Occasionally a story comes along that reminds us how much work we have to do to be the Navy we proclaim to be. Such is the case of Chief Boatswain’s Mate (BMC) Jeffery D. Butler who was responsible for training helmsmen on board the USS John S. McCain (DDG-56) before it collided with a tanker in 2017, killing 10 sailors. Butler was reduced in rank after pleading guilty for failing to properly train the helmsmen on watch at the time of the collision. In the harsh light of the recent National Transportation Safety Board (NTSB) report on the collision, however, the Navy should exonerate Butler, return his rank to chief, and place the onus on the institution as a whole.
The NTSB’s independent investigation into the accident clearly paints a picture of culpability in a Navy system that failed to provide necessary training and oversight, with responsibility reaching far beyond the bridge of the McCain. Although the commanding officer (CO) and his watch standers’ actions contributed to the collision, the report is sharply critical of the Navy’s lack of oversight in implementing a complex ship control system that was poorly designed, inadequately tested, and devoid of any accurate technical documentation and training. The conclusions of the NTSB report demand reconsideration of at least one aspect of the legal outcomes that were disproportional to the findings of fault and thus patently unfair. To this end, it is worth contrasting excerpts from Navy Times reports on Chief Butler’s court martial with parts of the NTSB report:
Navy Times: Chief Boatswain’s Mate Jeffery D. Butler pleaded guilty Thursday to a charge of dereliction of duty before a summary court-martial for his role in training and qualifying sailors who demonstrated that they were unable to perform basic ship-steering operations.
Butler, who reached his 20-year mark last November, was sentenced by Navy Judge Advocate, Cmdr. William Weiland to a reduction in paygrade to E-6. The maximum sentence possible was a reduction in paygrade, 60 days restriction and a forfeiture of two-thirds of one month’s pay.
Butler, the only Chief Boatswain’s Mate onboard the McCain at the time of the collision, was tasked with certifying sailors on the new, all-digital Integrated Bridge Navigation System, or IBNS, which had been installed on the destroyer four months before his August 2016 arrival to the McCain, the first destroyer he ever served on.
NTSB Report: The lee helmsman [responsible for controlling throttles] was temporarily assigned to the John S. McCain from the cruiser Antietam. Although the Antietam did not have the IBNS, the John S. McCain CO qualified the crewmember as helmsman and lee helmsman shortly after he joined the destroyer. The BMOW [Boatswain’s Mate of the Watch] was also temporarily assigned to the John S. McCain from the Antietam. The CO qualified him as BMOW on the day he joined the destroyer, without any underway instruction. Given differences between the Antietam and John S. McCain systems and the complexity of the IBNS, it is unlikely that either the lee helmsman or the BMOW was proficient with the IBNS when they began standing watch.
Although the report does not state why the two junior personnel were transferred to the McCain from the Antietam, it is common practice to fill gaps in one ship with sailors from another, often on short notice. The 2017 Navy Comprehensive Review of Surface Forces (CR) noted a shortfall of more than 6,000 sailors at sea and commented on this practice. Unfortunately, BMC Butler had no way of knowing that the McCain’s steering system was so unique and complex compared to the one the Antietam sailors knew well, and he was left with little alternative but to put the sailors on watch and have them learn whatever they could on the job.
Navy Times: Butler told the judge Thursday that he never took a single course on the new navigation system and was given just 30 minutes of training on the new tech from a master helmsman before being thrust into using it . . . And despite his requests for additional tech support and instruction, help never arrived.
NTSB Report: The NTSB has found that the operating procedures provided to the John S. McCain for the IBNS were inadequate. Specifically, procedures for the ganging1 of throttles and the transfer of steering and thrust control between bridge stations were incomplete or nonexistent.Training on the operation of the IBNS was also inadequate, as exhibited by most watch standers’ incorrect understanding of the steering control system and their inability to correctly follow emergency procedures during the accident.
The Navy Times reporting makes it sound as though Chief Butler failed to take the necessary steps to get his sailors the training they required. What the NTSB report shows is that the reason Butler could not get the required training for the sailors is because such training did not exist. As in many technological areas, Navy training often lags equipment rollout and a 30-minute training session provided at installation, as was the case here, is more the norm than the exception. One civilian master mariner I know noted that his certification included 40 hours on the operation of the ship’s radar. Only as a result of the Comprehensive Review has the Navy instituted formal classroom instruction and moved toward standardization on its many bridge systems. In the McCain’s case, who would have been responsible for this training, who should have been there to answer Chief Butler’s call for help, and where were they at his court martial?
Navy Times: . . . it wasn't until after the destroyer collided with the tanker that Butler discovered the McCain was the only ship in all of 7th Fleet outfitted with the new IBNS technology.
As a repentant Butler sat alone at his courtroom desk, he went over all the things he should have done differently. He should have persisted in pushing for more tech support. He should have performed more steering-loss drills for his junior sailors than the two he ran in the course of a year. He should have tested his sailors on the IBNS.
“If you didn’t know how to run the system, how did you know the answers they were giving you were correct?” the judge asked. "Looking back," Butler told the judge, “I should have gotten knee deep in that tech manual . . . dissect it page by page.”
NTSB Report: The Engineering Operational Sequencing Standard (EOSS) procedures on Navy vessels provide the crews with specific steps to complete when performing normal operations on installed equipment. Investigators reviewed the EOSS procedures from the John S. McCain and found that they did not contain steps for transferring control of thrust between bridge stations, there were no procedures for ganging and unganging throttles, and there were no notes or warnings about actions that automatically unganged the throttles. The reference used in developing these procedures, the technical manual, did not contain instructions for ganging throttles, and there was no description of the “ganged” indicator on the GUI display. Additionally, written instructions did not contain a procedure for shifting steering from one bridge station to another, other than a shift from the SCC to the HFS during the initial steering system alignment. The NTSB concludes that the steering and thrust control written operating procedures on the John S. McCain’s bridge did not describe the actions needed to transfer control between stations and therefore were inadequate.
If BMC Butler had gotten “knee deep” and dissected the technical manual, he still could not have trained the crew because the manual was wrong. In addition, other parts of the NTSB report go into detail on the excessive complexity of the ship control system. One user described the touch screen of this equipment as “Similar to an iPhone—but with 100 buttons on the display face.” Recently the Navy has consolidated bridge configuration under a single directorate within Naval Sea Systems Command (NavSea) and is in the process of divesting the fleet of the system that was installed on board the McCain and replacing it with more traditional, user-friendly, manual throttles. But this action only addresses a symptom, not the root cause. For that, we must look at the entire system.
Unfortunately for BMC Butler, the design engineers, human systems integration testers, Naval Education and Training Command representatives, and the technical warrant holder were not present in the court room during his court martial proceedings. The Navy should not necessarily prosecute anyone on the engineering team for the McCain collision, but Webster’s dictionary defines “root cause” as an “initiating cause of either a condition or a causal chain that leads to an outcome or effect of interest. The term denotes the earliest, most basic, 'deepest', cause for a given behavior; most often a fault.” In this case, the clear root cause was a poorly designed and supported system. A properly designed and technically supported ship control station would not have caused the confusion that resulted in the McCain collision.
The Navy likes to talk about accountability, but forcing BMC Butler to take the weight of the deaths of his shipmates and the failings of the Navy system on his shoulders—while Navy leaders consistently emphasized the role individual actions played in the crashes—is an abject failure of accountability.
Butler’s own words show that he holds himself accountable. “I want to give my condolences and ask for your forgiveness. They were more than just my shipmates—they were family members.” But the NTSB Report lays the blame at the feet of the Navy. “The Navy’s training organization and the CO’s superiors were required to assess and certify that the destroyer was safe to operate and that the watch stander qualification system was effective. The John S. McCain crew’s inability to effectively respond to the emergency calls into question the Navy’s assessment and certification process.”
Based on the NTSB findings, the Navy should do the right thing and reinstate Jeffery Butler to the rank of chief petty officer and ensure that he gets the retirement benefits he earned in an exemplary career. He has held himself accountable—now it is time for the Navy to do the same for itself.
1. “Ganging” throttles is the process of linking the port and starboard engines so that the turning rate of both propellers is adjusted in unison. “Unganging” throttles allows the lee helmsman to manipulate the port and starboard propellers independently.