KNB Grounding Incident USS Pearl Harbor (LSD 52) 21 JUL 08 KNB Grounding Incident

References Safety Message 271153Z OCT 08

Background On 20 July an evolution brief and daily OPS/INTEL brief were conducted onboard USS PEARL HARBOR (PHB) in preparation for the second day of scheduled amphibious operation on 21 July.

Background The AMPHIB OPS consisting of the backload of 15th MEU Assets, were constrained to inner and outer sea echelon areas (sea) located in Kuwaiti territorial water IVO Kuwaiti Naval Base (KNB).

Preparation Sea boxes were plotted by both Navigation and Combat Navigator reviewed both charts Failed to notice Combats’ was incorrect CO/XO did not review for approval Charts were not brought to OPS/INTEL nor was a Navigation brief conducted

The Operating Box The CO gave no direction and there was no discussion WRT location of operations in the inner sea box. PHB has already operated in this box one month prior and on 20 JUL in support of Amphibious Backload Ops. ORM was discussed, however grounding and navigational hazards were not specifically identified as risks!

21 JULY PHB operating in prescribed inner sea box The western edge of the box contained a small section of shoal water, 250 yds in diameter and marked at 1.9m deep IAW the CO standing orders, this is restricted waters Within 2nm of shoal water or <10 fathoms

Bridge Watch 0700-1200 The Navigator was the OOD with a U/I Nav Dept LPO was the conning officer Navigation detail was not manned No deck log entry made when entering restricted waters (as required by COSO) QMOW taking 6min fixes IAW Nav Bill Restricted waters requires 2min fix intervals Combat and Bridge not comparing fixes

Bridge Watch (cont.) The Conning Officer notice the ship not responding to commands The OOD checked the chart and realized the latest fix to show the ship in shoal water The ship was aground Damage included a section of scraped paint from frames 55 to 70

Human Factors Failure to Follow Procedure COSO/Nav Bill IAW NAVDORM, but published procedure for restricted waters not followed Nav Brief, Nav Detail, RMD not set No formal chart review DR, fix interval, fix comparisons, reporting procedures CO, Bridge Watch Team, Combat Watch Team, Navigation personnel, not adequately familiar with the instructions nor were they being followed.

Human Factors (cont) Knowledge of Regulations Inadequate COSO define restricted waters as within 2nm of shoal and/or depths <10 fathoms By definition the OP BOX is rest. waters Not recognized by CO, XO, NAV/OOD Know the Standing Orders

Human Factors (cont) Fixes plotted in shoal from 1000-1030 Lack of Attention to Detail/Unnecessary Distractions Fixes plotted in shoal from 1000-1030 Studying the chart before taking the watch Analyzing and comparing fixes Recognition of identical fixes and fixes plotted in shoal water QMOW phone talker during LCAC Ops Turnover (4 plotters in CIC within 1hr)

Human Factors (cont) Complacency Previous Ops, same box (4 weeks and day before) Dangerously close to shore during amphibious operations Watchstanders unfamiliar with SO, as it defines restricted waters

Human Factors (cont) Inadequate Training No formal Officer training or plan onboard Junior Officer training not monitored closely (no progress reports, etc)

Human Factors (cont) Inadequate Supervision The CO failed in supervisory duties of safe navigation His bridge and combat watch teams failed to operate IAW his Standing Orders No direction, insufficient chart study, and failure to conduct a thorough ORM review Watch not stood properly CO, XO, NAV/OOD, OOD U/I, Conning Officer, CICWO, CICWS

Human Factors (cont) BRM/Combat Communication Resource management for Bridge and Combat watch teams not incorporated Communications ineffective Combat not utilized as a useful resource No forceful backup from Combat

Human Factors (cont) Lack of Chain of Command Continuity PHB served under 3 different ISICs from workups to deployment Lack of continuous and dedicated squadron oversight Identify potential problems, training cycle

Summary Standing Orders alone could have prevented the mishap. Know the Standing Orders! Complacency/Distractions Inadequate preparation, briefs, ORM Poor watch standing Know your watch team. Maintain SA and know your OP Area, identify hazards before assuming the watch No formal training Continue to train your watch teams

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