ships 

as an Operations Officer, Chief Engineer, Weapons Officer, Combat Systems Officer, 

Plans and Tactics Officer or as a First LT aboard amphibious ships. The course is 

broken down into four distinct segments: (1) 12 weeks of Maritime Warfare Training 

which prepares students to stand the Tactical Action Officer (TAO) watch, (2) 3 weeks 

of navigation, seamanship, and ship handling training in the classroom and in the COVE 

simulators to refresh and reinforce mariner skills, (3) 5 weeks of Command 

Management that focuses on leadership, training, administration, and safety, and (4) 

approximately 6 to 8 weeks of billet specific training. The course has an annual 

throughput of 250 to 300 officers.

During the Department Head course, students are provided 24.5 hours of NSS 

classroom instruction and 24 hours of COVE simulation training in addition of 40 hours 

of Bridge resource management (BRM) training for a total of 88.5 hours of NSS training.
167

Evolution of Senior Officer Training

From Lieutenant Commander (O4) through Captain (O6)

Chronology of Major Changes to Senior Officer Training:

1967: Prospective Executive Officer (PXO) and Prospective Commanding Officer 

(PCO) courses of instruction stood up at the Naval Destroyer School in Newport, RI.

1976: Based on concerns with the material condition of the fleet, the Senior Officer Ship 

Material Readiness Course (SOSMRC) stood up in Idaho Falls, ID as part of PCO 

pipeline training. Training included a dedicated week underway aboard ship to reinforce 

classroom training.

1987: Major Command Course (MCO) stood up. 

1996: SOSMRC program dis-established and the majority of the material readiness 

curriculum incorporated into the expanded PCO course. 

2000: PCO course consolidated to 8 weeks plus a 1 week ship ride; PXO course 

consolidated to 6 weeks. In addition, following a number of at sea mishaps, a 5-day 

Bridge Resource Management course developed at Marine Safety International 

implemented for PCO training. The course shifted to SWOS Newport in 2005.

2009: In preparation for the SWO XO / CO Fleet Up, the PXO course is dis-established 

and the course material is incorporated into the new 9-week XO / CO Fleet Up course in 

Newport.

2010: Based on concerns with fleet material readiness expressed in the Balisle report, 

SOSMRC re-established at SWOS Newport as a stand-alone 5-week course of 

instruction which included a 1 week ship ride / ship visit capstone event. As before, 

attendance at SOSMRC preceded attendance of PCO. XO / CO Special Mission 

course of instruction stood up.

2012: At the direction of the SOSMRC Board of Visitors in February, the XO / CO 

Special Mission course changed to the C5I / CVN AUXO course at the direction.

2013: 13-week Surface Commanders Course (SCC) stood up combining SOSMRC 

with XO / CO Fleet up into a single integrated course of instruction. Additionally, as part 

of the Surface Warfare Command Qualification Process, a command assessment 

implemented for all post 1st tour Department Heads.

2016: As part of the 18-3-18 program, a 2-week PCO course stood up for officers in 

between completing their tours at XO and before taking command. SCC course is 

reduced to 10-weeks. Focus of the new PCO course: warfighting, leadership, and 

command management. 
168

Senior Officer Training Courses Defined:

The 10-week Surface Commanders Course (SCC) focuses Prospective Executive and 

Commanding Officers on the tactical, operational, navigation, seamanship, 

shiphandling, material readiness, and command management skills necessary to excel 

in command. The curricula culls the best practices from actual waterfront experiences, 

case studies, subject matter experts, and post-command mentoring sessions to identify 

where fleet leadership has encountered and overcome obstacles to better planning, 

training, and execution of operational tasking. Embedded within the Surface 

Commanders Course is the Senior Officer Shipboard Material Readiness Course 

(SOSMRC), which provides students the necessary background and tools to assess, 

monitor and improve ship material readiness. The course has an annual throughput of 

approximately 120 Officers. 

During SCC, students are provided 29 hours of NSS classroom instruction and 24 hours 

of COVE simulation training in addition to 40 hours of BRM training for a total of 93 

hours of NSS training.

The Prospective Commanding Officers (PCO) Course is a transitional course which 

provides an enhanced tailored professional development opportunity as officer’s 

transition from XO to CO afloat. This course currently provides PCO’s with 2 weeks of 

tailored training focusing on advanced management, leadership and tactical 

development. The curricula is developed from the best practices from actual waterfront 

experiences, case studies, subject matter experts and post-command mentoring 

sessions to identify where the fleet leadership has encountered and overcome 

obstacles to better planning, training, and execution of operational tasking. CY16 

throughput - 17 (course pilot/start up) with up to 100 anticipated in CY17 (all O-5 / O-4 

fleet up officers - 10 convenings)

The Major Command Course (MCO) is designed to prepare prospective Major 

Commanders, all of whom have had previous command, with the tactical, operational, 

material management, navigation, seamanship and ship handling skills necessary to 

excel in major and follow-on sequential command tours. The Major Command course of 

instruction also contains tailored training based on the student’s experience and 

ultimate billet and is reinforced through interactive lectures, seminars, simulators, case 

studies and group discussion with subject matter experts. The MCO course also 

addresses CSG/ARG warfare commander responsibilities and as well as Immediate 

Senior in Command (ISIC) responsibilities. CY16 throughput – 44. CY17 Planned –

around 50 students (5 convenings). 

During MCO, students are provided 31 hours of NSS classroom instruction and 20 

hours of COVE simulation training for a total of 51 hours of NSS training.
169

Evolution of Ship Handling and Navigation Training

Pre-2002: Ship handling training provided to 400 Department Head, PXO, PCO, and 

MCO students through a contract with Marine Safety International (MSI) annually. 

Individuals received training in notionally three 4-hours sessions with 2-3 other officers. 

2000: At the request of SWOS, Marine Safety International developed a 5-day Bridge 

Resource Management (BRM) course of instruction for all PCO students. 

2003: With support from the Office of Naval Research (ONR) and the Naval Air Warfare 

Center Training Systems Division (NAWCTSD) Orlando, SWOS developed an organic 

ship handling training capability called the Conning Officer Virtual Environment (COVE) 

and the following year ship handling training for DH, PXO, PCO, and MCO students 

shifted from Marine Safety International to SWOS. Amount of ship handling training 

increased from approximately 12 hours to 24 hours.

2005: The 5-day BRM course shifted from MSI to SWOS. Note: In 2011, the SWOS 

BRM course was certified (5-year certification) by the U. S. Coast Guard.

2007: 6-week Littoral Combat Ship Officer of the Deck (LCS OOD) course and an 8-

week LCS Junior Officer of the Deck (LCS JOOD) course established at SWOS 

Newport using COVE simulators designed to the specific LCS-1 and LCS-2 Bridge

configurations. 

2010: OPNAV N96 and COMNAVSURFOR-sponsored Surface and Expeditionary 

Warfare Training Committee established to better align available resources to Surface 

training requirements. SWOS assigned as the Navigation Mission Area Chair (MAC). 

First SEWTC-approved Surface and Expeditionary Warfare Training Plan (SEWTP) 

(POM-13) includes over $30M in navigation improvements to include additional COVE 

simulators for SWOS, VMS trainers, LCS trainers, Navigation Systems Technician 

training, and sustainment for the BDOC COVE simulators.

2011: In the wake of the PORT ROYAL grounding off Hawaii, a 4-week Surface 

Navigator (SURFNAV) course stood up at Newport for all Surface Navigators. Course 

later increased to 5 weeks. New course focused on traditional paper chart plotting as 

the foundation for understanding and operating electronic navigation, but also contained 

over a week of dedicated voyage management system training. Course also restored 

celestial navigation training. Additionally, the SWOS BRM course was certified by 

USCG (5-year certification).

2012: As part of CNO’s Navigation Senior Steering Group (SSG), a comprehensive 

Surface Navigation Training and Manpower Review conducted by SWOS to identify 

shortfalls in officer and enlisted navigation training. 

2013: Wholeness Review results published in 2013, reviewed at the 2013 Navigation, 

Seamanship and Ship handling Board of Visitors (BoV), and subsequently briefed to the 

four-star Fleet Commanders Readiness Council (FCRC) for endorsement. SWOS 

recommendations included (1) rebuilding the Quartermaster training continuum, (2) 

substantially revising QM A-School, creating journeyman level C-School and master-
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level QM training, (3) establishing QM NECs, standardizing navigation accession 

training across USNA, NROTC, and OTC, (4) providing navigation training for non-QM 

ratings, and other improvements. $27.1M in POM-16 investment approved by the 

SEWTC to resource SWOS-recommended improvements in addition to establishing 

COVE training in Bahrain and Rota for forward deployed forces. OPNAV N96 (Admiral 

Rowden) directed $800K in execution year funding to accelerate the delivery of the 

SWOS POM-16 improvements. BRM course recertified (5 year certification) due to 

turnover of personnel. 

2014: SWOS assumed responsibility for all Quartermaster (QM) training. At the time, 

the QM training continuum consisted of 8-weeks of QM A-School in Great Lakes with 

follow on VMS training in the fleet concentration areas (FCA) and the 2-week Senior 

QM Refresher course, also taught in the FCAs. There was no NEC producing 

journeyman level or master level training at that time. In 2015, SWOS established the 

0202 NEC producing, 5-week Assistant Navigator course in Newport for all prospective 

ANAVs and in 2016 established the 0203 NEC producing, 3-week QM Journeyman 

course (C-School) in the FCAs. The first 0203 Journeyman-level NEC was awarded in 

2017.

QMs graduating A-School are VMS trained in the Fleet Concentration Areas (Norfolk, 

San Diego) either before or shortly after reporting aboard ship. Training is conducted 

with same version of VMS existing on their ship. When a ship is upgraded to a newer 

version of VMS, the installation vendor provides onsite “difference training” between the 

old and new systems if within the same version (e.g. 9.3 to 9.4). If the ship is upgraded 

from version 8 to 9 for example, the QM must complete the full VMS course on the new 

system. 

2016: COVE III simulators fielded in Newport, RI and at (1) Bath, ME, (2) Pascagoula, 

MS, (3) Rota, Spain, and (4) Bahrain to support PRECOM as well as Forward deployed 

ship handling and navigation training. Navigation SAGT established for PC and MCM 

class ships in Bahrain. 

2017: Preparations for the May 2017 Navigation, Seamanship, and Ship handling 

Board of Visitors (BoV) conducted by SWOS and CSCS in San Diego, Norfolk, Mayport, 

Pearl Harbor, Everett, Sasebo, and Yokosuka fleet concentration areas to solicit direct 

feedback from the Fleet and the waterfront and to identify shortfalls in NSS training. 

Some 110 individual issues were identified, reviewed and vetted by an Advisory Board 

of O-6 representatives, and 19 major issues were subsequently briefed to the Surface 

Community flag leadership for further action. The BRM course 5-year recertification 

was recently approved in October 2017. The certification is good until 2023.
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Seamanship and Shiphandling Simulators Defined:

The Surface Force employs two types of ship handling simulator architectures: (1) The 

Conning Officer Virtual Environment (COVE) simulators employed by SWOS at the 

various SWOS learning sites, by SWOS and CSCS at Littoral Combat Ship Training 

Facilities (LTF), and by the Naval Service Training Command (NSTC) at several 

NROTC units, and (2) the Navigation Seamanship and Ship handling Trainers (NSST) 

employed by COMNAVSURFOR and COMNAVSURFLANT at the FCAs for shipboard 

individual and team training. 

Conning Officer Virtual Environment (COVE) simulator provide state of the art 

navigation and ship handling training for all of our Surface Officers. Trainers emulate 

every U.S. Navy homeports in addition to almost every routine port of call around the 

world. There are two types of COVE stations.

COVE I stations are used primarily for BDOC and 

ADOC students. These stations consist of a 

virtual reality (VR) helmet that gives them a 360-

degree view of their surroundings. Using a state 

of the art voice recognition system, students can 

give commands to the virtual helmsman, which 

are repeated back by the computer. SWOS 

employs 36 x COVE I stations across the 

domain: 9 at BDOC Norfolk, 9 at BDOC San 

Diego, and 18 at SWOS Newport. NSTC 

operates 10 x COVE I stations at various NROTC sites to include Old Dominion 

University, Boston University, Jacksonville University, and San Diego State College.

COVE 3 stations have the same functionality as 

the COVE I stations except they are viewed on 

three 50-inch displays to allow the student a wider 

field of view. The COVE 3 stations are primarily 

used by our Surface Navigator, Department 

Head, Surface Command Course, PCO and 

Major Command students. SWOS operates 8 x 

COVE 3 stations in Newport. There are four 

additional COVE 3 stations in use: 1 in Bath, 1 in 

Pascagoula, 1 in Rota, and 1 in Bahrain.

Full Mission Bridge simulates every Navy 

homeport and regular ports the Navy visits 

around the world, providing the student with a 

360 degree realistic virtual environment. Various 

students train in the Full Mission Bridge from 

newly commissioned Ensigns through Captains. 

Department Head students practice Anti-
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Terrorism and Force Protection (AT/FP) tactics using the full mission Bridge and like the 

Prospective Commanding Officer and Prospective Executive Officer (PCO/PXO) 

students along with Major Command students practice Bridge Resource Management 

(BRM). The Full Mission Bridge can simulate all naval surface platforms, which allows 

almost every student that comes through SWOS to train, through simulation, on the 

actual ship they will be serving on. To view more pictures please click on the thumbnails 

below. There are two FMBs at SWOS Newport.

The Littoral Combat Ship Full Mission Bridge

is a full sized trainer that students with orders to 

LCS ships can train on in preparation of reporting 

to their new command. Using the same software 

as FMB and COVE, the LCS trainer has every 

Navy homeport modeled and allows LCS student 

to navigate in and out of designated ports using 

the highly sophisticated controls of a real LCS. 

The LCS Bridge trainers are installed at SWOS 

Newport and at the Mayport and San Diego LTFs

Navigation Seamanship and Ship handling Trainers (NSST) provide a shore-based 

ship handling training for individuals and watch team training in all of the FCAs and are 

operated at the direction of the Surface Type Commanders. Two major NSST variants 

were fielded: the v1.0 for individual training, which was primarily designed for shipboard 

use but the program was subsequently discontinued and the v2.0 for team training 

ashore. The first shore-based simulators were fielded in Yokosuka and Sasebo, Japan, 

and at the U. S. Naval Academy in 2004. The first NSST v1.0 was fielded aboard ship in 

2006. By 01 May 2011, there were 84 NSST v1.0 trainers installed aboard FFG, DDG, 

and CG class ships (and at FCA shore sites), ten (10) NSST v2.0 simulators were 

installed at facilities in the seven FCAs (Norfolk, San Diego, Mayport, Everett, Pearl 

Harbor, Yokosuka, and Sasebo) and the U. S. Naval Academy in addition to two Bridge

wing simulators (BWS) – one each in Norfolk and San Diego – and two RHIB simulators 

– one each in Coronado and Little Creek.
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9.10 Classified Appendix

This classified appendix provides supplemental details to Chapter 6.