Keeping the blogosphere posted on the goings on of the world of submarines since late 2004... and mocking and belittling general foolishness wherever it may be found. Idaho's first and foremost submarine blog. (If you don't like something on this blog, please E-mail me; don't call me at home.)

Friday, April 22, 2005

Preliminary San Francisco Report

Robert Hamilton of The New London Day has an article (registration required after today) that is basically a synopsis of the Mishap Investigation Report on the San Francisco grounding. Excerpts:

"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 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...
..."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."

The first two inspections sound like a Tactical Readiness Examination (TRE) and a Pre-Overseas Movement (POM) inspection. These inspection results, along with the Operational Reactor Safeguards Exam (ORSE), are all classified, so those of us who would like to use them to argue that the Navy might be handling this situation wrong are unable to use them. The Navy, on the other hand, is free to declassify whatever they want to prove their point. (One thing that the article didn't say was that the Voyage Management System in January 2004 was, how shall I put it... "suboptimal", and my guess is that essentially every boat examined during this time period had the same comment on their inspection reports.)
Here's the deal: If you were to look at an inspection report from an above average boat, and compare it to one from a below average boat, if the grades were taken out, you'd sometimes be hard pressed to find a difference. All reports list several pages of discrepancies, with basically nothing positive; it's not the submarine force tradition to tell you what you're doing right, only what you're doing wrong. These inspection teams have lengthy checklists of things they check, and if the boat doesn't do some point exactly right in their spot checks, you'll see paragraphs that look something like this:

"1. The ship was tasked with making 100 peanut butter and jelly sandwiches. As an anomaly, only 199 pieces of bread were provided. The following deficiencies were noted:
a. Several sandwiches were not prepared IAW the menu card in use. Contributing to this, the mess cook selected to make the sandwiches had not completed PQS on the use of the hand towel.
b. At one point, the mess cook became confused and made several peanut butter and peanut butter sandwiches.
c. On several sandwiches, significantly less than 1 tablespoon of jelly was used.
d. The ship's monitor ate two sandwiches while observing the evolution, precluding analysis of those sandwiches.
e. Milk was not provided until requested by the Board.
f. Several of the napkins provided with the meal were torn.
g. Contrary to the scenario requested by the board, grape jelly was substituted for strawberry jelly."

What the Navy did in the Mishap Investigation Report was take several deficiencies from the ship's recent inspections, and use them to "prove" the ship was messed up. My questions are: Were they really more messed up than the other boats out there? Did other boats have similar issues that possibly also weren't addressed? (I won't answer these questions here, but all submariners know the answers.) And finally, would other boats, placed in the same situation with the same op order, have done essentially what the San Francisco did? Hopefully the powers that be in the Submarine Force are working behind the scenes to correct the root causes of this tragedy, and won't be satisfied with simply offering up the crew of the San Francisco as scapegoats.

Staying at PD...

Update 1431 22 April:

WillyShake offers his take on the article. He notes that the report mentions that the chart being used by the ship was not the most accurate available; as I mentioned earlier, it seems to me that the determination that the chart being used was not the most accurate is only true with 20/20 hindsight. (WillyShake actually has several good posts up today, including this one on a new Russian sub-launched missile and the completion of a decade-long overhaul for an old Typhoon.)

Gus Van Horn has a post on the subject. Chapomatic weighs in with a comment, and also posts an entry in his own blog.

Lubber's Line has another post on the chart issue that came out before the article in question.

Bell-ringer 2319 23 April: From the comments, here's a link to Steve's QM page.


Blogger 'Thought & Humor' said...

You have a riveting web log and undoubtedly
must have atypical & quiescent potential for
your intended readership. May I suggest that
you do everything in your power to honor
your Designer/Architect as well as your audience.
Please remember to never restrict anyone's
opportunities for ascertaining uninterrupted
existence for their quintessence.

Best wishes for continued ascendancy,

'Thought & Humor'
Cyber-Humor & Cyber-Thought
Harvard Humor Club

4/22/2005 3:40 PM

Anonymous Steve Ewing said...

I was just pointed to your blog... interesting site.

I left the Navy in 1997 after 16 years as a submarine QM.

Regarding chart selection/prep: the article says they were using chart E2203, which would be one of the series of classified bathymetric charts that are intended to (someday) cover the world. At least in the chart catalogues I saw had the numbers filled in, if not the actual charts created.

I was an Atlantic sailor, on two boomers and a fast boat, and we used these charts routinely in open ocean. They were as accurate as you could get: recall that skimmers in open ocean would use plotting sheets, literally charts with lat/long lines and nothing else: if the bottom is 2000 fathoms away, who cares, when you're on the surface?

Approaching the coast, and in constrained (if not restricted) waters, we would shift to local charts. As part of the chart prep, they would be corrected up-to-date with Notice To Mariners. The chart would be signed by the preparer, the ANAV, the NAV, and finally the CO, all checking the corrections, the route, the plotting of the track, and potential navigational hazards.

I've just read a bunch of articles/posts on this, so forgive me for misplacing the source, but I read that the chart was not corrected up-to-date. Even if the corrections did not affect the track, this is an indication of a serious lapse.

The ANAV, says the DOOW, was a "real" QM, so no snarky comments there.

The 12 miles referred to in the Day article is the distance (in the Atlantic Fleet in my day, and the PacFleet was in the process of syncing up procedures when I got out) at which we were required to station the piloting party for operation in restricted waters. In certain circumstances (such as being submerged) you would station a Modified Piloting Party, with at least the Nav or ANAV on watch in addition to the QMOW. This is 12 miles from land or other navigational hazards. For example, transiting to Tongue Of The Ocean in the Bahamas, we'd be skating close to the islands, and have a Mod Piloting Party stationed (not a good deal for the Nav/ANAV, but that's why they get the big bucks).

Someone mentioned a Yellow Sounding (a tripwire to indicate you weren't where you thought you were). If they got a Yellow Sounding and hit the seamount at flank, that is Bad. Immediate actions upon obtaining a Yellow Sounding are to slow, come shallow, and ascertain the ship's position, and, of course, to take another sounding. Getting an accurate sounding at speed is iffy, and the fancy modern fathometers in use now are "gated"; you have to know what range your sounding is expected to be in and set the fathometer accordingly. If you expect 500fm, and set the gate to 400-600, and the sounding is really 250fm, well, guess where it shows up (simplifying somewhat). You'd get the double echo. The old UQN-1 may not be particularly stealthy, but by God you could burn some paper with it (the sounding line is literally burned into the paper by a stylus).

But back to the speed: at high speed, sending a ping out in an acute cone, you might outrun the return. Plus, flow noise makes it hard to detect. I used to think I had a real flair for pulling a sounding off the BSY-1 we had on the USS Springfield (SSN 761), but when in doubt I cranked the power.

Whups-- Springsteen's on. Gotta go.

4/23/2005 8:09 PM

Anonymous steve ewing said...

...Springsteen's done.

In my previous comment, that thing with the slash-asterisk was supposed to be, restricted water is 12 miles from land or other hazard to navigation.

I continue...

That said, I agree with you that quoting lines from an inspection does not a true indication make of how good these guys were. See my web page,, where in the Sea Story section I post my comments from when I was an examiner at a navigation trainer session:

Those guys were pretty rusty, coming out of the shipyard, and some of the hits on an operational boat would be serious, but in any inspection you are going to find stuff like "1:50 sounding checked, fath not told, fath didn't push", meaning that in the fathometer log there would be no indication that a sounding actually checked. But it would be in the bearing book, for example.

Anyway, my first impression on reading the initial articles was that these guys ran into an Act of God. Maybe they were a little slack. The Yellow Sounding miss, if true, would be damning. But otherwise, there wasn't a hell of a lot they could do: if you want to poke around the ocean with a cane in front of you because the last survey was in 1947, then you are going to have to explain yourself to the Squadron Commander. And, while there is the standard "SubNotes take no account of navigational hazards", they *do* get reused, and there are standard subnotes; again, that one to the Bahamas hits the same points every time: there is a proven track and it is used. I don't know how often a sub transits from Guam to Brisbane, but surely this wasn't the first time-- and if it was, Squadron should have thoroughly vetted the track.

I just don't know: it's hard to get a handle on just going off the published reports: in events of which I have had direct knowledge the newspapers' (and specifically The Day's) reporting have lacked that, how should I put it, nuance that would reflect exactly what happened. Like the reporting of the inspection hits: in the article it seems rather important. I'd like to know how it really was.

I could tell some stories: on the USS Kamehameha we (the piloting team) were hit for being "lackadaisical" in well-known waters, outside 4NM from land, shooting 15 minute rounds, after we had piloted in for 8-12 hours (Scotland), picked up the TRE team, piloted 8-12 hours out, ran the TRE, and then were evaluated on the way in. Sheesh! I guess that means we sat down once in a while. I have gone roundy-round on a scope for two straight watches: it ain't fun. We blew away the TRE, FWIW.

4/23/2005 9:25 PM


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