This paper explores maritime accidents in 2017, based on the NTSB accident reports in 2019 and 2020. The collisions involved modern destroyers, i.e. the US Navy John S McCain and the US Navy Destroyer Fitzgerald. We have explored incidents, and have explored root causes based on a system perspective, i.e. exploring Man (Human Factors issues), Organizational issues, and Technology issues;. In addition we have explored how the blunt end (Command and control in the Navy) and the sharp end (i.e. crew on the bridge) has been evaluated by key actors such as the Navy, courts and the investigation authority - NTSB. We have based our evaluation on an accident investigation model as used by the safety investigation authority. Design challenges has been a part of our analysis. Both accidents happened during night time (where sensemaking is impacted by the circadian rhythm), with poor interaction with surrounding traffic - the AIS (automatic identification system) was turned off making communication with other ships challenging, the Navy’s ineffective oversight in the areas of crew training and fatigue mitigation, loss of situational awareness/ ineffective communication and cooperation on the bridge. In addition our limited survey of maritime accidents, have highlighted the poor quality of situational awareness on the bridge, too many alarms, insufficient training, insufficient passage planning, poor work load assessment and poor (safety) management. It seems that the operation of the destroyers created the environment for a n accident waiting to happen. However the John S McCain and the Fitzgerald case, the actors in the sharp end was blamed and punished for the accidents, thus indicating the need for a more “just culture” in the naval environment.

References NTSB (2020). Collision between US Navy Destroyer Fitzgerald and Philippine-Flag Container Ship ACX Crystal  (2019) Collision between US Navy Destroyer John S McCain and Tanker Alnic MC August 21, 2017