Investigations by the Navy and the National Transportation Safety Board, or NTSB, concluded that the navigation system itself had not malfunctioned. The ship's hard turn to the left and the inability to correct it was the result of a series of mistakes by Bordeaux and fellow sailors.Immediate responsibility, the Navy ruled, rested with Sanchez, his officers and senior sailors. They had been lax, even complacent, in their training of the sailors steering the ship. Sanchez had made a critical error in not adding more sailors to stand watch as the McCain navigated the treacherous strait. Sanchez was charged with homicide. A chief petty officer, responsible for training the sailors to use the navigation system, was charged with dereliction of duty. The chief petty officer had himself received less than an hour of instruction.
But a ProPublica examination shows that the Navy pursued prosecutions of the two men even as its investigators and those with the NTSB were learning that the navigation system, if it hadn't technically malfunctioned, had played a critical role in the deadly outcome in the Pacific.
Its very design, investigators determined, left sailors dangerously vulnerable to making the kinds of operational mistakes that doomed the McCain. The Integrated Bridge and Navigation System, or IBNS, as it was known, was no technical marvel. It was a welter of buttons, gauges and software that, poorly understood and not surprisingly misused, helped guide 10 sailors to their deaths.
Despite its issues, the IBNS operated for years without major incident. Navy sailors did what they have always done: They found ways to make do with an imperfect technology.
The NTSB put it plainly: "The design of the John S McCain's touch-screen steering and thrust control system," the board found, "increased the likelihood of the operator errors that led to the collision."
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