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PROFESSIONALISM
Training
MSI, Norfolk VA
07 DEC 00
The Grounding of
USS LA MOURE
COUNTY
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PROFESSIONALISM
Overview
• LMC participating in UNITAS 41-00
• While operating with Chilean navy ships Valdivia and
Galvarino, LMC was preparing to conduct an
amphibious assault at Caleta Cifuncho, Chile
• While proceeding to anchorage/marine debarkation
point, LMC ran hard aground along rocky shoreline
• LMC suffered significant hull and running gear damage,
flooding in several spaces, and spilled fuel spill IVO
Caleta Cifuncho
• LMC was aground for approx 98 minutes until towed
off rocks by GAL
References
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PROFESSIONALISM
• NAVSEA PMS470 initial estimate repair cost
• OPNAVINST 5100.19C NAVOSH Program Manual for Forces
Afloat
• Preliminary environmental impact report from NOAA office of
response and restoration
• OPNAVINST 3500.39, (ORM)
• CNSL/CNSP/SNAL/CNAP INST 3530.4A (NAVDORM)
• LMC Standing Orders, Navigation Standards, CIC Doctrine,
Restricted Maneuvering Doctrine
• NSTM 079, Vol 1 (DC, Stability and Buoyancy)
• NSTM 079, Vol 2 (Practical DC)
• WRN-6 Tech Manual
• LMC CART II Assessment Report
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PROFESSIONALISM
Background
• Time and date of mishap: 0517 (local), 12SEP00
• Geographic location: Caleta Cifuncho, Chile (25-37.1s, 070-38.8w)
• Weather conditions:
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Visibility: 10 nm, no moonlight, slight coastal mist
Temp: 60O F
Winds: 180-200t, 18-22 kts
Precipitation/lightning: none
Seas: 5-7 ft
Current: negligible flood
Tide: low at 0253, high at 0813
Sea state and direction: 2, from SW
• Ship's employment: underway, participating in UNITAS 41-00
Chilean Phase
Location
IQUIQUE
Caleta Cifuncho
CALDERA
PUERTO ALDEA
VALPARAISO
TALCAHUANO
PUNTA ARENAS
Location
Antofagasta
Caleta Cifuncho
(Cifuncho Bay)
Town of Cifuncho
(Population 42)
Coquimbo /
La Serena
The Capital city of
the middle of
freakin’ nowhere.
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PROFESSIONALISM
Timeline Background
• At UNITAS amphib planning meeting in Iquique, Chile, LMC and
Chilean Navy personnel modified amphib plan to launch AAV’s
from anchorage, requiring LMC to anchor one hour earlier (0530Q)
than original schedule to meet amphib timeline
• LMC used NIMA chart 22225 and Chilean chart 206 for transit to
intended anchorage. 22225 is WGS 84 compatible for use with
GPS. Chart 206 is not WGS 84 compatible. LMC personnel were
unaware that certain charts were not compatible with GPS. Lack of
knowledge of GPS capabilities/ limitations, over-reliance on GPS
as single source of determining ship's position, and loss of
situational awareness were the principle factors in LMC's
grounding.
A Recipe for Disaster
Actual Track History
Intended Track
(Uncorrected)
Intended Track
(Corrected)
GPS Chart Error:
191@1800 yds
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PROFESSIONALISM
Timeline: 11SEP00
• 1500: NAV Brief. Not attended by 6 of 15 positions including:
OOD, Conning Officer, Piloting Officer, and Shipping
Officer/senior OS. There is no discussion of making CIC primary
plot due to lack of visual nav aids. ORM was not briefed.
• 1630: CO signs sea and anchor watchbill, posted on LAN at 1645.
Several personnel do not realize they are assigned to watchbill until
late that night.
• 2200: Night orders direct LMC to loiter throughout the night, then
proceed to anchorage, setting Nav detail 0430, and S+A detail at
0445.
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PROFESSIONALISM
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Timeline: 12SEP00 (1)
0247: 1st lt assumes deck
0309: BM1 takes conn
0430: Station navigation detail
0430: Nav on bridge. Plotting on chart 22225 with WRN-6. Nav
observes RADAR video is not very clear.
• 0430: BM1’s relief never arrives on bridge
• 0430: CO, on bridge, notes fuzzy land edge on RADAR. Leading
QM1 tells CO radar not cutting. CIC personnel indicated that radar
picture was clear. CIC did not note any instance of poor RADAR
performance. Technicians for SPS-64 and SPS-67 never called to
troubleshoot either bridge radar.
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PROFESSIONALISM
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Timeline: 12SEP00 (2)
0445: OOD directs conning officer to follow Nav's
recommendations unless specifically told not to. This is conning
officer's first watch in restricted waters.
0445: Station S+A detail
0450: XO bridge
0456: OPS assumes watch as CICWO
0500: CO observes coastline obscured by fog. Distance to coastline
approx 2000 yds. Cannot correlate coast view to ship's track. Ship
appears parallel to coast. S+A detail stations report manned and
ready. 11 positions had been changed without CO's authorization.
Manned and ready checklist was not complete at time report given
to CO.
0500 Bridge shifts to chart 206. After first GPS fix on bridge, CIC
shift charts.
Chilean Chart 206
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PROFESSIONALISM
Timeline: 12SEP00 (3)
• 0500: First position 600 yds left of track, 2300 yds from nearest
shoal water
• 0501: CICWO goes to signal bridge, recognizes LMC visually far
left of track. CICWO returns to CIC to confirm observations based
on CIC's plot.
• 0507: GPS Fix in CIC 600 yds left of track. Piloting officer
attempts to obtain radar fix, but misidentifies radar reference
points. As result, radar fix does not cut.
• 0507: CIC recommends course 180 via 21MC. No action taken by
bridge team. CIC does not give reason for recommendation.
• 0508: CICWO comes to bridge to compare fixes and confirm left of
track. CICWO confirms fixes, but is not overly concerned because
“there is plenty of time to maneuver to starboard and regain track.”
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PROFESSIONALISM
Timeline: 12SEP00 (4)
• 0509: XO moves to bridgewing. Using NOD, observes close rocky
coastline. Recognizes nod has no 3-D capability.
• 0509: OOD asks navigator for report. Navigator has no updated
information.
• 0510: CO notes junior QM1 not on station. CO questions who
authorized him not being on station. QMSN goes below to awaken
him.
• 0511: XO approaches CO and voices concern that shoreline looks
awfully close in NOD. Recommends coming right to open
distance, just to be safe. CO acknowledges recommendation. XO
believes that ship is going to come right.
• 0512: XO questions JA phone talker and learns CIC has no fix
• 0513: CIC has no fix
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PROFESSIONALISM
Timeline: 12SEP00 (5)
• 0513: Coastline on beam, approx 1000 yds. CO directs XO to
supervise nav team.
• 0513: OOD checks bridgewings and sees nothing, returns to bridge.
• 0513: XO questions NAV to determine ship's course. Based on
response, XO believes ship is coming right. Nav recalls saying ship
could come right to intercept track, but Nav recommends
maintaining course 150. Ship does not alter course.
• 0514: CIC reports no fix, recommends bare steerageway. Nav notes
recommendation, recommends maintaining course and speed. CO
hears report from CIC and navigator's response.
• 0514: OOD checks RADAR, notes proximity to land, recommends
slowing. CO concurs.
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PROFESSIONALISM
Timeline: 12SEP00 (6)
• 0515: CICWS/Shipping Officer comes to bridge, directs Nav's
attention to situation, recommends coming right to 220. (several
conflicting statements)
• 0515: CIC recommends 200. OOD directs Conn to follow Nav's
recommendations because bridge plot is primary nav plot.
• 0516: CIC recommends 200. Unknown if recommendation was
acknowledged.
• 0516: Ordered speed change from 9 knots to 3 knots
• 0516: OOD urgently calls CO to port bridgewing. Rocks jutting
out from coast less than 200 yds dead ahead. CO orders "all back
full, all back full emergency." Speed over ground 9-10 knots
• 0516: CICWO comes to bridge, sees co ordering all back full,
returns to CIC. RADAR display shows ship between 2 fingers of
land. Ship misses first protrusion of rocks
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PROFESSIONALISM
Timeline: 12SEP00 (7)
• 0516: CO/OOD order right full rudder, then hard right rudder to
open distance from rocks
• 0517: Loss of steerageway. Rudder amidships. To check swing of
stern into rocks, XO orders all ahead full, left full rudder. CO/XO
believe ship is past danger.
• 0517: Main control hears loud unusual noise along hull
• 0517: Second protrusion of rocks appears forward of bow
• 0517: LMC hard aground IVO Punta Artigas. Series of engine and
rudder commands ordered to keep stern clear of rocks and avoid
broaching. Wave action pounds LMC on rocks.
• 0521: Forward fuel tanks crushed by rocks below, forcing fuel up
vent piping on focsle
• 0526: Flooding and ruptured fuel line in ATB. Space is evacuated.
General Quarters sounded soon thereafter.
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PROFESSIONALISM
Post-Grounding Timeline (1)
• 0530: Stern anchor let go to prevent stern from swinging into rocks
and broaching ship
• 0533: Flooding in MOGAS pump room.
• 0534: 1/2 to 1" water on deck in weight room.
• 0535: Chilean naval officer onboard LMC requests assistance from
Chilean ocean-going tug, Galvarino
• 0544: Repair 3 combating flooding in weight room
• 0545: 12" fuel on deck and level rising in ATB
• 0545: Flooding in FTB
• 0550: GAL standing by LMC stbd quarter
• 0555: 2 ft of fuel/water in ATB. 6" rupture in port ATB deck. Box
patch rigged and de-watering with a portable eductor begins. Level
of fuel on deck restricts patching team efforts.
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PROFESSIONALISM
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Post-Grounding Timeline (2)
0559: MOGAS pump room flooded solid, heavy fuel smell
0559: Flooding in ballast and fuel tanks
0620: Soundings are rising throughout forward part of ship
0628: LMC gives GAL permission to pass towing hawser
0635: Stern anchor dragging
0640: Rudder actuator in port aft steering punches through deck.
Hydraulic oil leak in port after steering gear room.
0640: I-type shoring on aft manhole cover in weight room complete
0640: Shot line received from GAL to stern of LMC, GAL takes
strain on towing hawser
0643: Sunrise. LMC begins moving off rocks
0647: De-watering of MOGAS pump room with portable eductors
begins
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PROFESSIONALISM
Post-Grounding Timeline (3)
• 0651: Level in ballast tank rising. De-ballasting of
ballast tank with installed ballast pumps begins.
• 0655 LMC floats free of rocks
• 0657 Secure de-ballasting of ballast tanks:
ineffective.
• 0748 Anchored in Cifuncho Bay
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PROFESSIONALISM
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Damage
Keel severed and deformed between frames 101-120 (40 feet)
Damaged port CPP, missing one blade
Damaged stbd CPP, missing one blade
Damaged port and stbd OD boxes
Damaged port and stbd struts and underwater shafting
Damaged port and stbd stern tube seals
Damaged port and stbd rudders to extent that entire assemblies
must be replaced
• Damaged stbd rudder to extent that entire assembly must be
replaced
• Damaged port steering gear
• Potentially damaged bow thruster
TOTAL
PROFESSIONALISM
Damage (cont’d)
• MOGAS pump room flooded solid with fuel/water mixture,
requiring replacement of all equipment and electrical/electronic
components in space
• Damaged deck and racks in aft troop berthing (ATB), requiring
replacement
• Stress crack in ATB fan room
• 2 holes (1/2" each) in fwd troop berthing (FTB) fan room deck
• Flooded fwd CHT pump room, requiring replacement of 2 CHT
pump motors, 4 controllers, lighting, alarm fixtures, and float
switches
• 20 fuel tanks ruptured and/or contaminated
• 4 ballast tanks damaged
• Six cracks in aluminum superstructure
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PROFESSIONALISM
Cost
• Estimated cost to repair or replace DOD property:
– Original: $70M+ (based on repairing in Norfolk area)
– Final: $10M+ to “sell” to Chile
• Estimated cost of non-DOD property damage:
– 120,000 Gallon spill of F-76, JP-5, and MOGAS, damaging a 1/4 mile
section of beach: approx 20,000 dead sea urchins along surf zone.
• Operating days lost: infinite (LMC decommissioned), deployed
USS Tortuga to fill UNITAS gap
• $30,000+ per day for services
• Travel costs for support teams: (NOAA, JAG, MIB, NAVSEA,
MDSU, lodging for 300 Marines ashore for 30 days)
• Undetermined cost of 45+ operating days for 2 Chilean Navy ships
and Chilean dive team
TOTAL
PROFESSIONALISM
Qualifications
All personnel involved in mishap were qualified with following
exceptions:
• Navigator:
– Did not complete navigator PQS (NAVEDTRA 43492-2C, 316)
– Did not complete required WRN-6 course
– No waiver submitted
• Leading QM did not complete required WRN-6 course
– No waiver submitted
• Port bearing taker did not complete required PQS (NAVEDTRA
43492-2C, 310)
• Aft lookout did not complete required PQS (NAVEDTRA 434922C, 302)
TOTAL
PROFESSIONALISM
Training
• CO reported onboard MAY00, XO JUL99, 1st LT (OOD) AUG99,
Navigator FEB00, OPS (CICWO, SWO) AUG99, CICWS JUN00.
• All major watchstanders had at least 1 yr onboard and were
experienced, other than conning officer
• No documentation of nav-related STT evolutions being conducted
after 13MAR00.
• Completed following major training milestones:
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Nav check-ride 16MAY98 (3 personnel still onboard)
RADAR nav team trainer 12MAR99 (3 attendees onboard)
CART II 11JUN99
FEP 03NOV99
INDEX 05-12APR00, 30MAY-15JUN00
ORM training 12MAY00
TOTAL
PROFESSIONALISM
Damage Control
• Exceptional! Simultaneously tracking and responding to all reports
of structural damage, containing multiple fuel and seawater
flooding incidents, and controlling stability of ship. Considering the
magnitude and complexity of damage, overall DC efforts met or
surpassed all standards.
• DC lessons learned:
– Firefighting boots had inadequate traction with fuel on deck
– Firex Firewalker Ranger boots were more effective on fuel covered decks
– De-watering of fuel/water deteriorated inner lining of fire hoses within 2
hours. CHT hoses were better suited for this purpose.
– Hydraulic jacks proved very effective during shoring operations
– Wet vacs especially effective during flooding cleanup
– DC personnel assessed S-type eductors to be more effective in combating
flooding from mishap than peri-jet eductors
– Steel shoring not covered by PMS
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PROFESSIONALISM
Probable Causes (1)
• Unaware chart 206 not WGS 84 compatible. Chart 206 is unsuitable
for GPS navigation using default datum. Chart 206 is valid only for
radar and visual navigation. Unaware of "user defined datum”
procedures in WRN-6 tech manual.
• While ship recognized lack of visual nav aids prior to event, LMC
failed to resolve ambiguity between GPS and RADAR fixes. Bridge
failed to take into account CIC recommendations and relied on GPS
as single source of navigation.
• Navigator never recommended course to regain track. Navigator
recommended courses based on bearings and ranges to a GPS
waypoint on chart 206.
• Despite known lack of visual nav aids, Navigator did not
recommend, and CO did not direct, shift of primary plot to CIC (per
NAVDORM).
TOTAL
PROFESSIONALISM
Probable Causes (2)
• Employed SPS-67 almost exclusively. SPS-64 minimally
employed, and 2 separate Furuno RADARS on bridge and CIC not
used at all.
• Following standards of navigation were not adhered to:
– CIC and bridge nav teams failed to compute set and drift
– Nav failed to provide standard position reports to
CO/XO/OOD/CONN
– Nav failed to relay CIC "no fix" reports to CO/OOD
– CIC and bridge nav teams failed to synchronize fix "mark" times
– Preparation of CIC and bridge charts did not include the addition
of marked danger soundings and danger ranges
• Junior QM1, assigned by the watchbill, not on bridge. QM1
knowingly violated the published watchbill
TOTAL
PROFESSIONALISM
Probable Causes (3)
• CO/XO/OOD allowed improper nav team position reports.
• SWO failed to ensure watchbill was adhered to and failed to ensure
that watchstanders were manning proper watch stations. Following
11 changes to approved watchbill were made without authorized
approval:
Conning officer
Navigation plotter
Stbd bearing taker
Nav bearing recorder/JW
BMOW
Master helmsman
Master lee helmsman
Status board/JL
Forward lookout/JL
CIC log keeper
Stbd aft steering helm
TOTAL
PROFESSIONALISM
Probable Causes (4)
• Nav plotter U/I was also performed duties as nav bearing
recorder/JW. CIC nav plotter also assigned as piloting officer.
• CIC did not effectively disseminate hazard to navigation
information. Upon shifting to chart 206, CIC temporarily lost
situational awareness. Upon resolving position ambiguity and reestablishing situational awareness, CIC failed to convey close
proximity of hazard to navigation.
• CICWO not proactive in performance of duties: did not maintain
effective exchange of information between bridge and CIC or aid in
resolving differences.
TOTAL
PROFESSIONALISM
Probable Causes (5)
• Lack of situational awareness on part of CO, XO, Nav, OOD,
CICWO to proximity of hazard to navigation.
• Loss of situational awareness by piloting officer and leading QM1.
Due to initial inability to correlate RADAR nav reference points
when bridge and CIC shifted to chart 206, nav team defaulted to
uncorrected GPS plot.
• Overconfidence in GPS created an atmosphere of complacency
• Overconfidence by CO, XO, OOD Nav in abilities of bridge nav
team. Despite 2 "no fix" reports from CIC, ship continued to
proceed to anchorage at 11 kts based on bridge nav team
recommendation.
TOTAL
PROFESSIONALISM
Probable Causes (6)
• Ineffective coordination and communication between bridge and
CIC nav teams. Lack of sea and anchor detail de-briefs perpetuated
miscommunication and lack of coordination between bridge and
CIC.
• Ineffective S+A watchbill coordination and execution. Watchbill
not promulgated until after nav brief. Numerous changes to
watchbill not approved.
• ORM ineffective. Nav brief contained ORM matrix. However,
hazards associated with this evolution were not effectively assessed.
• Command failed to ensure required personnel attended nav brief
TOTAL
PROFESSIONALISM
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Recommendations to LMC (1)
Increase emphasis on ORM
Scheduled a navigation LTT
Conduct STT events at every opportunity
Promulgate watchbills in timely fashion with increased emphasis on
ensuring qualified watchstanders at every station. Avoid dual
tasking key watchstanders.
Navigator and QM1 complete required PQS and schools
Review ship's policy for setting restricted maneuvering
Review CNSL Howgozit regarding safe navigation
Conduct log keeping training
TOTAL
PROFESSIONALISM
Recommendations to LMC (2)
• Promote environment emphasizing teamwork, coordination, and
communication between bridge and CIC nav teams
• Include use of all systems onboard for determining hazards to
navigation (i.e. SPS-64, Furuno)
• Ensure required personnel attend nav briefs and are familiar with
evolutions
• Attend MSI coordinated nav team training at earliest opportunity
• Conduct WRN-6 training for bridge and CIC personnel,
emphasizing capabilities and limitations of GPS
TOTAL
PROFESSIONALISM
Other Recommendations
For SWOS:
• Continue to emphasize navigation practices/ procedures at every
level of officer training
• Develop ORM practical exercise for inclusion in PCO, PXO,
department head, and division officer curricula
For COMPHIBGRU TWO:
• Conduct navigation check-ride onboard LMC at next available
opportunity.
For CNET:
• Revise WRN-6 STEP CD-ROM course. Course in present form is
not user friendly and needs to be reviewed if this is to be considered
the equivalent of the school-house taught course.
TOTAL
PROFESSIONALISM