Diving Into the Grounding Report (Part 2)

Originally posted by Bubblehead at 1921 10 May 2005:

I finally got a chance to go through the USS San Francisco grounding Investigation Report a little closer, and I was surprised by some of the things I read (or, more specifically, didn’t read). It looks like the Navy learned the lesson from problems from posting IRs on line that they had in Iraq with the Italian agent shooting IR, so I wasn’t able to read what they had under the blacked out portions, but “reading between the lines”, it looks like a lot more was blacked out than just names (which is understandable).
Some of the more interesting things I saw included:

In Admiral Greenert’s endorsement, he states in paragraph 1.B of Encl. (1), that, “Chart 81023 contains a “discolored water” site (surrounded by a “danger line”) 2.5 nautical miles (NM) south of USS San Francisco’s intended track and 2.0 – 2.8 NM from the grounding location. The light blue coloring of this “discolored water” feature reflects a navigation hazard at 20 meters (66 feet) depth or less, leading one to conclude that a larger navigation hazard exists in deeper water, particularly at 525 feet.” I personally think that this is a little disingenuous; the light blue coloring to me would not represent a hazard known to be less than 20 meters deep, but rather a default color used when they aren’t sure of the depth. I can’t remember exactly, but I know that there are several other potential hazards listed on these charts which may also have this default “light blue color”; such hazards include possible shipwreck sites, unexploded ordnance, and the like. No sub that I know of routes themselves around the “unexploded ordnance” marks on the charts, so I’m imagining a scenario where a boat happened to be passing by a 60 year old bomb that exploded as they were passing, causing damage. Would the Sub Force then do the same thing to that ship as they are to the navigation team of the San Francisco? My guess would be “yes”. Later, he states, in para. 4.B, that “Generally speaking, “Echo series” bottom contour charts are considered the most complete and accurate charts for submerged navigation.” Again, I can’t remember for sure, but I’m pretty sure that Echo series charts (like the one San Fran was using) do show “discolored water” on them fairly frequently, so it’s not as if it’s known that you have to transfer discolored water from other charts to your Echo series chart. Sometimes the Navy finds things that are not necessarily correct on other, non-classified charts, and as long as they’re not an additional danger those charts don’t show, I don’t think the Navy goes out of their way to correct the commercial charts. Not that the San Fran shouldn’t have transferred the information, but I don’t know that many other boats would have limited their transit speed because of this information.

Throughout the document, but particularly in para. 4 on page 107, it refers to the “CO’s own Standing Orders” as if the ship, and by extension the CO, were violating requirements that the CO came up with on his own. In actuality, the CO’s Standing Orders are put out by the Sub Force; COs are free to add additional items, but I think all the items that the ship violated were those imposed by higher authority. (If I remember right, part of the TRE checklist is to ensure the CO’s Standing Orders haven’t deleted anything from the Force-wide product.) Not that this makes the violation any less real, it’s just that the tone of the report (“The CO’s own Standing Orders specifically point out the danger of reliance on a single item for safe navigation”) seems weighted towards making the ship seem more culpable.I was interested in some things that were not blanked out with respect to external inspections on the ship, and some that seemingly remained blacked out. On page 78, para. 414, it discusses the ship’s last Tactical Readiness Examination (TRE), and mentions that the ship was evaluated as Below Average in Open Ocean Navigation. Normally, I would expect a squadron to take advantage of a subsequent Navigation Evaluation to determine if corrective actions had been taken for such a grade. On pages 79-80, the report mentions a Nav Eval, but all the comments there are blacked out, as is the overall evaluation. I wonder why the TRE area grade is considered to now be unclassified, but not the overall grade on the Nav Eval? Maybe they just don’t want to put out as unclassified things that are the opinion of just one person. Well, it turns out that that’s not true, because we see, in paragraphs 420 and 421, comments from a CDR (probably a Squadron Deputy) doing the ship’s POMCERT workup that aren’t too flattering. OK, we know that TRE grades were declassified, and since a POMCERT is basically a TRE, then I’m sure that San Fran’s POMCERT grade is included in the report as well. Nope – para. 417 on page 80 has the final grade on the POMCERT, as well as Navigation area grade, blanked out. I’m not quite sure how classification issues may come into this (TRE grades OK to publish, but not POMCERT grades) but I’m thinking it might be possible that the ship, in it’s last formal evaluation before the grounding, did better, which might call into question the abilities of the examining team(?)

Lastly, a comment from Eagle1's post on this issue is interesting (Eagle1 has added a couple of good updates to his original post, so if you haven't seen it in the last couple of days, it's worth going back to):
"(T)here were no factors beyond the ship's control which caused , or dramatically affected, circumstances that led to the grounding." Read para 74 on page 121 - looks like the Admiral did not read his own report."Eagle1 posts the referenced part of the report:"74.(U) The omission of the reported navigation hazard on the E2202 directly contributed to the grounding in that it is reasonable to assume that had the feature been added to the E2202, it would have influenced the CSG-7 SUBNOTE generation process and provided the SAN FRANCISCO's navigation team another opportunity to identify the navigation hazard near their track. (references omitted)"

Overall, the report does go into many problems outside the ship, including the numerous violations of CTF 74 SOP by the SubGru Seven Operations Department. Hopefully the proposed corrective actions included within this report will go a long way towards preventing a similar tragedy, but I can’t help but feel that this unclassified release of the report was edited to make the San Fran navigation team seem like an anomaly, rather than representative of the state of navigation throughout the fleet in January 2005. Reading the report would make it seem to a layman that there were a host of things wrong with the ship, but I bet that had a team gone down to any attack boat and done the same kind of review, they would have found a similar number of deficiencies. My belief, which is unchanged after reading the report, is that the San Francisco did no worse in responding to the situation they were placed in than would a majority of the boats of the Force, and I continue to ask: Is pulling the black marble a criminal offense?

Staying at PD...

posted by Bubblehead @ 8:01 AM