Tuesday, May 31, 2005

Preliminary San Francisco Report

Originally posted by Bubblehead at 0806 22 Apr:

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.


Post a Comment

<< Home