USS Guardian Investigation Reflects Lack of Leadership and Situational Awareness

A photo taken Jan. 20, 2013 of the USS Guardian. The vessel has since been removed from the reef.

“USS Guardian leadership and watch teams failed to adhere to prudent, safe, and sound navigation principles which would have alerted them to approaching dangers with sufficient time to take mitigating action,” wrote Admiral Cecil D. Haney, Commander of the U.S. Pacific Fleet in the 160-page investigation into the grounding of the USS Guardian.

Adm. Haney characterized the ex-Guardian’s grounding on Tubbataha Reef in the Sulu Sea as a “tragic mishap,” and notes that a “lack of leadership” led to the watch team’s disregard of visual cues, electronic cues and alarms in the hours leading up to the grounding, and that an ultimate reliance on what would turn out to be inaccurate Digital Nautical Charts (DNC) during the planning and execution of the navigation plan ultimately led to a degradation of the ship’s navigation ability.

The commanding officer of ex-Guardian, Lieutenant Commander Mark Rice, the executive officer/navigator Lieutenant Daniel Tyler, the assistant navigator, and the officer of the deck at the time of the grounding were relieved of their duties on April 3 by Rear Admiral Jeffrey A. Harley, commander, Expeditionary Strike Group (ESG) 7.

All received non-judicial punishment for the incident.

The report goes into great detail reflecting a clear loss of situational awareness by the watchstanders right before the incident occurred.  Similar, in a way, to how the watchstanders on USS Porter lost control right before they ran into a supertanker last year.  What’s different in this case, is that had anyone said something, acknowledging the fact that there was confusion, and taken action to slow or stop the ship, this accident would most certainly have been avoided.

Perhaps one of the most interesting sections of the Navy report is the timeline of what happened AFTER the Guardian ran aground, and the actions of her crew.  The following is a play-by-play directly from the report, names have been withheld.

The time is 0222H on 17 January 2013. USS GUARDIAN has just ran aground on the northwest corner of the South Islet of Tubbataha Reefs, RP, at latitude 08 degrees 48 minutes North, longitude 119 degrees

431. At 0222 H on 17 January 2013, the OOD, sounded the collision alarm and ordered all engines stop. The JOOD, announced on the 1MC, “Captain to the Bridge,”repeating the phrase twice.

432. The ship’s heading at the time of the grounding was 192 degrees true. The ship’s heading was not logged in the Ship’s Deck Log for the remainder of the crew’s time onboard.

433. At 0222H, The CIC General Log contains the entry “major vibrations.”

434. The CO was in his stateroom asleep. The CO felt a sensation like the shimmying of a DDG going down a large swell. He ran to the bridge. XO/NAV and DCA arrived on the Bridge right behind the CO. Condition II DC was ordered.
435. It was very dark outside with little background luminescence. The winds were on the stern, either the port or starboard quarter. The sea state was about four to six feet. The CO heard ANAV repeatedly state, “The fathom reads 200 meters … The fathom reads 200 meters.”

436. At approximately 0224H to 0228H, the EOOW, emergency stopped the fuel oil purifier and secured a fuel oil transfer. The DCA assumed control of damage control (DC) efforts and ordered Condition II DC set. DCA reported water intrusion in auxiliary machinery room (AMR) through hydrophone number four. CIC personnel were ordered to raise the hydrophone. Water intrusion was reported in bow thruster at approximately one half gallon per hour.

437. The CO spoke with XO/NAV and DCA. The DCA said words to the effect, “We have one shot to back off the reef.” At 0226H to 0229H, the CO ordered All Emergency Back Six. The EOOW started 1B and 2A Main Propulsion Diesel Engines and placed them online. The EOOW placed the port and starboard Main Reduction Gear lube oil pumps in manual.

438. MNCS came to CIC within minutes of the grounding and relieved MN2 as CICWS. MN2 left CIC and went to Repair and Assistance.

439. For Condition II DC, CS1 and MN2 are Investigators. CS1 and MN2 donne their investigating equipment and started investigating throughout the ship. They started at the Bos’n Locker and worked their way
back to the stern. They checked the HAZMAT locker for flooding and reported from Repair Locker 2 to CCS. They went to Bow Thruster and saw a crack right on the Sonar Trunk where it meets the hull. The flooding was slow at this time. They went to 15- man berthing and 40-man berthing. There was no damage or flooding, but there was a loud creaking noise in the 40-man berthing. They opened up Pump Room and there was no water underneath the deck plates. They went back aft and reported all conditions normal to CCS.

440. At 0230H, the Navigator shifted to 10 minute fixes. With respect to latitude and longitude as indicated on the AN/WRN-6, the ship remained fixed at her original position upon grounding.

441. At 0235H, CIC personnel were sent to raise the SONAR. The CO entered the Bridge.

442. At 0238H, the Communications Watch Officer was ordered to set River City throughout the ship.

443. CS1 and MN2 completed their initial round of investigating and were told to stand easy on station. The initial DC efforts were complete so MN2 went back to CIC. MNCS told him to look at the VMS console. MNCS showed MN2 the DNC that he saw on his watch and queried the box indicated by a purple dashed line. Upon querying this box, a mirror image of the original shape showed up directly over the track and the ship’s position. They changed the DNC®, queried the same box again, and the VMS displayed the ship aground with a bright red shaded box around ownship position. While on watch as crews, there were no such dangers or alarms indicated on the VMS; this was the first time that MN2 had seen them.

444. Approximately 20 minutes after ordering All Emergency Back 6, the CO ordered engines all stop because the ship did not move. The CO knew that USS GUARDIAN had to avoid broaching on the reef.

445. The CO called his Immediate Superior In Command, Commodore Truluck, COMMCMCRON-7, to give him a verbal OPREP-3 NAVY BLUE. Then he called the Task Force SEVEN SIX Battle Watch Captain (BWC), followed by the U.S. Pacific Fleet BWC. Then CIC prepared the written OPREP-3 NAVY BLUE messages and released them. Before daylight on 17 January, the CO was on the phone with the Commodore about three or four times to provide a status update.

446. At 0242H to 0245H, the EOOW aligned and started the Magnetic Mine Gas Turbine Generator (MMGTG) . The EOOW secured bow thruster and MMGTG due to the assessment that the ship was aground forward of frame 79 and the bow thruster was out of the water. The DCA ordered ZEBRA set throughout the ship. Navigation reported to the EOOW that the tide was falling and that the next assessed high tide would be at approximately 1400.

447. The ANAV used the STELLA program to calculate the tides, but the closest location with a tide table was Porta Princessa, RP, which was over 75 nautical miles away.

448. At 0246H, the DCA reported that the sea water leak in AMR through #4 hydrophone had been secured.

449. At 0248H, the OOD ordered all engines stop.

450. At 0250H, the EOOW aligned number one and number two reverse osmosis units to fill the potable water tank in space 3- 43-2-W.

451. At 0253H, CIC personnel sounded the SONAR sea chest and the water level measured six feet by lead line. Coral was visible at the bottom of the SONAR sea chest trunk.

452. At 0259H, the DCA reported a leak in bow thruster at a rate of approximately a half gallon per minute. DCA reported ZEBRA set throughout the ship.

453. At 0300H, the EOOW emergency stopped 1A and 2B MPDEs and placed them offline.

454. At 0307H, Navigation energized lighting indicating a vessel not under command.

455. At 0323H the CO ordered All Back 2 in order to keep the ship perpendicular to the reef and straight. The DCA informed the CO that All Back 2 was against standard aground procedure and the CO acknowledged. Sounding of the water depth from frame 79 to 107 was approximately 50 feet. The Port and Starboard shafts were clear of the reef.

456. At 0400H, the OOD energized the waterline security lights on the fantail in order to increase visibility.

457. At 0414H, Navigation shifted to DAGR to indicate the ship’s position because the AN/WRN-6 figure of merit indicated five.

458. At 0436H, USS GUARDIAN was resting on Tubbataha Reef with a list of zero degrees and pitch of positive 3 degrees. Tubbataha Reef was indicated on DNC® COA11D in VMS to be 7.5 nautical miles away bearing 113 degrees true.

459. At 0448H, the EOOW ordered a lube oil sample drawn on 2A and 1B main propulsion diesel.engines and both tested satisfactory. The EOOW ordered the alignment of #2 potable water pump to take suction from tank 3-43-1-W; potable water was available throughout the ship for drinking purposes only. The EOOW secured #2 air conditioning plant.

460. At 0510H to 0511H, the EOOW stopped #2 fire pump and #1 auxiliary seawater pump and aligned emergency cooling water to the auxiliary machinery room.

461. At 0513H, the EOOW conducted a water indicator paste test on storage tanks 3-34-2-F, 3-34-1-F, 3-29-1-F, 3-29-2-F and service tanks 2-87-3-F, 2-87-4-F, 2-87-1-F, 2-87-2-F, 2-27-2-F and 2-27-4-F to ensure fuel system integrity.

462. At 0517H, the CO ordered all engines stop.

463. From 0519H to 0522H, the EOOW stopped and placed all four main engines offline. The EOOW ordered a lube oil sample be drawn on the port and starboard hydraulic power units.

464. At 0536H, the EOOW secured potable water throughout the ship, stopped #2 auxiliary seawater pump and aligned emergency seawater cooling to the Main Machinery Room (MMR).

465. At 0603H, the Communication Watch Officer reported that River City set throughout the ship.

466. At daybreak, approximately 0610H to 0630H, a small boat approached USS GUARDIAN. The CO was on the Bridge speaking with the ISIC on the Iridium phone. ENS was on the Bridge as DC Plotter and heard the boat hail USS GUARDIAN on the BTB radio. ENS picked up the handset and responded to the hail.

467. The OOD called away the Snoopy Team to respond to a small craft approaching on the starboard side. The SCAT also manned their stations, but no order was passed to station the SCAT. The OOD directed that the weapons remain uncovered. The small craft identified herself as “Philippine Park Rangers” or “Park Rangers.” The vessel had approximately five personnel onboard and at least one man was armed with a shoulder carried weapon. The small boat was not flying a flag or displaying any other identifying markings.

468. The small grey boat had a few men onboard. There was no flag. I heard the small boat hail our ship on the BTB radio. I believe they called themselves “Philippine Park Rangers” or just “Park Rangers.” The small boat offered assistance. USS GUARDIAN responded that she was a U.S. Navy warship and did not need any assistance. Then the small boat requested to come onboard USS GUARDIAN. The OOD ordered the radio talker to inform the small boat via BTB radio that they could not come onboard.

469 . ENS made his very first log entry onboard USS GUARDIAN in the BTB Log: “0625 – Contact with Philippine Navy Craft- They are returning to Ranger station.”

470. At 0617H, the EOOW reported an engineering casualty of high jacket water temperature on lA Ship’s Service Diesel Generator (SSDG) . The Electric Plant Control Console (EPCC) removed the load from lA SSDG and placed USS GUARDIAN on single generator operations.

471. At 0618H, the EOOW stopped the port and starboard shaft Main Reduction Gears and controllable propeller lube oil standby pumps. The EOOW secured the port and starboard steering units and low-load electronic equipment in order to maintain a low load on the last generator, #2 SSDG, which was providing power throughout the ship. The EOOW emergency stopped lA SSDG due to uncontrollable overheating. The EOOW aligned emergency cooling to lA SSDG.

472. At 0635H, the CICWS logged that Mount 51 and Mount 52 were manned and the weapons were in Condition 4.

473. At 0639H to 0645H, the EOOW barred over lB SSDG and reported 92 percent potable water. The DCA reported the leak in bow thruster was under control and leaking at one gallon per hour, and that dewatering was in progress and being maintained by buckets and a vacuum. The DCA setup a P-100 portable pump in the event the ship lost number three fire pump.

474. At 0710H, Navigation secured the fathometer.

475. At 0730H, Navigation began logging the ship’s position in the Standard Bearing Book. The position logged was latitude 08 degrees 48.5 minutes North, longitude 119 degrees 48.5 minutes East. No bearings to the Tubbataha Reef lighthouse were recorded for the duration of the grounding. The last log entry was at 180453H January 2013.

476. At 0803H, the EOOW ordered a heat stress survey conducted in the MMR with a stay time of five hours. The EOOW ordered all four main engines barred over.

477. At 0849H, the CO entered the Bridge and ordered the start of anchor windlass in order to assist in rousting the anchor chain on deck and move it to the fantail in order to distribute weight aft.

478. At 0852H, the Bridge shifted control of port and starboard shafts to CCS. [Encl (14)]

479. Between 0859H and 0948H, eight shots of anchor chain were moved to the fantail for weight distribution. Shots nine and ten remained in the anchor chain locker.

480. At 1000H, the EOOW ordered the anchor chain locker gas freed. The gas free results were oxygen of 20.5 percent, carbon monoxide of zero, hydrogen sulfide of zero, and lower explosive limit ofzero.

481. At 1023H, DCA and MN3 a Search and Rescue (SAR) swimmer, entered the water to take video and pictures of the damage below the waterline.

482. At 1132H, the CO ordered to shift control of the port and starboard steering gear units from CCS to the Bridge and ordered the EOOW to come to split plant. The EOOW started the port and starboard steering gear units and transferred control to the pilot house with the starboard unit in the lead.

483. At 1134H, the EOOW aligned and started the port and starboard Main Reduction Gear and controllable pitch propeller lube oil and standby pumps.

484. At 1139H, the EOOW started and stopped the pre-lube pumps on all four main propulsion diesel engines. 485. At 1140H, the EOOW ordered the alignment and start of 1A/B and 2A/B MPDEs and verified the Bridge throttle control was placed at All Engines Stop.

486. At 1142H, the Bridge took control of the port and starboard shaft. The CO ordered All Engines Back 2. This order commenced the CO’s second attempt to back off the reef.

487. From 1148H to 1204H, the OOD ordered All Engines Back 4, Back 2, Back 6, Back 2, and finally Back 1 in an effort to free USS GUARDIAN from the South Islet of Tubbataha Reefs.

488. From 1221H to 1235H, the OOD ordered various engine and rudder combinations in an effort to free the ship from Tubbataha Reef.

489. At 1225H, the Main Propulsion Assistant, ENC, made the recommendation to secure 1A MPDE and place the engine out of commission due to a consistent overheating condition.

490. At 1300H to 1303H, the OOD ordered all engines back 6, and then all engines back 2.

491. At 1307H, the AMR watch stander reported a cracked beam in the AMR bilge but reported no water intrusion.

492. From 1330H to 1340H, the OOD ordered various engine and rudder combinations in an effort to free the ship from Tubbataha Reef.

493. At 1402H, the EOOW ordered 1A MPDE online.

494. From 1416H to 1434H, and for the last time during the mid day tide window, the OOD ordered various engine combinations in an effort to free the USS GUARDIAN from

495. At 1434H, the OOD ordered all engines stop.

496. At 1435H, the EOOW took control of the port and starboard shafts, transferred control of steering gear units to aft steering, and placed all four MPDEs offline in cool down. The EOOW reported to the OOD that the ship had 90 percent potable water.

497. At 1447H, the EOOW secured the port and starboard controllable pitch propeller lube oil standby pumps.

498. At 1449H, the EOOW notified the CO and the CHENG that port and starboard Main Reduction Gear lube oil standby pumps were secured and that the port and starboard shaft would not be jacked over in order to maintain a low load on #2 SSDG.

499. At 1459H, the OPS Officer assumed the watch as OOD.

500. From 1518H to 1521H, the EOOW aligned, started, and stopped the #2 fire pump. The #2 refrigeration unit tripped offline due to low firemain pressure.

501. At 1530H, the AMR watch stander discovered a ruptured pipe in #1 air conditioning plant auxiliary seawater supply system at the rate of one half gallon per minute. The leak was isolated and the watch stander attempted to apply a soft patch.

502. At 1706H, the EOOW conducted a follow on heat stress survey and determined the maximum stay time in the MMR was seven hours. The DCA reported that the soft patch applied to the piping in the AMR had slowed the leak.

503. At 1808H, the EOOW secured potable water throughout the ship.

504. At 1812H, the CHENG assumed the watch as OOD.

505. At 1900H, all watch stations throughout the ship reported all secure and seawater leakage was being maintained. Personnel were sent aloft to change light bulbs on mast.

506. At 2010H, all personnel working aloft were secured.

507. At 1900H, the sounding watch reported three feet sounding on the forecastle.

508. At 1930H, the sounding watch reported three point five feet sounding on the forecastle.

509. At 2032H, the sounding watch reported four feet sounding on the forecastle.

510. At 2052H, the sounding watch reported four feet sounding on the forecastle port and starboard side.

511. At 2054H, the sounding watch reported four feet sounding at midships frame 59.

512. At 2055H, the sounding watch reported eleven feet sounding on the the boat deck.

513. At 2100H, all watch stations through out the ship reported all secure and seawater leakage was being maintained.

514. At 2101H, the sounding watch reported 39 feet sounding at frame 79.

515. At 2119H, the DCA assumed the watch as OOD.

516. At 2131H, the sounding watch reported four feet sounding on the forecastle.

517. At 2150H, the EOOW reported 85 percent potable water.

518. At 2359H, CHENG reported all damage and flooding resulting from grounding appeared to be under control. Wave activity appeared to be banging/grinding the hull and keel against the reef, and he anticipated greater damage the longer the ship remained aground.

519. On 18 January 2013, the midnight entry in the Ship’s Deck Log midnight stated: “CONTINUED THE WATCH, SHIP REMAINS AGROUND AT 08° 48.537’N 119° 48.579’E. ZEBRA IS SET MAIN DECK AND BELOW. WATCHES STATIONED IN FWD PUMP ROOM AND BOW THRUSTER. THE ENGINEERING WATCH IS SET IN CCS AND INTERNAL ROVER IS SET THROUGHOUT THE SHIP. THE FORECASTLE LOOKOUT IS SET, THE AFT LOOKOUT IS SET, THE TOPSIDE ROVER IS SET. CONDITION II IS SET ON ALL CREW SERVED WEAPONS. THE CO IS OFF THE BRIDGE. “

To follow this along in the report, go to page 103 for the rest of the timeline.

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