Flawed Bridge Technology Set The USS McCain Up For Disaster

(Source: National Transportation Safety Board report)

By T. Christian Miller, Megan Rose, Robert Faturechi and Agnes Chang (ProPublica) 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.

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.

In the end, though, the Navy punished its own sailors for failing to master a flawed system that they had been inadequately trained on and that the Navy itself came to admit it did not fully understand.

Just before Sanchez’s trial, the Navy dropped a homicide charge and he pleaded guilty to dereliction of duty. The chief petty officer responsible for training also pleaded guilty and has since left the Navy.

In response to emailed questions, Navy officials said they had taken steps to fix the “complex touch-screen controls” of the navigation system. They said they had improved training on the system throughout the fleet.

Over the next seven years, the Navy will install physical throttles and simplified touch screens on newly built Navy destroyers and retrofit 32 existing destroyers with the improved design.

Cmdr. Clay Doss, a Navy spokesman, stood by the assertion that the navigation system did not play a major role in the accident. “There was no single cause,” he said in a written response to emailed questions. He cited human error compounded by “complacency, indifference, non-compliance, overconfidence and disregard for watchstanding requirements.”

“The Navy found these issues, we are addressing them and we are confident in our sailors to sail our ships safely,” he added.

Northrop Grumman, the Virginia-based defense contracting giant that developed the navigation system, defended it. The Navy has selected the company to carry out installation of the improved version across the destroyer fleet.

“We continue to work closely with the Navy to provide our advanced navigation capabilities to our warfighters,” said Tim Paynter, the company’s vice president for strategic communications.

In examining the Navy’s handling of the McCain crash, ProPublica interviewed current and former Navy officials and reviewed a confidential Navy report on the incident, court records, previously unreported transcripts and government reports. That examination shows that the Navy’s response to the loss of life on the McCain closely mirrored how it dealt with a deadly accident involving another 7th Fleet destroyer, the USS Fitzgerald. Two months before the McCain accident, the Fitzgerald collided with a cargo tanker off the coast of Japan, killing seven sailors.

The Fitzgerald did not have the new navigation system, but then, as with the McCain, the Navy laid blame on sailors and officers while downplaying the role of decisions made at the very highest levels of the service. The Navy disciplined several admirals in charge of the 7th Fleet, but it stopped short of senior leadership, including the former chief of naval operations, John Richardson, who allowed ships to sail without having enough time to conduct training or repairs. Now retired, Richardson told ProPublica this year that the two disasters were “avoidable tragedies” and that commanders “own” the outcome of their decisions.

The Navy has committed almost half a billion dollars to build the navigation system and install it on more than 60 destroyers by the end of the next decade — the entire fleet of the tough, stalwart warships that form the backbone of the modern Navy. Yet no one responsible for the development or deployment of the technology has faced any known consequences for the McCain disaster.

A number of current and former Navy officials remain convinced the navigation system should never have been put to use. And they worry about the Navy’s slow pace in installing a new, improved version.

“The IBNS has no place on the bridge of a U.S. destroyer,” said one former senior Navy officer with direct knowledge of the McCain accident. “It’s not designed to have the control that you need to navigate a warship.”

CHAPTER 1 “The Way of the Future”

IN THE EARLY 2000S, the Navy was seeking to modernize its aging destroyers and trim the number of sailors needed to man its fleet of ships.

One of the more modest efforts, almost unremarked upon at the time, was the IBNS. Up to a dozen or more sailors could crowd a bridge, issuing orders, steering, keeping lookout and even training there. The IBNS would allow as few as three sailors standing watch on the bridge to navigate a destroyer.

“The key benefit is the ability for operating with fewer watchstanders, reduced watch standard workloads and improved safety of navigation,” the Navy told Congress.

In July 2008, the Navy announced its first contract with Northrop Grumman for an initial payment of just under $7 million. Three years later, the USS John Paul Jones was the first Navy destroyer to sail out of harbor with the new system in place.

“The way of the future,” declared a young sailor in a Navy press release.

It did not take long for troubles to develop. Each retrofit took months. Contractors had to string more than three miles of cables and fiber optics throughout each ship. The Navy could only modernize three or four ships a year, as they rotated through previously planned long-term maintenance periods.

As the years passed, Northrop Grumman continued to make improvements to the system. That meant that controls on one ship might not look exactly like controls on another. It was like hopping from the driver’s seat of a Ford truck into a Mercedes-Benz roadster. Sailors could adjust. But it took a while to get a feel for the different controls — and on a fully armed warship, no less.

The IBNS was so complex that it overwhelmed the junior sailors who used it. Navy technicians would even disable the touch screen to avoid rudder changes caused by accidental taps, forcing sailors to use the manual wheel instead, according to a former Navy technician who worked on the system.

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’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 “I’m a Dinosaur, Maybe”

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.

But in the backup mode preferred by Sanchez, no such protection existed. Instead, the IBNS software makes “automatic offers” to other steering stations on the ship allowing them to take unilateral control.

The reason? In cases of emergency, such as if the bridge is destroyed during an attack, sailors from other parts of the ship need to be able to take control without waiting for additional approval.

Whatever the exact cause, neither Bordeaux nor Mitchell realized during the emergency that Mitchell had control of steering. Each man had an indicator on screen displaying the name of the station with control. But it wasn’t prominent — just a small box with green text a little larger than the 12-point font typically used in word processor programs.

Whatever the exact cause, neither Bordeaux nor Mitchell realized during the emergency that Mitchell had control of steering. Each man had an indicator on screen displaying the name of the station with control. But it wasn’t prominent — just a small box with green text a little larger than the 12-point font typically used in word processor programs.

When Bordeaux tried to turn the ship, he thought the McCain’s steering had malfunctioned. As trained, he called out loss of steering.

It was 5:20:39 a.m.

CHAPTER 3 “Why Are We Turning?”

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.

Mitchell, who was standing at the lee helm, told investigators that he eventually realized the mistake. He leaned over to Bordeaux’s computer screen and completed the transfer himself. (Bordeaux’s memory is different: He said he completed the transfer with Gillilan advising him on how to do it.)

“I hurried up and did it real quick,” he told investigators.

The transfer resulted in the third, and most serious, error.

When Bordeaux had control of the speed, the McCain’s two propeller shafts were working together. If you slid the touch screen’s buttons to speed up one shaft, the other shaft automatically sped up as well.

But during the transfer, control over the two shafts separated. Each began to operate independently.

Mitchell told investigators that he remembered checking a small box marked to join the shafts together again — a process known as ganging.

But the Navy and the NTSB analysis found that they continued to act separately.

As the McCain drew closer to the Alnic, a ship officer ordered a decrease in speed to 10 knots. Mitchell adjusted the touch-screen controls to lower the speed of the propellers.

He did not notice, but since the propellers were no longer operating together, only the port side shaft began to slow. The starboard propellers continued to churn, moving at around 20 knots an hour, the Navy’s logs showed.

Like a rowboat being pulled harder on one side than the other, the McCain began to veer sharply to the left — changing its course by more than 45 degrees over the next minute and 19 seconds.

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 “We Saved Our Ship”

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.

The confusion over the big red button was the center of the fourth, and final, mistake of the night.
With the steering seeming to malfunction, a ship’s officer ordered the sailors in the aft station to take control.

At 5:23:01 a.m., a sailor pressed the big red button at the aft steering station. For the first time in more than two minutes, someone had control of the McCain’s steering.
It did not last long.

Up on the bridge, another sailor responded to the officer’s order by hitting the big red button there in the mistaken belief that it sent control to the aft station. Just seconds after sailors in the rear of the ship seized control, it returned to Bordeaux’s station on the bridge.

After a few seconds of hurried conversation, the aft station finally regained control of the ship at 5:23:27 a.m.

All told, steering of the McCain changed hands three times in 16 seconds. During one of the transfers, the ship’s rudders mysteriously turned the McCain briefly and sharply left, hastening the turn toward the shipping lanes.

The aft watchstanders made one last effort to steer the McCain to the right and away from the collision.

It was too late.

At 5:23:58 a.m., the Alnic drove its bow into the port side of the McCain.

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
“I May Not Have Been a Perfect Chief”

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.”

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 “It Hurt Because I Always Wanted to Make My Grandfather Proud”

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.”

Read the full original article with artwork HERE.

T. Christian Miller is a senior editor and reporter for ProPublica.

Megan Rose is a reporter at ProPublica covering criminal justice.

Robert Faturechi is a reporter at ProPublica covering money in politics.

Agnes Chang is a creative story technologist at ProPublica.

3D modeling by Lucas Allen Hearl. Additional design and development by Al Shaw and Allen Tan.
Production by Vignesh Ramachandran and Jillian Kumagai.