Five minutes before the guided missile destroyer McCain collided with a commercial vessel in August, McCain’s commanding officer felt the helmsman was having difficulty steering the ship and controlling its speed — normal duties for the watch station.

The skipper then ordered the officer of the deck to change to the ship’s steering configuration so that another sailor could step in and help — a maneuver called splitting the watch.

But instead of fixing the problem, the helmsmen’s failure to properly carry out the procedure plunged the bridge into chaos and put the ship into a sharp turn that ultimately caused the collision.

Ten sailors died as a result of that collision.

The Navy’s accident report, released Thursday, called splitting the watch an “abnormal operating condition,” but multiple Navy experts tell Navy Times that it’s a job a properly trained and qualified bridge team should have been able to handle without incident.

Yet McCain’s bridge team was neither experienced nor qualified to the level they should have been to be steaming a warship through crowded waters, and the Navy’s report acknowledged as much, blaming the failures on the bridge team’s insufficient local training and qualifications.

That’s because multiple members of the bridge team on watch at the time of the collision were temporarily assigned from the cruiser Antietam and had never officially qualified to operate the bridge equipment on board McCain.

The report noted that the differences between the two ship’s steering systems were significant, but none of the watch-standers were given any training to learn the new system.

“Multiple bridge watch standers lacked a basic level of knowledge on the steering control system, in particular the transfer of steering and thrust control between stations,” the Navy‘s report concluded, placing the fault squarely on the ship’s watch-stander training and qualification program.

It’s a common thread between both the destroyer Fitzgerald’s collision in June and the McCain collision: A lack of training on key equipment and a weak understanding of ship operating fundamentals, which ultimately led to failures that killed, in total, 17 sailors.

The Navy’s report on its own internal review found this to be a common factor in all four of the major mishaps in the Japan-based 7th fleet, which included the Fitzgerald and McCain collisions as well as the grounding of the cruiser Antietam in Tokyo Bay in January and the cruiser Lake Champlain’s collision with a South Korean fishing boat in May.

“In each of the four mishaps, the qualification of individuals for specific watchstations did not translate to proficiency to safely execute the mission,” according to the review that was conducted by Fleet Forces Command commander Adm. Phil Davidson.

Many believe those shortfalls in training are rooted in decisions made years before the crashes.

“The leadership of the surface Navy 15 years ago began to cut training,” said retired Navy Cmdr. Kirk Lippold, who commanded the guided-missile destroyer Cole. “The result is that today, they don’t emphasize training. So consequently these commanding officers at sea are in the awkward position that they literally don’t know what they don’t know.”

On board the Fitzgerald, investigators determined the ship’s officers didn’t fully comprehend the International Regulations for Preventing Collisions — colloquially known as the “rules of the road” — that define international norms for how ships should interact at sea.

Retired Navy Capt. Rich Hoffman, who commanded both the frigate DeWert and the cruiser Hue City, acknowledged that being a professional mariner goes well beyond knowing the rules of the road. But without that basic knowledge, it’s nearly impossible for crews to safely perform complex operations in highly trafficked areas.

“Ultimately it’s the captain who is responsible for that lack of knowledge, but it goes much further than that,” Hoffman said.

“We don’t put people in airplanes and drive them around until they have ground school, and the surface warfare community doesn’t have a ground school. And if we don’t know what we’re doing on the most basic of levels, we’re a danger to ourselves and those around us,” he said in an interview.

But the problems on Fitzgerald went deeper than that. The report found that “watch team members were not familiar with basic radar fundamentals, impeding effective use.”

The end result was that “watch team members responsible for radar operations failed to properly tune and adjust radars to maintain an accurate picture of other ships in the area.”

The report also concluded that the command didn’t “foster a culture of critical self-assessment.”

In fact, the Fitzgerald’s crew had reported a near collision just weeks before the one that killed seven sailors, but that was never fully evaluated by the command’s leadership, the report said. No efforts were made to identify that incident’s root causes.

This negligence indicates that “command leadership was not aware that the ship’s daily standards of performance had degraded to an unacceptable level,” the report said.

Meanwhile, on the McCain, the chaos caused by splitting the control of steering and throttle in the final moments before the collision was both a lack of judgment on the part of the commanding officer and also a training failure.

Maneuvering during a loss of steering is something good bridge teams train regularly to handle. But on McCain, the order plunged the bridge into chaos.

According to the Fleet Forces Comprehensive Review of all the 7th fleet incidents, the commanding officer on the bridge saw the helmsman struggling to maintain both the steering and throttle for the ship’s two shafts. The CO gave the officer of the deck an order to split the helm which was relayed to the helm by the conning officer.

The move should have been simple, electronically transferring control of the ship’s throttles to the another console a few feet to his right, a watch station known as lee helm. But the transfer wasn’t performed properly and mistakenly sent the steering control to the lee helm, too.

The resulting chaos began when the helmsmen, unaware of the transfer error, announced that he’d lost steering. They tried to transfer the ship’s steering to another location in the back of the ship, but that station was unable to override what was happening on the bridge.

Amid chaos on the bridge, the watch team transferred the steering control between various bridge consoles five times in the moments leading up to the collision, the Navy report said.

Control over the ship’s two major propellers ended up being split between two different consoles. When one of the helmsman reacted to throttle control orders to slow the ship, the sailor was unaware he was only controlling the port shaft, so the slowing of only the starboard-side engine acted like a rudder turn and turned the ship sharply into the path of the commercial vessel, which McCain had just passed.

The report discovered that even the most senior officer responsible for maintaining training standards didn’t understand how to properly transfer control of steering or throttle functions between watch station consoles, nor did the sailors instructing those operating the system at the time of the collision.

“Personnel assigned to ensure these watch standers were trained had an insufficient knowledge to effectively maintain appropriate rigor in the qualification program,” the report said.

Further complicating the situation was the fact that some of the sailors on the watch team weren’t officially part of the ship’s crew, but were temporarily assigned from the cruiser Antietam to get more experience while their ship was being repaired after running aground.

The Comprehensive Review said those bridge team members included the junior officer of the deck, the boatswain’s mate of the watch and the lee helmsman.

Both the junior officer of the deck and the boatswain’s mate of the watch were not actually qualified to be standing watch that morning. Though the watch bill listed them as qualified, the dates associated with their “qualifications” were, in fact, the dates they reported to the McCain, and they had not done any re-qualifying since. The exception was the lee helmsman, who did qualify for his position within a few weeks of arriving on the McCain.

Both the report and comprehensive review noted there are significant differences between the steering control systems of both ships. Chief of Naval Operations Adm John Richardson, at a press conference on Nov. 2, identified this as a key contributor to the collision because those watch-standers weren’t given any kind of training.

’The requisite training and qualification for the systems that are on that receiving command have got to be in place to ensure that before they operate the equipment that they are trained, qualified and certified to do so, accounting for any differences in configuration between the two commands,” Richardson said.

“That was a gap on the John S. McCain. They did not do any kind of rigorous step to ensure that those watch-standers from Antietam were qualified on the equipment on the John S. McCain, and that ended up contributing to the confusion that led to the collision,” the CNO said.

Though the issues identified in the report are local command culture and climate issues, Lippold said the root causes leading to these gaps and shortfalls go much deeper.

“These skippers that we send out there, while they have 17 or 18 years of experience before they ever get to these ships, they are not receiving the mentorship, leadership or the time at sea necessary to train their crews to be able to run these drills to be able to do the routine things to operate their ship,” Lippold said.

“They’ve never experienced an in-depth, across-the-board training program in port and underway that would build that foundation of experience that would allow them to command their ships safely. And it’s something the Navy needs to focus on because not doing it is costing lives.”