Monday, November 20, 2017

Speech #I2, A Fatal Lack of KISS

Zebulon, NC

[I can't give you the goals for this speech because I screwed up.  Libby helped me to design this speech from the Entertaining Speaker book, but at the meeting I told them it was from the Speaking to Inform book; wrong.  Anyhow, Libby and I thought that is was the most fun speech so far.  Unfortunately for you the sound effects and timing that added drama don't come out in written form. I used Red text to indicate sound effects.  Verbally though, those sound interrupted me mid-sentence, adding to the drama.]

A Fatal Lack of KISS

Start the countdown. 5 minutes from now 10 people will die.

Ladies and gentlemen.


Last August, the destroyer USS John S McCain was in the Straight of Singapore. That is a congested area of the ocean with lots of ship traffic going in and out. In those circumstances, one would think that the captain would order all stations to be fully manned with the most experienced crew, including himself, the master helmsman and the systems engineer. That did not happen this night.

On the bridge are several stations. The CO or commanding officer, the helm on the left that steers and controls engine speed, the lee helm on the right, the aft station behind, and the radar man. [BUZZ 4 MINUTES]  The ship was modern, each of those stations had a screen, keyboard and mouse. Steering wheels and throttle levers don't exist any more. Normally there are also lookout stationed outside, but not this night.


At 520 in the morning, the McCain was moving fast at 20 knots. It was overtaking a tanker to the left traveling maybe half as fast. My information comes from the official navy report on the incident. What you see on the screen is the record of the actual positions of the two ships at one minute intervals

Suddenly, helm reported trouble steering and controlling throttles at the same time. The CO barked his order. LEE HELM YOU TAKE OVER THROTTLE CONTROL WHILE I HELP HELM WITH STEERING.

Lee helm says, “Aye Aye sir.” Then he used a pull down menu to select TRANSFER CONTROL.[BUZZ 3 MINUTES] 



What nobody on the bridge understood is that the software did not allow transfer of just throttle control. I transferred both steering and throttle to lee helm.

Helm believed that he still had steering control, but it wasn't working. He complained to CO. “Sir it isn't working at all.” The CO said, “Let me see.”

Radar reported, “Ship close by on the port side sir.” The CO responded, REDUCE SPEED TO 10 KNOTS. Lee helm said, “Aye Aye sir.” and he moved the throttle control slider on his screen to reduce engine power.

But lee helm believed that the slider controlled both left and right engines together. He didn't understand that on another pull down menu that option box was not checked.   So what actually
happened was that he reduced power to the left engine while the right engine continued full speed. That made the McCain start a gradual turn to the left.[BUZZ 2 MINUTES] 

Nobody noticed the left turn except the radar man. He said, “We are turning toward that ship sir. Collision alert.” The CO responded, “REDUCE SPEED TO 5 KNOTS”. The lee helm said, “Aye Aye sir.” and he did as ordered, again mistakenly only on the left engine. The rate of left turn increased.

The CO and helm were frustrated that steering control didn't work. CO ordered, “AFT STATION TAKE OVER STEERING CONTROL” [BUZZ 1 MINUTES] 

Aft station, said, “Aye Aye sir” and he used a pull down menu to select TRANSFER CONTROL..

But Aft helm forgot to preset zero rudder angle before the transfer. The previous rudder setting on his screen was 33 degrees left rudder, so after the transfer the computer moved the rudder to 33 left. Now the gradual turn became a lurching sharp turn to the left. The whole ship leaned to the right. It almost knocked the CO off his feet.

The CO screamed, “AFT STATION WHAT THE HELL ARE YOU DOING”

Lee helm spoke up. “Sir, I just realized that I set the throttles incorrectly. I'm attempting to correct that now.” But he didn't understand that he no longer controlled anything because aft station had the control.

Radar interrupted, “Sound collision alarm. Sir, should I warn that tanker on the radio and sound 5 blasts on the horn?”

The CO said, “Everybody shut up. I'm trying to figure out what is happening with the steering.”
[Crash]

On the screen are the names of the dead.

 
[At this point I stopped speaking and rang a bell 10 times to toll the dead.]
ding
ding
ding
ding
ding
ding
ding
ding
ding
ding
– 530--
So, what really happened? Who should we blame? The captain of course. The officers, the crew and the Navy. But, thinking like an engineer, one thing stands out. Kiss.

I don't mean Kiss in the romantic sense. I mean the KISS Principle in engineering design. Keep It Simple Stupid. KISS

Steering of any moving vehicle using screens, keyboards, and mouse.is insane and an egregious violation of the KISS principle.

Now, lets bring our attention back to those of us in this room. All of you may have occasion to make decisions in everyday life that could affect life and safety. There is one lesson I want you to learn from this speech. Remember only one word. What word is that? Everyone: KISS.


2 comments:

  1. Thanks for the great explanation of this accident.

    ReplyDelete
    Replies
    1. Thanks for the kind words. But you should really read the official Navy report linked in the post. There's only a couple of pages relevant, and they are shorter than my speech.

      Delete

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