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Sunday, May 08, 2005

Blame shared for the USS San Francisco submarine disaster?

According to the NYT, Navy Outlines Errors Preceding Fatal Submarine Crash. Let's see: (1) sub's CO (2) Navigator (3) navigation teams all get blamed for using the same charts everyone else was using and for not taking precautions when within 3 miles of a "potential"hazard and relying on a routing office assertion that the route had been used before.

Perhaps the most unusual aspect of the crash was that the mountain had never been identified on any navigation charts. But a potential hazard was noted on most charts about three miles from the crash site, and that should have provided enough warning to skirt the area, the report said.

However, neither the submarine's crew nor the officers onshore who set its basic routing studied those charts. Investigators found that they relied instead on the one chart that did not show the danger zone, which gave them the impression that the submarine's track was clear.
Unusual? I'd say so. Navigationally, and speaking as a former navigator, I would have thought a route 6000 yards (3 nautical miles) from a "potential" hazard was a pretty safe distance unless I had some pretty good reason to feel otherwise. And if I was told by the routing office that the route had been used before, my confidence in the safety of the route would have increased.
The submarine's captain and six other crew members were relieved of duty after the accident. Under Navy rules, they had the primary responsibility for keeping the vessel safe.

Navy officials said the crew should have cross-checked all the charts for the area and taken more frequent depth soundings.
These guys were screwed by 20-20 hindsight along the lines of "Well they hit the mountain, therefore it was their fault."

Bubblehead over at The Stupid Shall be Punished has this take on the mess and this on the Commander Pacific Fleet report, including a link. In fact, Bubblehead has been all over this incident and is worth roaming through if you have the time and interest.

Update: The Commander Seventh Fleet endorsement on the Command Investigation into the grounding contains the following:
...The command investigation concluded that failure to properly develop and execute a safe and effective voyage plan for submerged transit caused the grounding. After reviewing the investigation, I assert that responsibility and accountability reside with USS SAN FRANCISCO's command leadership and navigation team. Given the circumstances prior to and at the time of the grounding, I find it difficult to conclude absolutely that grounding could have been avoided. It is absolutely clear to me, however, if command leadership and the navigation team followed basic specified procedures and exercised prudent navigation practices, they would have been aware of imminent navigation hazards and therefore compelled to operate the ship more prudently. At a minimum, the grounding would not have been as severe.
b. The seamount USS SAN FRANCISCO hit was not annotated on Chart E2202, the chart being used for navigation when the ship grounded. Chart E2202 did not denote a navigation hazard in close proximity to the intended ship's track and grounding location. Other valid, readily available navigation charts in USS SAN FRANCISCO's inventory--including Chart 81023-- displayed a navigation hazard located in the vicinity of the Caroline Islands near USS San FRANCISCO's SUBNOTE track and intended ship's track...USS SAN FRANCISCO's navigation leadership/personnel did not adequately review other charts. Of note, 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" 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.

c. The command investigation examined and assessed USS SAN FRANCISCO's voyage planning, navigation watchstanding practices, casualty and medical response after the grounding, and navigation training programs. Parent squadron (COMSUBRON FIFTEEN) support; SUBNOTE generation; Submarine Force navigation standards; inspections and evaluations; Submarine Force navigation pipeline training; and Navy's (National Geospatial Agency) navigation chart generation, distribution and management directives were also reviewed. While opportunities exist for systemic improvement in function (formal and on-the-job training) and administrative (directives and inspections) areas external to USS SAN FRANCISCO, there were no factors beyond the ship's control which caused , or dramatically affected, circumstances that led to the grounding.
It goes on to point out that under the Navy system, the CO virtually always has to accept both responsibility and accountability when things go bad.

Update2: As I read through the report, I find that in "Basic 040 to 059", paragraph 282, the ship grounded at 07 degrees 44.7' N, 147 degrees 11.6'E. Based on my rough out the position, the grounding occurred at the approximate location of the red burst on the map below:



UPDATE: Thanks to the submariners who comment below. My "eyeball" approximation in the map above is off, as Bubblehead suggests by some distance. A corrected location appears in the map below which is now accompanied by the chart I have appropriated from NavET over at Lubber's Line. Thanks for the corrections and the comments, gentlemen. I was a lot more careful with my destoyer navigation...(some of which passed through these same waters). The yellow blob is a corrected guesstimate area.



NavET's chart work (which shows the "discolored water"on chart 81023):



Update2: As "Anonymous" points out in the comments, pararaph 74 on page 121 of the report is worth reproducing:
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)

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