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SASEBO NAVAL BASE, Japan — A series of errors, bad leadership decisions and poor planning contributed to the grounding in January of the USS Guardian on a protected Philippine reef, a Navy investigation released Thursday concluded.

The grounding damaged the reef — a World Heritage Site — and caused irreparable hull breaches to the $212 million ship, which was subsequently decommissioned.

The Guardian’s leadership and crew failed to reconcile differences between navigation maps and also neglected protocol, warning systems and visual cues that should have prevented the minesweeper from grounding, according to the report.

It cited a rash of other errors that included ignoring a list of dangers in the charted course and failing to ensure watch teams were knowledgeable and proficient. It also said imprudent personnel moves prior to the ship’s departure from its homeport in Sasebo left it without competent navigational personnel.

The 160-page report details panicked efforts to free the ship after it grounded, as seawater rushed in, and the harrowing process of abandoning ship in the Sulu Sea — some of the 79 crew members jumped into rough surf against Tubbataha reef with no rescue vessels in sight. No one was injured.

The onus for the loss of the vessel was put on the Avenger-class ship’s leadership — commanding officer Lt. Cmdr. Mark Rice, executive officer Lt. Daniel Tyler, the ship’s enlisted assistant navigator and the officer of the deck at the time — all of whom have been relieved. The report states that further disciplinary and administrative action is being considered.

“Ultimately, the lack of leadership led to increased navigational risk to the ship and her crew,” Pacific Fleet commander Admiral Cecil Haney wrote in his executive summary. “This tragic mishap was wholly preventable and was the product of poor voyage planning, poor execution and unfortunate circumstances.”

The report details a top-down lackadaisical approach to navigating tricky waterways rife with challenges and potential dangers. Rice discounted a general digital chart that placed their course on top of the reef before leaving Subic Bay and decided to rely solely on a less-detailed coastal digital chart, even though the two did not match. The coastal digital chart ended up being inaccurate.

To compound the error, Tyler told investigators that he ran a safety check of their course and that no dangers emerged. The report surmises that notification boxes, detailing dangers along the route that would have popped up had he done so, were ignored.

In addition, the crew either ignored or did not hear audible and visual alarms before the 2:25 a.m. incident on Jan. 17.

“Had leadership and watch teams adhered to prudent, safe and sound navigation principles, they would have been alerted to the approaching dangers with sufficient time to take mitigating action,” Pacific Fleet spokesman Lt. Anthony Falvo told Stars and Stripes.

Just before the crash, a sailor leaving the bridge during a watch turnover pointed out the reef’s closer-than-expected location to another sailor coming on in relief.

“The officer of the deck determined before grounding that the ship was closer to the South Islet of the Tubbataha Reef than expected based on the navigation plan, yet failed to take action to determine the ship’s true position in accordance with the CO’s Standing Orders,” Haney wrote.

The report also states that even if they had avoided Tubbataha, their poor navigational planning could have caused them to run aground soon afterward in the vicinity of Pearl Bank.

Over the following two months, the 224-foot ship slid around on Tubbataha, damaging the World Heritage Site and causing hull breaches. The ship was deemed a complete loss, and a $45 million salvage effort ran from Feb. 22 to March 29. The Guardian was stricken from the naval registry Feb. 15 and decommissioned during a March 6 ceremony at Sasebo.

The Guardian’s crew took over the USS Warrior minesweeper in Sasebo on May 2 due to force posture requirements in the region.

The grounding sparked protests outside the U.S. Embassy, and Philippine officials have called for the U.S. Navy and government to pay $1.4 million in fines, though they have not yet filed an official claim, Falvo said. The U.S. government has committed to paying for reef damage.

Despite the report’s conclusions, the full truth of what happened that night may never truly be known. Several witnesses contradicted each other and some statements from leadership could not be verified.

The ship’s leaders did not follow grounding protocol and neglected to save pertinent documents and data from the hours leading up to and after the grounding, the report said.

Navy officials would not say if this happened in the heat of the moment or amounted to destroying evidence. Some of the materials were lost at sea; others were left on board and compromised by seawater, according to the report.

“The full truth may never be known, but the big takeaway here is that the cause of the grounding was preventable,” Falvo said. “The root causes of the grounding were human error and a failure of command leadership to provide adequate oversight and direction in the planning and execution of the navigation plan.”

The report is sure to have a sweeping impact on the Warrior’s crew, the minesweeping community at large and the Navy. Former Guardian sailors placed on the Warrior will have to meet rigorous training, inspection and quality control standards. A curriculum review is underway at the Navy’s Surface Warfare Officer School. Changes have been made to the navigation watchstanding standards and procedures and the manning of minesweepers, and further review has been ordered for Navy policy and procedures.

Commanding officers are now required to report navigation-related discrepancies in their Digital Nautical Charts immediately, the report said.

The report contained some positive news. Six crewmembers — including a damage controlman who went into a compartment with water up to his neck to patch a crack and rescue swimmers who saved shipmates from drowning while abandoning ship — are being considered for awards.

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Matthew M. Burke has been reporting from Okinawa for Stars and Stripes since 2014. The Massachusetts native and UMass Amherst alumnus previously covered Sasebo Naval Base and Marine Corps Air Station Iwakuni, Japan, for the newspaper. His work has also appeared in the Boston Globe, Cape Cod Times and other publications.
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