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

2. References
Safety Message
271153Z OCT 08

3. 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.

4. 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).

5. 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

6. 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!

7. 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

8. 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

9. 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

10. 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.

11. 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

12. Human Factors (cont) Fixes plotted in shoal from 1000-1030
Lack of Attention to Detail/Unnecessary Distractions
Fixes plotted in shoal from
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)

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. Questions?