The Navy Installed Touch-Screen Steering Systems to Save Money. 10 Sailors Paid With Their Lives.

  <figcaption>
    The control screen was supposed to make it easier to navigate a ship. But many sailors found the system&rsquo;s arrows and buttons confusing. The large section labels above were added by ProPublica

      <span class="credit">
        (Source: IBNS Tech Manual)
      </span>

  </figcaption></figure>In 2014, Navy officials discovered a flaw in the IBNS. One component could not keep track of more than 150 ships at a time without malfunctioning, according to Navy investigators. The Navy&rsquo;s solution? Sailors were told to delete tracked ships before the total hit the magic number.

The navigation system could also become overloaded if too much information streamed in from a ship tracking database used worldwide to prevent maritime collisions. The Navy’s second solution was similar to the first: Drop the feed when it became too much.

They were patches on top of patches that left the Navy’s destroyers without a full picture of the seas around them. But none of the problems was serious enough to attract high-level attention. A Navy system designed to track problems in major ship systems did not contain any reports that mentioned the IBNS until last year, according to a Navy official.

In 2016, the McCain became the first ship in the 7th Fleet to receive the new system. Based in Japan, the 7th Fleet was a strange choice to test out the newest version. Unlike U.S.-based ships, 7th Fleet ships — the largest armada in the world — were constantly responding to real-world crises.

It didn’t take long for the McCain to experience problems with the new system. The IBNS had started to crash when it tried to integrate images from the radars and the ship’s navigation computer. Navy technicians who boarded the McCain in January 2017 could not reproduce the error.

But they told Sanchez that the “potential for these types of failures is inherent.”

By March, senior officers aboard the McCain had designated the IBNS as a major problem. In August alone, the navigation system issued alerts on 63 different occasions — most of them related to the steering system, and most of them quickly fixed.

The McCain’s crew could do little to find a permanent solution to the constant alarms, however. Because of staffing shortfalls, higher-ups had waived a requirement to have a technician on board with specialized training to maintain the IBNS.

Instead, the McCain relied on a workaround familiar to anybody who has ever called a help desk for problems with their computer. The McCain’s second in command, Cmdr. Jesse Sanchez, told investigators that few of the technicians on the McCain understood the “complex” system.

“Usually when we have a fault with that system,” Sanchez said, “their resolution is to reboot the system.”

                    Chapter 2


                    <h2>&ldquo;I&rsquo;m a Dinosaur, Maybe&rdquo;</h2>

Alfredo Sanchez, the McCain’s captain and no relation to Jesse, knew that the trip to Singapore to get the navigation system examined in August 2017 would be difficult, passing near Singapore Strait and the Straits of Malacca.

“The Straits of Malacca, that’s the place where you’re gonna see the supertanker, the fishing vessel and a guy in a canoe,” Sanchez had told his crew. “Everybody and their mother is going to be on the Straits of Malacca.”

Despite the peril, Sanchez ignored the advice of his navigator and his second in command to add extra crew for the approach. The Fitzgerald was on his mind. Word had spread that some of its sailors had been working 100-hour weeks before the collision. Sanchez wanted his men to get an extra hour of rest before awakening to pilot through the strait itself.

Sanchez got up a little after midnight to make sure he was on the bridge in case anyone needed help. In those early dark morning hours, he made two decisions about the IBNS that had fateful consequences.

At around 4:35 a.m., with the lights of the Malaysian coast in view, the navigation system suffered a problem. It was yet another false alarm. But after months of such hiccups, Sanchez had lost faith in the technology.

Sanchez had discussed the IBNS with two other captains in Japan, he told investigators. All three agreed that the system’s automated functions were too complex to use when navigating crowded waters.

In the next minute, Sanchez ordered the helmsman to place the IBNS into backup mode. In that configuration, Sanchez had more direct control over navigation.

“I’m a dinosaur, maybe, but that’s why I do it,” Sanchez told investigators. “When the system got installed and we went out for sea trial, we were comfortable in that configuration.”

But placing the system in backup mode also put the steering system into an emergency setting that removed some of the system’s built-in safeguards.

That danger, though, was not clear to Sanchez, or even the Navy. The Navy’s instruction manual did not contain details on how to implement some navigation maneuvers with the IBNS. And the manual on board the McCain was three years out of date.

About 45 minutes later, Sanchez made another fateful decision. Bordeaux was on the bridge acting as a lookout. But when the acting helmsman wanted to grab a meal, Bordeaux volunteered to take over for a few minutes. He had only steered the ship by himself six times previously.

Sanchez quickly noticed that his new helmsman seemed flustered by the difficulty of having to control the ship’s steering and speed at the same time. He decided to split the helm, giving Bordeaux control over the ship’s wheel. While Bordeaux remained at his station, Dontrius Mitchell, a second sailor on the bridge, was assigned to take control of the speed of the McCain at a neighboring station known as the lee helm.

Sanchez’s order was unexpected — he had not discussed the possibility in meetings with the crew before entering the straits. Nor had the crew practiced the maneuver much. Bordeaux could only remember doing it once or twice before.

“They were kind of rusty trying to follow those procedures,” said Jesse Sanchez, the executive officer.

When Bordeaux went to transfer the thrust to Mitchell, something went wrong. It was the night’s first mistake: Mitchell wound up with control of steering instead of Bordeaux.

Despite three separate reports examining the collisions, the Navy has never determined what, exactly, caused this.

In separate interviews weeks after the collision, Bordeaux, Mitchell and a third sailor present all denied touching any controls that could have transferred steering.

But two reports, one by the Navy and one by the NTSB, both ruled out a malfunction of the IBNS as a cause of the steering transfer mistake. They based their conclusion on digital logs kept by the navigation system that did not indicate any such error.

“Although the helmsman perceived a loss of steering, there was no malfunction of the John S McCain steering system,” NTSB investigators ruled.

The confidential Navy report concludes simply that a “watchstander had to have performed this action” — in other words, somebody pushed the wrong button.

The IBNS, however, indisputably played a role in the confusion that unfolded from the initial mistake.

In its normal, computer-assisted mode, the navigation system requires that both sailors press buttons to acknowledge a switch in steering before it happens.

                    Chapter 3


                    <h2>&ldquo;Why Are We Turning?&rdquo;</h2>

A second mistake, made at almost exactly the same instant, actually drove the McCain into the path of the oil tanker, the Alnic MC.

For propulsion, the McCain has two main shafts connected to propellers. The two shafts can operate independently, moving at different speeds if needed for sailing or maneuvering.

A third, more experienced sailor was standing near Bordeaux and Mitchell. Anthony Gillilan, the boatswain’s mate of the watch, was in charge of both sailors.

Gillilan and Mitchell had begun the year as sailors on the USS Antietam, but the ship ran aground in an embarrassing incident as it departed Yokosuka Harbor in Japan. The Antietam returned to the yards for repairs. Gillilan and Mitchell were sent to the McCain to fill manpower shortages. Neither Gillilan nor Mitchell returned requests for comment.

The Antietam, a cruiser, did not have an IBNS. Gillilan, a helmsman on the Antietam, received no formal training when he joined the McCain. Fellow chief petty officers “just kind of went through it a little bit” with him, he told investigators.

When Sanchez ordered the split helm, Gillilan leaned over the console to transfer control of the McCain’s speed to the lee helm. It was a two-step process that required Gillilan to transfer control of each of the McCain’s two main shafts.

First, Gillilan used a drop-down menu on Bordeaux’s screen to transfer control of the ship’s port thrust to Mitchell.

But before he could do the same with the starboard shaft, Bordeaux called out loss of steering. Ordered to broadcast the emergency over the ship intercom, Gillilan was distracted and did not complete the transfer.

To the officers trying to figure out what was going on, nothing made sense. The captain, Alfredo Sanchez, would later tell investigators that he recalled staring at an instrument panel in confusion. An indicator told him that the McCain’s rudders were set to 0 degrees — moving neither right nor left. But his warship was careening to the left.

“Why are we turning? Why are we turning?” his No. 2, Jesse Sanchez, remembered wondering.

Both men focused on the steering controls. They had failed so often before. They decided to try a last-ditch emergency procedure to regain steering.

Once again, the IBNS was at the center of the confusion that followed.

                    Chapter 4


                    <h2>&ldquo;We Saved Our Ship&rdquo;</h2>

The McCain can be controlled from the IBNS stations on the bridge and from a backup station in the rear of the ship.

The helm and aft stations featured a fail-safe device known as the big red button. Once pressed, the big red button overrides all other stations and returns control to its own location.

But numerous sailors on the McCain believed that the function of the big red button was to send steering control to the rear of the ship. It is unclear how this misunderstanding developed, or why it was so widespread among the crew. Mitchell told investigators that the instruction booklet on the bridge had not been updated to match the most current version of the IBNS.

Sailors remember a sharp, powerful blow that knocked them off their feet. The force of the collision locked the two ships together so that they lurched ahead, stuck to each other, for almost 10 minutes, before slowly separating.

The Alnic’s prow gouged a 28-foot-wide hole into two sleeping quarters, known as Berthing 3 and Berthing 5. Berthing 5, which sat below the waterline, flooded in under a minute. There were 12 sailors there. Just two escaped.

In Berthing 3, which held 71 men, sailors woke to find water filling the spaces around them. Two were trapped in the twisted metal of their bunks, unable to flee.

Bordeaux joined the crew that went to rescue them. Sailors hacked at debris with an ax, crowbars and a pulley to free the two men. In total, 48 sailors were injured in the crash.

Over the next nine hours, the sailors of the McCain fought back flooding throughout the ship, filling holes and using pumps to clear water. Rescue ships from Singapore and Malaysia, as well as the USS America, an amphibious assault ship, helped get the vessel to port. Fifty sailors were recognized for their bravery during the incident.

Bordeaux mourned the dead. But he and the other sailors took pride in saving most of their shipmates and the ship itself. They had stood in water filled with diesel fuel and chemicals and human waste, pumping it into the ocean.

“We saved our ship,” he said.

The McCain sustained hundreds of millions of dollars of damage and was in such bad shape that it took two months to tow the warship back to Yokosuka. It would take another two years before it was fixed.

                    Chapter 5


                    <h2>&ldquo;I May Not Have Been a Perfect Chief&rdquo;</h2>

On May 24, 2018, in a courtroom perched above a food court in the historic Washington Naval Yard, Chief Petty Officer Jeffery D. Butler sat alone at a desk before a judge.

Butler was the only enlisted man to face a formal court-martial in connection with the McCain disaster. He was charged with dereliction of duty — partly because he had failed to “gain a proper understanding” of the navigation system in order to train his sailors.

Butler was a fireplug of man, with glasses and a thick neck, wearing a sharply creased dress white uniform that seemed to almost gleam under the courtroom’s fluorescent lights. He had been a standout among petty officers, the sailors who form the core of the Navy’s enlisted leadership. He was selected as sailor of the year on a previous ship.

As a senior enlisted officer, it had been his job to train Bordeaux and other young sailors on the McCain in the use of the IBNS. Some of the crew had joined the McCain from the USS Antietam and needed to be schooled in how their new ship functioned.

Butler told the judge that he himself had only received about 30 minutes to an hour of training on the system. And he had cleared the Antietam sailors without putting them through proper training. Given the sailors’ previous qualifications, and the McCain’s heavy workload, it was his attempt to put them to work as soon as possible.

He was not making any excuses, though, he said.

“I should have paid more attention to the training,” Butler told Judge William Weiland, a Navy commander. “I could have told my junior sailors how to better operate their systems.”

                <aside class="promotion callout-box"></aside>Still, the evidence suggests that the Navy prosecuted Butler for failing to understand the operation of the IBNS even as it grew clear that the Navy itself did not understand it.

In October and November, the Navy sanctioned Butler and other crew members in a first round of discipline known as an admiral’s mast. Butler had to forfeit pay and received a letter of reprimand that all but guaranteed a halt to further career advancement. Alfredo Sanchez, the captain, and Jesse Sanchez, the executive officer, were both fired from their commands. Bordeaux was docked pay, demoted and put on probation.

A few weeks later, the Navy released its comprehensive review of the collisions in the 7th Fleet. Mentions of the IBNS were scattered throughout the document. Pieced together, with acronyms untangled, they offer a damning portrait of the system.

The review found that the “designed responses of the IBNS” featured “known vulnerabilities” in shifting steering and thrust.

The Navy’s training schools do “not address the depth of knowledge and skills needed to properly maintain complex electronic navigation systems on ships, specifically the Integrated Bridge Navigation System.”

The review offered a critique of the Navy’s drive to save money by installing new technology rather than investing in training for its sailors.

“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),” the report said, “without considering the effect to operators who are trained and proficient in operating legacy equipment.”

Adm. Phil Davidson, then the head of training and manpower for the Navy, led the review. The Navy fired or forced out five senior commanding officers above Sanchez, the McCain’s captain, including four admirals. Davidson was promoted to his current position, the head of Indo-Pacific Command, one of the most powerful posts in the military.

Later that fall, the Navy appointed four-star Adm. Frank Caldwell, who reported directly to the chief of the Navy, Adm. John Richardson, to investigate whether the McCain sailors deserved additional punishment.

As Caldwell launched his investigation of the McCain crew, the Navy’s engineering division conducted its own investigation of how best to operate the IBNS.

The inquiry resulted in a set of instructions issued to every destroyer in the Navy. The Navy decided not to abandon the system, so the instructions were an effort to better educate sailors about its flaws and known vulnerabilities, a choice that remains in effect today.

Called class advisories, the Navy instructions noted that the IBNS allowed control of the ship from four different locations on the bridge: “This flexibility in control provides the potential for inadvertent transfer of control or loss of awareness of control location.”

The new guidelines warned that IBNS instructions available on the bridge of the McCain and dozens of other destroyers did not include clear procedures for transferring steering and thrust.

And they required every destroyer captain to do exactly what Sanchez had done: Split the helm whenever using the IBNS, directing one sailor to steer and a second to control speed, in order to “maximize confidence” in the modernized system.

(Nearly a year later, in fall 2018, the Navy issued a second set of instructions. Now, ship captains have to certify that their crews know how to transfer IBNS controls to different stations.)

Despite these new instructions, Caldwell announced in January 2018 that he was recommending Butler and Sanchez for court-martial.

To the consternation of many of his fellow officers, Sanchez was charged with homicide. He eventually pleaded guilty to a lesser charge of dereliction of duty. He received a letter of reprimand and had to forfeit $6,000 in pay.

Sanchez did not respond to requests for comment on the navigation system, the Navy’s findings on the accident involving the McCain or his punishment.

Butler, like Sanchez, decided against risking trial. The Navy wanted personal accountability. Butler would give it to them.

At the May 2018 hearing, Weiland glanced down at the sheaves of exhibits before him. He seemed sympathetic to the idea that the steering console had problems.

“It seems relatively complex,” he observed to Butler.

“It can be, Your Honor,” Butler responded in a low voice.

Still, he told the judge he was guilty as charged.

Before Weiland pronounced sentence, Butler turned to face rows of people filled with grief. Wives in black, young boys in suits and teenage girls in dark dresses had all come to the courtroom to give testimony about their loved ones.

Butler wept and his voice broke as he apologized: “I am truly sorry for your loss. They were more than just my shipmates. They were family.”

Butler asked Weiland for one small mercy. The prosecution wanted to knock him down a rank. Butler pleaded to keep his position, which meant an additional $200,000 in retirement pay. It was money, he said, that he hoped to use for his daughters’ college educations.

“I may not have been a perfect chief, but I have put my heart and soul into that title,” he told Weiland.

Weiland turned down the request.

                    Chapter 6


                    <h2>&ldquo;It Hurt Because I Always Wanted to Make My Grandfather Proud&rdquo;</h2>

When Dakota Bordeaux entered bootcamp on Valentine’s Day 2017, it was the fulfillment of a promise. His grandfather had served as a sailor during the Vietnam War. He’d helped Bordeaux through a childhood pocked by many moves and school fights. Bordeaux enlisted in the Navy as soon as he could after graduating high school, and he had, he said, planned to spend his life in the service — “until I’m too old and they tell me and they kick me out because of my age.”

Today, Bordeaux is back home in Oklahoma, out of the Navy after a year and a half. After the accident, he had been taken with the rest of the McCain’s sailors back to Japan. There, he stayed in an old supply ship that had been converted into a sleeping quarters.

Bordeaux had trouble falling asleep in the bunks, which were similar to the ones on the McCain. And when he did, he had nightmares.

“I’m walking through everything that happened that night. I could hear the screams from the sailors who died during the collision,” he said.

Bordeaux believed that he might be suffering from post-traumatic stress, a mental disorder marked by nightmares, anxiety, flashbacks and startled reactions to loud noises.

A doctor he saw in Japan, however, diagnosed him with insomnia, he said. She gave him a book with tips to help him sleep, he said. It didn’t help much. Bordeaux began to drink heavily, going through as much as $500 of alcohol in a week.

As the months passed, Bordeaux noticed that he was having difficulty bringing enthusiasm to the job he had once loved. And he was confronted by a series of personal losses. The grandfather who had inspired his entry into the Navy passed away. So, too, did his other grandfather and grandmother. A woman he was dating dumped him.

One day, after a sleepless night, Bordeaux fell asleep at his post — a serious offense. The Navy busted him down to its lowest rank and dismissed him from service, he said.

Asked about his brief stint as a helmsman on a Navy warship, Bordeaux still feels both the excitement and the bewilderment.

“All I did was I kept the ship on course, did the adjusting of speed that I was ordered to,” he said. “I always made sure I wasn’t touching anything else.”

Today he works in a factory with his father. He makes plastic sheets for use in garbage bags.

On a recent day off in Oklahoma City, he wore a baseball cap, work pants and a U.S. Navy sweatshirt. His dismissal from the service is a dull pain he can’t get over.

“It hurt because I always wanted to make my grandfather proud,” he said. “I finally was able to join the Navy.”