Posted on 04/22/2005 9:39:45 PM PDT by SmithL
A preliminary report on the submarine that hit a seamount in the Pacific three months ago concludes that numerous warnings of shortcomings in the ship's navigation department existed at least a year before the accident.
In a January 2004 inspection, the USS San Francisco crew did not properly use its fathometer warning system and its electronic Voyage Management System, or VMS, which were both factors in the accident a year later, according to the report, a copy of which was provided to The Day.
In August 2004, during another inspection, the San Francisco navigation team was found deficient in the chart review process, and in a certification process in October 2004, the team failed to adequately highlight hazards to navigation on the charts, the report found.
The report outlines a series of weaknesses in the navigation process –– starting before the San Francisco left port –– that led to the Jan. 8 grounding that killed one crewman and injured almost everyone on board, 29 of them seriously enough to require hospital care.
“The navigation and command teams on SFO (San Francisco) failed to develop and execute an effective voyage plan that would ensure the safe and prudent navigation of the ship,” says the Mishap Investigation Report, as it is known. “This was the fundamental cause of the grounding.”
The report paints a grim picture of the first minutes after the accident, when the engineer did not recognize the ship had lost almost all its speed — the speed indicator was stuck on 25 knots as a result of the crash — and did not take steps to compensate for the reduced maneuverability of a submarine at slow speeds.
“This could have had drastic consequences,” the report says. “Although this lack of action in maneuvering did not contribute to the grounding, it could have resulted in the loss of the ship and crew had the forward main ballast tanks not held enough air to provide upward momentum.”
Within six seconds of the crash, however, the crew had the submarine in an “emergency blow,” rising quickly to the surface, but with the bow down as much as 14 degrees as it climbed 525 feet in less than 90 seconds.
The report provides considerable insight into the damage aboard the ship, and estimates it will cost $88 million to repair, though it cautions, “an engineering assessment is in progress that could substantially change this estimate.”
The report notes that all four torpedo tube doors were deformed and inoperable; that 15 torpedoes and two Tomahawk missiles had to be repaired, that the sonar dome was smashed and mostly missing and that the sonar sphere was breeched, along with three main ballast tanks.
It also lists page after page of other damage, such as computers, lockers, lights and other equipment that was smashed by men flying through the air.
The report praised the ship for doing an exceptional job at making sure equipment was stowed properly before the accidents so loose gear was not turned into missiles, and for a response to both the mechanical and medical problems that was very effective.
•••
The report found fault with Submarine Squadron 15 in Guam, where the San Francisco is based, and with Submarine Group Seven in Yokosuka, Japan, which oversees Squadron 15.
There has been considerable griping within the submarine community that that the San Francisco crew has shouldered all the blame while higher-ups have escaped criticism.
Although the report placed the blame for the accident squarely on the navigation team and command team on the San Francisco, it found that the squadron and the group could have done more to prepare the ship for sea.
In particular, the report noted that the squadron “did not take adequate action to correct previously identified deficiencies in open ocean navigation onboard SFO,” and did not even require the ship to report what it was doing to fix the problems.
In addition, the squadron did not provide adequate oversight of the San Francisco's navigation performance because it was understaffed, with two positions unfilled, and the squadron assistant navigator was assigned to one of the other squadron submarines for most of the previous year.
The report also notes the document known as a “Subnote” from the Group, which laid out a path and average speed, was delivered to the ship two-and-a-half days before San Francisco sailed, and the Group's own requirements are that it be to the ship three to five days before sailing.
But the report found the submarine captain spent as much time as he usually did reviewing the charts, as did other members of the navigation team, and that the timing of the Subnote did not contribute to the accident.
“Although the ship felt that the late delivery of the Subnote did not affect the method in which the voyage was planned, reviewed and approved, that is only because their process lacked the rigor to ensure such adequate voyage planning was accomplished,” the report concludes.
Capt. Matthew S. Brown, a spokesman for Adm. Walter F. Doran, commander of the U.S. Pacific Fleet, said the Mishap Investigation Report is an internal document, intended as a quick review of an accident.
“I'm not going to discuss the contents of a report that is not releasable,” Brown said. He said the final command investigation will be out soon, perhaps within another week or two, “that will go into much greater detail.”
•••
San Francisco left Guam just before 8 a.m. Jan. 7, headed for a liberty port call in Brisbane, Australia, according to the report, prepared by a team led by Capt. Kenneth D. Walker, commander of the Pacific Naval Submarine Training Center, in the weeks immediately after the accident.
At 1:53 a.m. the morning of Jan. 8, the navigation team shifted to chart E2203, which generally showed water depths of 7,200 to 7,800 feet along its intended path. But less than five hours later, the ship's fathometer recorded a depth of 5,610 feet.
From 6 to 7 a.m., the soundings were all about 1,200 feet shallower than what was shown on the charts. At 7:30 a.m., the ship went to periscope depth to use the global positioning system to fix its position on the charts accurately, and submerged again at 9:48 a.m.
At 11 a.m. the fathometer reported 8,652 feet of water; at 11:15, 5,988 feet; at 11:30, just under 6,588 feet.
At 11:43:21 a.m., the San Francisco ran into an underwater mountain at a speed greater than 25 knots, just as the crew was finishing lunch.
Machinist Mate 2nd Class Joseph Allen Ashley was killed as he was thrown into a large piece of equipment in the machinery spaces. Dozens of others were seriously wounded, and “nearly all of the 138 crew members suffered some sort of injury,” according to the report.
The investigation team faulted the San Francisco for not recognizing the shoaling water and for not becoming more cautious when the depths that were showing up on the fathometer did not match what was on the chart.
And it said the submarine should probably have been doing more than one sounding every 15 minutes — and certainly should have done one when the submarine changed its depth from 400 to 525 feet at 11:39.
“Had they taken a sounding at this point (four minutes prior to the grounding) it is likely that the sounding would have indicated a depth significantly shallower than charted water depth,” the report found.
A more serious problem emerged from a review of the use of charts on the San Francisco, the investigation found.
“All members of the (San Francisco's) navigation team believed that the E2202 chart was the best information available and that it was based on extensive U.S. Navy surveys,” the report found. “This assumption was invalid.”
In fact, the investigation team said, there was a notation that some of the features on the chart might be off by as much as three nautical miles, and the submarine had at least three other charts on board of the same area that showed an area of “muddy water” that was an indication of a seamount.
“The only chart on which this report does not appear is E2202, the chart in use at the time of the grounding,” the report says.
The investigation also found that the navigation team did not understand the nature of the hazards in the Caroline Island chain, where the accident occurred. Generally ships are told to use caution within 12 nautical miles of land; the San Francisco team was under the impression that two miles was sufficient.
•••
San Francisco had one of the most advanced navigation tools available today in the submarine force, the VMS. Though the system was not certified as a primary navigation tool, the ship could have programmed its Subnote into the system.
“Had this been done, the ship would have received a warning, alerting them to the presence of a navigational hazard along the ship's track,” the report says.
It found that the failure to use VMS was “the result of a lack of training, lack of adequate procedures and lack of supervision by both the internal and external chains of command.”
The report found that the Subnote did route the San Francisco through the area where it hit the seamount, and it recommends that in the future the group take more care to route submarines around known navigational hazards. It also said the Subnote “specifically states that navigational safety is not provided by the Subnote and rests with the ship.”
“Each member (of the navigation team) had an initial reaction of unease when viewing the charted transit through the Caroline Islands,” the report says. “However, each member convinced himself, without careful assessment of risk and evaluation of possible offsets, that the transit could be made safely as laid out on their chart.”
“After failing to conduct a proper assessment, the ship was left with a ‘business as usual' attitude exemplified by the CO's comment that he was operating on a 40 (nautical mile)-wide highway,” it continues.
The investigation also rejected the notion that the average speed laid out in the Subnote was too high, even though it was higher than the average in the last 30 Subnotes issued by Group Seven. In fact, at the time of the grounding, San Francisco was almost 40 miles ahead of where it had to be, and was going faster than required for operational considerations.
Single Ping
One ping only.
I'm having a little trouble with this, as a former navigator (not on subs... but still...)
They were taking 15-minute interval soundings in open sea, with over 8,000 ft of water under the keel. When soundings didn't match the chart (and not by all that much) they periscoped to get a GPS position. Position checked out, and there was nothing proposing a hazard to the ship... so they resumed track.
I don't see here what they *should* have done that would have seemed reasonable given the facts at the time. Sure, if they'd taken a sounding in the few minutes before the crash they might have had something to act on, but I don't see where that sounding looked at all like it was needed?
“All members of the (San Francisco's) navigation team believed that the E2202 chart was the best information available and that it was based on extensive U.S. Navy surveys,” the report found. “This assumption was invalid.”
So, they're saying that the nav crew should have relied on information that they would have considered as less credible than what they had, and acted on it, in order to satisfy prudent mariner standards. Yah. Oookay.
Ping, an update on a sad story
A notation on the chart they chose stated features could be off by three miles.
Soundings did not match the chart they were using.
Other charts on board showed shoaling.
Didn't use all the navigation aids they had.
Compilation of errors upon mistakes, spoiled their whole day
Three miles, laterally, in open sea is trivial. I navigated in Alaskan waters on charts showing a note that "soundings known to be in error by as much or more than 30 feet after a 1964 earthquake". This almost ended my own career when trying to find an anchorage one evening. Missed an uncharted rock spike by mere inches.
Soundings did not match the chart they were using.
Soundings *never* match charted depth. There is no such perfect world where charts are exactly accurate and every square meter of sea bottom is perfectly charted. How much they are wrong and what to do about it is and will always be a judgment call.
Other charts on board showed shoaling.
No, there is some reference to "muddy water". This is not something I've ever seen on open sea charts, so I have no idea what this might mean.
Didn't use all the navigation aids they had.
Yes, they did.
Compilation of errors upon mistakes, spoiled their whole day
Well, the day was spoiled, this is true. But I think it is also fair to say that it was ONLY because of the obviously outstanding training of the crew of this ship that it did actually survive the incident. There can be no doubt that individual and collective acts of heroism made sure that the ship and her crew survived what might easily have been a total catastrophic loss.
That's my .02.
I guess I'm not so amazed that it happened, as much as I'm amazed that they (except for one unfortunate soul) survived the event.
Having seen the pics of the sub in drydock, and how catastrophic the damage really was, it really is staggering that they managed to save that boat without losing everybody. They hit that rock *really* hard.
The taxpayer pays for 10 bizillions dollars worth of technology and Dobie Gillis run into a mountain?.....
[sigh] Whatever.
"'Didn't use all the navigation aids they had.'"
"Yes, they did."
I thought the report said they could have programmed the Subbote into the VMS to assist in the navigation, and they failed to do this as explained below.
"...San Francisco had one of the most advanced navigation tools available today in the submarine force, the VMS. Though the system was not certified as a primary navigation tool, the ship could have programmed its Subnote into the system.
“Had this been done, the ship would have received a warning, alerting them to the presence of a navigational hazard along the ship's track,” the report says.
It found that the failure to use VMS was “the result of a lack of training, lack of adequate procedures and lack of supervision by both the internal and external chains of command.”..."
Any idea what the VMS is?
The X.O. and the Navigator can kiss their careers goodbye...
The VMS system (and I will admit to being unfamiliar with this system) was not yet certified for use as a primary navigation system. Had they relied on this system and run aground the skipper would have been at least or more negligent.
When an experimental system shows different information from proven systems, which would be "reasonable" to draw conclusions from?
The long and short of this lesson is to remember that the captain goes down with the ship, even when there is little he might have done to fix it. This is a case of a skipper who crashed his boat, and whether or not he might have been able to see it coming... doesn't matter. The skipper eats the worm.
It wouldn't really have mattered if the sea bottom had risen in a volcanic blast immediately in front of his boat without even a second to react.
We Americans like to point blame at *some person* and therefore we will and we do. It is as simple as that.
Pretty much.
better training needed perhaps???
I remember that when this happened, reports indicated that the maps used were from 1989 and that newer maps were not provided (due to lack of money - I think) and that newer maps the Russians and others had showed the undersea mountain exactly where the sub hit it.
I would think that would have been mentioned in the report unless the navy is trying to save some politician or admiral's a$$.
This is a cover-up. The report is saying that the crew should have known better while ignoring the real cause which was failure to provide the ship with up updated correct maps.
If the crew had seen a map with a mountain on it does anyone think they would have driven the sub into it?
This report stinks!
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