Official report: Leadership, navigation errors led to San Francisco accident
 

Since 05-09-05

By William H. McMichael
NavyTimes Staff Writer

May 9, 2005

The nuclear attack submarine San Francisco sits dry docked at Apra Harbor, Guam, on April 29. The sub ran aground on Jan. 8, killing one sailor and injuring two dozen more.

— James J. Lee / Times staff

Failures of command leadership and the sub’s navigation team were the sole cause of the attack submarine San Francisco’s Jan. 8 collision with an undersea mountain, the Navy has concluded in its official investigative report. The sub struck the sea mount while traveling full speed near the Pacific Ocean’s Caroline Islands at a depth of 525 feet, killing one sailor, injuring dozens of others and crushing the sub’s bow, causing more than $88 million in damage and leaving the 24-year-old sub’s future in doubt. Specifically, an investigating officer and three admirals who reviewed the report concluded that then-San Francisco commanding officer Cmdr. Kevin Mooney and his navigation team failed to develop and execute a safe voyage plan, then failed to exercise enough caution while transiting through a region dotted with steep undersea volcanoes.

The Navy’s Pacific Fleet released the 124-page report at 6:30 p.m. EDT Saturday to organizations it said had requested a copy through the Freedom of Information Act. The initial report was completed Feb. 3 but release was delayed for official review and the deletion of material deemed sensitive. The report will be made available to the general public May 9. While the admirals were unanimous in blaming Mooney and his navigation team, they also equivocated slightly. In his endorsement of the report, Vice Adm. Jonathan W. Greenert, commander of 7th Fleet, noted that the sea mount struck by the sub was not on the primary chart being used at the time of the mishap and that “opportunities exist for systemic improvement in functional (formal and on-the-job training) and administrative (directives and inspections) areas.

”But he also found that the sub had other charts onboard that did indicate a sea mount within 2.87 miles of the sub’s “intended track” but that the charts were not properly reviewed during the planning process. “I find it difficult to conclude absolutely that grounding could have been avoided,” Greenert wrote. “It is absolutely clear to me, however, that 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 [been] compelled to operate the ship more prudently. “At a minimum, the grounding would not have been as severe.”

Mooney, Greenert said, failed to consider all available navigation information, which Greenert felt would have caused the sub commander to take a more conservative approach in a region “potentially hazardous to navigation.”  Instead, he said that neither Mooney nor his navigation team “exercised due care,” and that Mooney decided instead to operate the sub at maximum speed without exercising enough caution on a voyage track that included “several islands, atolls and rapidly shoaling areas.”

Those cautionary measures, Greenert said, could have included stationing additional navigation watchstanders, establishing limits on speed and depth and reducing the navigational sounding interval to more frequently check on variations in depth. Mooney declined to comment on the report, other than to provide a written statement to Navy Times that read: “I accept responsibility for the grounding as the ship’s CO.” Mooney was relieved of his command by Greenert Feb. 12 and is now assigned to an unspecified position in Washington state.

Greenert also criticized the executive officer and navigation team, saying their “failure to adequately and critically review applicable publications and available charts led to submission of an ill-advised voyage plan and hindered the commanding officer’s ability to make fully informed safety-of-ship decisions.” The navigation team consisted of Mooney and several officers and enlisted sailors whose names were deleted from the report. They included the sub’s executive officer and navigator, and three enlisted electronics technicians: the assistant navigator, a senior chief petty officer; the navigation supervisor, a first class petty officer; and the quartermaster of the watch, a second class petty officer.

The entire navigation team and one other enlisted sailor received nonjudicial punishment March 22, with punishments ranging from reductions in rate to punitive letters of reprimand. The crew’s voyage planning process began Jan. 4 when, according to the report, the 7th Fleet Submarine Operating Authority, or SubOpAuth, issued a basic track or “moving haven” for the sub to follow on a voyage from Guam to Brisbane, Australia. The track also includes a rough timeline the sub is expected to follow. The information, contained in what submariners call a “subnote,” allows the SubOpAuth to roughly track the submarine while underway and to ensure no other submarines are operating within its moving haven in order to reduce the risk of collision.

The subnote did not make note of any navigation hazards along the route, the report said. But nearly all information regarding the preparation and approval of the subnote is blacked out in the media copy of the Navy’s report. Information deleted includes historical data on other subnotes issued in the preceding five years, presumably for that general route; details included in a larger scale map of the Caroline Islands; and quotes from interviewees regarding their understanding of the subnote’s preparation and planning.

The San Francisco was due to deploy three days later, and Mooney and the sub’s navigation team wanted the subnote much sooner. The assistant navigator complained to the SubOpAuth that they needed to get subnotes out more quickly “because the review process will fall down because we don’t have enough time to get everything done. …  ”Yet the assistant navigator felt confident about the basic track, saying an official contact at the SubOpAuth told him that “other submarines had used this track previously.”

Mooney wasn’t as confident initially, saying of his initial review of the track, “I was concerned about the path. … I was familiar with the Caroline Islands as being a region that was going to be a concern to drive through.” But later, Mooney felt better about the route, considering that he’d be in the middle of a 40-mile-wide moving haven “that didn’t have any navigation hazards on it.”The navigation team was relying on a bottom contour chart labeled E2202 that includes historical sounding data for the region. To the team, the area where the sub ultimately grounded was a flat spot.

The team, including Mooney, did not look at a 1989 chart, DMA 81023, that contains a dotted-line circle labeled “discolored water” that was on the sub’s track — and which actually is about three miles south of where the mishap occurred. The discolored water indicates a potential hazard. Mooney told the investigator that he expected his navigator to examine every available chart on a given route, and that he wasn’t shown DMA 81023 and didn’t ask if another chart for that area existed.

According to the report, Mooney also said he considered charts containing sounding data to be significantly better. But he also said that, in retrospect, he thought his navigation team  “should have laid our track down on the 81023 chart … they should have looked around for navigation hazards, and then transferred them over to the chart.” At one point during the planning process, the navigation supervisor pulled DMA 81023 out of a drawer on the sub, looked at it but decided its detail was inferior to E2202. He put it back. Later, the assistant navigator looked at E2202 for 15 minutes but apparently did not notice the area of discolored water — the result of an incorrectly charted 1963 sighting.

The sea mount’s exact location was known, however, but not to the National Geospatial-Intelligence Agency, the government group that produces all U.S. military charts and maps. It was indicated on a 1999 Landsat 7 satellite image indicating a likely undersea mountain rising to within 100 feet of the surface, according to the U.S. Geological Survey’s National Center for Earth Resource Observation and Science. In addition, a shallow danger spot correlating to the incorrectly charted discolored water spot was loaded on a digital nautical chart loaded in the sub’s digital navigation system.

According to the report, “no watchstander noticed it.” Once in the Carolines on the night of Jan. 7-8, Mooney’s night orders called for depth soundings and a positional fix to be taken every 15 minutes. Deviations between actual and charted soundings would be cause for alarm, officials say. On Jan. 8, the 0645 sounding showed a depth beneath the keel of 832 fathoms, or 4,992 feet. According to the chart, it should have read between 7,200-7,800 feet. The discrepancy was not noted. The last recorded sounding in the sub’s fathometer log, taken at 1130, was 6,192 feet beneath the keel. Soundings in the preceding hour had been “trending shallower” but were consistent with E2202.Details regarding indications of depth and speed at the time of the grounding — 1138 — are blacked out in the report.

On Feb. 5, the National Geospatial-Intelligence Agency issued a Notice to Mariners to “add danger circle” at the longitude and latitude where the San Francisco struck the sea mount. That same month, Navy submarine commands began briefing all sub commanders on “the importance of following standard, proven procedures for voyage planning and safe navigation” and formed a team to comprehensively review all aspects of submarine navigation, said Lt. Cmdr. Jeff Davis of Pacific Fleet Submarine Force.

The study included a “thorough review of navigation voyage planning procedures,” he said. The report holds NGA blameless, noting only that, in the future, all critical navigational hazards should be included on soundings charts such as E2202. The investigator’s opinions regarding the performance of the 7th Fleet SubOpAuth are largely blacked out of the report. Mooney and his navigation team were held wholly responsible for the mishap.“The investigation reveals a series of bad judgments, faulty assumptions, poor attention to detail, and complacency among the navigation department, watch standers, and command leadership,” wrote Adm. Walter Doran, Pacific Fleet commander, in his endorsement of the report.

“But for outstanding damage control efforts and post-grounding leadership, this event could have had far more disastrous consequences.” Greenert agreed with the latter, offering praise not only for the crew’s successful efforts to save the sub and return safely to Guam, but also for Mooney’s prior record and performance.“ Although the grounding incident compelled me to punish (Mooney) and remove him from command, in my opinion it does not negate 19 years of exemplary service,” the admiral wrote. “Prior to the grounding incident, USS San Francisco demonstrated a trend of continuing improvement and compiled an impressive record of achievement under (Mooney’s) leadership.”William H. McMichael is the Hampton Roads bureau chief for Navy Times.
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Contributed,
YNCS Don Harribine, USN(ret)