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Dakota Bordeaux had rarely traveled outside his home state of Oklahoma before he joined the Navy in February 2017. He’d certainly never seen the ocean.
But only four months later, Bordeaux was standing at the helm of the USS John S. McCain, steering the 8,300-ton destroyer through the western Pacific. Part of the Navy’s famed 7th Fleet, the McCain was responsible for patrolling global hot spots, shadowing Chinese warships in the South China Sea and tracking North Korean missile launches.
It filled the high school graduate with pride.
“Not many people of my age can say, ‘Hey, I just drove a giant-ass battleship,’” said Bordeaux, 23.
To guide the McCain, Bordeaux relied upon a navigation system the Navy considered a triumph of technology and thrift. It featured slick black touch screens to operate the ship’s wheel and propellers. It knit together information from radars and digital maps. It would save money by requiring fewer sailors to safely steer the ship.
Bordeaux felt confident using the system to control the speed and heading of the ship. But there were many things he did not understand about the array of dials, arrows and data that filled the touch screen.
“There was actually a lot of functions on there that I had no clue what on earth they did,” Bordeaux said of the system.
<aside class="promotion callout-box"></aside>Bordeaux, one of the newest sailors on the ship, was joined in uncertainty by one of the most seasoned, Cmdr. Alfredo Sanchez, captain of the McCain.
A 19-year Navy veteran, Sanchez had watched as technicians replaced the ship’s traditional steering controls a year earlier with the new navigation system. Almost from the start, it caused him headaches. The system constantly indicated problems with steering. They were mostly false alarms, quickly fixed, but by March 2017, Sanchez’s engineers were calling the system “unstable,” with “multiple and cascading failures regularly.”
Sanchez grew to distrust the navigation system, especially for use in delicate operations. He often ordered it to run in backup manual mode, which eliminated some of the automated functions but also created new risks.
In August 2017, Sanchez and his crew steered the ship toward a naval base in Singapore, where technicians were waiting. The navigation system had indicated more than 60 “major steering faults” during the month.
“We were going to have the programmers,” Sanchez said, “give the system a full, a full check, a full clean bill of health.”
The McCain never reached its destination.
In the early hours of Aug. 21, 2017, the McCain was 20 miles from Singapore, navigating one of the world’s busiest shipping lanes. Sanchez was on the bridge to assist in the complex maneuvers ahead. He ordered Bordeaux to take over steering the warship while another sailor controlled its speed. The idea was to avoid distractions by having each man focus on a single task in the heavy maritime traffic.
To check that he had control, Bordeaux tugged the ship’s wheel slightly to the left. The McCain did not alter its course. Bordeaux rotated it slightly to starboard. Again, the McCain maintained its track. Bordeaux suddenly realized that the McCain was steaming uncontrolled toward the cargo ships sailing through the Singapore Strait.
“Loss of steering,” he called out.
The McCain began turning mysteriously to the left, slowly at first, and then faster. The ship drew closer and closer to the vessels plying the strait.
As Bordeaux remained glued to the screen before him, there was quiet in the dark of the bridge as sailors darted around, staring at gauges, flipping buttons, trying in one way or another to figure out what was happening. Sanchez’s eyes flew across the ship’s banks of screens in his own desperate attempt to avert disaster.
Three minutes and 19 seconds after Bordeaux’s cry, the McCain collided violently with a 30,000-ton Liberian-flagged oil tanker. Ten Navy sailors were killed and scores more were injured. It was the Navy’s worst accident at sea in 40 years.
Investigations by the Navy and the National Transportation Safety Board, or NTSB, concluded that the navigation system itself had not malfunctioned. The ship’s hard turn to the left and the inability to correct it was the result of a series of mistakes by Bordeaux and fellow sailors.
Immediate responsibility, the Navy ruled, rested with Sanchez, his officers and senior sailors. They had been lax, even complacent, in their training of the sailors steering the ship. Sanchez had made a critical error in not adding more sailors to stand watch as the McCain navigated the treacherous strait. Sanchez was charged with homicide. A chief petty officer, responsible for training the sailors to use the navigation system, was charged with dereliction of duty. The chief petty officer had himself received less than an hour of instruction.
But a ProPublica examination shows that the Navy pursued prosecutions of the two men even as its investigators and those with the NTSB were learning that the navigation system, if it hadn’t technically malfunctioned, had played a critical role in the deadly outcome in the Pacific.
Its very design, investigators determined, left sailors dangerously vulnerable to making the kinds of operational mistakes that doomed the McCain. The Integrated Bridge and Navigation System, or IBNS, as it was known, was no technical marvel. It was a welter of buttons, gauges and software that, poorly understood and not surprisingly misused, helped guide 10 sailors to their deaths.
Despite its issues, the IBNS operated for years without major incident. Navy sailors did what they have always done: They found ways to make do with an imperfect technology.
The NTSB put it plainly: “The design of the John S McCain’s touch-screen steering and thrust control system,” the board found, “increased the likelihood of the operator errors that led to the collision.”
The Navy investigators, for their part, determined that the system’s “known vulnerabilities” and risks had not been “clearly communicated to the operators on ships with these systems.”
The Navy, while publicly blaming the McCain’s crew, also took steps to make sure other sailors were better equipped to avoid similar disasters. Commanders issued new instructions to the Navy’s entire fleet of destroyers on how to properly use the navigation system to avoid the kinds of mistakes that could lead to “inadvertent” loss of control.
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