Investigation

‘Accumulation of Failures' Led to Near-Miss Between Navy Ships in San Diego Bay, Investigation Concludes

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A popular web cam overlooking the San Diego Bay suddenly has been switched off. NBC 7’s Joe Little explains.

The U.S. Navy investigation into the near-miss of two U.S. Navy ships — USS Momsen and USS Harpers Ferry — that came a little too close for comfort as they passed each other in San Diego Bay last year has been completed and published.

The investigating officer conducted voluntary interviews with 33 individuals from USS Harpers Ferry and USS Momsen, as well as one additional civilian pilot.

While both vessels were able to safely pass each other as they transited San Diego Bay on Nov. 29, 2022, luckily avoiding damage to either ship, the U.S. Navy's investigation report obtained by NBC 7 outlines seven key factors that led to the incident.

The final version of the report, issued by U.S. Navy VADM Roy Kitchener, confirms the Navy's belief that the "near-miss collision was preventable and resulted from an accumulation of failures" including:

  • Bridge Resource Management, described in a Navy training outline as the crew’s planning, risk management skills, and fatigue management program.
  • Lack of communications between the bridge, or pilothouse, of both ships;
  • Adherence to the "rules of the road;"
  • Navigation planning as well as;
  • Risk management

"In the critical moment when USS Harper's Ferry commanding officer and at least two others were giving direction to the sailor in command of the ship, it is clear that the situation overwhelmed them and she was no longer able to execute her duties," the report reads, outlining an example of poor "bridge resource management."

The investigating officer also outlined that it appeared the [USS Harper’s Ferry’s] whistle signals were separated by a period of time, casting doubt that the blasts would have sounded like five short blasts, therefore USS Momsen should have responded with either two short blasts to signal agreement or five short blasts to indicate doubt, which the report alludes did not take place.

Lastly, while the preliminary investigation officer found that not all members of both USS Harper's Ferry or the USS Momsen's bridge were qualified to hold the positions they were operating at the time of the incident, they subsequently found that "this discrepancy did not contribute to the near miss," the report reads.

The report also addressed that while situational awareness of those piloting a ship is not as significant as the commanding officer's role in the bridge, the expert knowledge of the harbor, provided by the pilot, should be taken into account during the commanding officer’s determination, particularly for a non-homeported ship such as USS Momsen, which is homeported at Naval Station Everett in Washington.

“Had USS Harper’s Ferry been on the outbound side of the channel, passage would have been more manageable," the preliminary inquiry officer wrote in the report, adding "However, the overarching guidance that vessels should not meet in a turn remains relevant”

The only discipline included as part of the report was listed that VADM Roy Kitchener ordered CDR. Eric Winn, commanding officer of USS Harper’s Ferry and CDR. Eric Roberts, commanding officer of USS Momsen, as well as their respective executive officers to report to him no later than Feb. 10, 2023, to provide a self-assessment of the incident and to outline what actions will be taken with their crew to prevent a similar situation in the future.

The Director of Fleet Training (N7) of Naval Surface Forces was also directed by VADM Kitchener to provide oversight to USS Harper's Ferry and USS Momsen to ensure the commanding officer is properly training the crew of each ship, on their roles and responsibilities during sea and anchor detail.

“The investigation findings focused on counseling and self-assessment of those involved in the incident, formalizing procedures and clarifying standing orders, and emphasizing continued professional growth of our command triads and bridge teams, " CDR Arlo Abrahamson, a Naval Surface Forces spokesperson wrote to NBC 7, adding "It’s also important to note that some members of the bridge teams were lauded for their actions in preventing a collision. As noted in the investigation findings, this inquiry was an opportunity to critically assess processes and implement lessons learned to ensure this type of incident does not occur again."

A copy of the Navy's full investigation report can be viewed here.

The Incident

The Nov. 29, 2022 incident took place between North Island's Ammunition Pier and the west end of Shelter Island and prompted a Naval investigation despite no damage to either ship.

In a safety book for boaters, the U.S. Coast Guard advises that when vessels are headed toward each other, port-to-port passing, or passing on the right so that each vessel's port sides are closest, is advised.

November's encounter saw USS Momsen and USS Harper's Ferry do the opposite, apparently out of necessity.

Radio traffic between USS Momsen, a guided-missile destroyer, and USS Harpers Ferry, a dock landing ship, starts out with a USS Momsen crewmember asking USS Harpers Ferry to confirm if it was planning a port-to-port passing.

USS Harpers Ferry's crew begins to respond but stops, then USS Momsen advises, "We are coming to port to avoid you." Harpers Ferry quickly radios back to Momsen advising, "We are coming to port to avoid you as well."

The webcam footage shows both ships veer to port, or to the left, and their starboard sides nearly brush against each other.

An investigation is under way regarding the incident involving the USS Momsen and USS Harpers Ferry.

"Both ships maneuvered to safety," said Lt. Sam Boyle of the U.S. Third Fleet. "There were no injuries or damage to the ships as a result of those maneuvers. The incident is under investigation."

Webcams Removal

This week, Barry Bahrami, operator of the webcam that captured this incident, contacted NBC 7 after it was apparent his cameras had gone offline.

The “San Diego Web Cam” has shown ships in San Diego Bay for nearly ten years. However, Bahrami, believes someone must be upset with him about a video he says may have embarrassed the U.S. Navy.

Bahrami says he operates the series of webcams, based at different locations showing a variety of angles around San Diego Bay "to show off our beautiful city."

Earlier this week, he contacted the National Park Service, which helped install the camera ten years ago. He was initially told it was an internet issue but didn't believe it. That's when he was led to believe it was a security issue, which he has taken into account over the last decade, by blocking out Naval Base Point Loma when it's in frame.

The National Park Service finally told Bahrami on Wednesday that the cameras were disconnected by request of the Naval Criminal Investigative Services.

A popular web cam overlooking the San Diego Bay suddenly has been switched off. NBC 7's Joe Little explains.

"NCIS verbally expressed force protection concerns to NPS related to the private webcams and YouTube channel, which provided 24-hour webcam monitoring of vessels and equities located aboard Naval Air Station North Island, including aircraft hangers/flight lines, Naval Base Point Loma submarine assets, and the tracking of military personnel working aboard Naval Base Coronado," Jeff Houston, a media affairs representative for NCIS wrote to NBC 7.

In a different statement, Houston added, "Ultimately the decision to remove the webcams was made by the National Park Service. We look forward to continuing close coordination with NPS."

When asked if the decision to remove the cameras was in response to the investigation into USS Harper's Ferry and USS Momsen near-miss incident, Houston replied, "No."

The National Park Service has not provided a statement, despite repeated requests.

— NBC 7's Joe Little contributed to this article.

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