| Recurring |
one_organization |
(a) The software failure incident related to the USS John S McCain's Integrated Bridge and Navigation System (IBNS) designed by Northrup Grumman has happened again within the same organization. The incident occurred on the USS Fitzgerald two months before the McCain collision. The USS Fitzgerald crash also involved a collision at sea due to steering control errors, and there were rumors that the crew had been overworked before the collision [93042].
(b) The software failure incident related to flawed touch-screen control systems causing collisions at sea has not been explicitly mentioned to have happened at other organizations in the provided articles. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident related to the design phase:
- The design of the USS McCain's touch-screen steering and thrust control system was found to have increased the likelihood of operator errors that led to the collision [93042].
- The Integrated Bridge and Navigation System (IBNS) installed on the USS McCain was described as 'flawed' and 'unstable' with 'multiple and cascading failures regularly' [93042].
- Problems with the IBNS system developed shortly after its introduction, with the system being complex and overwhelming for junior sailors who used it [93042].
- The IBNS system was prone to frequent malfunctions, and Navy officials discovered a flaw in the system in 2014 that caused it to get overwhelmed by too much data [93042].
- The Navy's solution to the IBNS flaw was to instruct sailors to delete data before it reached a certain point, indicating a design flaw in the system [93042].
(b) The software failure incident related to the operation phase:
- The crew members of the USS McCain struggled to manage the helm and propulsion control due to the complexities of the IBNS interfaces, leading to confusion and errors during operation [93042].
- The crew resorted to rebooting the IBNS system when it malfunctioned, as they lacked specialized training to maintain the system, highlighting operational challenges [93042].
- The crew mistakenly believed that pressing a big red button would revert control to the back of the ship, but it actually sent control back to its original location, indicating operational misunderstandings [93042].
- The crew faced challenges in settling the steering control between the front and back stations, leading to confusion and delays in correcting the ship's trajectory before the collision [93042].
- The Navy issued new IBNS instructions to address operator response to system malfunctions, emphasizing the importance of proper operational procedures to prevent errors [93042]. |
| Boundary (Internal/External) |
within_system |
(a) The software failure incident related to the USS John S McCain collision can be categorized as within_system. The incident was primarily attributed to the flawed Integrated Bridge and Navigation System (IBNS) installed on the warship. ProPublica's report highlighted that the design and implementation of the touch-screen control system within the IBNS contributed to operator errors that led to the collision [93042].
The ProPublica report detailed how the IBNS was described as 'flawed' and 'unstable', with multiple and cascading failures regularly occurring. The system was prone to malfunctions, and Navy officials raised concerns about its complexity overwhelming junior sailors who used it. Additionally, the report mentioned that the IBNS software did not provide adequate alerts or indications to the crew regarding critical changes in control, leading to confusion and ultimately the collision [93042]. |
| Nature (Human/Non-human) |
non-human_actions, human_actions |
(a) The software failure incident occurring due to non-human actions:
The software failure incident on the USS John S McCain was primarily attributed to the flawed Integrated Bridge and Navigation System (IBNS) installed on the warship. An NTSB investigation found that the design of the touch-screen steering and thrust control system of the IBNS increased the likelihood of operator errors that led to the collision [93042]. The ProPublica report highlighted that the IBNS system was described as 'flawed' and 'unstable', with multiple and cascading failures regularly occurring, indicating that the software failure was primarily due to the system's design and technical issues [93042].
(b) The software failure incident occurring due to human actions:
While the Navy initially placed blame on operator error, stating that the crew members did not follow protocol and were improperly trained on the complex IBNS system, the ProPublica report argued that the blame should not have been solely on the crew. It mentioned that no amount of training would have been adequate to run the flawed IBNS system, which was designed and installed by Northrup Grumman [93042]. Additionally, the report highlighted that the crew members mistakenly believed the function of a big red button on the IBNS console, leading to confusion and incorrect actions during the critical moments before the collision [93042]. |
| Dimension (Hardware/Software) |
hardware, software |
(a) The software failure incident occurring due to hardware:
- The incident involving the USS John S McCain's collision in 2017 was primarily attributed to the Integrated Bridge and Navigation System (IBNS), which was a touch-screen control system installed on the warship [93042].
- An NTSB investigation found that the design of the touch-screen steering and thrust control system on the USS McCain increased the likelihood of operator errors that led to the collision [93042].
- The IBNS was described as flawed, unstable, and prone to multiple and cascading failures regularly, indicating hardware issues with the system [93042].
- Problems with the IBNS emerged after a new version was installed in the USS McCain in 2016, leading to crashes when trying to integrate radar images in the ship's navigation computer, pointing to hardware-related malfunctions [93042].
(b) The software failure incident occurring due to software:
- The software failure incident on the USS McCain was primarily linked to the flawed design and functionality of the Integrated Bridge and Navigation System (IBNS) software [93042].
- The IBNS software was described as complex, overwhelming junior sailors who used it, and prone to frequent malfunctions, indicating software-related issues with the system [93042].
- The IBNS software had issues such as data overload, patches on top of patches, and a lack of a full picture of the seas around the ship, highlighting software flaws in the system [93042].
- The confusion and errors related to steering control transfers, propeller operations, and control station switching were all attributed to software failures within the IBNS system [93042]. |
| Objective (Malicious/Non-malicious) |
non-malicious |
(a) The software failure incident related to the USS John S McCain collision in 2017 was non-malicious. The incident was primarily attributed to the flawed Integrated Bridge and Navigation System (IBNS) installed on the warship, which was designed and installed by Northrup Grumman. The ProPublica report highlighted that the design of the touch-screen steering and thrust control system of the IBNS increased the likelihood of operator errors that led to the collision [93042]. The incident was a result of technical flaws and system failures rather than intentional actions to harm the system. |
| Intent (Poor/Accidental Decisions) |
poor_decisions, accidental_decisions |
The software failure incident related to the USS John S McCain collision in 2017 involved contributing factors introduced by both poor decisions and accidental decisions.
1. Poor Decisions:
- The Navy awarded Northrop a contract to install the Integrated Bridge and Navigation System (IBNS) on the USS John Paul Jones, touting it as the 'way of the future' to improve safety and reduce the number of sailors needed on the bridge [93042].
- The Navy continued with the installation of the IBNS on multiple ships despite problems developing with the system, including complexity overwhelming junior sailors, frequent malfunctions, and patches that left destroyers without a full picture of the seas around them [93042].
- The Navy allowed ships to sail without enough time for training or repairs, as highlighted by the former chief of naval operations, John Richardson, calling the USS McCain and Fitzgerald crashes 'avoidable tragedies' [93042].
2. Accidental Decisions:
- The captain of the USS McCain, Alfredo Sanchez, made decisions during the incident that had fateful consequences, such as putting the IBNS in backup mode and changing up the crew manning the bridge, leading to confusion over steering control [93042].
- The transfer of steering controls on the bridge and an error in the propellers causing them to operate separately were accidental decisions that contributed to the collision, with the Navy unable to conclusively determine how the error occurred despite multiple investigations [93042]. |
| Capability (Incompetence/Accidental) |
development_incompetence, accidental |
(a) The software failure incident occurring due to development incompetence:
- The incident involving the USS John S McCain's collision in 2017 was attributed to the Integrated Bridge and Navigation System (IBNS) installed on the warship, which was designed and installed by Northrup Grumman [93042].
- ProPublica's report highlighted that the IBNS system was described as 'flawed' and 'unstable' with 'multiple and cascading failures regularly' [93042].
- The Navy placed blame on operator error initially, but ProPublica's investigation concluded that the crew should not have been heavily blamed as the flawed IBNS system was a significant factor in the collision [93042].
- The complexity of the IBNS overwhelmed junior sailors who used it, and the system was prone to frequent malfunctions, requiring patches and workarounds to address issues [93042].
- Northrup continued making improvements to the system, leading to different controls on each ship, making it harder for sailors to familiarize themselves with the system [93042].
(b) The software failure incident occurring accidentally:
- The incident involving the USS John S McCain's collision in 2017 had elements of accidental factors, such as the confusion and errors that occurred during the steering control transfer on the bridge, leading to the collision with the oil tanker [93042].
- The ProPublica report highlighted that crew members mistakenly believed that pressing a big red button would revert control to the back of the ship, but it actually sent control back to its original location, contributing to the confusion during the critical moments before the collision [93042].
- The report pointed out that the misunderstanding among the crew could have been influenced by outdated manuals and lack of proper training on the IBNS system [93042]. |
| Duration |
permanent, temporary |
The software failure incident related to the USS John S McCain collision in 2017 involved both permanent and temporary aspects:
(a) Permanent Failure:
The software failure incident involving the Integrated Bridge and Navigation System (IBNS) installed on the USS McCain was characterized by permanent failure aspects. The ProPublica report highlighted that the IBNS system was described as 'flawed' and 'unstable' with 'multiple and cascading failures regularly' [93042]. The design of the touch-screen steering and thrust control system was found to have increased the likelihood of operator errors that led to the collision, indicating a permanent flaw in the system [93042].
(b) Temporary Failure:
On the other hand, temporary aspects of the software failure incident were also evident. The incident involved temporary malfunctions and errors that occurred during the operation of the IBNS system. For example, the IBNS began to crash when trying to integrate radar images in the ship's navigation computer, indicating temporary operational issues [93042]. Additionally, the crew resorted to rebooting the system when it malfunctioned, suggesting temporary solutions to address the immediate problems caused by the software failure [93042]. |
| Behaviour |
crash, omission, timing, value, byzantine, other |
(a) crash: The software failure incident in the USS John S McCain was characterized by a crash, where the system lost control and did not perform its intended functions, leading to the deadly collision with an oil tanker. The Integrated Bridge and Navigation System (IBNS) on the USS McCain suffered from multiple failures, crashes, and malfunctions, which ultimately contributed to the collision [93042].
(b) omission: The software failure incident also involved instances of omission, where the system omitted to perform its intended functions. For example, there were errors in the transfer of steering controls on the bridge, leading to confusion among the crew members. The system failed to alert the operators about the transfer of steering control, contributing to the collision [93042].
(c) timing: The timing of the software failure incident was crucial in the USS McCain collision. The system was reported to have performed its intended functions incorrectly at critical moments, such as when the steering control was transferred between different stations on the bridge. These incorrect actions at specific times led to the ship turning into the path of the oil tanker [93042].
(d) value: The software failure incident also involved failures where the system performed its intended functions incorrectly. For example, the IBNS software did not alert the operators about the transfer of steering control, leading to confusion and ultimately contributing to the collision. Additionally, the system's backup mode inadvertently removed some built-in safeguards, affecting the control of the ship [93042].
(e) byzantine: The software failure incident exhibited characteristics of a byzantine failure, where the system behaved erroneously with inconsistent responses and interactions. The IBNS on the USS McCain was described as 'flawed' and 'unstable,' with multiple and cascading failures regularly occurring. The system overwhelmed junior sailors who used it and was prone to frequent malfunctions, indicating inconsistent behavior [93042].
(f) other: In addition to the above behaviors, the software failure incident in the USS John S McCain also involved complexities in the system interfaces that led to the helmsmen struggling to manage the helm and propulsion control. The system's design flaws, complexity, and lack of proper training contributed to the incident, showcasing a combination of crash, omission, timing, value, and byzantine behaviors [93042]. |