Abordaje. El "Urduliz" es abordado por el portaviones USA " Eisinhower"

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Naval Science 304: Navigation and Naval Operations II

Lesson 14: Case Study: Ramming of the Spanish Bulk Carrier Urduliz by USS Dwight D. Eisenhower

EXECUTIVE SUMMARY

At approximately 0820, on August 29, 1988, the nuclear powered aircraft carrier USS Dwight D. Eisenhower (CVN 69), while entering the harbor at Hampton Roads, Virginia, struck the anchored Spanish bulk carrier Urduliz. The Urduliz was anchored adjacent to the Entrance Reach Channel waiting for a berth at the coal loading piers at Larnberts Point, Norfolk, Virginia. The Eisenhower was returning to its home port of Norfolk, Virginia, after a 6 month deployment in the Mediterranean Sea. No one was injured. The accident resulted in $2 million in estimated damage to the Eisenhower and $317,128 in damage to the Urduliz. The safety issues discussed in the report are:

1. The pilot employment practices of the U.S. Navy for its vessels transiting Norfolk harbor.
2. The location of the anchored Urduliz in relation to the channel.
3. The U.S. Navy harbor control of naval vessel traffic.
4. The non-navigational factors associated with the arrival from an overseas deployment which influence navigational decisions.
5. The Entrance Reach Channel width and navigation aids.

Recommendations concerning these issues have been made to the U.S. Navy and the U.S. Coast Guard. The National Transportation Safety Board determined that the probable causes of this accident were the delayed and insufficient action to correct the Eisenhower's deviation from the intended track by the navigator and the officer of the deck stemming from inexperience in piloting the vessel through the restricted channel in Hampton Roads; the selection by the navigator of a course through the Entrance Reach Channel that did not compensate for the current and the wind; and the inadequate monitoring of the navigation of the vessel by the commanding officer. Contributing to the accident was the navigator's order to reduce the speed from 5 knots to 3 knots in an attempt to reach buoy "3" at a prescribed time and the inadequate guidance by the U.S. Navy on the use of pilots on large vessels.

NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D.C. 20594
MARINE ACCIDENT REPORT
RAMMING OF THE SPANISH BULK CARRIER URDULIZ
BY THE USS DWIGHT D. EISENHOWER (CVN 69)
HAMPTON ROADS, VIRGINIA
AUGUST 29, 1988

INVESTIGATION

Events preceding the Accident
On August 13, 1988, the 897-foot-long Spanish bulk carrier Urduliz (see figure 1) departed Gijon, Spain, for Norfolk, Virginia, to load a cargo of coal, as part of a long term charter to deliver coal to Gijon. At 1219, on August 25, 1988, the vessel arrived at Hampton Roads, southwest of Old Point Comfort, Virginia, and anchored in berth "Z," anchorage "A" (see figure 2), under the direction of a pilot from the Virginia Pilot Association. The pilot anchored the vessel near the center of the 1,500-foot radius of the circular-shaped berth as marked on the National Oceanic and Atmospheric Administration (NOAA) navigation chart numbered 12245 (47th edition, dated June 30, 1984; this was the latest edition of the chart). He used the port anchor and six shots (540 feet) of anchor chain to hold the Urduliz in the anchorage and departed the vessel at 1330. The vessel remained anchored awaiting a berth at the coal loading piers at Lamberts Point, Norfolk, Virginia. (See figure 3.) Anchor bearings recorded in the Urduliz deck log on August 25, and marked on its navigation chart, located the vessel's navigation bridge within 300 feet of the center of berth "Z." The bow of the Urduliz was about 1,200 feet north of the northern edge of the Entrance Reach Channel as marked on NOAA chart 12245. This was also about 600 feet north of the new northern edge of the channel delineated by the Newport News Channel Lighted Buoy "2" and the Thimble Shoal Channel Lighted Buoy "22" which had been repositioned on March 24, 1988. (See the section entitled "Entrance Reach Channel and Channel Marking" for more details.) At 0650, on August 29, 1988, the vessel's agent notified the master of the Urduliz to be ready to move the vessel from the anchorage to the coal piers at 0900. According to the master, at 0700, in preparation for the move, all navigational equipment, steering, and emergency maneuvering systems were tested and found to be satisfactory.

On August 27, 1988, after a 6 month deployment in the Mediterranean Sea, the 1,090-foot-long United States Navy (Navy) nuclear powered aircraft carrier, the USS Dwight D. Eisenhower (CVN 69) (Eisenhower) (See figure 4) boarded about 500 "Tigers"¹ at Bermuda while on the final leg of its return voyage to its home port at Norfolk, Virginia. During the afternoon of August 28, the junior officer of the deck/conning officer (JOOD) scheduled to conn² the Eisenhower into Norfolk conducted a navigation briefing for entering port with the commanding officer (CO), the officer of the deck (OOD), the navigator, and the navigation teams. The OOD stated that procedures for entering port, courses, speeds, changes to channels and buoy placement, and other matters affecting the vessel movement were reviewed. Navigation charts had been corrected by the chief quartermasters using the weekly Notice to Mariners No. 18/88 dated April 30, 1988, to show new buoy locations. The corrected charts were used to plan the vessel's arrival. That afternoon, all of the fixed-wing aircraft assigned to the Eisenhower were flown off the vessel to return to their home units ashore. During the morning of August 29, 1988, the remaining helicopters were flown off to Norfolk area airfields while the vessel was inbound from Cape Henry, Virginia.

The Accident
At 0716, on August 29, 1988, the Eisenhower was in the Thimble Shoal Channel and passed through the southern opening of the Chesapeake Bay Bridge-Tunnel. (See figure 3.) The Eisenhower was proceeding at a speed of about 11 knots (55 RPM). On the bridge, there were at least 20 crew members for entering port: the CO, the navigator, the OOD, the JOOD, an officer liaison with the tactical operations plot (TOP) radar navigation team (he moved between the radar navigation compartment and the navigation bridge), several other officers, a chief quartermaster supervisor of visual navigation, a navigation plotter, a visual bearing recorder and sound-powered phone talker, a deck log keeper, two helmsman, a lee helmsman (engine order operator), two visual bearing takers, and several sound-powered telephone talkers connected to various stations throughout the vessel. In addition, there were 6 to 8 Tigers, news media representatives who interviewed the CO, and an undetermined number of other crew members on the bridge observing the activities. Sounds from orders and repeated orders, three radio channels, internal vessel telephones, flight operations, conversations, lookout reports, visual bearing reports, and other reports were heard on the bridge.

Many of the journalists and photographers who were embarked early on the morning of the accident for coverage of the port arrivals were on the flight deck at the time of the accident. While inbound, the Secretary of the Navy (SECNAV) and the Admiral in command of the Naval Air Force, Atlantic Fleet (COMNAVAIRLANT), arrived aboard the vessel via helicopter to formally welcome the crew of the Eisenhower on its return from its Mediterranean deployment. The COMNAVAIRLANT and the SECNAV departed the vessel via helicopter at 0732 and 0807, respectively.

At 0747, the Eisenhower exited Thimble Shoal Channel and continued on its course toward Old Point Comfort. At 0752, the OOD reduced speed to 10 knots (50 RPM). About 0753, the Eisenhower bridge watch sighted the Urduliz about 5 miles away. About 1 hour earlier, the bridge watch had been informed of a vessel anchored in berth "Z," anchorage "A," by the USS Thomas C. Hart (FF-1092), a naval vessel preceding them into Norfolk. About 0800, as the Eisenhower was approaching the turn at Old Point Comfort, the bridge watch received a bridge-to-bridge radio telephone call for a port-to-port meeting from a naval warship. The warship was "well off the port bow," and identified as a nuclear powered attack submarine. Safety Board investigators determined the submarine to be the USS Glenard P. Lipscomb (SSN 685) (Lipscomb). Port Services had scheduled it for departure from its berth at the Naval Station at 0730, and it departed between 0730 and 0800. Also about 0800, the navigator confirmed, via radiotelephone, to the Naval Station's Port Operations Department that the Eisenhower would be arriving at the Elizabeth River Channel Lighted Buoy "3" (buoy "3") at the previously scheduled time of 0845, to embark a Navy docking pilot for docking the vessel at the Naval Station. At 0805, the OOD ordered the Eisenhower's speed to be reduced to 5 knots (25 rpm). About 1 minute later, when the Eisenhower was about 0.6 nautical miles east of Old Point Comfort Light, the OOD ordered the course changed to the left to 229T from 258T. The new course of 229T was along the southern edge of anchorages "A" and "B" as marked on NOAA chart 12245 (47th edition). According to the CO, the vessel was following its preplanned track toward the northern edge of the Entrance Reach Channel and Hampton Roads. He also stated that on the new course, the wind would be coming from about 60 degrees off the port bow and a flood current of about 2 knots would be "pushing the vessel." The navigator stated that the computed wind was 23 knots on the port beam after the course change. At 0820, the meteorology officer on the Eisenhower determined the wind to be from 150T at 20 knots. The visual navigation plotting team was taking fixes at 2-minute intervals after leaving Thimble Shoal Channel and after the turn to the left obtained a fix at 0807. (See figure 2.)

The officers on the bridge of the Eisenhower observed the Urduliz anchored in anchorage "A," with its anchor chain leading forward under a moderate strain, with the bow pointing into the wind, towards the Entrance Reach Channel. The CO stated that the Urduliz heading was "just about perpendicular to our track." The officer on watch on the Urduliz estimated that his vessel was heading about 110T just prior to the accident. The navigator, OOD, and JOOD independently estimated, to themselves, that the Eisenhower would pass about 100 yards from the Urduliz and that the anchored vessel posed no hazard to their vessel.

The backup or radar navigation team took fixes at 3-minute intervals and advised the bridge that the vessel was "on track" at 0810, but the visual navigation team reported "no fix." At 0811, the navigator recommended that the OOD reduce speed to 3 knots (15 rpm) because the Eisenhower was about 4 minutes ahead of its scheduled time of 0845, for embarking the Navy docking pilot at buoy "3." The navigator recalled that he made the recommendation directly to the OOD "just loud enough for him to hear." The OOD then ordered the conning officer to reduce speed to 3 knots, who, in turn, ordered the lee helm⁵ to order the new speed to the engine rooms. The navigator stated that the reason he recommended that the OOD reduce speed was because: "I felt that --- I had some check marks on my chart and I knew where I was supposed to be when, in order to make that estimate, and I was within 4 minutes, in my mind, of being there right on time." When asked about arriving 4 minutes ahead of schedule, the navigator replied, "It's professional to be at a position when you say you're going to be there and I wanted to do that." He said that he did not want to be at "buoy '3' earlier than that and not have a pilot and tugs coming at me,... [when we are] ready to start our process of going alongside the pier." At 0813, the radar navigation team reported that the Eisenhower was 25 yards to the right of the intended track. At 0814, the Admiral in command of the Battle Group, quartered in the Eisenhower, entered the navigation bridge and his presence was announced. When asked if it was normal for the Admiral to be on the bridge, the CO stated, "That was about his third--for the morning, about his third time on the bridge. He just came by, said, 'How are things going?' and left. It didn't create any disturbance and we don't all snap to attention or anything like that when he comes on the bridge. Someone announces the Admiral's on the bridge and boom-boom there he is and somebody announces when he leaves, the Admiral's left the bridge, if somebody notices. It wasn't a disturbance factor." As the 0816 radar fix was plotted in TOP, the TOP liaison officer observed that the fix was "well right, [I] went out [to the navigation bridge] and told the navigator that the latest fix shows us at least 150 yards right, just to give him a heads up and the report came over the phone talker, officially to the OOD, the captain [CO] we were 200 yards right [of track]." The visual navigation team had not been able to obtain an acceptable fix between 0807 and 0817 and were unable to provide an explanation as to why. The chief quartermaster (chief) who was supervising the plotting of visual fixes said that at 0809 there was no fix, but that is not unusual to occasionally fail to get a fix because of missing the correct object or misreading a bearing number from the gyrocompass. But at 0810, there also was no fix. At that point, he believed that there may have been an equipment failure of some sort and had all the bearing takers check their equipment. The chief also said that the compass readings were within tenths of a degree of each other, "very minor." Attempts to get fixes continued at 1 -minute intervals, but the navigation plotter could not get a fix. About 0815, the chief relieved the plotter and erased part of the plot. He had the bearing takers check their equipment again, identify and describe the objects that they were to take bearings of, and ordered another round of visual bearings. At 0817, the visual navigation team obtained a fix that determined the Eisenhower to be about 380 yards to the right of its intended trackline. The chief said that as he was preparing to make his report, the OOD and the CO were taking action to avoid the collision.

At 0817, the OOD ordered left 10 degrees rudder and the vessel began to change course to 225T from 229T; he also advised the CO that the vessel's speed had been reduced to 3 knots. The CO stated that he had not been aware that the navigator had recommended that the OOD slow the vessel to 3 knots or that the OOD had ordered the speed reduced. The CO further stated that he "did not hear the call to the lee helm to indicate one five RPM .... which is 3 knots, and as soon as I was aware of this happening I ordered him to increase speed to 5 knots." About 0818, as the bow of the Eisenhower passed the extended centerline from the bow of the Urduliz, the CO, navigator, and OOD realized that the bearing to the Urduliz was no longer changing and a collision was imminent. The CO estimated that the distance between the vessels was about 100 to 200 feet at the time. The CO stated that the 10 degree left rudder was inadequate and directed the OOD to increase the rudder to 20 degrees left, and then to 30 degrees left; the CO then took over the maneuvering of the vessel.

The Navy docking pilot, on a tug en route to the Eisenhower, was about 1 mile away and believed that the Eisenhower was going to collide with the anchored Urduliz. He said that he didn't think the Eisenhower had much way (motion through the water), and was going sideways almost as fast as she was going ahead.

About 0819, the internal collision alarm and six blasts on the whistle (according to the inland Navigation Rules, the danger signal is five or more blasts on the whistle) were sounded on the Eisenhower. The CO stated that he ordered "shift your rudder" (rudder moved from left 30 degrees to right 30 degrees), and the engines were stopped about 0820. The Eisenhower struck the Urduliz about 0820, when it was about 400 yards to the right of its intended track. The CO stated that the nuclear attack submarine that had made the meeting agreement with them, was passing them in the Entrance Reach Channel on the port side, when the Eisenhower came into contact with the Urduliz. The submarine's berth was about 3.5 nautical miles from buoy "1ER." The Eisenhower struck the bow of the Urduliz with its starboard side between the No. 1 and No. 2 aircraft elevators. The bow of the Urduliz was caught under the overhang of the flight deck and the anchored vessel was dragged about 1,000 yards from its location in berth "Z," anchorage "A," to the southwest near the center of berth "Y," anchorage "B." The bow of the Urduliz also scraped along the starboard side of the Eisenhower for about 175 feet. The vessels remained together until 0833, when they separated without any action taken by either vessel.

The officer on watch (the third officer) on the Urduliz observed the Eisenhower approaching, but did not take any action or sound a danger signal because he believed that the vessel would come close but "would have sufficient measures to go by without colliding." However, he sent a messenger to notify the master of the potential danger. The first officer was in his room when he saw the Eisenhower approaching and went to the bridge. The master also observed the Eisenhower from a window in his office and proceeded to the bridge. On his way to the bridge, the master was met by the messenger. The master and the first officer arrived on the bridge of the Urduliz at the moment of collision. The master and the officer on watch did not hear the danger signal from the Eisenhower, but the officer on watch did hear the internal collision alarm sound from the Eisenhower. The master ordered the chief engineer to prepare the engine to be ready to answer bells and to start the emergency fire pump. He also ordered the first officer to the bow and to prepare to fight a fire, if necessary. The master and his deck watch stood-by on the bridge waiting for the Virginia Pilot Association pilot, who was en route, to move the Urduliz to the coal loading piers. About 0830, the pilot arrived on the bridge of the Urduliz. About 0837, after the vessels disengaged from one another, they were facing almost in opposite directions, with the bow of the Urduliz heading about 075T. Tension on the anchor chain caused the starboard stem of the Urduliz to swing toward the starboard bow of the Eisenhower. To prevent a second collision, the pilot on the Urduliz ordered "hard right wheel, [and] a slow ahead bell..." and moved the vessel away from the Eisenhower. The pilot remained on the anchored Urduliz and at 1700, he piloted the vessel to the grain pier south of the Naval Station for a damage survey and temporary repairs. The Navy docking pilot proceeded toward the Eisenhower after passing around the stem of the Urduliz. He did not see any propeller action from the Urduliz as he passed the vessel. At 0837, the CO ordered the rudder to right 30 degrees and the engines to slow astern. Shortly thereafter, the docking pilot arrived on the bridge of the Eisenhower and the CO passed the conn to the docking pilot. After taking over the conn, the docking pilot used four tugs on the port side of the Eisenhower, two on the bow and two on the stem, to push the Eisenhower further away from the Urduliz, and then proceeded to dock the vessel. At 0943, the Eisenhower was docked at the south side of pier 12, at the Naval Station.

Injuries to Persons
There were no injuries or deaths.

Damage to Vessels
Urduliz.--Damage to the Urduliz hull was confined to the bow above the waterline. The forecastle bulwark and deck were crushed and torn for a distance of about 12 feet aft of the stem on the centerline. The bow was also pushed in and holed into the forecastle. Permanent repairs to the Urduliz were accomplished between September 22 and 30, 1988, at the Bazan de Construcciones Navales Militares Shipyard, El Ferrol, Spain. The cost of temporary and permanent repairs of the damage to the Urduliz was about $317,128. During the repair periods, the owners of the Urduliz sustained additional financial losses of $341,587 for having the vessel out of service, for a total cost of $658,715.

Eisenhower.--Damage to the Eisenhower hull was confined to the starboard side between 50 and 65 feet above the waterline, along the underside of the flight deck. The damage extended from about midpoint between No. 1 and No. 2 aircraft elevators at the flight deck, aft to a point about midway under the flight deck level of the "island" superstructure, a distance of about 175 feet. There was minor structural damage to the underside, of the No. 2 elevator; however, the damage did not affect its operation. Walkways and safety nets were crushed and tom away from the underside of the flight deck. The CO's cabin located under the island was extensively damaged. In addition, 23 inflatable life rafts were dislodged from their stowed positions on the starboard side of the flight deck. Some of the life rafts came to rest on the forecastle of the Urduliz, while the others went into the water and were recovered by Coast Guard patrol boats. The cost of repairing the damage on the Eisenhower was estimated to be $2 million. The repairs were completed in conjunction with the Eisenhower's previously scheduled shipyard period between October 3, 1988, and March 10, 1989.

Crew Information
Urduliz.--There were 38 persons on board the Urduliz at the time of the accident; 36 crewmembers and 2 Spanish citizens carried as persons in addition to the crew. All crewmembers were Spanish citizens who were either licensed or documented by the Spanish government. The master of the Urduliz had held his position on the vessel for about 2 1/2 months, the period of time that the present owner had owned the vessel. He had been working for this company for 24 years and been master of several of their vessels for 15 years. The master had been going to sea for the past 34 years and had held a master's license for 26 of those years. The third officer had held his position on the vessel for about 20 days and had been aboard 4 months during the early part of 1988, when the vessel was owned by another company. He had been going to sea for the past 13 years.

Eisenhower.--When fully manned, the Eisenhower carries a crew of 6,042 officers and enlisted men, consisting of 3,105 in the ship crew, 72 marines, and 2,865 in the air wing.⁶ The CO, a 51-year-old aviator with the rank of captain, assumed command of the Eisenhower in October 1986. At the time of the accident, he had served in the Navy as a commissioned officer for about 28 years and had accumulated almost 14 years of sea duty. Immediately before his assignment to the Eisenhower, he had served 2 years as the CO of the combat stores auxiliary vessel USS Niagara Falls (AFS-3), preceded by almost 3 years as executive officer (XO) on the nuclear powered aircraft carrier USS Carl Vinson (CVN-70), a sister vessel to the Eisenhower. While assigned to the Vinson and the Eisenhower, he had completed numerous transits of Hampton Roads. Prior to his assignment as XO of the Vinson, about 7 years of his 14 years of sea duty was on aircraft carriers as an aviator assigned to various aviation units. The CO reported that during the night before the accident, he slept in his cabin between 2130 and 0430. He said that he had slept well, interrupted by only a few calls about vessel traffic. He awoke at 0430, went to the bridge, and remained there throughout the morning. He stated that he felt rested and that his judgment had not been impaired by fatigue. The navigator, a 42-year-old aviator with the rank of commander, was assigned as navigator of the Eisenhower in November 1986. At the time of the accident, he had served in the Navy as a commissioned officer for about 20 years. Prior to this assignment, he had about 2 1/2 years of sea duty, from September 1976, to January 1979, on board the aircraft carrier Midway (CV 41), stationed in Japan. He served as assistant navigator and qualified as OOD. Upon assignment to the Eisenhower, he completed the navigation officer shipboard celestial navigation course and a 2-day practical shiphandling course. He qualified as Command Duty Officer (CDO)(underway)⁷ in February 1987. He was the navigator during the Eisenhower's coastal, Latin American, and Caribbean operations, when the vessel was brought to readiness for fleet operations prior to departure to the Mediterranean Sea on February 29, 1988. He accrued a career total of 4 years of non-aviation sea duty in two assignments as assistant navigator and navigator aboard two aircraft carriers (Midway and Eisenhower, respectively) in the preceding 12 years before this accident, which were separated by 8 years of aviation assignments. Prior to the date of this accident, he had completed numerous transits of Hampton Roads while assigned as the navigation officer on the Eisenhower. He said that he "got 8 hours plus sleep the night of the 27th, which is embarrassing for a navigator." He also said that during the evening before entering Norfolk harbor (28th), he had "...plenty of sleep;" he slept 6 hours between 2100 and 0300, with two brief interruptions. He awoke at 0300, and arrived on the bridge at 0330. The OOD, a 32-year-old aviator with the rank of lieutenant, was assigned as assistant navigator on the Eisenhower in June 1987, for his first shipboard assignment. At the time of the accident, he had served in the Navy as a commissioned officer for about 10 years. He served as assistant navigator during the Eisenhower coastal, Latin American, and Caribbean operations before departing on the Mediterranean Sea deployment. He became qualified as OOD (underway) in August 1987. He had never served as OOD during a transit of Hampton Roads. He said that during the evening before entering Norfolk harbor, he had had 5 hours sleep, awoke at 0300 and arrived on the bridge at 0345 to assume the duties of navigation officer-of-the-watch. At 0530, the vessel's navigator assumed the duties of navigation officer-of-the-watch and the assistant navigator assumed the duties as OOD for entering port.

The CO, navigator, and OOD each reported that they were in good health and not suffering from any chronic or acute ailments or illnesses at the time of the accident. Each reported that his vision and hearing were within normal limits. This investigation disclosed no evidence of adverse medical history, chronic, or acute ailments to suggest that the performance of any member of the navigation crew was adversely affected by his physical condition. (See appendix 8 for additional details about the crew.)

Vessel Information
The principal characteristics of the two vessels are as follows (see figure 5):
Urduliz Eisenhower⁸

Urduliz.--The Urduliz, Lloyd's Register of Shipping number 7320526, originally named Urquiola, was built in December 1973, by Astilleros Espanoles DCN S.A., Bilbao, Spain, as a tank vessel. After a grounding and fire in May 1976, the forward and cargo sections were replaced in August 1983, at the Bazan de Construcciones Navales Militares Shipyard, El Ferrol, Spain. The rebuilt vessel was renamed Argos. The cargo tanks of the rebuilt Argos were strengthened to enable the vessel to carry heavy bulk cargoes. In May 1988, the vessel was purchased by its present owner, Naviera Vizcaina S.A., Bilbao, Spain, and renamed Urduliz.

The Urduliz was a single-rudder, single-screw, motor vessel powered by a two-cycle, single-acting 9 cylinder diesel engine. The deckhouse was located aft and it had a raised forecastle. The navigation bridge was located about 745 feet aft of the bow and the height of eye⁹ was about 84 feet above the waterline. Between the forecastle and the deckhouse were nine cargo holds/tanks. It had a normal bulk carrier bow, with the bow flaring forward about 15 feet from the hull at the 50- foot height above the keel to the forecastle bulwark to minimize deck wetness. The top of the bow bulwark was about 82.5 feet above the keel.

The Urduliz was equipped with standard navigational equipment, including two Raytheon marine radars, one Raytheon collision avoidance radar, one Magnavox satellite navigation system, one Decca navigation system, and one loran-C navigation system, one ITT direction trader, one Japan Marine Company fathometer, and an Anschutz gyroscope compass with a repeater on each bridge wing. The navigation charts for Hampton Roads had been corrected to show the latest buoy locations.

Eisenhower.--The Eisenhower was the third nuclear-powered aircraft carrier built at the Newport News Shipbuilding & Drydock Company, Newport News, Virginia. It was commissioned for service in the United States Navy on October 13, 1977. The ship had two rudders, four propellers, and was powered by four steam turbines. Main propulsion steam was provided by two Westinghouse nuclear reactors. The Eisenhower had a top speed in excess of 30 knots. The vessel cost approximately $1.9 billion to build. The navigation bridge was in the superstructure on the starboard side of the flight deck, known as the "island," about 673 feet aft of the bow. The height of eye on the navigation bridge was about 45 feet above the flight deck and about 108 feet above the waterline. The starboard side of the bridge was offset outboard from the starboard side of the hull about 60 feet and about 106 feet from the vessel centerline. The flight deck creates a "shadow area" within which small floating objects cannot be seen. The extent of the area obstructed from view varies depending upon the height of the observer above the deck. From the navigation bridge, the area obstructed varied from about 620 yards on the bow, to about 195 yards on the port beam, and to about 357 yards on the stem (see figure 6).

The Eisenhower navigation bridge measures about 40 feet from port to starboard and about 10 feet from forward to aft. Extending out from the starboard after comer of the bridge was an auxiliary conning station. It measured about 6 feet by 6 feet square. This station had windows on three sides for visibility from forward to aft on the starboard side of the vessel. The main navigation bridge windows provided a view to starboard, forward, to port, and a full view of the flight deck forward and aft. On the after side of the bridge was a passageway on each side leading from the bridge, and the TOP compartment forming the center after bulkhead. (see figure 7.)

The Eisenhower navigation bridge was equipped with a Raycas V marine radar, a Furuno radar, two radar repeaters, a Northstar loran receiver, a Shipmate Decca receiver, two satellite receivers, a fathometer, and five gyroscope compass repeaters (one at the chart table on the starboard forward corner, one on the port side aft by a window, two in the auxiliary conning station, and one that was on a 5-foot track at the forward center windows). The helm, engine order telegraph, two gyroscope compasses, and a magnetic compass were in a console to the left and aft of the center windows. There were two stationary chairs: one for the CO on the port side forward of the after gyroscope compass repeater and one for the navigator on the starboard side aft of the chart table. All navigation equipment was operating properly before, during, and after the accident. The navigation charts for Hampton Roads had been corrected to show the latest buoy locations.

Waterway Information

Norfolk, Virginia, is located at the southeastern part of the state and at the Southwestern corner of the Chesapeake Bay. The U.S. Naval Station piers at Norfolk are located about 18 nautical miles west of the entrance to the Chesapeake Bay from the Atlantic Ocean. To reach the piers, vessels from the ocean must transit Thimble Shoal Channel, which crosses the southern end of the Chesapeake Bay; pass through the bridge opening at the lower end of the Chesapeake Bay Bridge-Tunnel; pass between Old Point Comfort on the north and Fort Wool on the south; transit the Entrance Reach Channel at Hampton Roads; and enter the Norfolk Harbor Reach Channel which is adjacent to the west side of the Naval Station. The channels are maintained at a minimum depth of 45 feet. (See the "Other Information" section for more details on the channels.) Except for areas close to shore, the water is about 18 feet deep from the Atlantic Ocean to Hampton Roads. The channel boundaries are marked by numerous buoys along the route. The buoys are generally 1/4 nautical miles apart near turns to about 1 nautical mile apart along straight sections of a channel.

The predicted tidal currents calculated by the Safety Board from the Tidal Current Tables¹⁰ for 0.55 nautical miles east of Old Point Comfort (37 00.12'N, 076 17.72'W) for August 29, 1988, were:

Time State of Current Speed Direction
0421 slack water 0.0 ----
0807 flood 1.7 knots 251T
0931 maximum flood 2.2 knots 251T

The predicted tidal currents calculated by the Safety Board for 0.2 nautical miles south of Old Point Comfort (36 59.77'N, 076 18.88'W) for August 29, 1988, were:

Time State of Current Speed Direction
0646 slack water 0.0 ---
0815 flood 1.5 knots 240T
0938 maximum flood 2.7 knots 240T

The predicted tidal currents calculated by the Safety Board for 0.2 nautical miles northwest of Fort Wool (36 59.3'N, 076 18.42'W) for August 29, 1988, were:

Time State of Current Speed Direction

0614 slack water 0.0 ---
0815 flood 1.6 knots 240T
0851 maximum flood 2.1 knots 240T

The predicted tidal currents calculated by the Safety Board for mid-channel off Old Point Comfort (36 59.3'N, 076 19.3'W) for August 29, 1988, were (see figure 2 for the locations of the predicted currents):

Time State of Current Speed Direction

0646 slack water 0.0 ---

0815 flood 1.2 knots 260T

0951 maximum flood 2.5 knots 260T

Shortly after the accident, the Coast Guard checked the position of the Thimble Shoal channel buoys "21" and "22", and Entrance Reach Channel buoys "1ER," "3," and "5," and found them to be operating properly and at the position as required on the navigation charts of the area, as corrected by and listed in the weekly Notice to Mariners No. 18/88 dated April 30, 1988.

Meteorological Information

The weather as reported by the meteorological officer on the Eisenhower was 6 miles visibility, air temperature 78.5 F, wind direction from 150T at 20 knots, and 2-foot "wind" waves. The prevailing winds from March through August and November through January are from the southwest, in February from the north-northeast, and in September and October from the northeast. The temperatures are generally mild with about 2 days of heavy fog per month.

Other Information

U.S. Army Corps of Engineers Projects in the Norfolk, VA, Area.--In 1969 and 1970, dredging of the channels to a depth of 45 feet was completed in the Hampton Roads area and the Thimble Shoal Channel. According to the U.S. Army Corps of Engineers'(COE) Project Engineer for Dredging Management, Norfolk, the depths and channel configurations were maintained accordingly, until recently. In 1986, the COE was authorized under a project entitled "Norfolk Harbor and Channels, Virginia" to dredge channels in the Hampton Roads area and Thimble Shoal Channel to a depth of 55 feet, in two phases. During phase I, which was completed December 15, 1988, the COE dredged 650 feet of the outbound-side of the 1,000-foot wide channels at Thimble Shoal, Entrance Reach, Newport News, and Norfolk Harbor Reach to a depth of 50 feet and the remaining 350 feet on the inbound-side were maintained at 45 feet. The Entrance Reach Channel was also reduced in width from 1,500 feet to 1,000 feet. The COE expects to commence phase II, dredging the 650-foot channel width to the 55-foot depth and the 350-foot side to the 50-foot depth, in fiscal year 1991.

Entrance Reach Channel and Channel Marking.--The Entrance Reach Channel is located between Old Point Comfort and Fort Wool on the east and Sewells Point in the west, where it joins the Newport News Channel and the Norfolk Harbor Reach Channel. Prior to March 30,1988, the southern side of the Entrance Reach Channel was marked with the Elizabeth River Channel Lighted Horn Buoy (LHB) "1" (buoy "1") near Fort Wool and the Elizabeth River Channel Lighted Buoy "3" (buoy "3") northwest of Sewells Point. A line drawn between the buoys marked the southern edge of the 45-foot channel. The northern side of the channel was located on the southern edge of anchorages "A" (berth "Z") and "B" (berths "X," "Y," and "W"), and generally on a line drawn between the Naval Ordnance Lighted Buoy "T" (buoy "T") east of Old Point Comfort and the Newport News Channel Lighted Buoy "2" (buoy "2"). The distance between buoy "T" and buoy "2" is about 3.5 nautical miles. The width of the channel was 1,500 feet.

On March 24, 1988, Thimble Shoal Channel Lighted Buoy "22" (buoy "22"), near Thimble Shoal Light, was relocated close to the eastern side of Old Point Comfort. There are no buoys between buoy "22" and buoy "2" on the "new" northern side of the Entrance Reach Channel a distance of about 3.2 nautical miles. When the Coast Guard witness was asked how the northern side of the channel will be delineated from the anchorage, he said that: "There will be no markings adjacent to the channel or demarcation line adjacent to the channel. Generally, when you put buoys near an anchorage, they get run over and they serve only as a hazard to navigation." A vessel on a course coinciding with a line drawn between relocated buoy "22" and buoy "2" would be encroaching on the southern edge of anchorages "A" and "B."

On March 29, buoy "3," also located on the south side of the channel, was relocated about 200 yards to the north, on the 50-foot water depth contour curve. On March 30, 1988, buoy "1," located on the southern side of the channel, was relocated about 700 yards to the west at the edge of the 50-foot water depth contour curve and renamed buoy "1ER." As a result of these changes, the Entrance Reach Channel became 1,000 feet wide between the lines created by buoy "22" and buoy "2" (on the northern side) and the Elizabeth River Lighted Buoy "1ER" (buoy "1ER") and buoy "3" (on the southern side). Further, the new location of these buoys on the southern side of the channel, and the southern edge of anchorages "A" and "B" on the northern side of the channel, as marked on the navigation charts available at the time of the accident, reduced the width of the channel available south of anchorages "A" and "B" to about 700 feet near buoy " 1ER" and to about 900 feet near buoy "3." The charts on the Eisenhower and the Urduliz, in use on the date of the accident, had been corrected with these buoy changes.

The CO of the Eisenhower testified about the new channel configuration and said that "...there's not adequate room for two ships to pass. Not carrier-size ships or a carrier-size ship and a submarine."

Anchorages.--The anchorages in the Hampton Roads area at the time of the accident are described in the regulations at Title 33 Code of Federal Regulations (CFR) Subpart 110.168. In the Hampton Roads area, there are a number of anchorages for use by commercial and naval vessels. Counter-clockwise from Old Point Comfort to Newport News, Virginia, the anchorages were designated: "A," "B," "C," "E," "D," "Ig," and "F-l." Anchorage "A" was reserved for commercial vessels undergoing examination for quarantine, customs, or immigration. It was also used by deep draft vessels waiting for a dock to load or unload cargo. Vessel masters were not required to obtain permission to anchor in this anchorage. In the southeast corner of the anchorage was located the 1,500-foot-radius berth "Z." The edge of the radius of berth "Z" was about 650 feet north of the northern edge of the Entrance Reach Channel before the channel was narrowed. After it was narrowed, the outer edge of berth "Z" was about 300 feet from the channel edge. Anchorage "B" was a deep water Naval anchorage. Within the anchorage boundaries were located three circular 1,800-foot-radius berths: "W," "X," and "Y." The southern boundary of anchorages "A" and "B" (berths "W," "X," "Y," and "Z") was also the northern edge of the previous Entrance Reach Channel, but it was not marked by any buoys.

On March 22, 1984, the Coast Guard published an advance notice of proposed rulemaking announcing its intention to review and amend the anchorage regulations for Hampton Roads and adjacent waters. The proposal was made to accommodate the intended construction of the Newport News Bridge-Tunnel, a proposed widening and deepening of the Newport News Channel, and the construction of a Navy ammunition barge mooring facility in anchorage "B." The Coast Guard stated that after the proposal was published "there were a multitude of meetings held with the Virginia Pilot Association, industry groups and the U.S. Navy to discuss changes to the anchorages and channel realignment/marking." No other proposals were published until June 3, 1988, when the Coast Guard published a notice of proposed rulemaking to completely revise the special anchorage areas, anchorage grounds, and regulated navigation areas in the Hampton Roads area. The proposal to revise the regulations was prompted by dredging projects that had been completed, were in progress, or were planned for the Hampton Roads area and "a culmination of those meetings, discussions and negotiations [held between 1984 and 1988]." One of the changes adopted was the renaming of anchorages "A," "B," and "C" to "F," "G," and "H." Anchorages "A" and part of "B" became anchorage "F," parts of anchorages "B" and "C" became anchorage "G," and the remaining part of anchorage "C" became anchorage "H." Berths "X" and "Y" (in anchorage "B") and berth "Z" (in anchorage "A") were renamed to berths "G2," "GI," "Fl," and "F2," respectively. (See figure 8.) The southern boundary of anchorages "G" and "F" were moved northward in order to be aligned with the new northern edge of the Entrance Reach Channel. Berth "F2" has roughly the same southern position as the previous berth "Z" and is about 100 yards north of the new channel edge. The final rules were published in the Federal Register on January 9, 1989, and became effective on February 8, 1989.

Pilotage.--The Commonwealth of Virginia requires foreign vessels, or U.S. registered vessels departing on or returning from a foreign voyage, to engage the services of a State pilot (pilot). The Federal government requires a Coast Guard licensed pilot on a U.S. commercial vessel of 1,600 gross tons or more on a coastwise voyage while the vessel is in U.S. "pilotage waters." The master of a U.S. commercial vessel on a coastwise voyage can satisfy this requirement by employing a State pilot with a Federal license or independent federally-licensed pilot or by utilizing a member of the vessel's crew who has been issued a Coast Guard pilot's license for those waters. Federal law excludes military and other public vessels from State or Federal pilot requirements.

There are two state pilot associations for the Chesapeake Bay: The Association of Maryland Pilots and The Virginia Pilot Association (VPA). The pilots in these associations are licensed to pilot any foreign or domestic vessel to any respective Maryland or Virginia port. There is also a federal pilot association: the Chesapeake and Interstate Pilots (C & IP) whose members pilot domestic vessels not on foreign voyages on the waterways for which they are licensed by the Coast Guard. All pilots are embarked and debarked at the entrance to the Chesapeake Bay.

The Navy in Norfolk, Virginia does have contracts with pilot associations, and pilots are available for use by naval vessels. The Naval Station Port Operations Department will arrange for a pilot for a naval vessel upon request. If the pilots are not ordered through the Naval Station, then the services are charged to the requesting vessel's funds. In November 1985, the C&IP was awarded the Navy contract for piloting its vessels in the Chesapeake Bay area. The association's six pilots reported that between November 1985 and November 1988, they piloted about 292 naval ships of all sizes, most of which were large deep draft vessels (vessels with drafts in excess of 25 feet). Each C&IP pilot averages about 50 commercial ship transits a year in the Hampton Roads area. According to the Commander, Naval Station (COMNAVSTA), Norfolk, Virginia, between October 1, 1987 and September 30, 1988, 2,028 Naval vessels arrived or departed the Naval Station or the Craney Island Fuel Depot southwest of the Naval Station. The Navy did not have any vessel movement data for other locations in the Hampton Roads area.

Between November 1984 and November 1985, the last year that the VPA had the Navy piloting contract, the approximately 51 VPA pilots piloted 146 naval ships of all sizes, most of which were larger deep draft vessels. Each VPA pilot averages about 170 commercial vessel transits a year in the Hampton Roads area. Officers, including CO's of Navy vessels stationed in Norfolk, revealed that Navy vessels transiting Hampton Roads do not routinely utilize the services of pilots between the entrance to Chesapeake Bay and buoy "3," as use of these pilots is viewed by some as a poor reflection on the crew’s shiphandling ability. The navigator of the Eisenhower also said that it was uncommon for a Navy ship to embark a pilot going in or out of Norfolk, but that he had discussed doing so with the CO while planning the port arrival. The navigator of the Eisenhower said that: "I told him [CO] what I had learned [from a visit to the VPA station at Cape Henry, Virginia] and told him what their capabilities seemed to be and he [the CO] said, 'well, I don't think we need a pilot, but really I'll leave that to you. If you really feel strongly that we need a pilot, we'll get a pilot.' So I thought about it for a period of time ... and made my own determination that we just did not need a pilot." When the CO of the Eisenhower was asked about the policy of the Navy to utilize pilots, he replied, "I couldn't answer what the Navy policy is, I really don't know." The CO's responsibility concerning pilotage is set forth in Navy regulations at Title 32 CFR Subpart 700.754, and the CO's responsibility for safe navigation of his vessel is set forth in Subpart 700.755(a).

32 CFR 700.754: Pilotage.

(a) The commanding officer shall:

(1) Pilot the ship under all ordinary circumstances, but he may employ pilots whenever, in his judgment, such employment is prudent.
(2) Not call a pilot on board until the ship is ready to proceed.
(3) Not retain a pilot on board after the ship has reached her destination or point where the pilot is no longer required.

(4) Give preference to licensed pilots.

(5) Pay pilots no more than the local rates.

(b) A pilot is merely an adviser to the commanding officer. His presence on board shall not relieve the commanding officer or any of his subordinates from their responsibility for the proper performance of the duties with which they may be charged concerning the navigation and handling of the ship. For an exception to the provisions of this paragraph, see "Rules and Regulations Covering Navigation of the Panama Canal and Adjacent Waters," which directs that the pilot assigned to a vessel in those waters shall have control of the navigation and movement of the vessel. Also see the provisions of these regulations concerning the navigation of ships at a naval shipyard or station, or in entering or leaving drydock.

32 CFR 700.755 (a): Safe navigation and regulations governing operation of ships and aircraft.

(a) The commanding officer is responsible for the safe navigation of his ship or aircraft except as prescribed otherwise in these regulations for ships at a naval shipyard or station in drydock, or in the Panama Canal. In time of war or armed conflict, competent authority may modify the use of lights or other safeguards required by law to prevent collisions at sea, in port, or in the air. In exercises, such modifications will be employed only when ships or aircraft clearly will not be hazarded.

Bridge Personnel Relationships.--The OOD's relationship with the CO is stated in Navy Regulations at Chapter 10, article 1008: "Every person on board who is subject to the orders of the commanding officer, except the executive officer, and those other officers specified in article 1009, shall be subordinate to the officer of the deck."

His relationship to the navigator is stated in Navy Regulations at chapter 10 article 1009 subparagraph 3: "The navigating officer shall advise the officer of the deck of a safe course to be steered and the officer of the deck shall regard such advice as sufficient authority to change the course, but shall at once report the change to the commanding officer..."

Article 1011: "Except as prescribed in these regulations or as authorized by the commanding officer, the officer of the deck shall not change the prescribed course or speed of the ship unless necessary to avoid collision or imminent danger."

Article 1020: "Reports by the Officer of the Deck. The officer of the deck shall promptly report to the commanding officer all matters which affect or which may affect the safety of the ship ... or changes in course or speed made by the ships in company or by himself..." The CO and the navigator both said that the navigator recommends course and speed changes to the OOD and the OOD orders the conning officer to make changes to the helm or the engines. The navigator does not give conning orders directly to the conning officer.

Port Operations Department.--The Port Operations Department, in accordance with U.S. Navy Regulations, as the agent for the COMNAVSTA, Norfolk, Virginia, schedules the movement of vessels at the Naval Station and naval vessels transiting Hampton Roads. The requirements for the "Movement of Ships at a Naval Station" are set forth in U.S. Navy Regulations at Chapter 7 paragraph 0751:

--1. No ship or craft shall be moved or undergo dock trials during its stay at a naval station, except by direction or with approval of the commanding officer of such station.
--2. A ship arriving at, or departing from, a naval station shall be furnished such assistance, including tugs, when available, as in the opinion of the commanding officer of the naval station or the ship may be necessary for her safe handling.

The COMNAVSTA reported that every Thursday, the Naval Station conducts a berthing conference with all area squadrons and groups to determine the following week's vessel movements. Each squadron and group presents its vessels' requested movement times and the Port Operations Department prepares the final schedule based on tide constraints (if the vessel is deep draft), fleet operational commitments, availability of tugs and docking pilots, and vessel request/preferences. The schedule can be modified to accommodate changing conditions. Vessels may dock or undock without the use of tugs or docking pilots, but their arrival or departure times are still coordinated with the Port Operations Department for shoreside services and to avoid conflict with other naval vessel movements in the harbor. After receiving notice of arrival information from any large vessel scheduled to berth at the Naval Station Norfolk, the Station will advise the vessel of the time that it should be at the buoy "3," if tugs have been requested. If tugs have been requested, then a Naval Station docking pilot would be furnished. Destroyers and smaller vessels may also request these services, if desired. Tugs and a Naval Station docking pilot will meet the vessel and maneuver it into the pier. Docking pilots usually board aircraft carriers between buoy "lER" and buoy "3." When large deep draft vessels are assigned to berth on the south side of the piers at the Naval Station, they are scheduled to arrive on the flood current at Hampton Roads. Flood current keeps the vessel off the south side of the pier, enabling tugs to control the movement of the vessel as they push the vessel slowly into the Pier. The Eisenhower was arriving on the flood current because it was to moor on the south side of pier 12.

Regulated Navigation Area, Elizabeth River. Norfolk, Virginia.--Under "Restrictions on Vessel Operations During Aircraft Carrier and Other Large Naval Vessel Transits of the Elizabeth River" at Title 33 CFR Paragraph 165.501 (d)(11), formerly Title 33 CFR Subpart 165.505, the Coast Guard has established a regulated navigation area (RNA) to restrict the navigation near large naval vessels by other vessels. This regulation requires that: "...no vessel may, without the permission of the [Coast Guard] COTP, come within or remain within 500 yards from a naval aircraft carrier or other large naval vessel, which is restricted in its ability to maneuver in confined waters .... transiting the Elizabeth River between the Norfolk Naval Base, Norfolk, Virginia, and the Norfolk Naval Shipyard..." (about 11 miles south of the Naval Station).The regulations were requested by the Navy in 1982, and became effective on June 6, 1983. The preamble to the regulations stated that the Navy requested the regulations to prevent accidents due to the reduced maneuverability of the vessels caused by the slow speeds at which the vessels had to operate in the restricted channels between the Naval Station and the Shipyard. When the RNA for the Elizabeth River was designated around aircraft carriers in 1983, the Norfolk Harbor Reach Channel adjacent to the Naval Station was 1,500 feet wide. It is now 1,000 feet wide. If the Navy requests the COTP to establish an RNA around an aircraft carrier or other large naval vessel traversing the Elizabeth River, when granted, the Coast Guard broadcasts Notice to Mariners. The COTP normally provides two patrol boats to control traffic: one boat about 500 yards ahead and one about 300 yards astern of the large vessel.

Toxicological Testing of Navigation Personnel.--The use of alcohol and illicit drugs is prohibited aboard the Eisenhower. After the accident, navigation personnel were not asked to provide specimens for toxicological testing, nor were they required to do so. Navy instruction, OPNAVINST 5350.4, provides policy guidance for substance abuse prevention and control for Navy personnel. A CO, or an officially appointed investigation board convened for a safety investigation, "such as an aircraft mishap investigation," may order drug tests for a member's involvement in a serious accident or incident in which safety precautions were violated or unusually careless acts were performed. However, there are no specific guidelines in the Navy instruction similar to the Federal regulations for commercial vessel accidents. The chemical testing of Navy vessel crewmembers is not required by the Navy, when a Navy vessel is involved in an accident with a non-military vessel in U.S. waters, or with another U.S. vessel in any waters. The Safety Board has previously addressed post-accident toxicological testing of Navy personnel following the collision between the USS Richard L. Page (FFG 5) and the U.S. Fishing Vessel Chickadee in the Atlantic Ocean on April 21, 1987.¹¹ After that accident, members of the navigation crew of the Page were not required or asked to provide specimens for examination. The Safety Board recommended to the Navy:

Amend OPNAVINST 5350.4 (Substance Abuse Prevention and Control) to require drug testing of U.S. Navy personnel directly involved in an accident with a U.S. civilian vessel in international waters or any civilian vessel in U.S. waters. (Class 11, Priority Action) (M-88-38)

The recommendation is classified as "Open-Awaiting Response."

ANALYSIS

The Accident

At the time of the accident, the Urduliz was anchored in a designated anchorage (anchorage "A," berth "Z") with its bow about 400 yards from what had been the northern edge of the Entrance Reach Channel prior to March 30, 1988, or about 200 yards from the new channel edge established by buoy relocations on March 30, 1988. The pre-planned track of the Eisenhower in the Entrance Reach Channel was to follow the northern edge of the previous 1,500-foot-wide channel (this was also the southern limits of anchorages "A" and "B"). The Eisenhower bridge watch was aware that the Urduliz was anchored in berth "Z," as the bridge watch had been informed about 1 hour before the accident by a naval vessel preceding the Eisenhower into
Norfolk. Visibility was at least 5 miles and the bridge watch had the Urduliz in sight for about 30 minutes before the accident. Thus, the knowledge and the adequacy of the position of the anchored vessel, and visibility were not factors in this accident.

At 0805, the Eisenhower's speed was reduced to 5 knots and about 1 minute later the course was changed from 258T to 229T in the direction along the previous northern edge of the Entrance Reach Channel. The 0810 radar fix indicated that the Eisenhower remained on its intended track (229T), the vessel would have continued in the channel and passed clear of the Urduliz. However, the direction of the currents, which were about 1.2 to 1.6 knots at 240T to 260T, and the wind, which was about 20 knots from 150T, were setting the Eisenhower to the right of its intended track. The conning crew (the navigator, the OOD, and the CO) in discussions during the navigation briefing the day before the accident, had anticipated about a 2-knot flood current in Hampton Roads, greater than the actual current at that time. However, the conning crew did not compensate for the expected current (or the wind) in the Entrance Reach Channel, when they set their course along the northern edge of the channel at 229T. The Safety Board believes that setting a vessel the size of the Eisenhower on a course in the confined waters of the Entrance Reach Channel without compensating for the current was a fundamental navigation mistake by the navigator. Because the navigator relied more on plotting than on recognizing the effects of current by visual cues, he should have compensated for the current when setting the vessel's course to track the northern edge of the channel.

At 0811, the navigator recommended that the OOD reduce speed to 3 knots, to arrive at buoy "3" for embarking the docking pilot at 0845. The navigator should have been more concerned about navigating the vessel close to the intended track and avoiding traffic, including the anchored Urduliz on the starboard side and the approaching submarine on the port side, than with arriving at the scheduled time at buoy "3." He should have recognized that the track (course made good) would be affected by the current and the wind to a greater amount at the slower speed. The slower speed would have two effects: the amount of movement to the right caused by the current and the wind per unit of time would be increased and the rudders would be less effective. After turning onto 229T, the navigator should have observed closely the progress of the Eisenhower by the use of navigation fixes or visual piloting cues and adjusted the course and the speed to compensate for the current and the wind and keep the vessel close to its intended track and away from the Urduliz. However, after the conning crew had been alerted at 0813 by the radar navigation team that the vessel was 25 yards to the right of track and then at 0816 that the vessel was 200 yards to the right of track, immediate action was not taken either by the navigator or by the OOD. Although the visual navigation team was unable to obtain any visual fix from 0807 until 0817, the radar navigation team's vessel position information at 0813 was an alert and the notice at 0816 was corroborative evidence that the vessel had moved to the right of track. This later notice should have caused the navigator to recommend immediately a course change and speed increase to reduce the Eisenhower's set and drift to the right of track and keep it away from the anchored Urduliz. Further, neither of the other two members of the conning crew (the OOD and the CO) intervened in time to avoid the collision.

At 0817, the OOD ordered left 10 degrees rudder and informed the CO that the vessel's speed had been reduced to 3 knots. The CO stated that "...10 degree rudder isn't going to get you left very fast" and ordered the OOD to apply additional left rudder and to increase speed to 5 knots. The CO later stated that due to the delay in relaying orders through the OOD and the conning officer, he took over the conning of the Eisenhower and ordered left 30 degree rudder to maneuver the Eisenhower past the Urduliz. The Safety Board believes that had the CO been made aware earlier that the speed of the vessel had been reduced, he may have canceled the order, or taken the conn, and increased speed to gain greater rudder effectiveness. However, his orders were given at a time when the ramming was imminent.

By ordering an increase in speed to 5 knots and 30 degree rudder commands (left and then right), the CO made the vessel more maneuverable and he was able to first move the bow, and then the stern away from the anchored Urduliz. The left 35 degree rudder order was given in an attempt to swing the bow away from the Urduliz as much as possible, and the right 30 degree rudder order was given in an attempt to "kick" the stern of the Eisenhower away from the Urduliz to minimize damage. Despite the CO's orders, the Eisenhower struck the bow of the Urduliz with its starboard side between aircraft elevators Nos. 1 and 2.

In the 9-minute interval between 0811, when the Eisenhower was slowed to 3 knots, and 0820, when it struck the Urduliz, the current and the wind moved the Eisenhower about 400 yards laterally from its intended trackline course of 229T. A line drawn through the 0820 accident position perpendicular to the Eisenhower's intended trackline would intersect the 229T trackline about 1,385 yards from the vessel's 0811 position. This distance reflects the vessel's progress in that direction due to both its average propulsion speed through the water, and current and wind effects. If the Eisenhower's speed had been maintained at 5 knots during this period (0811-0820), the vessel would have been moved the same 400 yard distance laterally by the current and the wind, which were fairly uniform in this small area. Its movement in the 229T direction also would have been assisted by components of the current and the wind, and at 0820, would have moved about 1,885 yards in that direction. By trigonometry, it can be shown that at the 5-knot speed, the Eisenhower would have cleared the Urduliz by about 100 yards. The Safety Board therefore believes that the accident would not have occurred, even though the Eisenhower would have passed very close to the Urduliz, because it would not have moved as far to the right of track before it cleared the Urduliz's anchored position.

When the officer on watch on the Urduliz realized that the Eisenhower was going to pass close to his vessel, he sent a messenger to notify the master of the situation. After the master arrived on the bridge and assessed the situation, he could have ordered additional anchor chain to be backed out, or backed the engine to move his vessel further away from the channel. Backing out the anchor chain would have taken a few minutes because crewmembers would have to be sent to the bow and then they would have to prepare the anchor gear for release. Backing of the engine to drag the anchor may have taken less time, but such action would have to be taken with care to avoid parting the anchor chain. However, there was no time to accomplish either option because the collision occurred as the master arrived on the bridge.

The Role of the Conning Crew.--The Safety Board examined the training, shiphandling experience, and actions of the conning crew of the Eisenhower, to determine the factors that led to the ramming of the anchored Urduliz at Hampton Roads. The actions of the JOOD or conning officer were not considered a factor in this accident. This was his first conning assignment in Norfolk harbor and he only passed conning orders received from the OOD or the CO. He did not originate any independent orders while entering the harbor nor would he be expected to do so.

The development of the navigator's shiphandling skills occurred during two non-aviation sea duty assignments (totaling about 4 years), which were separated by 8 years of aviation assignments. Under these circumstances, it would have been difficult for the navigator to retain knowledge and skills he developed during his previous shiphandling assignment, and to adapt to the new operational circumstances. The navigator recognized this and before reporting to the Eisenhower, made a personal effort to renew and improve the shiphandling skills he had not used for years and to familiarize himself with the Hampton Roads area where he had not previously been stationed. He had supervised the Eisenhower's navigation department for 21 months, and had been responsible for successfully navigating the ship throughout coastal, Latin American, Caribbean, and Mediterranean cruises. However, the Safety Board believes that his training and experience were not sufficient to prepare him fully to pilot this large vessel under the conditions he faced that day in Hampton Roads and this deficiency in his experience contributed to the improper decisions he made that led to the accident. The navigator set the vessel on a course that had not been adjusted to compensate for the anticipated currents. Further, because he was unfamiliar with the practices of the Port Operations Department and its docking pilots, he did not know that the docking pilots generally arrived 1/2 hour before their assigned duty time and concluded that the arrival of the vessel 4 minutes early was not only unprofessional but could jeopardize preparations for docking the vessel. His recommendation to reduce speed to 3 knots to delay the vessel's arrival at buoy "3" without an accompanying course change worsened the set and drift of the Eisenhower putting it on a collision course with the Urduliz. However, greater evidence of the deficiencies in his ability to pilot the vessel through the restricted waters was his lack of action to correct the vessel's course when notified by the radar navigation team at 0816 (after the 0813 alert) that the vessel was
deviating, from its, intended course. Because the navigator had only limited recent experience piloting such a large vessel through Hampton Roads, he did not recognize from landmarks or other cues that the Eisenhower was setting to the right.

The OOD was the most junior officer and the most inexperienced shiphandler on the conning crew. His assignment as the assistant navigator aboard the Eisenhower was his first sea duty assignment, as well as his first shiphandling assignment, having previously served in aviation and administrative assignments. Upon his assignment to the vessel, he completed a basic shiphandling course, became qualified as OOD (underway) in 4 months, and stood watches in that position for 11 months. However, he had not had the opportunity to serve as OOD during a transit of Hampton Roads, and had only observed others acting in that capacity.

In response to the recommendation of the navigator, his superior officer, he ordered the speed reduction, apparently not recognizing the effect it would have on the track of the vessel under the prevailing current and wind conditions. Furthermore, because he apparently did not recognize the significance of the speed reduction, he did not discuss the prudence of the recommendation with the navigator, or make the CO aware immediately of the order he subsequently gave to the JOOD. These omissions may have been the result of insufficient shiphandling experience.

The Safety Board believes that the OOD's basic training and operational experience in shiphandling were insufficient to act as OOD during the navigation of a vessel the size of the Eisenhower in the restricted waters of Hampton Roads, and that he should have received greater guidance and supervision from the CO.

The CO had accrued considerable shiphandling experience in several non-aviation sea duty assignments during 7 of the preceding 8 years. He had completed a series of increasingly complex and demanding senior staff and command assignments which had provided him the opportunity to progressively develop shiphandling skills through training courses and operational experience. The CO demonstrated skilled shiphandling abilities on the day of the accident beginning about 3 minutes before the collision, when he became aware that the vessel's speed had been reduced to 3 knots in the prevailing wind and current conditions and assumed the conn in time to avoid more serious damage to his vessel and to the Urduliz. The recency, variety, and complexity of this previous experience made the CO a competent shiphandler, appropriately experienced and qualified for his duties at the time of the accident. However, the Safety Board believes that the CO should have monitored more closely the navigator's recommendations to the OOD, the OOD's conning orders, and the reports of the Eisenhower's position along the intended track.

The Safety Board believes the CO may have been distracted from his duties of monitoring the conning of the vessel by other activities taking place an the bridge.

Pilotage
During periods of restricted maneuvering, such as when the vessel is within the confines of a harbor, precise movement and control of the vessel is required. At those times, the workload increases dramatically for the visual navigation team on the bridge and for the radar navigation team located in a compartment aft of the bridge. The level of activity on the bridge is considerably greater as communications increase between stations to make certain that the exact position of the vessel is known, and that the vessel follows a safe course.

The visual navigation team, under the supervision of the navigator, must monitor the progress of the vessel by plotting its exact position on the bridge navigation chart at frequent intervals using information communicated to the bridge from visual bearing takers at remote stations. This process allows the navigation team to accurately report the location of the vessel to the conning crew. Each position report establishes the location of the vessel at the time the bearings were taken. Due to reporting and plotting delays, however, the navigation teams report the position of the vessel, relative to the desired track, about a minute after the vessel has actually left that position.

Based on his knowledge of where the vessel was located a minute earlier, the navigator anticipates the changes in rudder and speed necessary to keep it on a predetermined track. However, doing this in restricted waters under rapidly changing conditions is difficult, if not impossible, at times. Under such conditions, it is necessary to compensate for a lack of formal or plotted navigation information by visually observing the changing situation. Markers, buoys, ranges, landmarks, and other prominent objects then serve as an aid to visual plotting or navigating "by eye." Because there were no visual fixes between 0810 and 0817, and the radar fixes were 3 minutes apart, the navigator had to act as a pilot. However, the navigator was not a pilot who routinely navigated through these waters and was not trained to do so.

Without visual or radar fixes, it is difficult to estimate and anticipate the effect of the current and the wind on the movement of the vessel, especially in a setting with which the navigation team is unfamiliar. When piloting visually, the experienced eye uses physical indicators such as the wake or angle of lean of a buoy to estimate the current. The lateral displacement, or set, of the vessel which is being experienced due to the effects of current or wind is often determined by comparing the relative movement of fixed objects. The act of piloting in any restricted waterway is a skill which is developed over time.

During the Eisenhower's 6-month deployment, the Entrance Reach Channel had been reduced in width and shifted slightly northward, and buoys had been moved in the Entrance Reach and in the Thimble Shoal Channels. The conning crew was aware of the new buoy locations from the Notice to Mariners and the new positions were plotted on their navigation charts. However, the conning crew on the Eisenhower did not have any experience navigating the "new" channel and had not seen Norfolk harbor for 6 months. The Safety Board believes that although the crew's lack of familiarity with the "new" channel did not cause this accident, they would have benefited from a pilot's knowledge and extensive experience in handling large, deep draft vessels in the restricted waters of Hampton Roads. A harbor pilot probably would have recommended against slowing the vessel under the current and wind conditions which existed in the restricted waters of this channel. More importantly, a harbor pilot would have been able to recognize earlier that the vessel was setting to starboard and deviating from the intended track.

Most naval vessels do not utilize the services of pilots, at least in part because they believe that the use of a pilot implies that the crew does not measure up to the navigation task. However, all commercial vessels departing on, or returning from a foreign voyage are required to hire a State pilot, no matter how familiar, or competent, or how many times the master or other deck officers have transited the waterway to or from sea. Even though, a master or deck officer on a U.S. or foreign vessel may have a Coast Guard pilot license for the area, and the vessel is departing on or returning from a foreign voyage, the vessel still is required by state law to use a State pilot. Mariners who have not been in the harbor recently are not aware of changes in channel configurations or of the effects of such changes as is a pilot. A pilot would have the latest local knowledge about the peculiarities of currents, the problems of navigating each channel, local conditions, and movement habits of local vessels.

The CO of the Eisenhower stated that he was not aware of any official guidelines for the use of pilots from the U.S. Navy. However, he also stated that a pilot would have had more knowledge of local conditions, including the new harbor configuration, and would have been able to devote full time and attention to the navigation of the vessel.

The Safety Board believes that the use of a pilot was not necessary to avoid this accident. However the Safety Board also believes that a pilot probably would have recognized in a timely manner that the vessel was deviating from its course and taken action in time to avoid the accident. The use of harbor pilot should be strongly encouraged by higher command. Navy regulations provide a broad statement about pilot use, but do not provide specific guidance as to when they should be used. The Safety Board believes that the Navy should develop more detailed guidelines to provide CO's a basis for deciding when to use pilots. Such guidance should include consideration of changes in harbor configuration, crew experience in transiting the harbor, the length of time since the harbor was last transited, the extent of congestion and restriction of the waterway, and the size of the vessel. Further, this guidance should be provided in a manner that helps to minimize the belief that only crews who do not measure up to the navigation task need to hire a pilot.

Bridge Environment and Crew Coordination

The Safety Board is concerned that the CO did not hear the engine order during critical moments in the navigation of the vessel and was not aware of the speed reduction which had taken place during a time when the CO's attention was focused on other responsibilities. Because of the numerous demands upon the CO, including the many non-navigational duties which existed during the entrance to the harbor, the CO appears to have diverted his attention from the navigation of the vessel.

Because of other design priorities, space on the navigation bridge of an aircraft carrier is, very limited and consequently a large number of stations which affect and are necessary for control of the vessel are located remotely from the bridge. These remote stations, including the radar navigation team, lookouts, the combat information center, primary flight operations, and others, communicate with the navigation bridge using sound-powered telephones and electronic means, including radio, intercom, and video. Frequent communication between these stations and the bridge is necessary to coordinate the safe movement of the vessel. There were at least 20 crewmembers involved in the navigation and the conning of the vessel into port. In addition, there were 6 to 8 Tigers, the press, and other crewmembers not required to be on the bridge for arrival into port. These additional persons, merely by their presence, may have averted the CO's attention.

The CO did not know, and the Safety Board could not precisely determine, the duty or demands of his position that caused the CO to divert his attention away from his monitoring of the navigation of the vessel and prevented him from hearing the order to the engine order operator to reduce speed. However, the crowded and noisy environment of the aircraft carrier navigation bridge was not conducive to the safe maneuvering of the vessel in the restricted channel. The Urduliz, a similar sized civilian vessel, had been piloted to its anchorage with only four persons (pilot, master, mate, and helmsman) on its much larger sized bridge (about 13 feet by 54 feet, plus port and starboard bridge wings measuring about 10 feet by 37 feet), in contrast with more than 20 persons on the much smaller bridge (about 10 feet by 40 feet) of the Eisenhower.

Because of the high activity noise, and congestion levels on the bridge of a vessel of this size and complexity, a considerable potential for distraction is perhaps inevitable. But, obviously, to the extent practicable the sources of such distraction should be eliminated. Therefore, the Safety Board believes that the Navy should prohibit all non-essential persons from admittance to the navigation bridge of its vessels when they are being piloted through restricted waterways such as the channels to Hampton Roads.

The Safety Board is concerned also that, on the one hand, the CO did not explicitly direct the watch officers to keep him informed of developments as they occurred and, on the other hand, that neither the OOD nor the navigator took positive action to advise the CO. As a result, although sufficient operational information existed on the bridge to permit a successful transit of the Entrance Reach Channel, the CO did not become aware of it in time to use it effectively. The Safety Board believes that if there had been a more positive exchange of essential operational information among the key members of the bridge navigation team, the casualty almost certainly would have been averted.

The Safety Board believes also that increased emphasis on information exchange and coordination undoubtedly could improve bridge management of other naval vessels and enhance the safety of their navigation. But achieving such performance would require the development of bridge operating procedures and practices specifically designed to facilitate information exchange and crew coordination; it also would require systematic indoctrination of commanding officers and bridge team members in the use of such procedures and practices through specially designed training courses and practice exercises.

Safety Board marine accident investigations frequently have identified shortcomings in bridge management and coordination among masters, the navigation watch, and pilots as contributing factors in marine navigation casualties. As a result, the Safety Board repeatedly has advocated that greater attention be given to this aspect of marine operations. Fortunately, some progress has been made in the maritime community in developing bridge management and teamwork training courses for masters and bridge watch personnel, using bridge simulators, with encouraging results. The Safety Board is aware also that the Navy has devoted considerable effort and resources to the development and implementation of crew coordination and cockpit resource management training for flight crews of its large aircraft; and it has developed team performance training for its shipboard combat information centers. However, it does not have comparable training programs for its shipboard commanding officers and bridge navigation personnel. In light of the large number of Naval personnel involved in shiphandling operations, the immense value of the assets involved in the operation of vessels of the U.S. fleet, and the potentially catastrophic consequences of navigation casualties, the Safety Board believes that the Navy should allocate the necessary resources to research, develop, and implement a program of bridge crew management and teamwork training for all vessel commanding officers and bridge navigation personnel.

Waterway
It is difficult for the conning crew of a vessel using the Entrance Reach Channel to determine visually the new northern edge of the channel because there is no navigation aid in the 3.2 miles between buoy "22" on the eastern end of the channel and buoy "2" on the western end of the channel. Even though the anchorage berths on the northern side of the Entrance Reach Channel have water depths in excess of 50 feet, they should not be considered extensions of the channel width, but rather areas where vessels are expected to be anchored and thus unavailable for maneuvering outside of the channel limits. Proper marking of the northern edge of the channel is more critical because the channel has been narrowed and there is now less width available to maneuver a vessel.

The Safety Board does not agree with the statement by the Coast Guard witness that "... when you put buoys near an anchorage they get run over and serve only as a hazard to navigation." Vessels are expected to safely pass each other in the 1,000-foot-wide channel and, therefore, placing buoys about 1 mile apart along the northern edge of the channel should not interfere with a vessel navigating the channel or entering the anchorages to anchor. Further, if a vessel were to strike a buoy, the damage cost to the buoy and the vessel would be far less expensive than the damage cost resulting from even a minor collision between two vessels. The Coast Guard already uses buoys to mark channels adjacent to anchorages in Norfolk and in other harbors.

Not only would additional buoys on the channel's northern edge provide a channel marking, they could also be used by mariners to visually estimate their vessel's position and how the vessel's course is being affected by wind and current. The presence of additional buoys, for example, 1 mile apart may have provided an earlier indication to the conning crew that the Eisenhower was deviating from its intended courses allowing corrective action to be taken earlier, perhaps even in time to avoid the collision. The Safety Board believes that the northern edge of the Entrance Reach Channel should be marked with additional buoys to assist the mariner visually in determining the channel limits and his movement in the channel.

Port Operations Department

If the Eisenhower had followed its planned trackline, with its bridge on the northern edge of the previous Entrance Reach channel (700 feet wide at buoy "1ER"), its flight deck would have shadowed or visually blocked out about 590 feet of channel on its port beam, leaving about 110 feet of the channel visible from the navigation bridge to buoy "lER" and the southern side of the new Entrance Reach Channel. Had the submarine followed a trackline of about 100 to 150 feet to the left of buoy "1ER," the Eisenhower's bridge watch may not have been able to see the submarine. The large shadow zone on the port side of the Eisenhower prevents a continuous view of a vessel with a low profile or a small vessel, if it passes too close, especially a vessel such as a submarine.

The Safety Board believes that although the passage of the Lipscomb did not contribute to the accident, the Port Operations Department should have coordinated the departure time of the Lipscomb so that it would not have been in the Entrance Reach Channel at the same time as the Eisenhower. The Safety Board also believes that the Port Operations Department should control naval vessel traffic so that deep draft naval vessels (vessels with a draft of 25 feet or more) do not encounter another deep draft naval vessel when transiting the Entrance Reach Channel.

Regulated Navigation Area, Elizabeth River, Norfolk, Virginia

After an aircraft carrier is in the Entrance Reach Channel, and shortly before it arrives at buoy "3," it must slow down as much as possible, and still maintain steering control, to embark a docking pilot. The docking pilot attempts to board the vessel at or before reaching buoy "3." After he boards and after tugs are positioned, the vessel is maneuvered into its berth. This operation normally takes about 45 minutes and the channel is effectively blocked during this period inhibiting other vessel transits. Also during this period, the vessel is operating at a very low speed and is greatly hampered in its ability to maneuver, thus posing a hazard both to itself and other vessels in the narrow channel. Even if an aircraft carrier or other large naval vessel pivots only partially in the channel, there is no room available for a vessel to pass safely within the Entrance Reach Channel. The 1,000-foot width of the channel is narrower than the length of most aircraft carriers and only about 100 feet wider than battleships are long. The anchorage area north of the Entrance Reach Channel may not always be void of vessels to allow for vessels to move outside the channel and past a vessel maneuvering into its berth at the Naval Station. The Safety Board believes that the amount of channel available to another vessel in the Entrance Reach Channel, when a large naval vessel is maneuvering into a berth at the Naval Station, is too narrow for safe navigation. There is insufficient room to maneuver to avoid another vessel due to bad weather, or for a steering or other casualty. To avoid maneuvering difficulties with other marine traffic and as an added measure of safety, the Safety Board believes that the Navy should request the Coast Guard to expand the RNA (prescribed for moving aircraft carriers and other large naval vessels to, or from, the Norfolk Naval Shipyard) to include the Entrance Reach Channel.

Toxicological Testing of Navigation Personnel

Toxicological specimens were not obtained from the conning crew or the navigation teams, or any other person aboard the Eisenhower, following the accident. Post-accident toxicological testing was not required by Navy regulation, and as a result, neither the coming crew nor the navigation teams of the Eisenhower were requested to provide samples, precluding such testing. However, there was no evidence discovered during the course of the investigation to suggest that the conning crew was medically unfit, fatigued, or under the influence of alcohol or other drugs at the time of the accident.

In its accident investigations, the Safety Board routinely examines the toxicological aspects of accident causation, and it believes that the Navy should do so during its accident investigations as well, and that it should obtain and examine toxicological specimens from any crewmember whose activities could be associated with the circumstances of the occurrence. By requiring such testing following all accidents involving Navy vessels, especially those which involve civilian vessels, the Navy would enhance the safety of its operations, its personnel, and other seafarers. Accordingly, the Safety Board reiterates Safety Recommendation M-88-38.

Marine Accident Information Dissemination

The Safety Board interviewed numerous U.S. Navy personnel, formally and informally, in the course of its investigation. Many of the personnel interviewed had little or no relevant information and were extremely curious about the facts of this accident. They requested information about the accident so that they might learn from the experiences of the crew of the Eisenhower.

The Navy has a periodic publication, FATHOM, which includes information concerning accidents involving its vessels, similar to a publication associated with its aviation accident advisory program. Notwithstanding this publication, COs, navigation department personnel, and deck watchstanders, report that they are rarely exposed to detailed information as a result of the investigations which examine vessel maneuvering accidents in the fleet. These persons could use the knowledge learned from the details of vessel accident investigations and analysis to operate their vessels more safely and avoid accidents. However, the FATHOM is distributed to many agencies who may not need such information and the Navy may not deem it appropriate to include the in-depth information that could benefit its navigation personnel in the FATHOM.

Thus, the Safety Board believes that the Navy, in an effort to inform its personnel and prevent accidents involving its vessels, should establish an internal comprehensive marine accident information newsletter or similar publication to disseminate to its personnel in command, navigation, and other shiphandling assignments, reports of collisions and groundings, and related accident prevention information. Further, the Safety Board believes that the Navy should provide to commanding officers and navigation departments of its aircraft carriers copies of the Safety Board's Eisenhower accident report.

FOOTNOTES

¹The term the Navy uses to describe distinguished civilian guests of the Navy and male civilian family members of the crew who board a Navy ship returning from deployment. It is a morale enhancement activity for family members so they may see how the ship operates and what their sponsor does, and where he works.

²To control or direct the movement of a ship by rudder and engine orders.

³Senior enlisted man in the navigation department.

⁴This navigation team was located in the TOP radar darkroom compartment aft of the

after bulkhead on the bridge.

⁵The engine order operator who passes engine orders to the enginerooms.

⁶Polmar, Norman, "The Ships and Aircraft of the U.S. Fleet" (14th Edition), Naval

Institute
Press, Annapolis, Maryland, 1987, pp 82-83.

 
⁷A senior officer qualified to assume the operational direction of the vessel. On the Eisenhower, the navigator qualified the officer as CDO and the CO approved the qualification with a letter which was placed in the officer's service record.
⁸Polmar, page 11.

 
⁹Approximate elevation of one's eye above the waterline.

 
¹⁰Tidal Current Tables, 1988, for the Atlantic Coast of North America. Published by the National Ocean Service, National Oceanic and Atmospheric Administration of the Department of Commerce.

¹¹Marine Accident Report.--"Collision between USS Richard L. Page (FFG-5) and the U.S. Fishing Vessel Chickadee in the Atlantic Ocean on April 21,1987" (NTSB/MAR-88/04).

CONCLUSIONS

Findings
1. The intended trackline of the Eisenhower was appropriate for a vessel of its size and the width of the channel.

2. Had the navigator and officer of the deck observed closely the vessel's movement after the reduction of the vessel's speed, they would have been able to detect the Eisenhower's movement to the right of track and taken corrective action.

3. The navigator recommended, and the officer of the deck ordered, a reduction in the vessel's speed to a level at which the current and the wind greatly affected the vessel's movement to the right of the intended track and decreased the effectiveness of the rudders.

4. The previous piloting training and experience of the navigator and the officer of the deck did not prepare them sufficiently to pilot a vessel the size of the Eisenhower through the restricted and unfamiliar channels of Hampton Roads.

 
5. The commanding officer was not informed in a timely manner by the navigator or the officer of the deck that the vessel's speed had been reduced.

6. The commanding officer did not hear the speed reduction ordered by the officer of the deck or the conning officer's order to the lee helm because his attention may have been diverted from the vessel's navigation by other duties.

 
7. Although the commanding officer recognized the hazard associated with the speed reduction when informed of it by the officer of the deck, the commanding officer's actions came too late in the accident sequence to prevent the ramming.
8. The commanding officer used his shiphandling experience to avoid a more serious ramming.
9. Commanding officers of naval vessels need more specific guidance on the use of pilots than that provided for in U.S. Navy regulations.

10. The use of a pilot would have compensated for the inexperience in piloting of the navigator and the officer of the deck, and probably would have prevented the accident.
I 1. The Port Operations Department scheduled the submarine's movement so that it was in the Entrance Reach Channel when the Eisenhower was scheduled to be in the channel, restricting the maneuvering room available to the Eisenhower.

12. The Urduliz was properly anchored in berth "Z" in anchorage "A" which was within the new anchorage boundaries and outside of the new channel edge and did not contribute to this accident.

13. Additional buoys on the northern limits of the Entrance Reach Channel would have assisted in clearly delineating the northern edge of the channel limits.
14. Permitting other vessels to operate in the vicinity of aircraft carriers and other large naval vessels transiting the Entrance Reach Channel significantly reduces the space for maneuvering such large naval vessels in the Channel.

15. The presence of non-essential persons on the navigation bridge of naval vessels while maneuvering in restricted waters may cause conning crews to be distracted from their operational duties.

16. Bridge management and team coordination principles are not adequately emphasized in the training of shipboard commanding officers and bridge navigation personnel on Navy vessels.

17. The establishment by the Navy of an internal marine accident advisory publication to provide vessel accident reports and other accident prevention information to commanding officers, navigators, and other personnel in shiphandling assignments would improve safety in the fleet.

Probable Cause

The National Transportation Safety Board determines that the probable causes of this accident were the delayed and insufficient action to correct the Eisenhower's deviation from the intended track by the navigator and the officer of the deck because of inexperience in piloting the vessel through the restricted channel in Hampton Roads; the selection by the navigator of a course through the Entrance Reach Channel that did not compensate for the current and the wind, and the inadequate monitoring of the navigation of the vessel by the commanding officer. Contributing to the accident was the navigator's order to reduce the speed from 5 knots to 3 knots in an attempt to reach buoy "3" at a prescribed time and the inadequate guidance by the U.S. Navy on the use of pilots on large vessels.

RECOMMENDATIONS

As result of its investigation, the National Transportation Safety Board made the following recommendations:

-- to the U.S. Navy:

Provide in an appropriate U.S. Navy directive, guidance and requirements to commanding officers of vessels about the use of Federal or State pilots; consider such areas as changing harbor configurations, the crew's experience in transiting the harbor, the length of time since the harbor was last transited, the extent of congestion or restriction of the waterway, and the size of vessel. (Class II, Priority Action) (M-90-1)

Develop and implement a program of bridge crew management and teamwork training for shipboard commanding officers, navigators, and other bridge navigation personnel. (Class II, Priority Action) (M-90-2)

Establish a policy which excludes non-essential persons from the navigation bridge of U.S. Navy vessels maneuvering in restricted waters. (Class II, Priority Action) (M-90-3)

Require the Norfolk Naval Station to schedule and control naval traffic departing or arriving at Norfolk so that no deep draft naval vessels meet in the Entrance Reach Channel. (Class II, Priority Action) (M-90-4)

Request the Coast Guard to extend the Regulated Navigation Area at Title 33 Code of Federal Regulations Paragraph 165.501 (d)(11) in Norfolk harbor to include the Entrance Reach Channel for aircraft carriers and other large naval vessels. (Class II, Priority Action)(M-90-5)

Establish and publish an internal newsletter or other publication that provides comprehensive vessel accident information, including U.S. Navy vessel accident reports and related accident prevention information, and disseminate it to personnel in command, navigation, and other shiphandling billets. (Class II, Priority Action)(M-90-6)

Disseminate this accident report to commanding officers and navigation department personnel of all aircraft carriers in fleet. (Class II, Priority Action) (M-90-7)

--to the U.S. Coast Guard:

Establish additional buoys on the northern side of the Entrance Reach Channel to delineate the channel limits. (Class II, Priority Action) (M-90-8)

Also, the Safety Board reiterated the following safety recommendation to the U.S. Navy:

M-88-38
Amend OPNAVINST 5350.4 (Substance Abuse Prevention and Control) to require drug testing of U.S. Navy personnel directly involved in an accident with a U.S. civilian vessel in international waters or any civilian vessel in U.S. waters.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD
James L. Kolstad Acting Chairman
LaBu.mett Member
John K. Lauber Member
Lemoine V. Dickinson. Jr. Member

January 3, 1990

APPENDIXES

APPENDIX A

INVESTIGATION

The National Transportation Safety Board was notified of this accident about 2 hours after it occurred on August 29, 1988. Because the accident involved a U.S. Navy (public), vessel and a commercial (non-public) vessel in U.S. waters, the Safety Board and the U.S. Coast Guard agreed pursuant to the Memorandum of Understanding between the two agencies, dated September 28, 1981, that it would be in the public interest for the Safety Board to conduct the investigation with Coast Guard participation.

Safety Board investigators were dispatched on August 29, 1988, to Norfolk, Virginia, the home port of the naval vessel and the location of the moored commercial vessel.

Sworn testimony was taken in accordance with the authority granted to the Safety Board by Section 304(b) of the Independent Safety Board Act of 1974, from three crewmembers of the Spanish Bulk Carrier Urduliz on September 2, 1988, and from seven crewmembers of the USS Dwight D. Eisenhower (CVN 69) on September 14, 1988. Testimony was also taken from the Navy docking pilot on the Eisenhower, the harbor pilot on the Urduliz, and from the Chief of the Planning and Waterways Management Section of the Aids to Navigation Branch, Fifth Coast Guard District, on September 15, 1988. Parties to the investigation were: The owner of the Urduliz; the U.S. Navy, the operator of the Eisenhower; and the U.S. Coast Guard.

APPENDIX B

PERSONNEL INFORMATION

Captain Gary L. Beek, USN

Captain Gary L. Beck, 51, CO of the Eisenhower, was commissioned through the Aviation Officer Candidate Program in 1960, earned his "wings" in 1961, and was assigned as a naval aviator to various aircraft attack squadrons, including several assignments aboard aircraft carriers. In these assignments, he served as a pilot, line officer, instructor, operations officer, executive officer (XO), and commanding officer (CO) until 1979. During this period of service as an aviator, Captain Beck graduated from the U.S. Naval Postgraduate School with a Master of Science Degree in Aeronautical Engineering. He also graduated from the Navy's Test Pilot School and served as a test pilot.

In 1979, Captain Beek's career development progressed to non-aviation duties. He took graduate level nuclear engineering courses, and qualified as shipboard engineering officer of the watch. He completed training in the operation of naval nuclear propulsion plants and Navy Leadership Management Education training, which are provided to prospective COs and XOs prior to assignment to nuclear-powered vessels. He was subsequently assigned as operations officer aboard the USS Carl Vinson (CVN 70), a newly constructed nuclear-powered aircraft carrier which was being prepared for commissioning. The Vinson was commissioned in 1982, and Captain Beck was assigned as XO; he qualified as command duty officer (underway) and as a conning officer during replenishment at sea operations.

He was selected for a major afloat command as CO of the USS Niagara Falls (AFS 31), a deep draft combat stores and underway replenishment ship. En route to that assignment Captain Beck attended various Navy training courses, including a two-day practical shiphandling course, a four-day course in navigation rules of the road, and five days of ship control simulator training. He attended the Surface Warfare Prospective CO Course, and assumed command of the USS Niagara Falls in June 1984. He completed this assignment in June 1986.

Captain Beck was selected for command of the Eisenhower and assumed command in October 1986. The Eisenhower completed overhaul and was brought to readiness for fleet operations in 1987, following coastal, Latin American, and Caribbean operations.

Captain Beck's professional accomplishments and career highlights include deployment during the Cuban Missile Blockade in 1964, two combat deployments to Southeast Asia in 1968 and 1969, during which he completed 140 combat missions, and service as a test pilot at the Naval Air Test Center. His awards include 14 Air Medals, Navy Commendation Medal, Presidential Unit Citation, Navy Unit Commendation, Armed Forces Expeditionary Medal, Vietnamese Gallantry Cross, and the Navy Achievement Medal.

Commander Peter N. Maxwell, USN

Commander Peter N. Maxwell, 42, navigator of the Eisenhower, was commissioned through the Aviation Officer Candidate Program in 1969, earned his "wings" in 1970, and was assigned to land based aviation antisubmarine warfare (ASW) patrol squadrons. He served as navigation officer, line division officer, plans and programs officer, and pilot until 1976. In 1976, CDR Maxwell completed the OOD (basic) training course and the Fundamentals of Marine Navigation course prior to his initial shipboard assignment as assistant navigator aboard the aircraft carrier Midway (CV 41). CDR Maxwell remained in this assignment until January 1979, during which time he became qualified as an OOD (underway). He completed the prescribed course of instruction at the Armed Forces Staff College in 1979, prior to being assigned to a series of ASW patrol squadrons for 4 years. During these assignments, he served as pilot, pilot instructor, retention officer, training officer, command management director, and operations officer. Between 1983 and 1985, CDR Maxwell served in Washington, D.C., as the assistant for Shore and Sea Based ASW Plans and Programs, and in 1985, he completed training which led to C-130 aircraft certification and assignment as CO of a fleet support squadron through 1986. He was assigned as navigation officer of the Eisenhower in November 1986.

CDR Maxwell's professional accomplishments and career highlights include combat service as a patrol plane commander in Southeast Asia during 1971 and 1972, for which he received an Air Medal. His awards also include the Navy Commendation Medal and a Meritorious Service Medal.

Lieutenant John A. Sullivan, USN

Lieutenant John A. Sullivan, 32, assistant navigator and OOD on the Eisenhower, was commissioned through the Reserve Officer's Training Corps program in 1978 and was designated a naval flight officer in 1981, upon completion of Advanced Navigator Training. LT Sullivan was assigned to various land based ASW patrol squadrons between 1981 and 1985, and served as personnel officer, safety officer, training plans officer, assistant operations officer, and patrol plane navigator and mission commander. Between 1985 and 1987, he was assigned as Flag Lieutenant to the Commander, Naval Space Command. Upon his assignment to the Eisenhower, LT Sullivan completed a 5-day practical shiphandling course. He is the recipient of the Navy Achievement Medal.

Master Juan Luis Plaza-Gavicagogeascoa

Captain Plaza-Gavicagogeascoa, 52, master of the Urduliz, had been going to sea for 34 years and had held a merchant marine master's license from the Spanish government for 26 years. He had worked for the owners of the Urduliz for 24 years and had been master of several of their vessels for 15 years. He had been the master of the Urduliz for 2 1/2 months, the length of time that the present owners had owned the vessel.

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