The Weekly Reflektion 47/2025

We have earlier published several Reflektions on the Helge Ingstad collision where a mental picture of the situation was agreed between the Officer of the Watch and his relief which turned out to be in error. The collision between USS Fitzgerald and the container ship MV ACX Crystal also highlights how anchoring, confirmation bias and rigid mental models can undermine situational awareness even among trained teams.

The damage to the USS Fitzgerald caused by the collision with the MV ACX Crystal

Do you encourage a culture for challenge, especially when something doesn’t feel right?

Early on 17 June 2017, the United States Navy destroyer USS Fitzgerald collided with MV ACX Crystal, a Philippine-flagged container ship, about 80 nautical miles (150 kilometres; 92 miles) southwest of Tokyo, Japan. The accident killed seven of the crew on USS Fitzgerald.

The investigation concluded that, in the minutes leading up to the collision, the bridge team aboard the USS Fitzgerald formed an early mental picture of the surrounding traffic. They believed they had identified the primary risk vessels, that the destroyer’s manoeuvring intentions were clear to others, and that they had sufficient time and space to maintain course. This initial assessment became the anchor that shaped their interpretation of the evolving situation.

At about 01:17 Fitzgerald‘s OOD (Officer of the Deck), misjudged the course of ACX Crystal. At 01:25 the OOD, noticed ACX Crystal getting closer, and ordered a turn to 240T (that is, to turn to the right and pass behind ACX Crystal), but then rescinded the order. Instead, the OOD ordered an increase to full speed and a rapid turn to the left (port) to pass ahead of ACX Crystal, but these orders were issued too late and failed to prevent the collision.

Once the mental model was established by the OOD and their team, subsequent observations were filtered through it. Changes in the relative bearing of ACX Crystal, increasing closure rate, and contradictory radar information were not enough to shift the team’s understanding. Instead of prompting a reassessment, these signals were either overlooked, underweighted, or rationalised to fit the initial belief that the destroyer was not on a collision course. The anchoring bias was compounded by communication breakdowns on the bridge, key observations were not shared, assumptions were not challenged, and no one explicitly articulated that the developing picture no longer matched the original one.

Similarly, the ACX Crystal bridge team made their own assumptions, that the destroyer would take early and substantial action to avoid collision, consistent with expectations of naval manoeuvring. This mutual anchoring to expected behaviours on both vessels created parallel, incompatible mental models where each crew believed the other would act in the way they anticipated, and neither recognised the discrepancy in time.

This incident illustrates how quickly an early mental model can become “locked in,” particularly under time pressure or when team members assume shared understanding. The incident highlights the need for explicit, continuous reassessment of the mental model rather than relying on first impressions. This requires clear and assertive communication, ensuring that observations and concerns are verbalised. Continuous cross-checking with other team members is required, and people need to be encouraged to challenge the prevailing view. A culture that normalises speaking up, especially when something feels inconsistent with the expected scenario, is needed. It is also important to avoid clinging to assumptions when evidence starts to indicate they may be wrong.

The USS Fitzgerald collision is a reminder that in an operational environment, situational awareness is not a one-time task but an ongoing process that requires continuous updating. Anchoring can make skilled professionals cling to the first picture that forms, even as the environment moves on. Recognising and challenging these cognitive traps is essential for safe operations, effective teamwork, and preventing accidents.