US Navy Submarine Casualties Booklet 1966

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SUBMARINE CASUALTIES

BOOKLET

tlOne can advise comfortably from a safe port. 1t

(Schiller)

Prepared by:-

U~ S. Naval Submarine SchoolU. S.Naval Submarine Base

New London, Connecticut

1966Changes 1 & 2 entered


LIST OF EFFECTIVE PAGES

Table of Contents

List Of Effective Pages

PART A A-l through A-33

PART B B-1 ~hrough B-56

PART C C-l through C-54

PART D D-l through D-44

PART E E-l through E-66

PART F F-l through F-2l

PART G G-l through G-42

PART H H-l through H-4

Change 2


SUBMARINE CASUALTIES BOOKLET

TABLE OF CONTENTS

Part A - Major Disasters

Part B - Collisions

Part C - Floodings

Part D - Groundings

Part E - Miscellaneous Casualties

Part F - Material Casualties

Part G - Escape and Rescue Cases

Part H - Administrative Failures

Change 2


SUBMARINE CASUALTIES BOOKLET

FOREWARD

The safety record of U.S. submarines in peacetime operations isprobably unmatched by any other conveyance of modern warefare. Indeed,the millions of hours of sUGh operations have been marred by so fewaccidents that it is quite probable that submarines have a bettersafety record than has the family bathtub. There have been somecasualties and near-casualties, however, each of which contains valuablelessons for the prevention of similar incidents in the future.

This Casualty Booklet is written to fill a long felt need to provideyoung officers and men entering the submarine service with the sternlessons of the past. These lessons not only provide the backgroundand reasons behind many well-established methods and procedures, but alsothe misfortunes, often tragic, of departing from proven procedures andbasic fundamentals that are essential for safe operations.

The following narratives were derived from various sources, includingreports of official investigations, when available, and from informationsubmitted by persons who were on the scene when the casualty occurred.The "Opinions and Findings" are paraphrased versions of the remarksmade by any investigating or reviewing officers; no change has beenmade in the substance of these qpinions. The comment paragraph represents the lesson to be learned and other helpful or associatedinformation, composed in the cold, clear light that is so characteristicof "hindsight". These comments in themselves are mute testimony to"Hindsight is damned easier than foresight ll

, and it is hoped that theywill be viewed in the objective light in which they are intended: tostimulate more foresight. .

Contributions to this booklet are welcomed and invited; such contributions should be addressed to the Officer in Charge, U.S. NavalSubmarine School, U.S. Naval Submarine Base, New London, Connecticut.


PART A - MAJOR DISASTERS

The enviable safety record that u. S~. submarines enjoy is not the resultof mere chance. It is the result of a continuing effort toward betterdesign and well-trained officers and men. The major disasters that haveoccurred since 1920, excluding wartime losses by enemy action, are astern reminder that the road has not been an easy one.

While many of the disasters were the result of some e~uipment failure,it is striking to note that in almo~t every case some action could havebeen taken which might have averted the tragedy. Regardless of the improvements made to the submarine itself, the key to its survival remainswith the officers and men who man it, for their training may mean thedifference between sinking and survival.

The disasters of the "early daysl! may be considered "ancient history".They are includ~d not only for the valuable lessons therein, but alsoto provide the modern submariner with an appreciation of submarinedevelopment in the last 40-odd years.

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*

*

*

YEAR

1915

1917

1920

1921

1921

1923

1923

1925

BOAT

F-4

F-l

S-5

R-6

s-48

S~38

0-5

S-5l

INDEX

BRIEF

Failed to return from a submerged run offHonolulu, 15 March. No survivors (21 lost).Cause of dis~ster not determined. Locatedby oil slick and air bubbles in 305 feet •.Raised 29 August after salvage diVing thatset record for depth.

Rammed by F-3 in fog off Point Loma, California. Sank in 600 feet, five surviversfrom to~side, nineteen lost.

Sank during full power trials off DelawareCapes, Stern blown to surface, and after36 hours of cutting hole in stern, abovewater line, all hands escaped; last manemerged 51 hours after the sinking.

Sank in nest by flooding through torpedotube. Two men lost.

Sank off Bridgeport, Connecticut in 67feet, during builder's trials, by floodingthrough ballast tank manhole cover. Bowwas brought to surface and all escapedthrough torpedo tube.

Sank alongside tender by flooding fromsea valve when bonnet was removed.

Rammed and sunk off Alantic entrance toPanama Canal. Three lives lost. Two mentrapped in torpedo room were rescued whenbow raised 31 hours later.

Rammed and sunk off Block Island by theCity of Rome at night, 25 September.Three survivors, thirty-three lost. Subsequently raised. Salvage efforts recounted in On the Bottom by Ellsberg.

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-I

YEAR

1927

1939

1941

BOAT

s-4

SQUALUS

0-9

s-26

R-12

COCHINO

INDEX

BRIEF

Rammed and sunk off Provincetown, Massachusetts in 102 feet, no survivors, byCoast Guard vessel Paulding. Subsequentlyraised.

Sank on 23 May in 220 feet, off Isle ofShoals during trials. Boat flooded aft ofcontrol ro'om through main induction. 33survivors rescued by rescue chamber fromFALCON. Subsequently raised and re-namedSAILFISH.

Lost off Portsmouth, New Hampshire with allhands, during trailf? Located in 440 feet,diver found evidence that hull had failed towithstand pressure.

Rammed and sunk by PC escort at night, 24January, three survivors.

Sank suddenly while running on surface offKey West, Florida, six survivors.

Sank off Norway after battery explosions.All hands saved by TUSK except for onecivilian technician who was washed overboard from TUSK.

* - Not included in case histories herein.

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CASE

/Sinking of S-»,September 1921, by flooding through main in-

duction.

PRINCIPLES

1. Standard procedure must be followed.

2. Inaccessible valves should be fitted with reach rods to enableqUick closure.

3. Training must stress that each member of the crew is responsiblefor carrying out his assigned tasks to the exclusion of other work.

NARRATIVE

While diving off the Delaware Gapes during a 72-hour endurance run, th~ S-5 failed to level off and imbedded her bow in themud bottom at 160 feet. Water had entered through the open maininduction valve and had passed through the induction piping (ventilation system) to the torpedo room (forward). The inboard valvein the torpedo room could not be shut because of the pressure ofwater pouring through it. Other inboard valves on the same line wereshut; those in the control room and engine room immediately upondiving as per diving procedure; that in the motor room only after 80tons of water l;tad entere.d through it. The water in the motor roomwas dumped into the battery compartment (forward) by cracking watertight doors. The control room was abandoned when chlorine began toseep in from the battery compartment, but not before a 700 down anglehad been put on the boat by blowing the after main ballast and fueltanks. Two passing merchant vessels sighted the stern protrudingabove the surface, and on investigating, cut a hole in the sternwhich allowed the entire crew to escape. The boat sank shortl;r afte.rward and was never salvaged.

OPINIONS AND FINDINGS

1. The man detailed to shut the main induction on diVing left hispost to aid a shipmate in another duty just after the diving alarmwas sounded. He realized his error too late, and his hasty effortsto shut the valve resulted in its jamming open.

2. Although procedure called for shutting the four valves inboard ofmain induction upon diving:

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a. This was not the actual practice in the torpedo room because theinboard valve was not readily accessible.

b. This was not the actual practice in the motor room, where thevalve was not normally ~hut until the boat was leveled off after submerging.

COMMENTS

It is most interesting to note that this same failure to carry outprescribed procedure, i.e., shutting of the inboard induction valves,also resulted in the sinking of the SQUALUS in 1939.

Elimination of personnel error can be accomplished only throughthorough training and constant awareness on the part of every personaboard that his duty is an essential part of successful operation ofthe ship.

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CASE

Sinking of R-6 while moored in harbor, 26 September 1921.

PRINCIPLES

1. Torpedo tube in~erlocks do not completely insure that both tubedoors will not open at the same time.

2. Personnel should check safety devices whenever they are used.

NARRATIVE

R-6 was moored in a nest of seven submarines in Los Angeles harbor.Two torpedomen, having completed final adjustments on a torpedo, commenced to load it into a tube. On opening the inner door, the torpedoroom flooded tbrough the tube, trapping the two torpedomen, who werelost. The entire boat flooded rapidly,. but all other personnel aboardescaped. other submarines in the nest cut their lines to the R-6 toprevent damage to themselves, and she sank in 30 feet of water. Shewas later salvaged and recommissioned.


1. The torpedo tube was flooded and its outer door was open when thetorpedomen opened the tube to load.

2. The interlocking mechanism failed to operate.

COMMENTS

No safety device is a cure-all. Despite attempts to design a foolproof interlock, there is no substitute for checks by personnel of thedevices themselves and of the hazards they seek to prevent.

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CASE

Sinking of s-48 by flooding after section of ship through ballasttank manhold, 7 December 1921.

PRINCIPLES

A thorough check of all hull openings is mandatory when departing ashipyard.

NARRATIVE

s-48 departed the Lake Torpedo Boat Company at Bridgeport, Connecticut} for New London on builder's trials. Although manned by acivilian crew, she carried five naval representatives to perform thewitness tests~ The boat, which had made several dives on preceding days,submerged in Long Island Sound off Bridgeport Harbor. As the after mainballast tanks filled} a man-hole cover in the hull betweenthe engine room and number 5B main ballast tank unseated and the shipbegan to flood rapidly. Personnel in the after part of the boat escapedforward as she bottomed in 80 feet of water. The boat completely floodedaft of control room/after battery compartment bUlkhead. By blowing allforward main ballast, fuel, and variable ballast tanks, and droppingboth anchors, a 400 up-angle was obtained. All hands escaped through atorpedo tube. s...48 was salvaged, repaired, and accepted for commis- ~

sioning many months after scheduled delivery.

OPENIONS AND FINDINGS

Since the s-48 had nQt yet been commissioned, there was no formalnaval investigation. The Lake Company discovered upon salvage thatthe manhole cover which failed had not been secured properly. Nutsholding the cover had not been tightened and the pressure of waterentering the ballast tank outboard of the engine room stripped thebolt threads.

COMMENTS

Every time a submarine completes repair or inspection of fittingsinvolving watertight integrity, a more-than-perfunctory check is inorder before the boat puts to sea. Failure to do so is an invitationto disaster. Such fittings must be tested under pressure prior tosailing. On all dives, these fittings must be watched carefUlly, withpersonnel standing by to isolate possible damage. Had this latterprecaution been observed, flooding probably could have been confinedto the engine room, considerably minimizing the damage attendant toflooding the entir~ after half of the ship.

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CASE

Sinking of S-38 while moored alongside tender, 19 July 1923.

PRINCIPLES

1. Maintenance work affecting watertight integrity must be supervisedby competent personnel.

2. All submarine personnel, no matter what their experience, must befamiliar with the basic systems within their assigned province beforethey are permitted to perform any task involving such systems.

NARRATIVE

S-38 was moored alongside U.S.S. ORTOLAN, a minesweeper acting astender, in Anchorage Bay, Alaska. During upkeep routine, the bonnet ofthe after trim tank sea valve was removed, causing the motor room, inwhich the valve was located, and the stern room to fiood. The boatsettled by the stern, the after platform deck of the conning towerfairwater becoming awash. Further sinking was prevented by use ofsalvage air pressure, confining the flooding to aft of the engine room,and by quick action of ORTOLAN in cutting after mooring lines andgetting additional bow lines OVer. S-38 was towed to shoal water,where salvage divers plugged the hole and pumped her 9ut in about18-hours. While there were no serious personnel casualties, the boathad to be tawed to a shipyard and much time was lost in reconditioningher.


1. The sinking of S-38 resulted when an inexperienced man removedthe nuts holding the bonnet of the after trim tank sea valve whilehe was attempting to clean the valve.

2. The man was not properly instructed in his duties, nor was heunder competent supervision at this time.

COMMENTS

The flvalve-twister" is the arch enemy of submariners.. This caseis a classic example of the extreme result of allowing an inexperienced, untrained man to tamper with a system of which he has insufficient knowledge.

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CASE

Sinking of S-5l by collision with SS City of Rome, off Block Island,25 September 1925.

PRINCIPLES

1. A submarine is difficult to identify at night, often being mistakenfor a fishing vessel.

2. Because her lights do not comply with the Rules of the Road, a SUbmarine is almost certain to be held at fault if involved in a collision.

3. As a result of 1. and 2. above, a submarine officer~of-the-deckmustavoid placing his ship in a situation where even the risk of collisionexists.

NARRATIVE

While proceeding off Block Island on night surface operations, S-51was sighted broad on the starboard bow by City of Rome. Visibility wasexcellent and the liner had the submarine's masthead light under continuous observation during the 22-minutes prior to the collision. Althoughit was a crossing situation with S-5l as privileged vessel showing alarge port angle-on-the~bow, the City of Rome assumed she was overtakinga small tug or fishing craft. Despite the merchant captain's doubtsabout the light held in sight, neither ship took any action until invery close proximity.

When several ship~lengths away~ City of Rome commenced to altercourse to the left to pass the supposedly overtaken vessel. A fewseconds later, the red side light of S-51 became visible slightly tothe right of the masthead light. Too late the true situation wasrealized. City of :Rome I s rudder was put right full and the enginesbacked full, but the .ship rammed the S-5l just forward of the conningtower on the port side. The boat flooded and sank immediately in 132feet of water. Three men in the conning tower escaped and were pickedup, five officers and twenty~seven men were lost. None of the survivors had any knowledge of the submarine's navigation at the time ofthe collision •.

OPINIONS 'AND FINDINGS (U.S. Federal Court)

1. The City of Rome 'Was flagrantly at fault for failure to:

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a. Yield the right of way as the burdened vessel in a crossingsituation;

b. Reduce speed when in doubt as to movements of 8-51;

c. Sound proper whistle signals when coming left just before theimpact.

2. 8-51 was equally at fault for running with improper lights, aprincipal cause of the disaster.

COMMENTS

This case is the original classic example of the deceptive appearance of a submarine at night. More than thirty years have passed sincethe S-51 incident, and submarines are still in the same predicamentregarding lights, and no doubt alwaya will be. Also, because of herlow freeboard, a submarine sometimes presents a deceiving appearance,particularly during low visibility. For this reason submarines shouldtake early action to avoid collision, and should avoid being placed inthe "privileged!! status. Once in the "privileged" role, however, everyeffort should be made early too exchange identification with the othervessel, and to determine its intentions. It is well worth the troublethat it takes to rig the l21'T signal-searchlight to have it availablewhen needed for this exchange of identification.

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CASE

s-4 rammed and sunk by the PAULDING, 17 December 1927.

PRINCIPLES

1. A careful look around at periscope depth is mandatory prior tosurfacing.

2. Naval vessels should be alerted to the presence of submarines intheir operating areas.

NARRATIVE,

s-4 was running standardization trials on the range off Provincestawn,Massachusetts. Visibility was fair to poor. Late in the afternoon shesurfaced at the end of a submerged run. The Coast Guard Cutter PAULDING(an ex-Navy destroyer) which was conducting exercises in the area rammeds-4 while making 18 knots, just as the s-4's hull reached the surface.Holed on the starboard side forward of amidships, the boat floodedcompletely, except for the forward room where six men managed to isolatethemselves. The boat sank immediately in 102 feet.

At first PAULDING did not know that she had struck a submarine asshe was not aware that s-4 was ;i.n the area. Her suspicions were checkedby radio with the Boston Naval Shipyard, after Which extensive rescueefforts were initiated.

A diver from the FALCON, who descended twenty-two hours after thecollision identified tapping signa~s as coming from the torpedo roomwhere six men remained alive. A storm rendered rescue efforts impossibleand there were no survivors.

COMMENTS

Since there were no survivors, the situation aboard the s-4 canonly be conjectured, Apparently the submarine failed to see the PAULDINGdue to law Visibility or failure to take a good look around prior tosurfacing. At any rate this case is the basis for the responsibilityfor avoiding collision resting with the submerged submarine.

A-15


The 8-4 tragedy had strong repercussions, coming as it did on theheels of the 8-51 sinking two years previous. The pUblic outcry thatfollowed provided much of the impetus behind the developmental effortswhich led to the submarine escape appliance and the submarine rescuechamber. The 8-4 was raised, repaired and used for training divers insubmarine salvage and in use of the rescue chamber. In addition,legislative investigators saw the need for and insured passage of abill authorizing hazardous duty pay for submarine personnel •

•

A-16


CASE

Less of SQUALUS from flooding through main induc~ion valve, 23May 1939.

PRINCIPLES

1. A visual. check of the main induction valve mechanical indicator ismandatory when diving.

2. Inboard induction valves must be shut 'as soon as possible on diving,and prior to' the submerging of the main induction valve.

NARRATIVE

Having previously made eighteen successful dives, SQUALUS was contin~

uing builder's trials off the Portsmouth Naval Shipyard. She was riggedfor dive and so reported to the Commanding Officer. The boat sUbmergedat 16 knots, main engines on propulsion. Prior to opening the vents, a"green board" with .2 inches pressure in the boat was obtained. Whenpassing 50 feet, the commanding officier in control received a reportthat the engine rooms were flooding. All main ballast tanks were blownbut the boat CQuld not be surfaced because of the extensive flooding.She came to rest on the bottom, at 240 feet.

Water had entered through the induction system and flooding progressed from the engine rooms to the after end of the ship as well as to theafter battery compartment through open doors and ventilation flappers.The control room was secured immediately and flooding stopped at itsafter bulkhead. The entire after end of the ship was flooded, drowningtwenty-s ix members of the crew.•

The submarine rescue vessel FALGON(at the time of this writing 1966 - the only ASR which has ever conducted actual sUbmaring rescue}used her rescue. chamber to save the thirty-three persons who remainedalive. SQUALUS was raised after several months, reconditioned and restored to duty as SAILFISH.

Inspection on salvage showed the following valves were NOT shut;main induction, forward engine room air induction, after engine roomair induction] ventilation hull supply in the after battery and theventilation hull exhaust in the after battery compartment. The outerdoors of the upper torpedo tubes aft were cracked and their inboardvents were opened. It was customary to flood these above-the-waterline tUbes in this manner on the first dive daily.

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The watertight door between the after battery compartment and theforward engine room had been reported on the latch before diving andwas eVidently dogged just after the flooding started, but not beforesome water entered the after battery compartment through it. Unsucessful attempts had been made to shut the forward engine room ventilationsupply bulkhead flapper and the exhaust hull stop on the ventilationsystem.

A post-salvage examination of material aboard SQUALUS disclosed that:

a. All operating gear was in the correct position for diving exceptfor the main engine induction valve gear which was latched wide OPEN.

b. The single lever on the hydraulic manifold which controlled boththe main engine induction and the main ventilation induction valves wasin the SHUT position.

c-. The main ventilation induction valve operating gear was in theSHUT position.

d. Upon test with hydraulic power supplied by hand pump the mainengine and main ventilation induction valves operated properly.

e. With the main engine induction valve gear in the latched OPENposition, the gear could be moved a sufficient amount toward SHUT tobreak the red light contact, leavi~g the latch still in position to holdthe gear OPEN and giving neither red nor green light on the hull openingindicator.

f. The main engine induction valve indicator lig~t was locateddirectly below the main ventilation indu~tion valve indicator light nextto a blank indicator box on an otherwise symmetrical board.

OPINIONS AND FIrIDINGS

OPINION OF BOARD OF INQUIRY

1. The submarine was lost due to a mechanical failure in the operatinggear of the main engine induction valve.. This mechanical failure wasnot discovered in time because of an electrical failure in the valve indicator or a mistake in reading this indicator by operating personnel.

2. No offenses have been committed and no serious blame has been incurred.

RECOMMENDATIONS BY BOARD OF INQUIRY

1. Separate hydraulic control levers should be provided to operate themain engine induction valve and the main ventilation induction valve.

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2. The hull opening indicator board should be rearranged to group thehull openings which are shut on "Rig for Dive" separately from thosewhich are shut during the diving process; the main engine induction andmain ventilation induction valve lights should be together on a separate board in the control room.

3• The ventilation supply and exhaust hull valves and engine air induction hull valves should be qUick-closing. These valves should be equipped with electrical indicators which indicate on a separate board in thecontrol room.

4. The latching arrangement for :the engine induction and main ventilation induction valves should be redesigned to insure positive operationfor locking and release for both OPEN and SHUT positions.

5. Ventilation duct bulkhead flapper valve housings should be pressure-proof.

6. All deck hatches of all submarines should be fitted to receive therescue chamber.

COMMENTS BY SECRErARY OF THE NAVY

"_ ~. When the operating lever was moved to the proper position toshut both the main engine induction valve and the main venti.lationinduction valve (hereafter referred to as "Valve At! and "Valve B" respectively), the red lights, indicating that they were open, Went outand the green lights came on, showing to the operating personnel thatboth. of these exterior valves were shut.. The barometer showed an increased air pressure in the boat, further indicating that all exterioropenings were shut. Such was the testimony of eye witnesses in thecontrol room. Reliance was placed upon these devices. Water enteringthe boat was the first sign that some exterior opening was not shut.Either these witnesses, however, honest in their convictions, weremistaken in their observations, or the instruments upon which theyrelied were not in proper working order, for it is established thatValve A either did not shut or, if it did, did not remain shut.

- - Water entered the submarine through Valve A, the piping behindit, and the outlets therefrom into the hull. The pipe lines fromValve A lead to the forward and after engine rooms. Those from Valve Blead to the after battery compartment.

Hull stop valves are provided at the four points of entranceinto the hull of these systems of piping, i.e., one in each engine roomand in the after battery compartment. These stop valves back up ValvesA and B by closing the air piping at points of entry into the hull.Specifications for these hand operated hull stop valves require that

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they be capable of being shut in 15 seconds and practice shows that theycan be shut in much less time (6 or 7 seconds). Had these hull stop valvesbeen shut prior to submergence of Valve A, which normally will occur innot less than 35 seconds after commencement of the dive, only the pipelines! and not the compartments, would have been flooded •.

- - The two hull stop valves backing up Valve A cannot be shut whensUbmerging until the engines to which they supply air are ~topped. Theengines While in operation require such a large quantity of air that ina few seconds a partial vacuum would be created in the engine roomswith serious and probably fatal injuries to personnel, if the air supplylines be shut with the engines running.

- - The or~nization and orders on the submarine required closure oftwo hull stop valves backing up Valve A after the engines were stoppedwhen diving. Likewise, they required, on rig for diving, that the twohull stop valves backing up Valve B be tested for free closure, that theybe shut on the diving alarm, and that they be reopened when normal submerged condition was reached.

- - However, in view of the evidence adduced, and the endorsementshereon, the Secretary of the Navy holds that the sinking of the submarine was primarily due to the mechanical failure of the operating gearof the main engine induction valve and also to the non-closure of fourhull stop valves.

- - The record shows that the closure of all hull stop valves wasprescribed as routine procedure in the sub~rine..The facts remain,however, that these four hull stop valves were open when the ship madeher last dive and that evidence was adduced that it was not the practicealways to shut these valves.

- - AlthOUgh the failure to shut the two hull stop valves in themain engine air induction system may have been the result of specialcircumstances known only to the personnel who died at their post ofduty in the forward and after engine rooms, there is no adequate explanation of the failure to shut the two hull stop valves in the afterbattery compartment. This, together with the fact that a substantialdoubt remains as to the habitual practice Of shutting the hull stopvalves) indicates that the training) supervision and indoctrinationnecessary to insure the timely closure of these important hull stopvalves, while diving, was lacking in emphas is • It

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CASE

Sinking of 0-9 during deep dive, 1941.

PI1INCIPLES

Deep dives should be made in water not much deeper than test depth.

NARRATIVE

Having completed a reconditioning overhaul after nearly ten yearsin the reserve fleet, 0-9 proceeded from Portsmouth Naval Shipyard toher operating area near the Isle of Shoals for a test deep dive. Shesubmerged and was never heard from again. She was located in 440 feetof water and a diver descended to identify her. He landed on the wreckand definitely identified it as the 0-9, reporting also that the hullappeared to have been crushed. No attempt to raise her was made.


1. 0-9 was presumed to have suffered a casualty SUbmerged which causedher to exceed her test depth.

COMMENTS

The test depth of the 0-9 was 212 feet. Her sinking :trougllt aboutthe requirements that initial dives following overhaul be limited torelatively shallow water, i.e*, 150 feet, and that the deep dive bemade after the initial dive and in water not much greater that thetest depth of the boat, and that for all test dives a vessel capable ofunderwater communication be standing by.

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CASE

s-26 rammed and sunk by escort, 24 January 1942.

PRINCIPLES

1. Accurate station keeping in formation is essential to safety.

2. A 180- degree turn is a most dangerous maneuver for a ship ahead ofa formation.

3. The usual deceptions of night vision are compounded when running withships darkened.

NARRATIVE

A formation of five darkened ships enroute from Balboa, Canal Zoneto patrol stations was arranged as follows: two columns of two submarine eac4, interval 1,500 yards, distance 1,000 yards; PC 460, guideand OTC, 1,500 yards ahead of the sUbmarines, with a column on eachquarter; course 169OT, speed 10 knots. s-26 was astern of S-21 in thestarboard column.

At 2152, PC 460 signalled to S-21: "Changing course to 1500T toavoid ship ahead". All submarines followed this change in varyingamounts at varying times. s-26 suffered a steering casualty and madea late turn in hand steering. She came to 1100T to compensate for herloss of station resulting from the delay in turning. After the approaching vessel was clear, the formation returned to base course.s-26, which had restored normal steering, was somewhat to the right and2,000 yards astern of S-21 and steered 1650T to regain station. At2210, the PC signalled to S21: IIThis ship is 14 miles west of SanJose Light X Submarines proceed on duty assigned X This ship willmake wide turn to the right." The message carried no addresses andonly S-21 received it.

At 2213, PC 460 turned right with small rudder at 14 knots toleave the formation. She crossed the bow of S-21 at about 400 yardsand passed down the starboard beam of that boat at about 300 yards,While continuing the turn to the right.

At 2221, s-26 sighted a darkened ship (soon discovered to be thePC) on her port bOW, crossing from port to starboard. She immediatelychanged course left to 150OT. s-26 then observed the PC to be turningdirectly toward her. Left full rudder was put on, the screws were

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backed emergency, and the collision alarm was sounded. The blinker tubewhite light was flashed at the PC. Just before the flashing light wasseen, PC 460 sighted 8-26 dead ahead. With her bow pointing at the starboard side of 8-26, aft of the conning tower, the PC increased rudderto right full, and attempted to back. Her engines failed and at 2223she struck 8-26 amidships on the starboard side. Within seconds thesubmarine sank in 300 feet of water. Two officers and one man weresaved, while the remainder of her complement, three officers and fortythree men, perished.

OPINION8

1. 8-26 was to the "west of her proper station as a result of the steering casualty when the course change was made to avoid the approachingship.

2. 8-26 should have taken prompt action to regain station.

3. When PC 460 left the formation, she did not have a correct estimateof the positions of the other ships.

4. PC 460 did not increase speed until the right turn had been started,and the continuous turn placed the PC closer to the submarines than shehad foreseen.

5. PC 460 erred in not taking a steady course divergent from the formation for a long enough time to clear the formation before startingthe turn to the right.

6. PC 460 failed to recognize the existing danger that collision with8-26 was imminent When she sighted 8-21 (first ship in column and aheadof 8-26) close aboard instead of at an intended safe distance.

7. By the time danger of collision was imminent, the swing left by 8-26contributed to the severity of the collision. Had she swung right, thecollision might have been avoided, or at least minimized.

8. By swinging right with full rudder, PC 460 made the collision practically certain. The use of left full rudder probably would have avoidedthe collision and certainly would have minimized the damage to 8-26.

FINDINGS

1. The responsibility for the collision rested with PC 460 for badjUdgement and poor seamanship in handling the formation and in taking

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departure from it, as well as for poor seamanship in maneuvering whencollision was imminent.

2. The responsibility for the collision rested also with 8-26 for herfailure to regain promptly her proper station in the formation and forpoor seamanship in maneuvering when collision became imminent.

COMMENT8

This case points up the danger of assigning surface ships to operatewith, and maintain formation with, submarines when the former are notfamiliar with the limitations and vulnerability of the latter, and thefact that due to their low freeboard and small silhouette they are mostdifficult to see from a surface ship at night. A similar accident occurred in the British Royal Navy in World War II with the same result.arcs and Commanding Officers of surface ships must understand thecapabilities of submarines in order to work with them with safety information. This understanding should be the basis for the choice offormation, interval, distance, speed, and positions for the submarinesassigned.

Every seaman is aware of the difficulties of night Vision, particularly the inability to jUdge distances accurately~ ~he absenceof running lights further complicates the problem. The conning officermust allow a much greater safety margin when leaving formation courseand speed at night. than when "seaman's eye" estimates are available.In failing to make this allowance PC 460 nearly collided with 8-21•.The most tragic part of this close brush was that "seaman I s eye" ~available to the PC once 8-21 was seen clearly and should have beenused at that time as the basis fQr changing course radically awayfrom the formation.

Any ship which reverses course while running close ahead of aformation is inviting adversity, even under conditions of perfectvisibility. There are few emergencies which justify such a procedure.

A-25


CASE

Sinking of R-12 while underway on surface, 12 June 1943.

NARRATIVE

While proceeding to po~ition for a practice torpedo approach off KeyWest, the Commanding Officer was turning over the bridge watch to ajunior officer when the collision alarm was sounded from below. Wordwas passed up that the forward battery compartment was flooding. TheCommanding Officer immediately ordered all main b~llast blown and thebridge hatch shut. While he was speaking OVer the MC-system, the boatsubmerged. About fifteen seconds elapsed from the time the alarm wassounded until· the boat was under the surface. The Commanding Officer,Officer of the Deck, one other officer and three men were washed fromthe bridge. All other personnel, including two Brazilian officersundergoing training, were lost as the R-12 sank in 600 feet of water.


1. While pronouncing the cause of the sinking as unknown, the Courtof Inquiry gave the opinion that the boat flooded through an opentorpedo tube.

COMMENTS

The most striking feature of this case is the speed with which itoccurred, leaving no time for corrective action. It is illustrative ofthe fact that once major flooding has begun, it is impossible to maintainor regain positive buoyancy unless the boat is stopped by the bottom inher downward plunge.

A-27


CASE

Loss of COCHINO as a result of battery explosion, 26 August 1949.

PRINCIPLES

1. A relatively minor casualty can develop into a major catastropheunless prompt action is taken.

2~ Personnel must be keenly aware of the danger of hydrogen evolutionwhen snorkeling.

NARRATIVE

While operating in Arctic waters, COCHINO secured charging batteriesand submerged at 0500, 25 August 1949. The reqUirements for a normalcharge had. not quite been met. She ran sUbmerged on the batteriesuntil about 1030 when she commenced snorkeling. A heavy sea (State 4)made depth control extremely difficult and she alternately broached andexceeded snorkel depth often.. After snorkeling· for about ten minutes,the forward engine room reported considerable water entering through thesnorkel induction s.ystem. An investigation by the executive officerrevealed no serious flooding.

At ;1.046, t1!e high vacuum cut out secured the two snorkeling enginesin the forward engine room. Two minutes later, a series of explosions,described as a muffled thud by witnesses, occurred in the after batterycompartment in the after port corner near the series-parallel switch.The ship surfaced imediately and the after battery compartment wasrigged for fire. Maneuvering removed the load from the after battery.

Shortly after 1100, the ammeters in the maneuvering room indicatedthat battery number four was discharging into battery number three atthe rate of 3,500 8,!llperes. The controllerman went forward immediatelyto inform th~ executive officer (in charge at the scene) of the immediatenecessity to pull the battery disconnect switches. By this time, though,the compartment had been abandoned because of smoke and gas, and hadbeen sealed. In rigging this space, the disconnect switches had not beenpulled nor had the covers been placed over the battery well intakes.

A muster was co~ducted by the exe~utive officer at this time toinsure no personnel remained in the after battery compartment whilepreparations were made to reenter it through the after door of thatspace. The .forward engines were started to clear smoke, and as theexecutive officer, wearing a rescue breath~ng apparatus, cracked thedoor both engines began to accelerate. Fuel was secured to both engines,but number one continued to accelerate. An explosion took place withinthe ?fter battery compartment, while, simultaneously, another occurrednear the blower af number one engine, burning five persons in the engine

A-29


room. The executive officer managed to shut the d.oor, but was able tosecure it with only one turn. The forward engine room was evacuated.

A few nimutes later, two chief petty officers returned to the forwardengine room, extinguished several small fires and secured the compartmentexcept for the engine sea water cooling systems and the door to the afterbattery compartment.

At the same time that the attempt was made to reenter the after battery compartment prior to the second explosion, a man was washed overboardafter going topside through the after torpedo room hatch. He was engpgedin carrying out an order for all personnel not on watch or fighting thefire to iay topside. The Commanding Officer maneuvered the ship andrescued him.

About 1145, the Commanding Officer ordered all excess personneltopside to go below via the conning tower. They remained below until 1208,at which time all personnel forward were evacuated because of smoke andgases.

At 1215, another violent explosion (the third) rocked the after battery. Shortly afterward, the hospital corpsman1s reports of treatment ofthe injured being conducted in the after torpedo room became more alarmingand his requests for medical supplies became more urgent. The CommandingOfficer requested TUSK, in company, to come alongside to remove the injured and the excess personnel. This was attempted but found impossiblebecause of the heavy seas, but at 1410 the medical supplies arrived fromTUSK by rubber boat.

At 1420 one officer and a civilian technician attempted to transitto TUSK by boat. The boat overturned throwing both men into the water.While TUSK was hauling them aboard, the technician received a severe,head injury, was knocked unconscious, and was pulled aboard apparentlydrowned. When TUSK personnel_were attempting to administer artificialrespiration,. two huge waves swept eleven crewmen and the civilian overboard. Five crewmen were recovered but the others could not be locatedduring a two-hour search.

During the afternoon, three attempts were made to enter COCHINO'sforward torpedo room from topside to clear it of gpses. An attempt wasmade to vent the after battery compartment through the high externalsalvage valve but this valve would not open. The men suffering fromgas were being revived and treat~d. The generai situation was beingdiscussed with the hope of fi~ding solutions to the problems. At1537 aUXiliary power was lost when a short circuit tripped out theforward battery auxiliary circuit breaker. At 1610 the engines werestopped when the clean fuel oil tank became empty.

A-30


Auxiliary power was restored about 1800 and shortly thereafterCCCHINO get underway, steering for the nearest land with the screwsonly. .Rudder steering was restored about 1900. For the next fourhours, COCHINO proceeded astern of TUSK. Personnel who had been evacuated from below were sheltered in the sail.

At 2306 J the fourth and explosion occurred (probably in theforward engine room) and filled the after engine room with fire andgases. The latter space and the maneuvering room were abandoned at once.Around midnight, the remaining personnel below, all in the after torpedoroom, were ordered topside.

Ten minutes later, TUSK came alongs and transfer of personnel toher was commenced. At 0036J because of a starboard list and low freeboard aft, the Commanding Officer ordered CCCHINO abandoned. The Commanding Officer trans~erred at 0043 and three minutes later CCCHINO sankin 170 fathoms of water •

.OPINIONS AND FINDINGS

FINDINGS OF COURT OF INQUIRY

1. The initial of explosions were probably hydrogen flashestouched off by a spark in the Vicinity of the series-parallel switch inthe after battery compartment.

2. The excess· hydrogen probably existed in "and near the battery forabout five hours and "had not been purged or been brought into a danger~)Us conc~ntrationuntil sno::l:'keling was commenced"..

3. Responsible officers erred in failing to note the dangerous concentration of hydrogen when it occurred and in not taking corre9tive action,particulariy in the light of Bureau of Ships Instruction covering suchmatters.

COMMENTS AND RECOMMENDATIONS OF TEE CONVENING AUTHORITY

Although agreeing that tIle probable cause of the first relativelyminor explosions was hydrogen (not positively determined), the ForceCommander, as convening authority, did not concur in the recommendationto censure certain officers for their errors. It was "obvious thatcurrently available hydrogen detection equipment was inadequate to indicate promtly the dangerous situationll which existed.

A-31


He stated that the ship might have been saved had the muster about1100 not been taken and had, instead, an immediate attempt been made toenter the after battery compartment to open the disconnect switches.Although conclusive evidence was not availabl~, the convening authoritybelieved that COCHINO sank as a result of flooding ot both engine roomsfollowing a derangement of sea water piping and valves in the forwardengine room after the final explosion at 2306. The ship might have remained afloat, he stated, had the after engine room been secured priorto its abandonment.

The Force Commander followed his direct comment on the court's proceedings.with a series of recommendations to CNO for submarine materialchanges as a result of the disaster. The following were based upon thepremise that the first explosions were caused by hydrogen:

1. The storage battery, its ventilation system~ and its electricalarrangement in the well should be redesigned to make it safe from concentrations of hydrogen regardless of submarine internal atmosphericconditions accruing from wartime operations, snorkel or otherwise.

2. Increased safety should be provided against short circuits andgrounds involving cells, cabling, switches and other electrical elementsof different potential within the well.. The part played by the seriesparallel switch in the COCHINO disaster indicates that all switches mightrequire shielding with a gas-tight enclosure, perhaps employing theprinciple of the safety screen.

3~ Series-parallel switches should be modified to protect againstmaloperation, whether from personnel error or material failure. Thisshould include positive interlock between switches and between eachswitch and its battery disconnects. An "OFF" position should be provided on each switch.

4. Operating personnel should have improved instruments to enabletheir determining'safe conditions of resistance to ground, hydrogenconcentration, and ventilation air flow.

The following changes were recommended based upon possible means ofcontrolling an initial casualty such as coeHINO's and of providing forcontinued operation of the ship:

1. Remotely controlled battery disconnect breakers should be installed providing full operation from the maneuvering room and withcontrol of tripping from either side of the end bulkheads of batterycompartments.

2. Protection should be provided against faults and grounds in thetake-off leads for aUXiliary power, ship1s lighting, emergency lightingand other directly connected loads. Such occurrences may have been

A-32


involved in the COCHINO case as they were in previous uncontrollablesubmarine electrical fires.

3. Submaripes should be provided with more qUickly operable rescuebreathing apparatus. The ideal type should be rechargeable' on board.

4. At least two fire extinguishers should be provided which can berecharged on board.

5. A f~ame~proof suit and smoke helmet should be carried by submarines.

6. The main propulsion plant should be modified so that main generators could provide power for excitation, the plant auxiltaries, andfor ship control" indpendent of the battery.

A final recommendation involving training of personnel requestedthat the Bureau of Ships prepare a single publication covering themodern submarine electrical plant with emphasis on the compromiseswhich have been accepted, operating procedures, safety precautions andelectrical casualty procedures.

COMMENTS

Since the majority of our boats in the postwar era were conversionsinvolving addition of Guppy batteries or snorkel or both, the.lessonslearned were many and important.

Re~rdless of the origin of the first explosion in COCHINO it seemsapparent t.hat there were several points during the aftermath at whichcorrective action could have saved the ship. ~enecessity for completelyrigging compartments for emergencies is. most evident, as is the reqUirement for electrical isolation in cases of casualties of electricalorigin. The ratio of the ounce of prevention to the pound of cure hasnot been altered by advances in technology.

Most of the recommendations by the Force Commander have bornefruit and are now considered standard: open-tank ventilation, remoteoperated battery disconnect breakers, modified series-parallel switches,improved ground and hydrogen detection, dry chemical fire extinguishers,and more efficient rescue breathing apparatus.

It is extremely fortunate that the entire crew of COCHINO was notlost, as almost certainly would have been the case had she been operatingalone. Loss of life was an indirect result of the casualty. Such hasnot been the case with most other battery explosions.

The man overboard problems encountered by both submarines involvedwere aggravated by the heavy seas. The rescue of the man lost from

A-33


COCHINO during a Gr~s~s in the catastrophe is worthy of note. Thesafety-line track alteration 'Was an outgrowth of these incidents.

The maxim that trouble breeds trouble 'Was proved time and againthroughout COCHINO's last hours. Lessons to be drawn from the minordifficulties encountered are almost too numerous to permit completelisting. A bridge sound-powered telephone proved invaluable as theIMC-7MC systems were knocked out shortly after the first explosion.With no power for her searchlights, COCHINO 'Was reduced to using abattle lantern for night communications, a situation which has 'beenremedied by the Aldis Lamp. The rapidly-being-forgotten art ofsemaphore was used by day but 'Was limited by. wind and the signalman IS

exposed position. The medical supplies, other than those in theafter battery compartment,- were limited to first aid kits in thetorpedo rooms. Present practice calls for more such supplies instowages forward and aft. Several of the life jackets were found tohave been p~ct~red by the bunk·springs upon which they have beenstow:ed.. Althoug'll many occasions called for use of a knife, only twowere available, ~hese the personal possessions of two crewmen. Withthe control room and conning tower abandoned, steering 'Was ~mpossible

except from the afte:r torpedo room with a makeshift lever to move thesteering pump control valve. Steering with the screws only was ineffeCtual. The emergency steering method employed by COCHINO is now partof the standard repertory of after torpedo room crews.

While material improvements have lessened the possibili~y of thetype casualty which caused COCHINOf sloss, submariners should have ahealthy respect for hydrogen and its dangers whether at sea or inport, ~s long as they .sail with the lead-acid battery.

A-34


PART B - COLLISIONS

The following are discussions of collisions, both at sea and in port,

resulting from a large variety of causes--causes ranging from sheer

stupidity to non-culpable aggressiveness in attack.

It is noteworthy, however, that most collisions resulted not from

unusual sea, weather, or traffic conditions, but from simple violation

of the elementary and well-known practices of good seamanship.

In compiling these cases from available records, an effort has been

made to include all the facts which were pertinent to the situation and

to exclude extraneous matter. This was not easy, and may not have been

successfully accomplished, as some of the investigations were quite

complex. A federal judge, after years of hearing a('imiralty cases, has

observed, lITl:J.e testimony regarding collisions always is conflicting.

In fact, it Seems the typical ~ollision cccurs when two vessels sight

each other on a clear day at ,~ distance of several miles on opposite

and approaching courses, and each vessel backs full until the collision

occurs II •

B-1


CASE-'--

Collision between submarine (submerged) and AKA.

PRINCIPLES

1. Description of target disposition to fire control party by Commanding Officer during attack on multiple targets is essential.

2. Use of number two periscope in state five sea inside the screen ispreferable to use of ST scope •

.NARRATIVE

A submarine penetrated f?creen for attack on fOI'!!J,ation of two columnsof two ships each: AF and AGC in one column, AKA and AF in second column.After three attacks AKA was observed at 2,500 yard on the port bow withstarboard 45 angle on the bow. The submarine then commenced attack. onend ship in column. After this attack the Commanding Officer made a look.around and steadied on the AKA. Somehow, the picture was lost, andthinking the AKA to bean the starboard quarter vice the port bow, h~

ordered "Left full rudder, all ahead fulli!. At 400 yards range the mistake was realized and the order was given to "Take her downu • A collision resulted before the submarine could gain' depth. The submarinesurfaced immediately since a previous look around bad shown the AKA tobe only ship near.

OPINIONS

1. The Commanding Officer erred in failing to make clear the tacticalsituation of the fire control party and in losing the picture himself.

2. Going deep after last attack would have been good procedure.

3. The Conuri9.nding Officer did not have a clear picture to justify sur..facing immediately after collision.

COMMENTS

It is interesting to note that the Commanding Officer was apparentlyaware of the possibility of having to go deep, as he had so informedthe fire control party, but he had done nothing about it.

Once the SUbmarine is close to the screen or inside of it, the use ofnumber one periscope is poor practice, especially in rough seas. In this


situation the use of number two periscope would have afforded the fol- \lowing advantages:

a. Easier and better depth control by virtue of deeper periscopedepth.

b. Less danger of periscope being sighted.

c. Less depth to gain to prevent collision.

No mention is made in the report of· sonar bearings being obtained,information which should have been available to indicate clearly thedanger of collision with the AKA.

B-4


CASE

Collision between submerged submarine and destroyer escort.

PRINCIPLES

1. When submerged, a submarine accepts the responsibility for avoidingcollision.

2. Precautions must be taken when returning to periscope depth fromdeep submergence.

NARRATIVE

The submar~ne was making S-2-T rehearsal ruh. Destroyer escort"ALFA" was being screened by destroyer escorts "BRAVO" and "CHARLIE".At 1512, after passing between escorts "BRAVO" and "CHARLI;E" , thesubmarine fired "down-the-throat" at "ALFA" which was bearing 004OT,1,300 yards,angle-on-the-bow starboard 10, speed fifteen knots. Thesubmarine came to 0900T at fuil speed in order to pass under the targetand then fire a stern shot when lIALFA" has passed overhead (the submarine',s JT lost lIALFAlIonthe starboard bow when going deep and increasing speed). About 1513 IIBRAVQlI reported a sonar contact to "ALFN'who, in turn, ordered all ships to turn to the starboard to 250OT. At1514 the submarine's TDC operator reported the generated target to bepassing overllead. The submarine slowed to two-thirds, came to course0290T. The JT operator reported regaining contact with lIALFAlI bearing110~; the WFA sonar reported one ship at 2150R arid another at 250OR.The Commanding Officer ordered 58 feet. At this time the reported JTbearing checked within a degree of the TDC solution although the CPAwas indicated as only 260 yards. Thirty to forty-five se~onds later asecond JT bearing Was obtained which required a two or three degreecorrection in the TDC. Then, at 1516, with lIALFAH on a heading ofabout 2300T, coming right to 250OT,making turns for seventeen knots,and with the submarine on aheading of 029~, at two-thirds speed, 58feet depth, the two ships collided. The result was damage to the submarine's shears and periscope--$44,000. lIALFA'sll damages were estimatedat $110,000.


l~ The JT bearing of 110~ reported to be lIAL~AlI was Iilost likelylICHARLIE" and the WFA bearing of 250~ was a spurious one, probably aminor lobe, giving the Commanding Officer the indication that lIALFAlI

B-5


was passing down his starboard side leaving the other two ships aba:ft hisport beam.

2. The COIll!JlS.nding O:f:ficer apparently :failed to require a care:ful allaround search to be made, did not use number two (high) periscope, and:failed to set condition "BAKER".

3. Both ships should have maintained more accurate tactical plots o:f theexercise.

4. Use o:f the high periscope and better in:formation :from the sonar plotmight have prevented the collision, or at least have reduced the damages.

5. Collision resulted :from errors o:f judgement on the part o:f the submarine's Commanding O:f:ficer.

COMMENTS

Use o:f the high periscope a:f:fords two advantages - an earlier lookand more sa:fety to the submarine by providing a greater d.epth o:f waterover the pressure hull; thus reducing. the seriousness o:f collision.This greater depth alsoreducea the possibi~ity o:f broaching when in apoorly controlled ascent or heavy seas.

Agreement between a sonar nearing and the TDC generated solutionshould not be relied upon to the extent o:f omitting a care:ful all aroundsearch by sonar.

B-6


CASE

Collision between submerged submarine and destroyer.

PRINCIPLES

The primary responsibility for avoiding collision rests with thesUbmerged submarine.

NARRATIVE

A submarine was attacked by two destroyers when carrying out nightscreen penetrations. The submarine came to periscope depth to counterattack, fired at destroyer llBRAVO lf ahead and then shifted to lfALFA lf

which was crossing astern at between 300 - 500 yards with an estimated30 - 40 port angle-on-the-bow. The submarine lost sight of llALFA'slfhull but still saw her lights and was receiving reports of range of 500yards and steady. He estimated angle-on-the-bow to be 900 port. Momentslater the report "300 yards and closingll was received, and at the sametime the hull again came into view. This gave a new angle-on-the-bow of 00 and showed collision to be imminent. The CommandingOfficer ordered down scope, standard speed and 70 feet. Collision occurred before the orders could be carried out with the exception oflowering the scqpe while at 60 and the gaining of a slight downbubbl", at two-thirds speed. Upon being struck the boat rolled 50-d-egrees to port and went to 72 feet. A large up angle resulted fromthe stern planesman inadvertently putting the planes on rise when theroll from collision occurred. The submarine was immediately riggedfor collision, the running lights turned on, a red flare fired, andwas then brOUght to the surface. The damage was valued at $190,000to the submarine and $27,700 to the destroyer.

OPINIONS

The submarine's Commanding Ofi'icer was operating aggressively andthe collision was a result of his haVing erred in estimating the destroyers angle-on-the-bow.

COMMENTS

After a submerged collision'has occurred, the greatest -dangerusually exists when surfacing quickly. The first step prior toSUrfacing should be to get the submarine to a safe depth until it isknown to be safe to surface, using the procedure prescribed for a disabled SUbmarine. The fact that approximately a minute and a halfpasses between the order to fire a red flare and the time the flareis actually airborne should be kept in mind.

B..7


CASE

Collision with a mooring buoy.

PRINCIPLES

1. Tide and current tables should be used in planning courses.

2. The Officer of the Deck should have and use a chart on the bridge.

3. There 'must be a complete exchange of information between the Commanding Officer, the officer of the deck and the Navigator.

NARRATIVE

During a routine transit of a harbor, the Navigator informed theofficer of the deck that it was safe to pass a mooring buoy on the porthand. The commanding officer suggested that the ship would pass tooclose to the buoy, whereupon the Officer of the Deck ordered a changeof course to the right. At the same time the Commanding Officer askedthe Navigator if there wasn't shoal water by the pier toward which theship was heading. The Commanding Officer's remark alarmed the Officerof the Deck and he ordered left full rudder. The Commanding Officerupon seeing the buoy passing down the ship's port side issued the order"starboard stop". Shortly thereafter, the ship struck the buoy, damaging the port screw which had become entangled in the chain of themooring buoy.


1. The Officer of the Deck and the commanding officer had not usedthe Tide and Current Tables prior to getting underway, since theCommanding Officer considered tides to be of little consequence.

2. No chart was on the bridge since the Commanding Officer believedthe simplicity of the harbor warranted no such aid, although the officer of the deck had not been instructed in the hydrographic characteristics of the harbor.

3. The Commanding Officer had not required the navigator to keep acontinuous and accurate plot of the ship's position and to keep theOfficer of the Deck informed thereof.

4. There was no complete exchange of navigational information betweenthe Navigator, the Commanding Officer and Officer of the Deck, lack

B-9


of which resulted in the Officer of the Deck erroneously believingthere was an immediate danger of grounding.

5. There developed considerable confusion as to who had the Conn-the Commanding Officer assumed the Officer of the Deck had it, butthe Officer of the Deck was uncertain of whether he did or did not.

COMMENTS

There is no substitute for following the sound navigational procedures for piloting as laid down in DUTTON's-procedures which wereflagrantly violated in this case. Of utmost importance are thepreparations prior to getting underway such as studying the charts,tide and current tables, and laying out the track to be followed,with danger bearings clearly indicated on both the navigator's chartand the conning chart. Of equal importance is the practice of takingfrequent cuts while on soundings, as required by Navy Regulations.

It is essential that there always be a positive understanding ofwho has the Conn. Failure to establish this fact is usually thefault of the Commanding Officer. CINCLANrFLT Instruction 3530.2Ais most pertinent on this subject.

B-10


Submarine collision w:!.th Buoy 2A, Long Island Sound.

PRINCIPLE

1. Use of true bearings to determine risk of collision is essential/for safe operation of ships.

2. Allowance must be made for current in setting courses.

NARRATIVE

A submarine enroute to a local operating area off New London roundedSarah's Ledge Buoy and set course to pass Buoy 2A abeam to starboard.At 0954 the buoy bore 229.5 degrees true, distance 4,000 yards, with thesubmarine on course 225 degrees true, speed eleven knots. Current wasshown by the tables to be 1.2 knots to the north (flooding). The coursewas maintained until the buoy was about 150 yards away, at which timethe OOD began small course changes to the left. The ship struck the buoyamidships and damaged the starboard screw.

FINDINGS AND OPINIONS

Collision resulted from the OOD's failure to determine by truebearings the relative motion of the buoy.

COMMENT

Although not available from the record, it would appear that no allowance was made for current in setting the course of 225~; it also isprobably safe to assume that the OOD was totaily unaware of the current conditions.

The OOD (as the one in this case sadly learned) shares the responsibility with the NaVigator for the safe navigation of the ship. Toomany OODs fail to note where the course to be steered will take them,what navigational aids are to be used, what currents are to be expected, the depth of water in which operations are to be conducted--inshort, they blindly rely 100% on the Navigator to keep them advised. ofsuch essential information. The prime responsibility of the OOD forthe safety of the ship must never be slighted in the least--if heblindly acts merely as a "mouthpiece" for the NaVigator, he is notdoing his job properly.

B-ll


CASE

Collision of submarine with Buoy 2A, Long Island Sound.

PRINCIPLES

1. Allowance must be made for current when plotting courses.

2.. OOD must keep the Navigator and Commanding Officer informed ofsightings and course changes, and assure that the former is informedof the ships navigational position at all times.

3. Risk of collision with any object can be ascertained by observingits true bearing.

NARRATIVE

Upon departing New London, and after passing Sarah's Ledge Buoy,a course of 2280T was recornmended by the Navigator. This course wasplotted to clear Buoy 2A by 300 yards, but did not allow for any current. Visibility was between 3,000 and 4,000 yards. The Navigator andthe Commanding Officer left the bridge upon clearing Sarah's Ledge Buoy.SUbsequently, the OOD sighted Buoy 2A dead ahead at a range of about2,500 yards, but neglected to inform either the Commanding Officer orthe Navigator. When the range had closed to 900 yards the OOD changedcourse to 225°T, then a bit later to 233~, and finally to 220~.

While on this last course and at a speed of 11 knots the submarine'sbow passed the buoy by fifteen feet, but the stern collided with it,causing extensive damage to the starboard screw and shafting.


1. The NaVigator erred in not allowing for a northerly set.

2. The OOD failed to inform the Navigator and the Commanding Officerupon sighting the buoy and of course changes made to avoid it. Moreradical course changes should have been made once it became apparentthat there was a danger of collision with the buoy.

COMMENT

The magnitude and direction of the current in the area where thisaccident occurred is readily obtainable from standard publications, butthe Navigator failed to determine and use such current information inadvising the initial course.

B-13


Further, the OOD should be informed on the existing current, and in thiscase he apparently was not. Poor initial course or not, however, it ismandatory for an OOD to observe the true bearings of objects which heapproaches, and it is well-known that something must be done if thebearing remains steady or nearly so--unless the objective is to ram!It is also worthy of note that as the buoy was approached a total coursechange of only 8 degrees was made, beginning at a range of 900 yards,until the buoy was hit. Apparently the OODbelieved that some danger ofcollision with the buoy existed. when he commenced these minor courseadjustments, but his action was not sufficiently positive; he should haveused rudder orders to positively and immediately head the ship clearof the buoy rather than to use trifling course changes. It is ofinterest that this casualty is almost identical with the previous caseinvolving the same buoy--a buoy which has at least 1,000 yards ofnavigable water on any side of it!

B-14


CASE

Collision between submarine and DD moored to a pier.

PRINCIPLE

Parallel means of communication are essential when maneuvering a shipin restricted water.

NARRATIVE

The submarine was tied up outboard of another submarine which in turnwas outboard of a destroyer. The inboard submarine got underway,and theoutboard submarine breasted out to facilitate the maneuver. While breastingback alongside the destroyer, the submarine Commanding Officer observedthat his ship was getting forward motion, therefore, he ordered "starboardback 1/3". The helmsman repeated the order correctly,but actually rang up,II starboard ahead 1/3", which maneuvering answered. The JA talker on thebridge correctly repeated the order to maneuvering but was unable to receive in acknowledgement. As the ship's headway increased,the CommandingOfficer ordered, "starboard back 2/3" ,but the helsman rang up starboard ahead 2/3, and again the JA talker was unable to get through themaneuvering. As the ship gained headway rapidly, the Commanding Officerordered, "all back 2/3" over the }MC, but it was too late to prevent acollision of the submarine 'With the DD. Fortunately, the damage to bothships was slight.

OPINIONS

1. The primary cause of the collision was the failure of the helmsman toring up the proper orders.

2. The secondary cause of the collision was the fai~ure of the JAtelephone circuit.

COMMENT

All communication and control circuits should be tested prior to getting underway. Anytime a ship is breasted out to permit another to moveit should be considered a getting-underway operation--because under suchconditions it frequently becomes necessary to get underway. Further,telephone talkers should be trained to notify the Conning Officer immediately when they apparently are not getting orders through-it willoften provide a clue to an accident about to happen:

B-15


CASE

Collision by submarine with Mole at Key West, Florida.

PRINCIPLES

1. Conning Officer and Commanding Officer must at all times be acutelyaware of bells ordered and the response actually received to the orders.

2. Deviation from established maneuvering practices in confined watermust not be permitted.

3. Watch stations for all special evolutions must be manned by the verybest personnel available, and such manning should never be secondary toleaving men in port.

NARRATIVE

Submarine got underway from north side of Pier 4, Key West, Fla.,with Engineer Officer as Officer of the Deck and Commanding-Officer onthe bridge, wind and weather conditions good. The watch in the maneuvering room consisted of an unqualified officer observing, a chief electrician's mate, and two third class electricians, rated as the ship'snumber two and number five controllerman respectively. The maneuveringroom talker was a seaman apprentice standing his first watch on thisstation; the talker was also assigned the task of keeping the bell book.The watch in the maneuvering engine room consisted of a single EN1.This distribution of personnel resulted from the factthat only 55% ofthe ship's complement was on board, the remainder having been left inport for one reason or another.

The initial bell upon getting underway was all back two-thirds;other bells following were: starboard stop; port back full, starboardahead full; port back 2/3; port stop; all ahead full; all ahead flank.At this point the submarine struck the concrete mole (260 yards fromthe end of Pier 4) stern-first, and all stop was ordered.

Considerable damage resulted to the after tube nest, necessitatingnavy yard availability for repair.

It was SUbsequently learned that the port shaft had been on propulsion as directed by the Conning Officer, but the starboard shafthad never turned over owing to the fact that the starboard generatortrip switch had never been cut in. The bridge was first informed bymaneuvering that there was no power on the starboard shaft about 10

B-17


to 15 seconds before the ship struck the mole; bridge personnel hadnot observed the fact that the shaft was not turning at any time.


1. The maneuvering room watch was not of the efficiency and experiencerequired in maneuvering a ship in confined waters. The Officer stationedtherein vms not qualified, and the telephone talker was not only notqualified but was assigned duties (keeping the bell book) which shouldnot have been required of a well-qualified talker. The Commanding Officerwas negligent in failing to have a fully qual~fied watch in the maneuvering room.

2. The Commanding Officer was negligent in failing to have a full andefficient maneuvering watch stationed in the engine rooms, i.e., onlyone engineman was stationed therein.

3. The Commanding Officer was culpably negligent in failing to recognize that the starboard shaft was not turning over and in failing toissue proper countering orders in time to avoid the casualty.

COMMENT

The number of violations of proper sea-going practices contained inthis case is equaled only by the interesting variety of same.

Compliance with the standard practice of testing shafts before gettingunderway 'Would have prevented the accident. It is also possible thatthe failure would have been detected in time to take corrective actionhad the well-established practice been followed of always using, "allback 1/3" as the initial bell (until it is definitely determined thatthe shafts are properly responding) when backing away from a pier.

It is difficult to understand how so much maneuvering could have.gone on with neither the Conning Officer nor the Commanding Officerbecoming aware that the starboard shaft was not answering. Whetherthe maneuvering room watch was not aware of the failure of the shaftor whether they were aware of it and failed to take action or reportit to the bridge is not known from the records available. It is hardto believe that the failure was unknown to the maneuvering roompersonneL Had they known of it, correct action should have been toanswer the bells on the battery and report the casualty to the bridge~

B-18


Of course, the underlying cause of the entire debacle is the factthat critical maneuvering stations were manned by inexperienced personneland in inadequate numbers due to so many of the crew having been left inon that particular day, but it is interesting to note that the existingship's engineering orders were also so inadequate that the maneuveringstations were properly manned in accordance with those orders~ Why wereso many men left in that day? The exact reasons are probably diverse and'multitudinous, but it is probably safe to assume that the decisions toleave in the various persons was made without coordination between theExecutive Officer, the departments concerned, and the Watch, Quarterand Station Bill.

B-19


CASE

Collision between submerged submarine and DDE.

PRINCIPLE

Attention must never be concentrated on a single target to the exclusion of others.

NARRATIVE

A submarine commenced an approach against a DDE, acting as thetarget, which was escorted by two other DDEs. At problem time 31, thenearest escort was observed by periscope to be heading toward at a rangeof 1,400 yards, therefore the submarine went to a depth of 100 feet.Sonar tracked the closing escort until it had passed overhead and hadmerged with the submarine screws, at which time the submarine Commanding Officer believed the escort to be well past and came to periscopedepth for a shot at the primary target. Just as he was getting hisfinal bearing on the target, a jolt was felt, and the Commanding Officer, realizing that he had been run dawn, went to 100 feet. Hesubsequently made proper surfacing signals and surfaced, whereupon hediscovered his periscope severly damaged. No damage was suffered bythe DDE. It was subsequently determined that the escort had sent thecontact signal !lCCC ll upon commencing his run in after initially passingover the submarine, but he got no acknowledgement for the signalj itwas also learned that the JT sonar operator had reported screws closeaboard and closing just before the submarine got to periscope depthfor its final observation, but this report was not acknowledged byanyone in the conning tower.


1. If the contact signal from the escort had been acknowledged thisaccident could perhaps have been avoided.

2. If the sonar had continued to track the escort instead of droppinghim as soon as he appeared to have passed overhead, the run back incould have been detected.

3. If the report of closing screws received from JT had been acknowledged the accident could have been avoided.

B-21


COMMENT

This incident is clearly a case of the Conning Officer becoming soengrossed in the primary target that he neglected to keep up with theother targets. Not only did he fail to use his sonar to ascertain thatit was clear for coming to periscope depth, but he neglected the elementary precaution of a quick look around in low power before he allowedhimself to become absorbed in his final bearing on the target. Suchnegligence could mean the loss of the ship in wartime.

B-22


CASE

Collision with submarine tender during landing.

PRINCIPLE

All ship control circuits and indicators should be tested prior togetting underway.

NARRATIVE

The OOD got a submarine underway from a nest in order to permitinboard ship to underway. While attempting to come back alongsidethe tender, the OOD noted the rudder angle indicator showed the rudderto be left full. This rudder angle had not been ordered, and in theresulting confusion the OOD lost control of the situation and rammedthe tender.


The rudder angle indicator has been disconnected by a torpedomanin the after room without .notifying anyone of his action.

COMMENT

Proper preparations for getting underway, which includes the checkingof such indicating and control circuits, would have prevented thiscasualty.

Further, the OOD apparently was not watching his rudder angle indicator as he should, else the casualty would have been discoveredimmediately upon getting underway rather than in attempting to comeback alongside. The bridge rudd~r angle indicator is for the use of theOOD, and he should cultivate the habit of checking it after each orderto the helm.

B-23


CASE

Submerged collision with attacking destroyer.

PRINCIPLE

Safe operations at periscope depth with attacking surface ships require some means of quickly getting negative buoyancy.

NARRATIVE

intertypeNegativelinkage.

A radar picket submarine was conductingunrestricted counter-attacks by destroyers.commission due to a failure of a flood valve

exercises involvlingtank was out of

While approaching a DD at periscope depth, the submarine was detectedby the DD, who immediately turned toward to counter attack. The submarineattempted to get down to a safe depth by using speed, but her air-searchradar mast was struck by the destroyer's screw before she could getunder.

COMMENT

During such operations as this it is important to be able to get theboat to a safe depth quickly. With negative out of commission, itwould have been possible to use safety tank as a negative tank byleaving a bubble in it and venting it out through the main vent in caseit was necessary to go deep. This would, of course have left a bubble,but it would 4ave been of small importance compared to the need ofgetting down out of the way of the attacking ship. It would also havebeen possible to have blown negative flood open before starting theexercise, and then to have run with it to the mark at periscope depth-flooding could then have been accomplished quickly by simply openingnegative tank vent. This procedure would have had the disadvantage ofthe boat's trim changing as the depth was changed, but for the criticaldepth for periscope observations this would have been unimportant, andat deeper depths it could have been handled very easily by shiftingvariable water.

B-25


CASE

Collision with sea wall on getting underway.

PRINCIPLE

1. Orders to maneuvering room should be paralleled by phones duringmaneuvering watch.

2. #2 line should not be taken in until the first back bell is properlyanswered.

NARRATIVE

In getting his submarine underway from a pier in Key West the OODordered, "take in all lines, all back 1/3, one long blast". Helmsmanrang up all ahead 1/3 by mistake. The order was not paralleled by thebridge phones. With no lines over and the shistle interfering the shipcollided with the sea wall before corrective action could be taken tocheck headway.

COMMENT

If the first ordered bell had been all back 2/3 or all back fullas is standard practice on some boats, considerable damage would haveresulted. #2 line should always be held to check the headway if amistake such as this occurs. The long blast should not be soundeduntil the first back bell is answered properly and the lines have beentaken in to obviate any interference with the orders from the bridge.This has the additional advantage of having the boat actually movingwhen the blast is sounded, permitting neighboring ships to identifythe ship getting underway. If reliance is placed on the soundpoweredphones and talkers are properly trained, this type casualty can beprevented easily. Indeed, the only reason for manning the phones isto provide additional safety when maneuvering in confined waters.

B-27


CASE

Collision between submarine and telephone booth on pier.

PRINCIPLE

1. Adequate interior communications is essential to safe maneuvering ofa ship.

2. Acute awareness of a vessel's motion is necessary for satisfactoryshiphandling.

3. Established procedures must be followed at all times.

NARRATIVE

A submarine was to get underway from alongside a pier at New London,Connecticut using only the duty section. The section maneuvering watchwas stationed, but the bridge talker was sent on deck to handle lines.The OOD used a handset to give orders to maneuvering, paralleling the.annunciator circuitj his instructions to maneuvering were "man yourphones. I will use mine when I need to". When the lines were in, theOOD ordered, "all back 2/3". The helmsman erroneously rang up "allahead 2/3". The order was properly transmitted over the telephone circuit, but maneuvering answered the annunciators vice the telephone orderas they were under the impression that the OOD was not yet using thephone circuit for orders. Further, all stations in maneuvering weremanned with a total of two junior men with no supervisionj these inexperienced men saw nothing unusual in an initial ahead bell whenpractically against a sea wall.

The OOD belatedly noted that the ship was moving ahead rather thanastern and ordered all back full. Again the helmsman rang up allahead full. By this time the ship had hit the pier, sliced severalyards into it, and crushed two telephone booths. The next order, "allback emergency" went out over the 7MC and the lMC and was correctlyanswered.


1. The OOD erred in not placing a competent talker on the bridge andestablishing proper communications between maneuvering and the bridge.

2. Maneuvering erred in not demonstrating submarine sense and awareness in failure to doubt the annunciator error, especially during

B-29


unusual maneuvering and personnel situations and when conflicting motororders are received by phone.

3.andand

The OOD erred in failing to handlepersonnel situation and in failingpreliminary screw wash.

properly an unusual maneuveringto be aware of the ship's motion

4. The helmsman erred in ringing up the wrong bells, and in failing toshow submarine sense and awareness of what should be happening.

A primary reason for having a duty section on a submarine is to be J

able to get it underway with the personnel on board at any time theneed arises. Though it is not an every-day occurrence, it certainlyis not an unusual evolution and the duty section must be trained toaccomplish it safely. Further, the fact that it is a maneuver con-ducted with something less than the first-string maneuvering watchmakes it even more imperative than usual that standard organizationalpractices and the accepted practices of good seamanship be meticulouslyobserved. Had the bridge talker been properly stationed, and hisphones and other ship control circuits tested, this accident might havebeen avoided. Had the OOD followed the standard practice of initiallyordering a 1/3 bell in backing away from a pier it is entirely possiblethat he would have caught the wrong bell in time to prevent the collision. Holding of #2 line until the first backing bell has beenanswered is another aid to prevent this type accident, but is of littleUse when the initial bell is for 2/3 instead of 1/3.

B-30


CASE

Collision of submarine with channel marker (Eastern Triangle) inmain ship channel, Key West.

PRINCIPLES

Maneuvering in confined waters requires that the best use be madeof personnel and equipment available.

NARRATIVE

The submarine was proceeding out of Key West, with the CommandingOfficer and Division Commander on the bridge. While on the last legof the channel passing signals were exchanged with a YF ahead whichwas being overtaken. Course was 1650

, speed was increased from standard (12 knots) to full (13.5 knots). The OOD ordered course 1630 togive the YF a wider berth in passing. The Commanding Officer told theOOD that this course was too far to the left and the GOD directed 50right rudder. At this time the boat was about 600 yards from EasternTriangle and about 300 yards astern of the YF. Both the CommandingOfficer and the Division Commander observed and informed the OOD thathe was getting wrong rudder as indicated by the rudder angle indicator.GOD then ordered 100 right rudder and received 100 left rudder. Atthis point the Commanding Officer relieved the OOD, ordered right fullrUdder, traIl back emergehcy", and sounded the collision alarm. Thesubmarine struck one leg of East~rn Triangle "a glancing blow at aspeed of about 4 knots. The triangle scraped down the port side toabout abeam of the bridge, at which time it toppled over out of thechannel. No damage resulted to the submarine.

OPINIONS

1. Helmsman became confused and applied rudder opposite to that orderedby OOD. The close confines of the channel and the nearness of theEastern Triangle made time of the essence and the corrective actioncame too late.

2. The OOD could have diagnosed the situation earlier had he beenwatching the rudder angle indicator more closely.

B-31


COMMENT

This is a good example of the necessity of having completely re-and experienced personnel on maneuvering watch stations. A

speed of 13.5 knots and passing in this channel at the area in questionwere poor practice. Although such speeds may be customarily used,this casualty is prima facie evidence that there is no room left forhuman or mechanical failures with any margin of safety. Submarineofficers can do well to cultivate the habit of checking the rudderangle indicator immediately after each order given to the helm. Notonly does this practice provide timely warning to prevent accidentssuch as this one, but valuable experience will be gained in observinghow the ship responds to the rudder.

B-32


CASE

Submarine collision with the pier while making a landing.

PRINCIPLE

1. Safety in maneuvering can be assured by:

a. Proper use of sound powered phones to parallel essential communication circuits;

b. Training of lookouts to report screw wash after each order tothe screws;

c. Stationing an experienced officer in the maneuvering room tosupervise proper operation of the main control cubicle.

NARRATIVE

Submarine had twisted into position and was approaching the pier fora starboard-side-to landing. Shortly after giving !!all ahead 1/3" toget the sh,ip moving into the sliP., AC power was lost • Circuits ofin~erest which became de-energized were as follows:

Annunciators

Shaft Revolution Indicators

1 and 7 MC

Controller Wrong DirectionAlarm

The OOD ordered "all stop" without knowing AC power was lost. Thisbell was answered by maneuvering via the sound powered phones. Theofficer in maneuvering attempted to query the bridge using the 7 MCthen realized the loss of AC power. While maneuvering began to restore AC power, things began to happen rapidly on the bridge. "Portback 2/3" was the next bell; the reverser on the port side was stillin the "ahead!! position from the previous "all stopH bell, and withthe controller wrong direction alarm out and the annunciator still onthe "ahead 1/3" bell to further confuse him, the port controller mananswered with "ahead 2/3 11

• "All back 2/3 11 Was ordered, answered correctly on the starboard side. Then in rapid succession came Hallback full", back emergency", CRUNCH! On the order l1all back full!!the phone talker in maneuvering (an ICFN) corrected the port controllermans (an EMl(SS» who then answered the bell correctly. The officerin maneuvering failed completely to see the mistake. On the bridgethe lookouts failed to report the screw wash to the OCD, and both the

B-33


OOD and the Commanding Officer failed to note the screw wash from theport screw. The collision with the sea wall caused moderate damageto the bow of the ship.


The direct cause of the submarine striking the sea wall was due tothe port controllerman giving "ahead 2/3" on the port shaft when "back2/3" was ordered.

COMMENT

The primary reason for having an officer stationed in the maneuvering room is to insure that the orders to the screws from the ConningOfficer are answered correctly. He should not let himself get involvedin other details to the extent that this responsibility is neglected.Had the mistake of the port controllerman been caught immediately thecollision would not have resulted. A contributing factor to the mistakeby the controllerman was his failing to bring the reverser lever to the"off" position when "all stop" was ordered.

The advantage that submarine OODs have in being able to qUicklycheck the screw wash can be realized only be developing the habit ofchecking the screws after orders to maneuvering. This habit should bebacked up by training of the lookouts to report screw wash after eachorder to the screws. Had either the OOD or lookout checked the portscrew wash, the accident could have probably been prevented. Thisaccident conclusively proves that the assignment of lookouts to themaneuvering watch and their training is just as important as that of.other stations.

B-34


CASE

Collision between submerged submarine and destroyer escort.

PRINCIPLE

1. A submerged submarine has the responsibility of keeping clear ofsurface vessels.

2. The collision alarm should be sounded as a steady sound to preventits being confused with the surfacing alarm.

NARRATIVE

Two destroyer escorts, ALFA and BRAVO were conducting target servicesfor a submarine. AlthOUgh the directive for the exercises called for aninitial range of 5-6 miles, a run was commenced at 0810 with ALFA 6,650

'yards from the submarine. ALFA was 1,500 yards ahead of BRAVO, zigzagging on base course 2700, speed 20 knots. On receipt of the "Execute"the submarine dove, disappearing from ALFA's radar at range 6,150 yards,bearing 2680 •

The Commanding Officer of the submarine commenced his approach andbetween 0814 and 0822 made seven observations, three with #1 scope andfour with #2 scope. Only two of these were complete setups on thetarget, destroyer escort BRAVO, which was maintaining station 1,500yards, bearing 0900 from ALFA •. TOC obtained no solutions; plot gavethe conning tower a solution of 2500, but plot's speed solution of 20knots was not received by the Conning Officer. At 0816% submarinechanged course to 1500 and increased ;peed to standard. At 0819 SUbmarine slowed to 1/3, and at 0820% ordered full speed, left full rudderto· 0400• While swinging on this turn and raising #2 scope the submarine collided with destroyer escort ALFA, keel depth 62 feet; noflooding resulted. At the collision, the Commanding Officer shouted"take her down" through the open lower conning tower hatch, and thehatch was shut from the control room. While clearing the conning towerof the excess personnel, someone - whose identity could not be established later - gave an order to "shift steering below" and steeringand annunciator control was shifted to the control room. However, noone in control remembers lining up the annunciators prior to shiftingannunciator control below.

Immediately thereafter, a report was received from the DivingOfficer, "I can't get her down - she is coming up". The CommandingOfficer concluded that the submarine was being dragged to the surface

B-35


by the colliding destroyer escort. He ordered a red flare fired by thetorpedo room.

#1 scope was ordered raised and found to be damaged and useless.Depth was found to be 26 feet, so the lower hatch was shut and the Comminding Officer proceeded to the bridge where he found the submarineto be clear.

In the control room the crew had begun rigging for collision when theorder "take her down" was received. The Diving Officer ordered 1!floodnegative" and sounded the collision alarm, giving, he stated later, threeblasts. Planes were put on full <dive, but with control room annunciatorson "all stop" when steering was shifted to control, all stop was answeredby maneuvering while the ship broached.

At this time the Diving Officer reported not being able to get theboat down. On looking at the air manifold he discovered tanks beingblown, and deciding the boat would be .safer on the surface, orderedbow buoyancy blown. No report was made to the Commanding Officer.SUbsequently, it was disclosed that the air manifold operator thoughhe heard the DiVing Officer pronounce the word "blOW", and saw him makea characteristic signal with his hand, Whereupon the air manifoldoperator blew safety, negative, and main ballast tanks in that order.The DiVing Officer denied haVing given the order to "blow", or havingmade any hand signal.


1. The submarine Commanding Officer did not have sufficient informationto make a proper attack, and he should have discontinued the attackbefore bringing his ship into danger of collision.

2. Throughout the exercise the attack party and personnel in generalof the submarine exhibited a lack of initiative, agressiveness, andknowledge and an unsatisfactory state of training and readiness. Bytaking no steps to correct this, in effect the Commanding Officer condoned this poor performance.

3. Neither Commanding Officer nor crew of the submarine reacted properly to the collision. Proper orders were not carried out, unauthorized orders were given, and only good luck appears to have preventedthe situation from turning into disaster.

B-36

/


4. The Commanding Officer of ALFA, as OCE, erred in not complying withthe prescribed condition instructions for the exercise, but this did notcontribute directly to the collision.

COMMENT

In this situation, with the submarine submerged throughout the exercise, it was clearly the responsibility of the submarine to keep clearof the two surface vessels. By failing to take positive steps to avoidthe escort destroyers the Commanding Officer became solely responsiblefor the collision. Although sonar was used to track ALFA, and providedthe Commanding Officer with relative bearings, no use was made of thesonar information. Had accurate true bearings been used instead of therelative bearings which naturally gave a high bearing rate when the sUbmarine was swinging, the real picture of the position of ALFA would havebeen apparent.

By not providing the fire control party sufficient information, atimely solution could not be obtained. The handling of the periscopeswas inexpert, involving several shifts .between scopes, extra observationsin order to obtain range data on BRAVO, exposures at high submarine speed,and an improper picture as to the position of ALFA relative to BRAVO andthe submarine, resulting in ultimate loss of ALFA by the submarine.

When collision occurred, the Commanding Officer acted properly inordering Iltake her downtr , and had his order been carried out the submarine would have been taken out of danger of further collision withsurface ships within seconds.

Throughout the run, the submarine fire control party prOVided theCommanding Officer with almost no assistance, although they were properlystationed and did have a certain amount of information to work with.

Knowing that further collision was possible, the Commanding Officerused questionable judgement in opening the lower conning tower hatch toevacuate a few men from the conning tower. After the submarine hadbroached, the action in opening the conning tower hatch without ordering"surface ll or ordering the tanks blown was most dangerous.

Several men in the control room were confused. The decision at theair manifold to blow all tanks on receipt of the single trblowtr and thewaving of a finger signal was premature, and indicates that the manwas not thinki.ng clearly. This coupled with the fact that negative wasblow and not bow buoyancy indicates a high state of excitement.

B-37


Apparently a 3-blast signal was sounded on the collision alarm.Such a signal is dangerous as it could be mistaken for the surfacealarm. Three blasts should not be used on any alarm except on thediving alarm as a signal to surface.

In the midst of the confusion in control, firm and positive actionshould have been taken by the Diving Officer. Whether this confusionexisted despite his best efforts or because he failed to exerciseproper leadership during the emergency is not clear. Regardless, hisdecision to remain on the surface after finding that the tanks werebeing blown should have been communicated to the Commanding Officerimmediately because it was directly contrary to the latter's order.

When informed by the Diving Officer that he could not get the submarine down, the Commanding Officer was faced with the decision ofcontinuing to try to go deep or of surfacing and avoiding furthercollision on the surface. He made no decision and issued no ordersother than to raise #1 scope. If the ship was rising so fast thatpossibility of getting it down again was remote, the Commanding Officershould have issued orders to get it on the surface in the qUickestpossible time. If such was not the case, he should have taken stepsto see that the Diving Officer was doing everything possible to submerge.

B-38


CASE

Collision between a nest of four submarines and a floating restaurant.

PRINCIPLES

1. A trained alert topside watch is essential.

2. Attention to tidal conditions and moorings when berthed in unfamiliarharbors is essential.

3. The duty section must be organized to provide a section maneuveringwatch capable of getting the ship underway.

NARRATIVE

Four submarines were moored to a pier in Wilmington, N.C.; just aheadwas a floating restaurant. They were advised for a relatively strongcurrent, the tables placing it at about 3 knots. The inboard ship had 4breast lines doubled" and =/fr2. and #3 were doubled as springs. In additionthe outboard ship had a line through the bullnose to the pier. Themoorings were inspected by the four Commanding Officers, the owner of therestaurant, and a local Navy Liaison Officer, all of whom consideredthem adequate. The pier had been used p~eviously with no complications.At 0630, after two complete changes of tides, the second flood tide(the ebb was listed in the tables as the stronger) created havoc. Thecleat holding the #4 breast line of the inboard boat was pulled out,bolts and all. The topside watch who was inspecting the lines at thatvery moment iwmediately sounded the alarm and attempted to put overanother #4 breast line. This line was not enough. The nest, which wasrapidly swinging away from the pier, pulled the cleat over; then theline parted. =/fr2. and #3 lines were around 12" pilings and they brokethe pilings. At this point the nest was swinging around the #1 line ofthe inboard boat and into the restaurant. The line was cut free withan ax and as all four ships backed on eight screws, the nest was ableto clear the restaurant with only minor damage to it. The boats thendropped their anchors in midstream and rode to the current. Later theybroke the nest and returned to other moorings.


1. The lines were adequate.

2. The current was greater than that predicted in the Current Tablesfor that area.

B-39


3. Prompt and effective action was taken.

COMMENT

From the time of the cleat pulling loose until the submarines wereanchored in midstream was approximately fifteen minutes. The promptand effective action taken by everyone concerned, from the topsidewatch, alert at his post, to the conning of eight propeller shafts wasa credit to the Submarine Force. Much praise and gratitude was expressed by the citizens of Wilmington and the owner of the restaurantfor the skillful and alert action by the boats.

The key man here was the topside watch • Without his warning andthe immediate response thereto by the duty sections, a very seriouscasualty would have occurred. Below docks the training paid hugedividends. Stations were manned in a matter of seconds. Teamworkand coordination was outstanding. As one engineman was starting anengine, two more were lining up the fuel and water systems. Menaroused from sleep were topside immediately, handling lines withouttaking time to dress.

This is a good example for the need of continual training to preparefor the casualties that happen in spite of all precautions. It hasbeen and always will be the forte of the Submarine Force to maintain areadiness to cope with any difficulty and gain control before the situation becomes critical.

B-40


CASE

Submarine collision with a cruiser on the surface.

PRINCIPLE

At night submarines should take early action to avoid surface ships.

NARRATIVE

A squadron of submarines was at sea on course 1800, speed 14 knots information of two columns. Submarine "A" was formation guide and leadship of the left hand column of three ships; guide of the right handcolumn of four ships was 1,000 yards on the starboard beam of "A".The Squadron Commander was arc and embarked in "A". Cruiser was oncourse 2730 at 13 knots. About 2330 sight and radar contact was reportedto the Commanding Officer of submarine "A" of a ship bearing 1370, .19,700 yards. This was the cruiser. About 2338 the masthead, range,and side lights of the cruiser were in sight bearing 1370, 14,500 yardsand, so reported to the Commanding Officer. At about 2345 the Commanding Officer was notified that the range was 6,500 yards and that thebearings had remained constant. The Commanding Officer came to thebridge about 2348 and. took the conn, assigning the OOD to take bearingson the cruiser. Neither the Commanding Officer or OOD reported thecontact to the Squadron Commander.

On the cruiser the group of submarines had been reported to .theCommanding Officer at 2340 as seven lights from a fishing fleet bearing3160, 12,000 yards. The only other report to the Commanding Officerwas made at 2358 when "vessel at 860 yards" was reported. The cruisermaintained course and speed until about one minute before collisionwhen the rudder was put left full and the engines stopped and backed full.Two blasts were sounded on putting the rudder over.

The submarine maintained course and speed as the priVileged vesselin the crossing situation until the range closed to about 1,050 yardsand the bearing had been determined to have decreased to 126°. Atthis time the Commanding Officer ordered "all ahead fUll", and increase-of about l~ knots. On sighting the bow of the cruiser close aboard afew seconds before the collision, the Commanding Officer ordered "allstop", "all back fUll", "all back emergency II in rapid succession.About 2400 the two ships collided at an angle of about 300, the submarine's bow striking the cruiser about 75 feet aft of the stem, re~

lative speed between the ships about 20 knots. The bow of the submarine forward of frame 11 was bent 900 to starboard, but there was

B-41


no damage to the pressure hull. The cruiser suffered four floodedcompartments and five partially flooded. One man was killed on thecruiser.


1. The cruiser was burdened, the submarine the privileged vessel.

2. Neither vessel was aware of the naval character of the other norwas any attempt to indicate their naval character, nor did they communicate with each other during their approach. A mutual exchange ofsignals might have avoided the collision.

3. The collision was due to the fault, negligence and inefficiency ofthe ODD and the Commanding Officer of the cruiser.

4. The Commanding Officer of submarine "A" erred in not informing theOTC embarked in his ship of the situation.

COMMENT

Because of their deceiving appearance at night, submarines shouldalways exchange calls with ships met at night; failure to do so invariably results in the submarine being considered a small fishing vessel.The sinking of the 8-51 in 1925 resulted from a collision with theCity of Rome in an almost identical case. It was fortunate indeed thatthis case did not result in a similar tragedy.

Not only can exchange of identification be effected with the signallight, but the single letter international code signals can be used towarn the burdened ship to keep clear if there is doubt as to her intentions.

B-42


CASE

Submarine collision with moored destroyer on getting underway.

PRINCIPLE

Determination of local current conditions is essential for safe·navigation in unfamiliar harbors.

NARRATIVE

The submarine was moored starboard side to the North Quay at Destroyer Berth 2, Ribault Bay, Mayport Carrier Base, Florida. Approximately 100 feet astern were two DDs moored port side to the Quay Wall.Weather was good, wind 7 knots from NW. Current was ebbing in theSt. John River, time approximately l~ hours after maximum ebb (1.8knots) • See accompanying diagram.

Submarine twisted her stern out, holding #1 line. The CommandingOfficer, wh,o had been standing on the main deck forward of the bridge,came to the bridge and advised the OOD to take in #1 line and to use aport ahead 2/3 and starboard back full twist. As sternway was obtained,the Commanding Officer became aware of current acting on the port quarter,setting the ship down toward the stern of the outboard DD. He relievedthe OOD of the conn, requested tug assistance, and tried to twist andback clear, but the submarine was set down against the stern of the destroyer. By reducing the way on the submarine before contact was made,the impact and resulting damage was slight. #5A fuel ballast tank wasruptured and the propeller guard of the DD was bent.

FINDINGS

1. The submarine Commanding Officer had considered current and had consulted Tide Tables 1956 and Current Tables 1956~ U.S. Coast and GeodeticSurvey.

2. Normal sources of naVigational information do not cover the situationexistent in Ribault Bay.

OPINIONS

1. The assumption that a tug was unnecessary was a reasonable one basedon the belief that there was no current.

2. There was moderate current toward seaward. (toward the DDs' sterns)that was negligible alongside the quay wall at the submarine's berth dueto the overhang of the carrier moored at the carrier berth ahead of thesubmarine.

3. The submarine experienced difficulty in twisting the stern out andthat the Commanding Officer attributed the difficulty entirely to thefact that" the starboard bow was pivoting on a piling.

B-43


4. The stern could have been swung further to port) i.e.) to clear theDDs) either by longer use of a high power twist while holding #1 line)or by using a tug.

5. After taking in #1 line and becoming aware of the effect of the current) a high backing bell might have carried the submarine clear; such amaneuver would have resulted in considerable damage had it failed.

•

6. The information concerning the current inseminated to the Submarine Force •

basin should be dis-

COMMENT

Local authorities should always be consulted about the particular tideand current conditions, even though the landing upon arrival may havebeen uneventful.

---

1500I

SCALE IN FT.

500 1000

------

//

-J

-------CARRIER BASIN

----

/////L '-- ...----

:.--'..............~

..............

B-44


CASE

Collision between submarine and overtaken merchant ship in narrowchannel.

PRINCIPLE

1. Excessive speed should not be used in narrow channels.

2. Helmsmen should be alerted to situations requiring particular attention of the helm.

3. Commanding Officers should take timely and positive actions toinsure safe and smart handling of their ships.

NARRATIVE

A submarine proceeding down a narrow ship channel attempted to passa merchant ship. The submarine was llsucked inll and collided starboardside forward of the conning tower with port quarter of the merchantship. Channel llspeed limit" was 10 knots, merchant ship speed was 12knots. The submarine had ordered speed of 16 knots to pass. Thebridge gyro was inoperative and the helmsman had not been altered tothe passing situation. A pilot with no previous experience in submarines was at the conn and closed the merchant ship under her sternusing small compass heading changes of course to pass close aboard.

OPINION

1. Use of 16 knots speed to pass a ship doing between 10 and 12 knotsin this channel is hard to justify.

2. Failure to alert the helmsman as to the need for smart handling ofthe helm in this passing situation shows a lack of prudent; seamanship.

3. Proceeding in a channel with the bridge gyro inoperative requiresthe Co~nding Officer to be particularly alert.

4. The Commanding Officer exercised poor judgement in permitting thepilot to con the ship into a position of imminent danger close aboardthe merchant ship before taking personal and positive action towardinsuring safe and smart handling.

COMMENT

None

B-45


CASE

Collision between submerged submarine and destroyer.

PRINCIPLES

1. When collision i,s imminent, the submerged submarine must avoidtaking down angles of such degree as will jeopardize the stern.

2. When collision and flooding occur submerged, the natural tendencyto blow to the surface must be repressed if there are surface shipsin the area.

3. Under otherwise exc ellent sonar conditions the I'knuckle" createdby a vessel turning at moderate or high speed can almost completely blankpassive sonars over a wide sector.

4. Personnel below decks must be prepared to control the sUbmarine,sUbmerged and surfaced, in the event that the conning tower and/orbridge is isolated through communication casualty or damage.

NARRATIVE

A Guppy submarine was operating in the Virginia capes area in athree-Submarine Delta formation, which was opposing a group Of sevendestroyers. Depth of water was in excess of 100 fathoms; the time wasmid-afternoon with good visibilitYj water was isothermal to 200 feet orgreaterj sonar conditions were classified good to excellentj and the.sea state was rated at two plus.

The submarine was conducting an advanced exercise in which exercisetorpedoes Were fired at several destroyer targets, and the submarinewas, in turn, intermittently counter-attacked by various destroyers.These attacks and counter-attacks had occupied more than an hour andthe submarine, along with its companions, were· being forced below periscope depth more and more frequently. Destroyers were simulatingAhead-ThroWn Weapon and Depth Charge attacks and were noticeably intensifying their efforts. Because of the desire to maintain such formationas would provide mutual torpedo fire protection, the submarine waslimited in evasion to changes in depth and minor course and speed changes.

The submarine I s sonar installation consisted of a BQB3j a QBj and aJK!QC equipment. The latter two equipments were interim installationsand were obsolescent at the time (1955). The most experienced sonaroperator manned the BQR3 eqUipment in the conning tower. The two other

B-47


equipments were manned by less experienced, but competent operators inthe sonar room and forward torpedo room. The submarine was at battlestations throughout the exercise.

A destroyer had just completed an excellent run, forcing thesubmarine to 100 feet. At a speed of 18 knots, the destroyer hadpassed directly overhead from astern, then moved ahead and to the right,fading from contact near the position of one of the other submarinesof the Delta (3000 yards distant). Loss of contact was estimated at3500 yards (later confirmed by the destroyers track chart). A seconddestroyer, which was being tracked by the fire control party preparatory to taking it under fire, was positioned on the submarinets portquarter at a range of about 2300 yards and on a roughly parallel courseat 13-15 knots. QB sonar had been directed to search all around andreport all contacts, preparatory to resuming periscope depth and theattack.

After careful search, both sonars reported no contacts otherthan the target on the port quarter. The Commanding Officer of thesubmarine ordered IIM1 ahead standard; watertight doors on the latch;60 feet, smart1y.1I The submarine responded promptly, and at thepoint of passing 75 feet, number two periscope was raised and trainedon the bearing of the target. As the periscope broke water, the Commanding Officer observed the target checking perfectly, and began tolook all around. At that instant, .BQR3 reported "screws closing,close aboard; bearing (port bow). 11 The periscope was trained on thatbearing and the Commanding Officer saw only 1Igray painttl • The periscope was instantly lowered and the Commanding Officer ordered "takehe down, fast; use negative. f1 Hearing negative flood, and feeling agood angle coming, on the boat, the Commanding Officer advised theDiving Officer not to take more than 120 down as that would endangerthe stern. .

About 4 seconds after the sighting (periscope had just seatea),collision occurred. Keel depth was about 63 feet and was almostinstantaneously increased to 80 feet, and the submarine heeled about50 to starboard. On impact, fairly heavy streams of water beganentering the conning tower around the perisco~e (about the strengthand volume of six or eight heavy garden hoses). Several of the ;firecontrol party recollect the impression of arcing, though this was notpositively confirmed. -The Commanding Officer immediately orderedII Sound the collision alarm; shut the lower conning tower hatch;shoot red flares, aft.1! Noting the sudden increase in depth, hereasoned that rupture may also have occurred below the conning tower,C1ad ordered tlB10w main ballastl! (via 7MC system). (Note: This orderwas not acknowledged and was apparently not received in control; theDiving Officer had also noted the descent and had given the sameorder. As the descent checked, he countermanded the order; and theCommanding Officer did not repeat his order, since it was apparentthat it had not been heard and was not necessary.)

B-48


The Diving Officer reported that he could hold the boat at 100feet and was ordered by the Commanding Officer to do so. The Commanding Officer then announced by underwater telephone to all stationsthat the submarine had been struck and requested all surface vesselsto clear the area of red flares for an emergency surfacing. He alsorequested the Submarine Group Commander to advise when the area wasclear and to conn him if necessary on the surface, in the event thatthe bridge could not be manned.

In approximately three minutes the area was reported clear.The submarine surfaced with an extra blow and the bridge was mannedwithout the difficulty which had been anticipated. Before communications with control could be established, an emergency partyhad been sent on deck through the forward torpedo room hatch andwas actually on deck before being ordered below. After surfacing,it was necessary to rig an emergency antennae and to replace a damaged running light, following which the submarine proceeded to portwithout further incident~

Damage to the submarine was extensive in the sail area and to thefoundation and supports for all retractable masts as well as the fixedinstallations on the sail. There was no damage below the sail and therewere no injuries to personnel.

OPINION AND FmDINGS

A Board of Investigation was convened in this case and was ofthe opinion that the collision was not the result of negligence on thepart of any person involved. It felt that the submarine was aggressively handled and operated within the terms of the advanced exercisebeing conducted. It was of the opinion that the collision was the result of an error of decision on the part of the Commanding Officer ofthe submarine, understandable and formed on the basis of misleadingnegative sonar information. The Board noted, further, that the collision might well have been prevented by the installation. of a scanningtype of sonar. Failure of the submarine to detect earlier the destroyer was attributed to the presence of a "knucklell in the watersurrounding the boat. Recommendation of the Board was that no disciplinary action be taken against any person involved.

COMMENT

Review and retrospect raises several points of interest in thiscase. The decision of the Commanding Officer to resume periscopedepth was an aggressive action in keeping with the spirit of the exercise. It was formed on the basis of generally good to excellentsonar conditions and performance of the submarinets equipment andoperators, and the fact that another destroyer was tracking perfectly at a range greater than 2000 yards. Sonar operators were experienced and reliable; each had engaged in numerous exercises ofthis type. Finally, it was reasoned that the counter-attacking destroyer

B-49


might well have taken up attacks on the other submarine which was positioned in the area where contact had faded.

The election to resume a periscope depth of 60 feet for #2 periscope observations was based on the sea state and the need for a goodclear look. The Commanding Officer estimated that 61 feet was theminimum at which such a look could be effected. The additional footwas intended for the Diving Officer to prevent I "undershootingll

• Itis noted that a destroyer draws about 19-1/2 feet at the propellertips and the sound dome. The submarine sail is 49 feet and the #2periscope 66 feet above the keel. Thus in order to avoid any possibility of collision (with periscope lowered) the submarine must remain below (:J3-1/2 feet. Use of a deeper depth for the first looklhoweverl would have at least lessened the damage.

Modern practice is to set Condition IlBAKERII preparatory to comingto periscope depth. This condition includes shutting water-tight doorslbulkhead flappers I and the lower conning tower hatch. This case is agood example of' how shutting the lower hatch places reliance for communications to the Diving Officer on a reliable system. Sound poweredphones are less subject to failure than the MC system and shouldalways be used. To be usefull howeverl in emergencies such as this lthey must be used habitua11YI just as they are in passing orders tomaneuvering during the maneuvering watch.

Of interest in this case was the completeness of the. logs andrecords during emergency. The QM notebook and UQC log were maintainedunder rather adverse conditions after collision, and proved invaluableto the reconstruction of the case.

B-50


CASE

Coll.ision between submarine and destroyer.

PRINCIPLES

1. A submarine must remain in her assigned area when conducting submerged operatipns.

2. The necessity for an effective visual search when at periscopedepth cannot be overemphasized.

NARRATIVE

While operating at periscope depth preparat9ry to a landing exercise, a submarine exceeded the boundaries of her assigned area.After evading a passing DE she sighted a previously unnoticed destroyerclose aboard with a very small angle on the bow. She went deep butwas struck by the DD while passing 66 feet. Without exception, allelectronic masts and both periscopes were bent or broken. The mastand periscope shears were bent and buckled. Total da.m.a.ge requiredthree months repair at a cost of over $140,000. The submarine continued to 90 feet after the collision and surfaced about 45 minuteslater. There were no personnel casualties. On the destroyer, theperiscopes were sighted about 25 feet to starboard abreast thestem. At this time the ship was swinging right and the order,lILeft Fu.U- Rudder" was given. Collision on the starboard quarterwas felt as the ship commenced swinging left.

OPINIONS .AND FINDINGS

1. The Commanding Officer erred in not conducting an effectiveperiscope search.

2. The navigation of the submarine was poor in that the ship wasallowed to proceed out of her assigned area.

3. The Commanding Officer of the destroyer erred in swinging hisstern into the submarine after sighting the periscopes.

COMMENT

This casualty could have been averted by proper periscopetechnique. The importance of keeping a clear picture of the surfacesituation under all circumstances cannot be overemphasized. Hadthe Commanding Officer taken a thorough look around at any time inthe previous ten minutl:ts he would have discovered the presence ofthe des~royer and probably been able to avoid. This case graphicallyillustrates the pitfalls encumbent with over-concentration on anyparticular surface contact.

B-51


Furthermore, had the submarine properly remained in her assignedarea, the avoiding action would never have been necessary. Leavingthe assigned area when submerged is an error of gross proportions,the safety of the submarine being of paramount importance in anypeacetime maneuver.

B-52


CASE

Collision of submarine with YTF.

PRINCIPLE

Operations at periscope depth close aboard a surface ship arehazardous regardless of the seeming simplicity of the exercise.

NARRATIVE

The exercise being conducted was designed to test the effectiveness of submarine sonars at very close target ranges. It involvedthe submarine submerging at 1500 yards and passing the target (an.NJ!F, lying to) very close aboard while at periscope depth. Duringthus run the submarine was approaching at a depth of 55 feet withzero bubble at about 5-1/2 knots until within 200 yards. At thispoint the Commanding Officer ordered negative flooded and a depth of90 feet. The submarine struck the ATF while passing 66 feet, dentingher skin and buckling one frame. Both periscopes and the periscopeshears were bent, along with severe damage to the electronic mastsand antennae and related equipment. The total cost of submarinerepairs was over $100,000. No personnel casualties were sustained.

COMMENT

Besides this case there have been numerous near-collision casesduring similar operations with a surface ship either lying to oranchored. All bear up the point that every precaution must be takento prevent a collision such as happened in this case. Apparentlythe diving team was not aware or readY for the possibility of goingdeep if in the time available before collision only 11 feet ofdepth could be gainedl

In another case a snorkeling submarine barely averted a collision with a sound survey boat when the latter parted its anchorchain and began drifting.

B-53


CASE

Collision of submarine with buoy 2CB off Virginia Beach, Va.

PRINCIPLES

1. ~finitive action must be taken w):len approaching an object whosetrue bearing is constant unless the intention is to ram.

2. Tide and current data must be used in planning tracks.

3. Both Navigator and OOD must be aware of the expected currentand of the current being experienced.

NARRATIVE

A submarine stood out of Chesapeake Bay on course 121oT, speednine knots; visibility at the time was about ten miles, wind velocitywas about five knots from the east, and sea state was one. The intended track had. been laid down 6n an apprOpriate chart and had beeninspected by the Connnanding Officer. At about 2211, the flashing lightof buoy 2CB was sighted bearing 123OT; this buoy was in sight both fromthe bridge and by periscope, but was not reported to the ConnnandingOfficer or the Navigator. A fiX at about this time indicated the shipwas nearly a quarter of a mile southwest of the intended track, andthe officer of the deck, observing the bearing of the buoy to be drawingto the left, requested a better course from the quartermaster in orderto avoid the buoy. At about 2226 the Navigator got a fix which showedthe ship nearly a half mile southwest of the intended track, and at2228 the course was changed by direction of the NaVigator to 1160T inorder to leave the buoy to starboard. At 2239, with buoy 2CB deadahead at a range of 2500 yards, the OOD on his own initiative changedcourse to 1l00T; the NaVigator was informed and concurred in this change.The Officer of the ~ck pointed out to the NaVigator that the ship wasbeing set badly. The Na.vigator concurred, and admonished the OOD"D:m't hit the bUOY," whereupon the NaVigator went below. At 2246 theOOD, observing that the buoy was still draWing to the left, changedcourse to 105°T; about one minute later, noting that the five degreecourse change was not going to cauSe the ship to miss the buoy in theeXisting set, he ordered left full rudder and all back emergency. At2248 the starboard sid.e of the ship struck the buoy near frame 40,; thebuoy cable scraPed along the side until it became entangled in the screwand rudder, causing damage amounting to more, than $21,000 .00.

In the ensuring investigation, the following additional facts werebrought to light: There was plenty of water on all sides of the buoy,the nearest shoal water being six miles away. The DRAI had not been setnor was it operating, and set and drift had not been computed; further,no reference had been made to on-board naVigational publications to determine the predicted set and drift. For some thirty-seven minutes thebuoy was under continual observat~on and was known to be maintainingvery close to a constant true bearing during this period.

B-55



1. That the collision of this ship with buoy 2CB was directlycaused by:

a. Failure of the OOD to take prompt, positive and sufficientaction as the ship approached the buoy, and

b. Failure of the Navigator and Executive Officer, in the absence of such action by the OOD and with the authority invested in himas Executive Officer, to take such action himself.

2. That collision of the ship with the buoy was indirectly causedby the following items:

a. Failure to determine expected set and drift from appropriatepublications and failure to compensate for them.

b. Failure of the Navigator to maintain a proper dead-reckoning track.

c. Failure of the Navigator to inform the Commanding Officerof the set being experienced and of the fact that the ship had deviatedfrom the track.

d. Failure of the OOD to recognize a constant bearing situation.

e • Failure of the OOD to take action far enough in advance.

COMMENT

It is interesting to note how precisely the OOD adjusted his coursefor a period of 37 minutes in exactly the correct direction and amount tooffset the effect of current and thus maintain a collision course on thisstationary buoy. There was at least six miles of navigable water in alldirections around the buoy, therefore there was no justification for suchsmall, and obViously inadequate, measures to avoid the buoy.

Further, with plenty of water to p~ss the buoy on either side itwould have been more prudent to leave the buoy to port, thus the set wouldhave moved the ship away from the danger rather than toward it.

This case is strikingly similar to two other cases described in thisbook (See pages B-ll and B-13). The comments contained in those casesregarding the determination and use (by both Navigator <and OOD) of current data, the need for maintaining an accurate DR track, <and the necessity of complete exchange of information between the Commanding Officer,the Navigator, and the OOD at all times are equally applicable in thiscase.

B-56


PART C - FLOODING CASUALTIES

Flooding is one of the major emergencies that may occur on a sub

marine. The entry of water into the boat varies all the way from minor

pump packing leakage through partial flooding of a compartment to com

loss of the submarine.

Over the years the "reserve buoyancy" of submarines has decreased

to the point that in some the flooding of a single compartment cannot be

compensated for by the blowing of every ballast/special ballast tank on

the ship. Watertight integrity is essential for survival as well as for

safety.

Untold time, effort, money, and designing has gone into establish

ing the material construction of a submarine for active and safe sub

merged performance from test depth to the surface.

The casualties listed in the following paragraphs are not com

pletely comprehensive nor do they illustrate every conceivable means of

flooding the boat. In stUdying the general theme of the lessons, note

that material failure was only partly responsible for most floodings.

Basically the casualties occUrred because of a relaxation in the single

standard of performance that is acceptable of submarine watch standers;

i.e., trained proficiency and moral competence.

C-l


CASE

Flooding resulting from "pooping" sea.

PRINCIPLE

Precautions must be taken in heavy weather to minimize the probability of pooping and its effect.

NARRATIVE

A submarine had been cruising on two engines for two days invery rough seas. Officers and crew were weary from seasickeness and thecontinuous effort required to remain on their feet at their watch stations. During a false lull in the seas, the OOD opened the main induction and increased speed to standard on four engines. Suddenly ahuge comber passed over the boat from the stern and immersed the bridgein a tremendous volume of water. Water poured through the main inductionand the conning tower hatch until the forward engine room was nooded tothe floor plates, the after engine room to a depth of three feet, thepump room a similar amount, and the after battery deck to a depth of aboutone foot. Shut bulkhead flappers in the maneuvering room preventedentry of water into that compartment. All five generators were floodedand grounded, the trim pump armature was burned out, and the drain pumpstarting panel was rendered inoperative. Water was prevented from entering the after battery well by building a dam around the battery wellhatch with dungarees and by bailing water into the storeroom. Water wasdrained from the ventilation lines by removing inspection covers fromthe line in the engine rooms, as the ship was down by the stern. Afterconsiderable jury-rigging and washing down with fresh water, the waterwas finally removed from the ship and its machinery, and propulsionwas resumed.

OPINION AND FINDINGS

Only rapid action prevented a major casualty from developing.

COMMENT

This casualty occurred on a neet boat; most boats nowadays cansnorkel, thus permitting them to operate the diesels on the surface withthe main induction shut. When danger of taking water down the conningtower hatch andlor the main induction exists, the following precautionsare applicable:

C-3


1. The helmsman should be alerted to shut the brid.ge hatch atthe first indication of water entry.

2. The control room watch should be alerted to the possiblenecessity of quickly shutting the main induction.

3. The inboard ventilation hull induction valve should be shutto prevent entry of water into the ventilation lines and to preventdamage to the ventilation blower impellers.

4. And, of course, courses and speed should be chosen tominimize sea conditions whenever possible.

c-4


CASE

Partial flooding due to pooping seas (II).

PRINCIPLE

Operations in rough seas require especial alertness on the partof the OOD.

NARRATIVE

The submarine was cruising surfaced in heavy seas when she waspooped by a large wave. Approximately six tons of water was flooded inthrough the main induction and a lesser amount through the conning towerhatch. The ship was rendered inoperative, on a war patrol, for twentyfour hours while repairs were effected.

COMMENT

Whenever possible, courses should be chosen to ~n~~ze the possibility of pooping. Under cond.itions of heavy weather, the OOD mustbe alert for such a casualty, however, and should order the main induction shut immediately when pooping appears imminent. Similarly,under such conditions he should run with the upper conning tower hatchshut; when necessary to open it for some reason, it should be tendedby a man instantly ready to shut it upon entry of water. With mostmodern submarines it is possible to use the snorkel for engine air induction, thus reducing the probability of being pooped. Bulkheadflappers should be kept shut in such dangerous weather unless requiredopen due to battery charging, etc. (See Case 1).

C-5


CASE

Partial flooding while surfacing.

PRINCIPLE

Heavy weather requires extraordinary precautions during surfacingoperation.

NARRATIVE

The ship surfaced at night in very heavy seas. Under conditionsof darkness and visibility which made it impossible for the CommandingOfficer to determine the direction of the seas, the submarine surfaced.Seas were heavy, but the submarine conductea. normal surfacing procedure,opening both the conning tower hatch and main induction in the routinemanner, with the blower running. First indication of trouble was solidstreams of water entering all comparments through the ventilation supplylouvers; the supply blower then grounded out all lighting circuits. Shipwas sealed up and major damage was luckily avoided.

COMMENT

When surfacing under such conditions it is prudent to let themain induction remain shut until the Conning Officer has definitely determined that he has blown up sufficiently and that his heading isoptimum to avoid being pooped. Generally, he can blow up enough beforethe vacuum in the boat gets excessive, but if it is necessary to get intake air to complete the blow then he will do well to use the conningtower hatch for the purpose , with a man stationed at the lanyard to immediately shut it in case of water entry.

It is al~o good practice never to open the inboard induction forship's ventilation until completely blown up, thus reducing the degreeof water entering comparments through t he ventilation system and/orgrounding the supply blower or damaging the blower impeller.

C-7


CASE

Partial flooding of conning tower due to jannning of bridge hatch.

PRINCIPLE

Loosely hanging objects adrift should never be allowed on bridgepersonnel, on the bridge, or in the conning tower.

NARRATIVE

A key ring containing keys, a knife, and a smaJ.l crescent wrenchbecame detached from the belt of a lookout while clearing the bridgeduring a routine dive. These hung in the upper conning tower hatchmechanism. When the quartermaster attempted to dog the hatch it became jammed and could neither be opened nor shut. By quick action thedive was stopped before much water had entered the conning tower.

COMMENT

Bridge personnel should never have equi~mentor clothing hangingfrom their person in such a manner that it could possibly foul the hatch.This includes, moccasins which-could easily come off, rags in pockets,keys on belts, etc. Further, no object should ever be adrift on thebridge or in the coming tower which might move with water flow or largeboat angle to foul either the bridge hatch or the lower conning towerhatch.

C-9


CASE

Flooding through after battery hatch.

PRINCIPLE

Precise attention to detail is required in checking rig for dive,with special attention necessary for such openings as hatches.

NARRATIVE

The submaxine submerged with a green board and pressure in thesubmarine; at 25 feet the after battery reported flooding through theafter battery hatch.

Alert action by the crew minimized the' effects of the flooding bystuffing mattresses in the doorway leading to the berthing space, byopening the refrigerator cold room hatch to drain away the water to prevent it getting in the battery well, and by efforts to stop the entryof the water by securing the hatch.

Subsequent investigation disclosed the cause of the flooding tobe the hatch lanyard hung between the hatch gasket and seat.

OPINION

L The hatch had been shut from topside, therefore its fouling by thelanyard could not be seen.

2. A seaman secured the hatch with depth charge dogs on rig for divewithout noticing the fouled lanyard.

3. The officer checking rig for dive entered the trunk with a flashlight and examined the hatch wheel, but failed to note the fouledlanyard.

4. The hatch was shut tightly enough to give a green light, yet nearlyfifty gallons of water flooded through the seating.

COMME:NTS

The best submarine practice is to secure hatches from topsideafter inspecting hatch seal and gasket, after which checking from belowdecks is done.

C-ll


All personnel should be trained to include in their check ofhatches, when rigging for dive, a careful inspection to see that gasketsare not cut, no foreigh matter is on the seats, lanyards are hangingfree and clear, and that the hatch dogs are evenly seated.

0-12


CASE

Flooding of after torpedo room, alongside a pier.

PRINCIPLE

1. Watertight hatches and doors should always be free for closing.

2. Main ballast tanks should never be flooded until positive assuranceis available that the boat is either ready to submerge safely or hassufficient positive buoyancy and will not submerge.

NARRATIVE

The submarine was alongside the pier with the underway sectionon watch, less the topside lookouts acting as Deck Watch, and OOD on thepier near the brow. In order to perform work on the bow superstructureit was desired to put an up angle on the ship and thus bring the bow outof the water. The ship was rigged for surface, except that safety andnegative were flooded, which fact was unknown to the Commpnding Officer,OOD, and others who should have known. The after torpedo room hatch wasopen with the bitter end of #4 line leading below decks where it was tobe stowed on departure during extended operations. The line had beendoubled up improperly with the result that one section had parted.Ballast changes were initiated by two officers neither of whom informedthe Commanding Officer or OOD of what was being done ,nor had they takenproper regard for the safety of the ship prior to adding this ballast.

Initial trimming was from forward to after trim. When this failedto bring the bow sufficiently out of the water, #6c and.#6D were ventedby hand. When notified by the officer at the scene of the work (via 7MC) that the boat would have to be·· flooded down further aft, an officerbelow decks (who did not realize safety and negative were flooded) proceeded to the engine room and ordered #6Aand #6B emergency vents opened.He then wen.t to the control room and informed the bridge, via ?MC, that6A and 6B were to be flooded, and on receiving an acknowledgement, ordered 6A and 6B vented hydraulically. Actually, all 4 sections of#6MBT were then vented. The extra ballast taken on by this action plusthe fact that safety, negative, and after trim were already full wassufficient to cause the stern to sink below the water. The after torpedo roam and the store roam below it were completely inundated throughthe open and fouled hatch.


The primary cause of this flooding was the lack of clear cutresponsibility and understanding, caused partially by the haste tocomplete repairs and depart on assigned mission, among those personscarrying out the various evolutions of trim and repair. Ballastchanges were initiated by two officers who neglected to inform the

C-13


Commanding Officer, OOD, or others of what they were doing, and furtherwho did not take prudent measures with regard to the safety of the shipprior to taking on additional water ballast.

#4 line was not doubled properly and had been led through theafter torpedo room hatch, fouling same. The ship was not completelyrigged for the evolution being carried out and the above named exceptions were not known by officers who should have had this knowledge.

COMMENT

One of the greatest dangers of evolutions such as this is that anofficer may assume and carry out personally, all the necessary actions.This frequently results in no central authority being cognizant of thecomplete picture and in the remaining officers and crew taking littleactive interest. Such evolutions should be planned and carried outmethodically to provide maximum safety, utilizing the experience andtalents of the entire watch section. The incident related is one ofthe best examples of complete disorganization compounded by what appears to have been complete disregard for the principles of basic seamanship with regard to mooring lines.

Many so-called small errors in judgment or procedures were enoughto add up to a major casualty:

L Lack of any watch on the bridge to insure proper communica-tions.

2. Failure to check the topside hatches shut and dogged priorto any flooding, or to determine the condition of watertight integrityexisting within the ship in case the ship should submerge unexpectedly.

3. Failure to check TP-TR circuit for indications of hull openings in after end of ship.

4. Failure to note gages which would have shown safety and neg ...ative tanks to be flooded.

5. Failure to insure maximum posit i ve buoyancy before commencing flooding by blowing forward tanks, safety, and negative tanks.

6. Failure to insure slow and controlled flood~g.

7 • Failure of the OOD to be on the bridge and in charge of theflooding. Whether or not the tanks were rigged to be blown, and aman standing by the manifold, is not known.

8. Fortunately there were no personnel casualties. One man ina forward upper bunk remained in his bunk in the air pocket until thestern was surfaced.

c-14


CASE

Flooding in forward torpedo room through sound head packing,alongside.

PRINCIPLE

Work which may result in flooding requires that compartment pressure be equal to sea pressure.

NARRATIVE

A submarine in upkeep was changing a bottomside sonar head bywithdrawing it inboard with the sea chest door shut. Upon removing thelast securing bolt, water started flooding, indicating that the seachest door was not holding. The compartment was sealed and air pressure introduced. Flooding was not stopped, however, until considerabledamage had occurred to electrical motors and equipment.

COMMENT

Prudence dictates that dependence not be placed on a single valve(sea chest door) in any work of this nature. The compartment shouldhave been sealed and a pressure placed in it before the final stage ofthe work was started. The slight pressure required to equalize seapressure at keel depth, surfaced, is not in the least bothersome tomost submariners, and will not impair their health or work.

C-15


CASE-Flooding o:f the Forward Torpedo Room upon sur:facing.

PRINCJ:PLES

1. The rig :for dive by topside personnel should be accomplished priorto checking o:f rig :for dive :from below.

2. Operating gear :for hatches, doors, valves, and other :fittings shouldbe checked on "rig :for dive" by manua.l1y testing the position o:f thegear in addition to a visual check.

3. Torpedo loading hatches should be secured with depth charge dogswhenever the hatch is shut.

NARRATIVE

A submarine made an initial trim dive, placing one-hal:f inch o:fpressure in the boat. During the obtaining o:f trim, negative tank wasre-:flooded and blown three times. This raised the pressure in the boatto about 1 1/2 inches. Upon getting a trim the boat was sur:faced. Areport was innnediately received that the :forward torpedo room was :flooding. Collision alarm. was sounded and main ballast tanks were blown.The conning tower hatch remained shut and the blower was not run. The:forward room :flooded completely and the bow o:f the ship sank to thebottom in about 105 :feet o:f water, with the stern still on the sur:face.The fuel ballast tank valves were opened (a:fter cutting the locks o:f:f)and the FBTts were blown, thus sur:fac~g the boat with the :forward roomstill :flooded. No personnel were lost, but a six-week availability wasrequired in the Navy Yard to e:f:fect repairs in the :forward torpedoroom.

OPmIONS

L The ship ts rig :for dive procedure was not coordinated to insure thatthe topside rigging was completed be:fore the compartments were checked:from below.

2. The torpedoman in charge o:f the :forward room and the o:f:ficer whochecked the rig :for dive did not check the hatch dogged.

3. Material (torpedo-handling equipment) stowed in the loading hatchprobably prevented a clear look at the hatch and its condition.

C-17


4. Depth charge dogs instaJJ.ed on the hatch would have prevented thehatch from blowing open as it did.

COMMENT

The officer who checked the rig for dive in the compartment hadshut the hatch and dogged it himself the last time torpedoes were loadedwhich was the last time the hatch was known to have been opened (oneor two days before). The hatch was evidently una.ogged by some one tostore additional material or by someone rigging for dive who thought hewas dogging it. This latter could have occurred after the hatch waschecked from below.

Had the ship in surfacing followed the procedure of starting theblower at 35 feet, instead of waiting for orders from: the commandingofficer, the pressure in the boat might have been reduced sufficiently toprevent blowing the hatch open. Possibly the ship might have been blownup high enough out of the water to prevent water from entering the shipthrough the loading hatch. This would not, however, in any fashionrectify the fact that the loading hatch was not dogged.

The use of padlocks on the FBT air manifold and the flood valveoperating mechanisms seriously impedes the use of these tanks duringemergencies when their buoyancy is required immediately.

<Had this accident occurred in relatively deep water it isdoubtful that the ship could have been stopped before striking thebottom, or collapsing, and she would have been lost with all hands.

c-18


CASE-Flooding an engine roam while moored to a pier.

PRUlCIPLES

1. Compliance with routine measures of water-tight integrity is essential to the safety of the ship.

2. The performance of all watchstanders must never be allowed to became perfunctory.

NARRATIVE

A submarine moored alongside a pier completed a battery-charge at2300. At 0730 the following morning a crewman returning to the ship(Nor of the duty section) discovered about. forty inches of water in theengine room bilges. Considerable damage had occurred to the high pressure air compressors due to the flooding. Subsequent investigationdisclosed that the battery charge engineman had failed to shut the mainengine sea and stop valves when the main engine was secured. The engineroom had flooded through an open vent valve on the engine salt wa.tercirculating pump. It was further determined that the last inspection bythe duty officer or the duty. chief had occurred at 0200.

OPINIONS AND FIND~

.1. That ship I s orders and below decks check-off lists were sufficientlyclear and complete to have prevented this casualty has they been properly complied with.

2. That required hourly inspections by the below decks watch werecareless and perfunctory.

3. That both the duty officer and duty chief petty officer erred in notconducting the required inspections after 0200.

COMMENT

The pattern of overall standard o-r per-rormance :eor this watchsection was demonstrated by the enginemen who deliberately left the seaand stop valves open (despite ship I s orders which required them to beshut when not in use) on the excuse that the engine would be again usedwhen the ship got underway the following morning. Similarly, the belowdeck watches apparently were not making proper inspections, else they

C-19


could not have missed the rising water in the bilges. This is not surprising, however, considering that the example set for them by both theduty officer and duty CPO was so abjectly poor. Most ship's orders reqillte .,an itl:Spectic:n by t he duty officer and chief petty officer at inieW~is of hbt more than four hOUl's, gen~rally a1terilating every twohours~ These inspections should be so scheduled as to provide the bestcoverage of the ship--not to avoid inconvenience to the inspectors.Further, inspections of lower flats are properly conducted only by goingdown into the flats-never by peeping through the upper hatches.

C-20


CASE

Flooding the main propulsion motors, alongside.

PRINCIPLE

The vulnerability of a submarine undergoing overhaul must be appreciated by all hands.

NARRATIVE

Prior to, or at the beginning of a yard overhaul a submarine issubjected to a noise survey. The submarine in question was moored atthe Ordnance Pier, the shipyard had readied its equipment, and since internal noise -must be at a minimum, all hands of the duty section exceptthe OOD and Below Decks Watch were berthed on the pier.

The sound survey proceeded apparently satisfactorily with the OODand Below Decks Watch moving through the boat operating the specifiedequipments •

The survey was completed, having run somewhat behind SChedule,and the maneuvering watch (all hands) was stationed for the down riverpassage and entry into the shipyard. An unusually low ground exist.edon both main propulsion motors.

OPINIONS AND FINDmGS

L The flooding of the main motors is attributable to a combination ofcircumstances wherein the motor room bilges were allowed to flood toan abnormal depth. The damage to the main motors 'Would not have oecun-edhad the casing been watertight.

2. Had ship's orders relative to below decks watch standing been carriedout, the c.asualty would not have occurred.

3. The inspections made this night by the below decks watch, the dutychief, and the duty officer were, in varying degrees, perfunctory tothe extent that the -amount of water entering the ship was not revealed.

4. Sabotage by individuals on board incident to the sound survey isa remote possibility.

5. The quality of the inspections made, t he fact that water leakinginto the ship, pumping of bilges, and radically ~essened ground reading

C-2l


on the main motors were not reported to responsible officers, and thefact that those who did observe that water was leaking into the ship tookno action to stop the flow are indicative of an unacceptable low standard of in-port watch keeping.

COMMENTS

The main motors were both partly innnersed in river water, whichentered the "water tight II lower half of both motor endbell casingsthrough four missing bolts at the bottom of each motor.

Under reconstruction, water entered the motor roan when the below decks watch, having finished running the main motor circulatingwater pumps, climbed up from the lower flats and in so doing stepped onand broke off the small vent pipe' and valve atop the main motor circulating water starboard strainer.

There were no personnel injuries but replacement of two lowerfield coils in each motor was required.

When the shipyard completed repair of the motors they were onceagain· assembled minus the four bolts, exactly as had· been done one ortwo overhauls previously, because of the almost impossible location ofthe bolts.

That the motors had never flooded before was due entirely to thegeneral watchfulness of the ship's personnel over the Years.

This flooding'incident is intended to illustrate the vulnerability of a submarine undergoing overhaul: - first, the paramountconcern of the duty officer and below decks watch is the safety ofthe ship, rather than a complete absorption in the performance ofshipyard tests to the point that ship's procedures and safety routinesare obviated; second, the ship is the final authority on the satisfactory completion of yard work which is generally no better normore complete than the ship insists it be.

C-22


CASE---Flooding the main induction via the snorkel induction system.

PRINCIPLES

1. Equalize pressure in the boat as a step separate from liSecureSnorkeling!!.

2. Personnel must be trained to think and observe prior to taking action.

NARRATIVE

The submarine was snorkeling under normal conditions when"Secure Snorkeling" was ordered over the lMC. The Diving Officer leftthe mast raised and the snorkel induction valve open so that he couldequalize the pressure in the boat. The cook on watch without lookingat the indicator immediately locked the snorkel induction in itsIlopen!! position, thinking that he was locking it shut.

When the pressure was equalized the Diving Officer ordered thesnorkel induction valve shut and the mast lowered. With a wet-snorkelinstallation the mast lowering flooded the housing and continued throughthe snorkel induction piping to the main induction piping. Neitherthe Chie~-of-the-Watchnor the Diving Officer had checked the snorkelboard to see if the snorkel induction valve had shut.

Upon the first indications of water in the Engine Room, thepersonnel took action to prevent further flooding of the Engine Roomand the ventilation system.

OPINIONS

1. The ship I s procedure for IlSecuring Snorkeling" should be followedto completion once it is put into effect. The action needed toequalize the pressure in the boat should be sepat'ate and be accomplishedeither prior to or following the IlSecure Snorkeling!! procedure.

2. Personnel must be trained to think prior to acting and also to actonly with concrete knowledge of what they are accomplishing, notmerely a hazy idea. Alertness on the part of either the cook, DivingOfficer, or Chief-of-the-Watch could have averted this casualty.

C-23


COMMENTS

The Diving Officer should the pressure within the boatas. a step separate from the "Secure Snorkeling" procedure. This willpreclude the possibility of confusion arising out of a departure fromthe confines of a set procedure.

The need to "equalize" at all is fUrther debatable. The vacuumdrawn is relatively small and usually won't bother the operation ofthe ship.

c-24


CASE

Flooding of an Engine Room while snorkeling.

PRINCIPLES

1. Use adequate speed to assure depth control.

2. Whenever the snorkel head valve fails to shut a possibility offlooding exists.

NARRATIVE

An SSK was snorkeling on two engines in the North Atlantic inJanuary, in a state 7 sea, at an ordered depth of fifty feet, at deadslow speed. A following sea forced the ship down to a depth of 70feet. Seconds later the Diving Officer became aware that the headvalve had not shut. The auxiliaryman moved the hand lever on thesnorkel head valve operating gear, but the llHold Open" air did not ventoff, hence the head valve would not shut. The snorkel induction valvewas shut at this instant. A large quantity of water had entered theengine room through the engine air induction piping. This, togetherwith the fact that the boat had been trimmed 20,000 pounds heavy tohold depth, resulted in a rapid descent. The Diving Officer blewnegative, requested speed, and ordered full rise on the planes. Theresultant up angle caused the water in the engine room bilges toflow aft, flooding out both generators. By using standard speedand blowing safety tank the boat was stopped 50 feet from test depth,then returned to 100 feet, where it remained.

Investigation showed that a broken linkage was preventing theproper operation of the head valve operating gear hand lever, withthe result that the air could not be vented off and the valve wouldnot shut. The head valve operating mechanism was repaired, the bilgeswere pumped, and one generator was restored to an operating condition.Snorkeling was resumed.

COMMENT

When snorkeling in such heavy weather, sudden large variationsin depth and frequent cycling of the head valve are common, sometimesresulting in momentary doubt as to whether or not the boat is in factunder control. There should be no hesitancy on the part of theDiving Officer to use all means at his disposal, including speed andthe blowing of safety and negative tanks, to prevent such large depth

C..25


changes. Nor should he hesitate to shut the snorkel induction valvewhen the head valve is submerged and there exists the slightest doubtconcerning its proper operation.

Depth control when snorkeling at fifty feet in extremely heavyseas is most difficult at best, and as shown in this case is nearly impossible at low speeds. Higher speed would have provided better depthcontrol, and with the prevailing sea conditions the increased screwnoise probably would have.been insignificant from a detection orlistening point of view.

c-26


CASE

Partially flooding the After Torpedo Room via the signal gun.

PRINCIPLE

Unusual trim changes require investigation as to cause.

NARRATIVE

While operating submerged at periscope depth during routine localoperations the boat appeared to be in good diving trim. It then becamesomewhat heavy aft. The Diving Officer took the necessary correctiveaction by pumping from after trim tank to sea. The boat became heavyaft again, with the Diving Officer taking action once again. Thiscondition recurred at least eight times. A total of 17,000 pounds ofwater was pumped from after trim to sea, yet the Diving Officer madeno investigation into the possible cause.

At this point the After Torpedo Room watch reported ~looding,

with additional information that the water level was already severalinches above the deck plates. The collision alarm was sounded, theword "Flooding in the After Torpedo Room" was passed on the lMC,and the boat was surfaced.

It was then found that both the outer door and the drain on thesignal ejector were open. These were at once shut and the After Roomwas pumped dry. There were no casualties to personnel nor damage tomaterial.

OPINIONS

1. An informal investigation determined that the signal ejector hasbeen fired just prior to surfacing to recover a torpedo. Throughnegligence it had never been properly secured, with the result thatthe compartment started flooding, slowly while on the surface andmore rapidly when again submerged.

2. It was also found that the After Torpedo Room watch had not discovered this condition until his feet felt wet, whereupon he lookeddown from his seat to see the water over the deck plates.

C-27


COMMENT

Unquestionably the torpedoman on watch was guilty of grossnegligence, both by not securing the signal ejector and by not discovering the casualty until such a late state of development.

It was also a most serious omission on the part of the DivingOfficer not to have checked into the cause for the repeated heavyaft trim condition.

c-28


CASE

Flooding of the After Torpedo Room through the signal gun.

PRlJiICIPLE

Violation of established safety precautions breeds accidents.

NARRATIVE

A torpedoman in the After Torpedo Room fired the submerged signal ejector by the pneumatic expulsion system. He shut the outer door,drained the gun, and started to open the inner door. At this momentthe SEIS exploded, blowing open the outer door and springing the innerdoor so that it would not shut. The room was partially flooded by thetime the submarine was surfaced and the hole plugged.

COMMENT

This accident was the direct results of failure to adhere towell-established safety precautions. The required precautions areposted in the vicinity of all signal ejectors. There· can be no validexcuse for failure to follow such well known and simple proceduresas that of determining that the signal ej~ctor is clear before shuttingthe outer door and opening the inner door. Numerous casualties, including serious injuries to personnel, have resulted from. this· samefailure.

C-29


CASE

Flooding in the Forward Torpedo Room.

PRINCIPLE

Positive action should be taken by the Diving Officer uponany unaccountable weight change.

NARRATIVE

The ship had been submerged at 300 feet for about 6 hours. Thewatch in the Forward Torpedo Room was near the tubes. Sonar was mannedin the Conning Tower. The Diving Officer noted the boat getting heavyforward and sent the messenger to check bilges and No. I sanitary.In about one minute "Flooding in the Forward Torpedo Room" came overthe 7MC.

The packing on the bottomside WFA head had given w~ allowingsonar bilges to flood, slowly and unnoticed at first. Just as themessenger arrived in the forward torpedo room, the packing which hadbeen leaking slowly gave way and began leaking rapidly. Pressurewas put in the compartment, and the ship came to 80 feet to slowflooding and surfaced shortly thereafter. Only slight damage :wassustained.

COMMENT

Had the Diving Officer taken no positive action when theweight change was realized, the casualty would, no doubt, havebeen much more serious. Also, the watch is in the compartment forsafety in peacetime as well as for torpedo readiness in comb~t.

In this instance it appears that he was serving no pur:pose at all.

C-31


CASE

Flooding of Engine Room at 300 feet.

PRINCIPLE

Sea valves should be shut on any non-operating salt watersystem.

NARRATIVE

A submarine operating with DE's went to 300 feet quickly. Aninspection plate (4 inch diameter) on the forward engine 'room saltwater cooler carried away with the main engine circulating water seaand stop valves open. When the engine room was reported flooding,all main ballast tanks, safety and bow buoyancy were blown. Thetrim and drain pumps were put on the bilges. The throttle man inthe forward engine room dove under the water in the lower flats tosecure the main engine circulating water sea valves. The CommandingOfficer in the conning tower had ordered "All Ahead Flank" and thecollision alarm sounded on receipt of the flooding report. Boat 'Wassurfaced with a 20° up angle about 1200 yards from the closest ship.The amount of flooding was about 25 tons of water which flooded thebilges of the engine room to a depth of about 5


1. Flooding was caused by the studs on the cover plate carryingaway due to metal fatigue.

2,. The main engine circul~ting water sea valves should have beenshut after diving as required by the engineering orders.

3. Reach rods should be installed to permit the shutting of seavalves from the upper level.

4. Studs, bolts, etc. should be checked for proper material inall systems exposed to sea pressure.

COMMENT

"First and foremost is the utter uselessness of having ordersand instructions aboard which are tacitly ignored and only serve thepurpose of covering the number. Violation of established proceduresprescribed in Department Orders serve only to breed contempt for all

C-33


orders. In this case those ord.ers prescribed that suction I¥ld discharge stop and sea valves were to be secured upon diving, but thatunknown to the Commanding Officer, Executive Officer, or the EngineeringOfficer, the men on watch in the engine rooms did not do thisunless the boat were to go below 100 feet. The fallacy of suchreasoning is apparent when one considers all factors which may force asubmarine to go deep without being able to advise the engine roomwatch. Such flagrant disregard of orders and diving procedure can-not be tolerated. ll

"This casualty was proficiently handled. The significant point,brought out by the Commanding Officer, is that the engine room watchpromptly got the word to the conning tower that the room was flooding,rather than wasting valuable time in investigating the cause of flooding. This together with the action in getting the sea valve closedenabled the Commanding Officer to take prompt and correct action tosave the ship ll

(Squadron Commander)

C-34


CASE

Flooding of compartment while in drydock.

PRINCIPLE

Extra precautions must be taken and more frequent inspections madethan normally required while ship is undergoing overhaul.

NARRATIVE

A submarine was undergoing regular shipyard overhaul and was indrydock. Extensive rearrangement work was in progress in the motor roomand considerable piping was broken. The main motors had just been returned to the ship, having been inspected, overhauled, and cleaned.

At about 2000, shipyard personnel requested premission of the OODto put a hydrostatic test on one of the NFO tanks. Permission was granted and an ENl assigned the task of assisting in lining up the compensating water system to fill the tank. with water. At about 2030 the OOD madean inspection of the boat and all was normal. At about 2400, th~ OOD wasnotified that a considerable amount of water was in the lower flats ofthe motor room. The water level was just above the centerline of the mainmotors. Explanation of this flooding is as follows: During the day theENI had noticed that the main motor circulating water connection to thecompensating water line was broken, but the compensating water line flangewaS secured with a blank flange. Consequently, he did not check thatportion of the compensating water line when preparing to fill the NFO tank.Subsequent to his sighting of the flank. flange, but prior to the attemptedfilling of the NFO tank, the flange had been removed by the shipyard personnel and not replaced. Thus, instead of the water running from the compensating water line into the NFO tank, it was flowing into the motor roomvia the main motor circulating water connection to the compensating waterline.

The cost of rectifying this error was approximately $5,000.00.

COMMENT

Because of the various stages of disassembly of the many systemsand items of machinery during a shipyard overhaul, and because of therelative unfamiliarity with the ship by shipyard personnel, the possibility of casualties is multiplied many times over the normal possibility.Ship I S force must be more alert, make more frequent inspections, and aboveall trust nothing to shipyard personnel.

C..35


CASE-Loss of stern tube packing while at deep submergence.

PRINCIPLE

and proper action often is the sole difference between aminor and a major casualty.

NARRATIVE

The submarine was operating submerged at a depth of 300 feet,rigged for deep SUbmergence, and proceeding at nine knots. Themaneuvering room watch reported the port stern tube leaking and anindication of packing being forced out. A few minutes later thepacking blew out and water began to rise rapidly in the motor roam.The Commanding Officer ordered depth changed to 100 feet to lessenthe pressure and maneuvering reported that the drain pump was keeping up with the flooding. In changing the depth to 100 feet theDiving Officer was faced with the problem of keeping an up-angleso that the water would not enter the main motors (the casing lowerhalf of which are nominally "water-tight", upper half IIsplash-proof"and obviously of not rising above 100 feet until the area was determined clear for surfacing. This he successfully accomplished.

The packing was replaced on the surface by locking the portshaft and putting a pressure in maneuvering room while repacking.


It was believed that the portresulting in chewing of the packing.not harmful, but at deep submergenceto force the damaged packing out.

shaft was slightly scored,At shallow depths this was

the pressure was sufficient

COMMENT

The 'alertness of the maneuvering room watch resulted in theearly discovery of this casualty and prompt operation of the drainpump. Together with properly controlled change in depth, this minorcasualty was prevented from becoming a major one.

C-37


CASE

Flooding as a result of a pooping sea.

PRINCIPLE

Illustration of "the neglect of any precaution which may be required by the ordinary practice of seaman, or by the special circumstance of the case" (borrowed from International Rule 29).

NARRATIVE

While attempting to avoid a hurri cane, a Guppy II submarine :wasproceeding downwind at standard speed on three engines, adjusting speedto gradually overtake the state 4 to 5 seas and using rudder to maintainan even keel. The ship rode comfortably in this condition for severalhours. Thus no precautions against pooping seas were made; upper ConningTower hatch was open to provide communication to the helm, personnel onthe bridge were not lashed to prevent being washed overboard, the ConningTower ventilation (via periscope well) was not shut, and the well drainswere open.

Shortly following the relief 'of the watch the ship was pooped andbroached. The bridge personnel were submerged in water (An officer onanother submarine about,two miles away was washed over the side and wassaved by his safety belt.) The flow of water and list to st::u-bo::u-d prevented the helmsman from shutting the hatch and water flowed into theConning Tower and Control Room. The lower hatch was shut but onlyafter about 2 inches of water had. accumulated in Control. Shutting thelower hatch caused the Conning Tower to flood to about one foot. Watercontinued to spray into Control even after the hatch was dogged. Waterfilled the periscope wells and flowed into the ventilation supply linesdischarging into Control, Radio (over the TBL), and Forw::u-d Battery untilthe Conning Tower ventilation flapper was shut. The After Battery waskept dry by action of the cook who heard. the water flow in the supplyline and rapidly shut the bulkhead flapper.

The condition of the ship was then as follows:

Ship Control: Ship in the trough and unres,ponsive to the rud.der.

Bridge: Out of communication with the rest of the ship forsome three minutes as a result of the submersion and general confusionresulting therefrom.

Conning Tower: Isolated..

C-39


Control Room: Water on deck, people slipping and falling; Commanding Officer attempting to establish communication with the bridgeto advise of the radar position of a nearby contact.

Pump Room: Flooded. to d.epth of six inches over the deck plates.

Forward Battery: About one quart of water entered. the batterywell. The steward. receiyed. a minor shock while attempting to removethis water with a toweL All bunks were drenched. via the individualventilation outlets. Most of the water was absorbed. in linens andbedding in order to stop entry into the battery well through the leaking deck hatch.

COMMENT

This is a good example of the danger of underestimating the seastate and its potential. The boat was very fortunate not to lose theentire bridge watch. Do not wait for the Commanding Officer to comeup to tell you to take heavy weather precautions. As the Officer ofthe Deck, initiate whatever steps or precautions are deemed requiredfor the safety of the ship.

c-40


CASE

Flooding of After Engine Room through Expansion Tank Vent.

PRINCIPLES

1. The cause of any ground that suddenly appears should be determined.

2. Below decks inspections must be carefully made if they are to provide any real security.

NARRATIVE

In complying with the "Cold Weather Bill" a boat blew expansiontank partially dry and then opened the tank vent (inboard). This wasdone to allow the compensating water line topside to drain down intoexpansion tank in order to prevent its freezing of the line topside.Since the venting is somewhat slow, the vent was left open and forgotten.

At 2300 a battery charge was commenced on the forward engines.At 0300 a full voltage ground sppeared which was traced to the auxiliarygenerator. The charge was interrupted, tile field excitation of the aux-.iliary generator was opened, and then the charge was resumed. At 0400another full voltage ground appeared. This ground was traced to thelighting circuit and found to be on the lights in the auxiliary generator. This circuit was isolated and the charge cont inued.

Upon completion of the charge, the forward engine room throttleman went aft to blow down expansion tank. He discovered the floodingof the lower level which had caused the grounds on the auxiliary generator, and which had gone unnoticed by the below decks watch, theduty chief, and the duty officer over a 6 hour period.

COMMENT

The appearance of a full voltage ground. is not to be takenlightly, they do not appear without reason. While it is expedient toisolate the offend.ing circuit or equipment, that is only half thestory. The cause of the ground must be determined also. In anycase, all such grounds should be reported to the duty officer and dutychief.

Below decks inspections made in a perfunctory manner can onlylead to trouble as this case clearly shows.

C-41


CASE

Minor flooding, resulting in other casualties.

'PRINCIPLE

Minor casualties, if not handled properly from the beginning,can result in other major casualties.

N1\RRATIVE

While crU1s~ng submerged at 310 feet during an SSK exercise, abarely intelligible message was shouted on the 7MC to the effect thatthe motor room was flooding. Few of the personnel in the control roomunderstood the message and no amplifying word was received. The flooding in the motor room was actually caused by a ruptured gasket in the airconditioning circulating water strainer; however, the shape of the opening caused the water to spray 360° and with considerable force. Theelectrician I s mate on watch d.id not know where to secure the sea valve,so before qualified personnel could reach the scene, casualty #2 occured; a cubicle fire from the water.

In the meantime, the Conning Officer had ordered standard speed,a 10° up-angle and was preparing to surface. No amplifying reportswere forthcoming, so main ballast was blown from about 300 feet to thesurface. At this point the·helmsman/controllerman (K-l class submarine)reported casualty #3:. loss of cubicle control. This casualty was laterdetermined to have occurred from improper operation, probably occasionedby excitement. The order was then sent to the motor room to take cubiclecontrol. The electrician's mate/controllerman on watch previously mentioned, in attempting to disconnect the remote cubicle controller preparatory to taking local control, caused casualty #4 to occur. Insteadof disconnecting the remote cubicle controller, he opened the adjacentand identical appearing switch, the main motor field switch.

By this time, the circulating water to the air conditioning system had been secured and flooding stepped. A relatively small quantityof water had been taken aboard.

When the boat reached the surface, its rolled some 30° to 40°,having come up well past the normal waterline by momentum and havingvery little stability while in this "high and dry" condition. Thislarge roll with the attendant sh~fting of loose gear further confusedthe issue.

c-43


Finally the cubicle was cranked down to STOP (with no field onthe motors) accompanied by a great deal of heavy arcing.

Although·the actual damage from this series of casualties wasslight (burned insulation and pitted contacts in the cubicle), majorcasualties almost occurred. Three good lessons in the avoidance ofcompounded casualties are apparent:

1. Clear and concise casualty reports, followed by amplifyingreports, must be made in order that the Conning Officer can take intelligent action.

2. Men on watch must know their watch thoroughly enough to correct minor casualties on the spot and be able to perform their dutiesunder stress.

3. No loose gear should be tolerated That can complicate acasualty by coming adrift during an unexpected roll or angle.

c-44


CASE

Flooding an Engine Room while snorkeling.

PRINCIPLES

1. "Safety Circuits" do not, in themselves preclude casualties.

2. Electrode test buttons on the snorkel panel do not "test" theelectrodes themselves, but only test the solenoid circuit to insure thatit vnll operate to shut the head valve.

NARRATIVE

A submarine enroute to refresher training after yard overhaulwas snorkeling at 63 feet in a calm sea. Previously she had snorkeledsuccessfully at 62 1/2 feet, and was attempting to determine the maximum depth at which snorkeling was possible. Shortly after reaching63 feet, flooding was reported in the forward engine room. The shipsurfaced, concurrently for collision. Greatest depth reachedwas 65 feet ,1-5 to 30 seconds flooding time. The forward roomwas flooded to a depth of 66 inches above the lowest point of the bilge.

COMMENTS

The flooding was caused by failure .of the head valve to shut whenthe electrodes became wet. Upon disassembly of the snorkel controlpanel it was found that a pin broken on the electrode selector switchand bent switch shaft allowed the switch to actually be in a blank position instead of the indicated. F-P-S position. Using the push buttonsto test the head valve prior to snorkeling was not a test of the electrodes themselves; but rather of the air solenoid circuits. The bestpractice to check the head valve is by actually dunking it before commencing snorkel operations.

c-45


CASE

Partial flooding of an engine room alongside.

PRINCIPLES

,1. Compliance with routine measures of water-tight integrityand standard operational procedures are essential to the safety of theship.

2. Watchstanders must never become casual in their performanceof duty.

NARRATIVE

While moored alongside a pier a submarine renewed the zincs inthree fresh water coolers, a procedure which required opening of thesalt water drains for the coolers. Several hours later it was discovered that two of the drains had been improperly left open. Theywere shut and the third was tried and believed to be properly shut.The engines were tested and secured at 2050, but, contrary to existing instructions, the two main sea suction valves and the associatedengine stop valves were left open in anticipation of their possible usethe following morning. About 2200 the engine room bilges were pumpeddry by the below decks watch. During the night various inspections weremade bY'the below decks watch, but it is doubtful if he at any time actually went into the lower flats for his inspection. THE DUTY OFFICERAND THE DUl'Y CHIEF MADE NO INSPECTIONS BETWEEN THE HOURS OF 2400 and0700. At about 0700 the water level was discovered to be about 8inches above the lower flat deck plates. It was also discovered thata main generator had flooded due to water entering its casing throughoil separator ring drain and vent holes. Subsequent investigation indicated that the flooding had occurred through the salt water valve onthe fresh water cooler, and that such flooding must have been in progress since 2200 in order for such a quantity of water to have entered.


1. That ships orders and organizational procedures had nomajor inadequacies.

2. That below decks inspections, if conducted at all, wereperformed in a perfunctory and casual manner.

c-47


•

COMMENT

This case sounds like a repeat of the case described on page C-19.It is another example of engine room sea and. stop valves being deliberately left open, in direct violation of existing instructions, simply asa convenience for the operation of the engine on the following morning.It is another example of perfunctory performance on the part of a belowdecks watch who attempted to conduct his inspection of the lower flatswithout entering the lower flats, and who failed to discover either theimproperly opened sea and stop valves or the rising water resultingtherefrom. And it is another example of the standard of watch performance being established by the duty officer and the duty chief -neither of whom made an inspection of the ship between the hours of 2400and 0700 .

c-48


CASE

Partial flooding of Motor Room alongside.

PRINCIPLES

1. Adherance to fundamentals of submarine water-tight integrityis essential to the safety of the ship.

2. Casualness or perfunctory performance on the part of anywatchstander must never be permitted.

NARRATIVE

A submarine was moored alongside a New Lond.on pier in the winterwith its cold weather bill in effect. Incident to this bill, the mainmotor cooler drain valves were open and a notice to this effect wasposted in the Maneuvering Room. At about 2100 the battery chargingcontrollerman started the main motor circulating water pumps withoutclosing the drains to the main motor coolers, resulting in salt waterentering the motor room bilges through the open drain valves; the waterattained a depth of about eight inches above the bottom of the afterend bells of the main motors before being discovered. This partialflooding resulted in damage to number 1 and number 3 main motor, dueto water entering the motors through warped. end-bells and faulty endbell gaskets. Restricted availability at a naval yard was requiredto effect repairs at .a cost to the government of $58,000.00. The ensuing investigation revealed the facts that the required below decksinspections had been made-- one of them approximately 5 minutes afterthe circulating water pumps had been st~ted--but that inspections ofthe motor room had been conducted from the upper deck le.vel by simplypeering through the hatch rather than by actually going into the lowercompartment.


1. That the flooding of the motor room bilges was due to thefailure of the controllerman to shut the cooler drains before operatingthe main motor circulating water pumps.

2. That the failure of a watertight seal of the after mainmotor end bells caused the water to enter the motor casings.

c-49


The person directly responsible for this casualty, was, of course,the controllerman who failed to shut the drain valves; the reviewingauthority classed his performance of duty as negligent. It is worthyof note, however, that the flood.ing could have been detected before thewater level got high enough to do damage had the below decks watch madehis inspection properly: by going into ,the lowe;r flats instead ofp~ering down from above. This standard of watch-standing was set by theexample of the duty officer, who himself conducted his inspection ofthe motor room from the upper level in violation of basic submarinepractices. The reviewing authority remarked in his forwarding endorsement, itA duty officer's responsibility does not entail merely makinginspections or ascertaining that the required number of inspections aremade. His responsibility extends to ensuring that watchstanders areproperly discharging their duties. Likewise, his own inspections mustbe thorough. It

C-50


CASE

Flooding of motor room bilges and main mbtor casing while inport.

PRINCIPLES

1. The performance of watchstanders must never be allowed to become perfunctory.

2. Good submarine practice dictates that sea and stop valves beshut on salt water systems which are not in use.

NARRATIVE

A submarine completed work on the main motor circulating watersystem and assigned an electrician t smate to flood and vent the watersystem. Immediately upon completion of this assiginnent, the motor roombilges were pumped dry. About two hours later the Duty Officer noteda reading of 5000 ohms on the maneuvering room ground detector, and detailed a man to localize the ground. Incident to locating .the ground,the electrician's ~te discovered, still an hour later, that the motorroom bilges were flooded to a depth of about five i:p.ches a1?ove the deckplates. It was subsequently determined that the port main motors wereflooded internally to a depth of about twenty-two inches, and that thewater had entered the bilges from the stern tube flushing lines andthrough the port high point vent which had not been completely shut uponcompletion of the circulating system venting. The water had thence entered the motor casings through a universal pipe union which was notproperly connected between the port motor casing .drain manifold and thesuction side of a hand pump.

In t.he ensuing investigation, it developed that no one had en-'tered the below ,deck spaces of the mot~r room from the time the venting had been completed until the ground.-chasing electrician discoveredthe flooding-"a period of over three hours. During this period, theDuty Officer and two different below decks watches made severai in-'spections of the ship, but not one of them entered the lower flats-each made his inspection merely by looking through the grating of thehatch.

OPINIONS AND FnIDINGS

1. That the below decks watchstand.er was negligent in his performance of duty d.uring the watch in that:

C-5l


a. He failed to enter the motor room during his inspection.

b. He carried. out his inspection checkoff by memory ratherthan properly utilizing the checkoff list provided..

2. That the Engineer Officer was remiss in his duties in that:

a. He did not require compliance with an engineering department instruction in regard to shutting the stern tube flushing sea andstop valves during periods when the submarine was in port.

b. He did not exercise adequate supervision to insure shutting of all of the stop valves on the port main motor casing drainmanifold, when good submarine practice d.ictated that they be shut whennot actually in use.

3.in that heto wit, he

That the Duty Officer was negligent in his performancefailed to make a proper and thorough inspection of thefailed to enter the motor room d.uring these tours.

of dutyship;

4. That the Commanding Officer was not cognizant of certain unacceptable conditions and practices aboard his ship. He did not condonethe malpractices brought out by the investigation. However, since thesemalpractices existed, it is evident that he failed to keep himself informed to an extent which would permit him to direct correction of theseunacceptable conditions and practices.

COMMENT

This case is another example of the principles to be learnedfrom several similar flooding casualties in this boo}r. Salt water systems should be secured when not in use. Ship's orders should directthis procedure and compliance must be insured by proper supervision.Inspection by watchstanders, inclUding the Duty Officer and Duty Chief,must be thorough, objective and cover at the minimum all those items onthe inspection checkoff list. BILGES CANNOT BE PROPERLY INSPECTED BYPEERING THROUGH THE HATCH CRATING! ! ;

C-52


CASE

Partial flooding of motor room while in port.

PRINCIPLE

Watchstanders must discharge their duties properly.

NARRATIVE

A submarine was in port, moored to a seawall. At 0145 the below decks watch was relieved and the oncoming watch shortly thereafterdiscovered the motor room bilges flooded to a of about 28 inches(one inch above the deck plates). An immediate check revealed that theflooding was by fresh water and was coming through the drain pump priming tank, the two fresh water filling valves to this tank being open.The valves were secured and bilges pumped dry. Water had entered themain motor casings and the resistance to ground on the series and shutfields of the main motors were essentially zero.


1. Mathematical computations made by using the amount waterintroduced water pressures, size of piping, and other factors, estab..... .l...:lu<;;u. that the minimum time during which this flooding took place was4.5 hours and the maximum time could have been up to hours.

2. That the duties and responsibilrties designed to preventsuch occurrences as well as damage from such occurrences are contained in the Ship's Organization.

3. That the Duty Officer did not conduct complete inspectionsof the ship as required by the Ship's Organization.

4. That the Duty Chief Petty Officer did not properly performduties as required by the Ship's Organization.

5. That the quality of below decks watchstanding performed byall parties involved is below the required standard.

COMMENTS

This is still another" illustration of the results of poor watchstanding performance and general laxity. The fresh water filling valveswere left open due to negligence, initiating the flooding. Laxity on

C-53


the part of the Duty ,Officer and Duty Chief in not making inspections atthe required time intervals allowed the flooding to progress withouttheir discovering it, and was reflected in the below decks watchstanderswho failed to make proper inspections of bilges. In his statement, oneof the watchstand£rs said. that on each inspection, he "missed checkingthe bilge in (the) maneuvering room . . . because the hatch was shut II •

It is interesting to note that the man who finally discovered theflooded condition did not dD so by entering the lower level, but bypeering through the hatch and seeing the water after it was above thedeck plates. This is too late to discover the flooded bilge, asevidenced by the fact that all main motors had already flooded by thistime. In regard to this case, the Force Commander stated "...it isapparent that the cause of this casualty was a complete disregard ofbasic fundament ls in submarine watch standing. It is axiomatic thatthe degree of alertness exhibited by watchstanders is in direct proportion to that demanded and exhibited by officers, from the Commanding Officer right on down to the most junior. Ultimately, it is aCommanding Officer's responsibility to ensure that watchstanders aredischarging their duties properly."

C-54


PART D - GROUNDINGS

Submarines have managed to go aground. both on the surface and

submerged with equal facility. The cases herein are illustrative of

this fact, and they are almost invariably caused by the failure to

"follow the basic requirements of safe piloting. The prudent navigator

uses every means at his disposal to keep his ship in navigable waters

and does not wait for a fix before planning his next course. The

importance of piloting can be judged from this quote from Dutton:

"Piloting requires the greatest experience and nicest jUdgement of

any form of navigation. Constant vigilance, unfailing mental alert

ness, and a thorOUgh knowledge of the principles involved are es

sential. Mistakes in navigation on the open sea can generally be

discovered and corrected before the next landfall. In piloting there

is little or no opportunity to correct errors. Even a slight blunder

may result in serious disaster involving perhaps the loss of life.

The problems of piloting are fundamentally very simple, both in

principle and in application. It is the proximity of danger which makes

piloting so important."

D-l


CASE

Submarine grounding in Cape Cod Canal.

PRINCIPLE

Maneuvering in a restricted channel at night requires a speedthat is consistent with the conditions of reduced visibility.

NARRATIVE

This submarine was entering the Cape Cod Canal from the west atnight. It was snowing; visibility was between one to two miles. Thetemperature was 32 degrees. Speed was 14 knots (standard on two engines). A minor casualty had necessitated the shift of st~ering to thecontrol room. Width of the channel was about 200 yards. The weatherhad deteriorated to where indentification of buoys was extremely difficult even with the 12 inch signal light. The section maneuveringwatch was stationed and the anchor detail was standing by in the controlroom. Lights were sighted ahead, believed to be the masthead and rangelights of a merchant ship whose presence at the eastern end of theCanal had been previously reported. The lights, bearing on the starboard bow, appeared to give the ship a small port angle on the bow.The Commanding Officer believed collision imminent and changed courSeto the right preferring to ground than to collide. These lights wereactually located on the beach and were not those of a ship. The submarine ran aground, shearing the sound head and holing the chain locker.


It was considered that in view of the overall conditions confronting the Commanding Officer, the USe of standard speed of 14 knotswas highly imprudent in the section of the canal in which the submarinegrounded, and that speeds were available to the Commanding Officer whichwould have assured adequate maneuverability without placing the submaripe in a situation where the supposed sighting of oncoming trafficwould leave the options of collision or beaching.

COMMENT

The speed used should be consistent with the conditions ofvisibility, weather, and maneuvering room. A change can always be madeto the movement report. A good general rule for shiphandling, including conning the ship in confined waters such as this is as follows:

D-3


The ship should. be handled in such a way as to allow for amistake by anyone in the ship control team, including the ConningOfficer himself, without damaging the ship.


CASE

Subma~ine grounding while approaching Norfolk, Virginia.

PRINCIPLES

Safe and thorough navigation when approaching land includesthe following:

1. Use of all aids to navigation, i.e. radar, fathometer.

2. Taking into consideration factors such as known currents,gyro error, wind and sea conditions when setting courses.

3. Observation of bearing drift of prominent landmarks.

4. The danger in relaxation of navigation procedures just because the port is familiar.

NARRATIVE

This submarine was returning to her home port ~om the VirginiaCapes operating Areas. She was in re~esher training having recentlycompleted a shipyard overhaul. After passing the Chesapeake BayLightship, course was set for Norfolk. During the passage it wasnecessary to alter course to avoid shipping. At one time the ship hadto stop and back to avoid closing a merchantman ahead. At this pointthe Commanding Officer came to the bridge. The OOD retained the conn,however, while -the Commanding Officer gave his instructions andmaintained overall supervision. The ship made a circle to the rightand then proceeded to the harbor entrance . It :was again necessary toalter course to -avoid a fishing boat. The wind was about 30 knots~om the northwest; the sea state was 3 or 4; visibility 6 miles. TheNavigator was stationed principally on the bridge but on severalocassions went to the conning tower to obtain cuts through the periscope. Of the quartermasters aboard (1 Q}1C,1 Q}:Il, 1Q}f2, and 1 00),the Q}1C stood Chief of the Watch and none of the others were assignedto the Navigator. The radar operator was an ET3' who h~d been aboardonly one month. The helmsman was also extremely inexperienced and,in fact, just a short time before the grounding, was admonished by theOOD for being 12 degrees off course. At this time (approximately1930) the ship was being rigged for surface and the maneuvering watchwas not stationed. The fathometer had not been used since 1750 hours.No radar ranges were taken to Cape Henry Light or the nearest land.At 1935 the ship grounded, at which time a radar range of about 2000

D-5


yards was reported to nearest land. After several hourse the ship backedclear on her own power and returned to port. Material damage was minor.

OPINIONS ~i\ND FINDINGS

1. A known current across the line of advance was not taken into account.

2. The last azimuth to determine gyro error was taken three daysprior to the grounding, at which time an error of over a d.egree wasfound to exist. The steering of courses, uncorrected to compensatefor this gyro error, tended to take the ship off the proper track inthe direction in which it was ultimately grounded.

3. A prominent navigational aid was in sight throughout the approachto the harbor. Bearings on this light were not observed or plotted.

4. The" Board investigating this grounding was handicapped in pippointing the precise act or omission which resulted in the groundingof this submarine by reason of the multiple violations of law, regulations, customs, good judgement, and normal organization and administration which preceded this inexcusable grounding.

COMMENTS (BY COMSUBLANT)

In this instance the performance by this submarine demonstratedan overall inability to properly approach and cope with the difficulties attending the accomplishment of a routine task.

"The Commanding Officer, in hi.s basic responsibility for safenavigation, is charged with the duty of insuring that adequate,competent personnel are assigned to required operating stations.Until the OOD took action to replace the obviously ineffective helmsman, there is no evidence that the ship's 'organization required, orthat anyone took, affirmative action to supplement the normal underway watch, although radical maneuvering was in process and the op- •erating conditions were considered difficult".

"The navigation of this submarine leading to this grounding willnot bear even casual scrutiny as to the procedures and difficultiesimposed by the limited facilities for navigation on the Guppy typesubmarine, plus the congestion to be expected••.•. it is even moreimperative that the Navigator provide himself with competent assistantsto man whatever stations to which.he cannot personally attend and thathe make maximum use of the fathometer readings, radar observations andloran navigation".

D-6


CASE

Grounding submerged while particpating in ASW services.

PRINCIPLES

1. The Commanding Officer and Navigator are responsible for the safenavigation of the ship.

2. All course and speed information must be passed to the Navigator.

3. The OCE is also responsible for the safety of the submerged submarine.

NARRATIVE

This submarine was furnishing ASW services to de$troyers in anoperating area off St. Thomas, V.I. Shortly after submerging, theOCE ordered a base course change from 180QT to OOOQT. The CommandingOfficer had the conn. The Navigator was not informed of this change.At the time of the course change the submarine was about a mile southof the northern boundary of the operating area. Just beyond thisboundary was the 100 fathom curve which shoaled rapidly. After running north for awhile the Commanding Officer realized that he was leavingthe operating area and he changed course to 270 QT on his own accord.This was also not reported to the Navigator, nor to the OCE. Whileconducting full evasion, the submarine went another 400 yards north ofthe track and struck a submerged pinnacle. This pinnacle was outsidethe assigned operating area. Meanwhile, on the surface ships, the OCEhad realized that the submarine was getting out of the area and attempted to order a course change. Although this course change was notreceived by the SUbmarine, it would have been too late anyway.


1. Initially, the Cornma:nd.ing Officer should have called the attention of the OCE to the fact that the ordered base course would takethe submarine out of her area.

2. On recognizing the danger of the base course, the OCE failed totake positive and immediate action to direct the submarine to surfaceto prevent grounding.

3. The Navigator failed to keep a running plot of the ship's position throughout the day's exercises and failed to keep the Command.ing

D-7


Officer advised of the shipt s position with relation to the areaboundaries and the imminence of danger.

COMMENTS

The Commanding Officer is still primarily responsible for thesafety of his ship. If given a base course that would run his shipinto danger by an OCE or OTC it is his duty to acquaint the superiorwith the fact. The only way to maintain a knowledge of position submerged is by keeping an accurate DRT track with the limits of the areamarked on the DRT. If doubt arises as to position or safety, then ayellow flare should be fired and the position requested from a surfaceship.

D-8


CASE

Submarine grounding while backing away from a pier in Port auPrince, Haiti.

PRINCIPLES

1. All available information, such as Sailing Directions, Fleet GUid~s,

and Briefing Pamphlets should be studied prior to entering a port.

2. When entering strange ports, in particular foreign ports whoseharbor maintenance is sometimes dUbious, exceptional caution should beexercised.

NARR.ATIVE

A submarine visited Part au Prince, Haiti, for a recreationalweekend. No unusual difficulty was experienced in entering .port.It was noticed, however, that of three buoys listed on the chait toindicate shoal water in the vicinity of the pier only one was present.On the completion of the weekend, the submarine got underway. Fiveminutes later, she had backed onto a 16 foot shoal spot and wasaground. Damage was minor consisting of bent propeller blades.


1. The Commanding Officer did not familiarize himself with availableinformation concerning the area which indicated that extreme cautionshould be used in entering and departing the harbor of Port au Prince.

2. Had the ship allowed more margin of safety by staying in deeperwater closer to the pier while backing out the grounding would havebeen averted.

3. Determination of the exact location of the only buoy present ofthe three shown on the chart would have disclosed that the buoy marking the 16 foot shoal spot was missing.

COMMENT

It pays dividends to be extremely careful when entering foreignports. And when only one of three buoys is in fact present the definite identification of the buoy is mandatory and the locations of theother shoal buoys should be avoided like a plague. When informationis lacking and you have eased your way into a port it is a commonpractice of good seamanship to go out the way you came in. You knowthat is good water.

D-9


CASE

Submarine grounding submerged.

PRINCIPLES

1. Responsibility of the Navigator for safe navigation.

2 The necessity for the Conning Officer to be fully aware of allaspects of the control of the ship.

3. When operating in the vicinity of shoal water, positive steps(danger bearings and/or ranges) should be used to avoid difficulty.

NARRATIVE

A submarine was conducting a photo reconnaissance of Sand Keyoff Key West. The Commanding Officer decided to make a hand diveprior to the final submerged photo recon run. A fix was taken at 1244and the Commanding Officer estimated that there would be 15 minutesbefore the arrival at the initial point for the reconnaissance. At1253 the ship made a hand dive. The Executive Officer (also the Navigator)was supervJ.sJ.ng in the control room. This was the first hand dive madeby the ship in 18 months. The Commanding Officer became interestedin the course of the hand dive and left the Conning Tower to go to Control. A LTJG, acting as Assistant Navigator was piloting in the ConningTower. He obtained a fix at 1256 and recommended to the CommandingOfficer a course change from 300 0 T to 040 °T • The Commanding Officerdid not order the course change. The Assistant Navigator made nofurther recommendations or warnings to the Commanding Officer. Theship had been making two thirds speed submerged during the dive, andshortly thereafter, increase to Standard on orders of the CommandingOfficer. The Assistant Navigator was not aware of the speed change.At about 1306, 13 minutes after diving, the ship ran upon a shoal inabout 32 feet of water. Damage was limited mostly to the sound head.


1. The ship grounded in broad daylight, in good visibility and withan abudance of land marks available.

2. Soundings were not being relayed to the Conning Tower.

D-ll


3. Safety measures for safe piloting in shoal waters were lacking andthe exchange of information concerning the safe piloting of the ship wasinad.equate.

4. The Commanding Officer made an error in judgement as Conning Officerin electing to stay in the Control Room to supervise the hand. dive.

5. The Assistant Navigator erred in:

a. Not recognizing that a dangerous situation existed when theship's course was not changed to 040 0 T as advised.

b. Not requiring soundings to be furnished him.

c. Not advising the Commanding Officer of the reason for changingcourse and the location of nearby shoal water~.

COMMENTS

In this instance, it is a case of trying to do too many thingsat once. The decision to make a hand dive (the first in 18 months)without prior practice and immediately before another mission, coupledwith the facts that the submarine was approaching shoal water and thatthe Commanding Officer left the Conning Tower to a LTJG, yet retainedthe conn is indeed remarkable. Here the ship was well aware of thefact that they were approaching the beach. The provision of limitingranges, bearings and/or soundings would have avoided this grounding.

D-12


CASE

Grounding submerged during a mine plant.

PRINCIPLE

Bow Buoyancy and Forward Group Vents shouJ,d be open whenfiring the f'orward tube nest.

NARRATIVE

A submarine conducting a mine plant at periscope depth wasoperating in 160 f'eet of' water. The Diving Of'ficer, after flooding anabnormal amount of water into forward trim tank, noticed Bow Buoyancyand the Forward Group vents shut. He ordered them opened, vfuereuponthe boat took an irmnediate down angle, hitting the bottom and shearingoff both sound heads.

COMMENT

Several submarine "good practices" were violated in this instance. First of' all, it is and has always been customary to openBow Buoyancy and the Forward Group Vents when firing the forward tubenest. Indeed, a good majority of submarines run submerged with themain ballast tank vents open. The job of Diving Officer f'or a mineplant is not an easy one, but the problems connected with it can begreatly reduced by advance planning. Had this Diving Officer anticipated the trim changes f'or various points during the mine plant, hewould have noticed that Forward Trim was getting too much water bef'orehe reached the danger point. Even then, had he cycled the ventsquickly at f'irst rather than just opening them he could have maintaineddepth control with speed while pumping the excess water out of ForwardTrim.

D-13


CASE

Submarine grounding off Hog Island, Virginia.

PRINCIPLES

1. All course changes and all navigational aids sighted must be reported to the Navigator.

2. When approaching a landfall full use of all navigational equipmentshould be used.

NARRATIVE

The submarine just out of the yard was enroute from New Londonto Norfolk. Its position was fixed by three Loran lines at 1837R whichagreed within three miles of a celestial fix obtained at 1816R (thiscelestial fix was not used). At OOlOR, a two line Loran fix was obtained and was the basis for a course change from 231 0 T to 239°T at0048R on the advise of the Navigator. The Commanding Officer wasnotified of this change. Weather was moderate with the sky overcast,clouds forming, and a minimum visibility of between 2 and 3 miles.During the midwatch the OOD changed course to the right to avoidshipping, then returned to base course. This was reported to theCommanding Officer but not to the Navigator. Also on the midwatch,rad.ar contact was obtained at a range of 24,000 yards on the starboardbow, this was evaluated by the OOD as rain squalls.

While preparing to relieve the watch (04-08), the oncomingJOOD observed the radar scope in the conning tower and saw what hethought to be land extending from 210 0 T to 280 °T . No one else wasnotified of this fact, nor were they aware of it.

At about 0350R, during the change of OODs, a light was sightedforward of the starboard beam, but was neither identified nor reported to either the Commanding Officer or Navigator. The Navigatorwas at this time in the control room attempting to get a Loran fix.

At 0410R a white flashing light was sighted on the starboardbow, timed as flashing every four seconds, but was not identified.

At 041lR a fathometer reading was obtained' which showed fivefathoms of water under the keel.

At about 0413R a lookout reported disturbed water from about010 to 170 relative. The JOOD verified the report, but the OODcould not substantiate the report, therefore he took no action toreduce speed from 16 knots or to change course.

D-15


At 0415R, various personnel on board felt a series of bumps asthe ship ran upon a shoal. The Commanding Officer was called by theChief of the Watch. The Navigator had been up and about during themidwatch and from 0300R until the grounding he had been trying to fixthe position of the ship. Neither the Commanding Officer, nor theNavigator received the reports of lights sighted or the five fathomreport. With the exception of the sounding at 041lR the fathometerhad not been used since midnight. No flooding or damage resultedand the ship was backed clear.


1. Loran fixes were found to be inaccurate.

2. A carefully computed DR, taking into acoount-the two coursechanges to the right to avoid shipping, was not plotted or advanced.

3. The fathometer was not used througho1Jt the night when it wouldhave been of great assistance.

4 Radar operators, QMs, and the OOD failed to recognize land onthe radar scope.

COMMENTS

Some of the principle errors contributing to this grounding werethe failures of the CODs to report course changes and the sighting ofnavigational aids to the QOIll!l1aIldirig Officer and Navigator. The OODalso failed to take action when grounding was imminent. Another factorwas the failure to use the fathometer and the establishment of a minimum sounding by the COIll!l1aIlding Officer in the Night Orders.

\

The Navigator of this submarine was a junior officer (LTJG) and.as a result of this case the requirement was established that theNavigator of a submarine be at least the third officer and not belowthe rank of Lieutenant.

CINCLANTFLT ' s endorsement in part stated I! •••• grounding notserious if measured in terms of damage ....however, it was exactly thetype of incident which the training and organization of personnelaboard ship is designed to prevent. Furthermore, this grounding didnot occur as the result of a single isolated instance of poor jUdgment, negligence, or carelessness, nor did it occur as the result ofthe shortcomings of a single individuaL Rather, it occurred as theresult of the failure to act properly in a number of instances by anumber of different inaividuals . The sum total of which leads to theconclusion that in this ship, at least, the training and indoctrination of personnel concerned was insufficient to assure the safenavigation of the vessel under normal conditions."

D-16


-CASE

Submarine grounding while exiting a channel.

PRINCIPLES

1. Use of Fleet Guide for piloting information.

2. Duties and responsibilities of the Coniroanding Officer, Navigator, and OOD in piloting, specifically in preparation and familiarization with the track to be followed and navigational aids.

NARRATIVE

A submarine was leaving port via a restricted channel withthe Commanding Officer and OOD on the bridge using one HO chartand the Navigator in the_ Conning Tower using a different ch~t.

The Navigator's chart contained a printed, dashe~line indicatingthe channel, but no track line had been laid on it before the shipgot underway. The Fleet Guide for the area indicated a track whichcleared all shoal water by 300 yards.

As the submarine approached an unnumbered beacon marking theport side of the channel, making standard speed on 2 engines, theNavigator recommended a change of course. The OOD had sighted thebuoy marking the limit of the channel well before approaching theintended turning point, but he failed to realize the danger to thesubmarine and did not inform the Commanding Officer or the Navigatorof the buoy's location. The Commanding Officer ordered a fu:1otherchange of course on which it appeared that the submarine would passthe beacon 200 yards to port. The Navigator then ordered anothercourse; the OOD ordered right 15° rudder; and the Coniroatiding Officerordered Right Full Rudder. While coming right the submarine bumpedseveral times then ran hard aground. Extent of damage: $10;000.


1. The Navigator erred in selecting the dashed track line of thechart when it clearly showed a well marked shoal within 50 yards,and since the available channel width was 800 yards. He also failedto advise the Commanding Officer of a safe course to be steered, touse all aids to navigation at his disposal, and to maintain an accurate plot of the ship's position.

D-17


2. The OOD failed to inform himself of the track line to betraversed in exiting the channel.

3. The Commanding Officer failed to consult the Navigator aboutthe track to follow; he failed also to take congnizance of the navigational advice in Fleet GUide, or to take judicious notice of allavailable aids to navigation. And, when the ship had reached aposition of in extremis he failed to resort to emergency measuresto change heading and/or headway of the sUbmarine.

4. As in most cases of this nature, a contributing factor wasthe confusion regarding whether the Commanding Officer or the OODhad the conn in the last few moments before grounding.

COMMENT

The ship would not have been endangered had the officerstaken early and sufficient action for safe navigation prior to reaching in extremis.

On most submarines it is feasible to navigat~ on the bridgewith little difficulty, and such a procedure, had it been followedin this case might well have prevented this unfortunate grounding.Plotting on -the bridge has many advantages that should be weighedbefore the Navigator is permitt~d to retreat to the comfort of theconning tower. The ship' s position, track, DR posits ,,--et-c:~-;-arf::

instantaneously available to the Commanding Officer and the OOD andthe exchange of information that is vital to the safety of the shipis greatly enhanced. Perhaps the most important advantage is thatthe,Navigator has a much better perspective of the ship's positionand nav:j..gational aids. In almost every case, the piloting should bedone on the bridge except when manifestly imposible due to weatheror when using radar as the primary means of obtaining navigationalinformation.

D-18


CASE

Grounding submerged off St. Thomas.

PRINCIPLES

1. Accurate navigation is a necessity, especially when operating inthe vicinity of shoal water.

2. Area boundarie s should be placed on the DRT along with othercaution points or shoal spots.

3. When operating in the vicinity of shoal water, Bottom Contour Charts should be consulted..

NARRATIVE

This submarine was furnishing services for advanced ASW exercises off St. Thomas. The initial position for the exercise was ~t

the center of the northern boundary of the assigned operating area.Approximately one mile to the north of this area was the 100 fathomcurve which shoaled rapidly. The Navigator of the submarine got afi~ which placed him in the area and. then transferred it to the DRT.He neglected, however, to include on the DRT the boundaries of thearea or the 100 fathom curve. In an attempt to evade a sonobuoypattern, the submarine took a course of 285°T. This took them outof the area (of which fact they were unawar~) and 20 minutes afterdiving they struck a submerged pinnacle at a depth of 345 feet,causing severe damage-to the bow.


1. The cause of striking a coral projection in this case wasthat the submarine maneuvered outside her assigned operating area.

2. The proximate cause was the failure of the Navigator to laythe area boundary on the DRT plotting sheet.

COMMENTS

The first lesson is a simple one. If performing extensivemaneuvers SUbmerged, you must keep t rack of where you are, not onlyof where you have been. In plotting on the DRT, navigation ispractically useless unless area boundaries, shoal spots and thelike are included on the plotting sheet.

D-19


A secondary lesson to be learned here has been pointed outnumerous times since this particular occurrence. This lesson isto make use of those items tucked away in the Forward Battery knownas Bottom Contour Charts. Many Hydrographic Office charts arecharacterized by a sparcity of sounding information. This is especially true when the depth is greater than 50 fathoms. One reason is thatsurface ships are little concerned if their bottoms are not imperiled.Yet with the advent of increased operating depths for submarines thisbecomes an extremely important factor. The Bottom Contour Chartfor this particular area showed a 20 fathom pinnacle 5 miles southof the actual grounding position which was itself south of the 100fathom curve. The HO chart is use by the submarine showed over1000 fathoms at the spot.

D-20


CASE

Submarine grounding off Race Rock.

PRINCIPLES

Safe navigation when piloting requires that:

a. Navigational lights be positively identified;

b. All navigational aids be used, Le. radar and fathometer;

c. An accurate dead reckoning track be scrupulously maintained.

NARRATIVE

A submarine conducting shakedown training shortly after goingin to commission in 1944 was returning to New London from BlockIsland Sound. The night was dark with overcast sky but visibilitywas such that navigational lights could be seen for at least 6miles. At 2045 a fix using bearings on 3 lights was obtained andthe pit log mileage recorded; this was repeated at 2100. Additionalfixes were obtained until 2152 when a fix.was obtained using CerberusShoal Buoy, Little Gull Light, and what was throught to be Race Rockbut what was in fact the station ship south of Fishers Island. Thisfix was sufficiently accurate, however, in that it indicated that therun to Race Rock was 3.9 miles. Course 270° was set to pass RaceRock abeam to starboard. At 2155 course was altered to the left toclear .a "navigational light" that later turned out to be the Stationship previously mentioned. At 2159 after a run of approximately 1.5miles from the 2152 fix, thinking that Race Rock had been passed tostarboard, course was changed to 300°. Identification of the StationShip as Race Rock had been made by the Navigator because of theshape discernable through binoculars. At this time because of thewar, Race Rock was not exhibiting its normal characteristics and wasshowing instead a fixed white light. It had in fact been sightedat 2142 by the Commanding Officer when he came to the bridge, buthe had not identified it nor had anyone else on the ship. At 2204a darkened object was sighted ahead, identified as a tug and towpassing port to starboard, and the submarine was maneuvered to avoid.This tug and toW was in fact low head lands of Fishers Island withthe apparent eastward motion caused by the submarine's set to thewestward by the current. At 2207 course was changed to 340 0 T tohead for Southwest Ledge ~ight. At 2216 calls were exchanged withthe RECP on Mt. Prospect on Fishers Island with the mistaken beliefthat they were being exchanged with a Coast Guard patrol vessel.At 2217 the boat grounded in 15 feet of water just east of Race Rock.

D-21



1. Race Rock was at no time identified by the personnel of thesubmarine.

2. Had a fix been obtained using navigational lights that were insight showing proper characteristics and had radar ranges and bearings of Race Rock been taken and plotted, it would have been apparentthat the light was Race Rock.

3. Use of the PPI rad.ar scope would have clearly shown the outlineof Fishers Island in time to have prevented the grounding.

4. The Connnanding Officer, Navigator, and OOD did not check thecharacteristics of the lights of the Station Ship as compared withthose of Race Rock.

5. The fathometer was not used to ascertain that the ship was insafe water, nor was the DR: track followed to insure that the ship waskept in safe water.

6. Determination of the current was not made although the information was readily available, notwithstanding the fact that both theConnnanding Officer and Navigator were well aware of the dangerousand unpredictable currents and tide rips in the vicinity of the Race.

COMMENT

There is no excuse for the failure to follow the proven and .age-old procedure of safe piloting: that of following, by use of anaccurate DR track from fixes obtained fro~identified landmarks, apreviously laid intended track with ranges, distances, danger andturning bearings and ranges clearly marked, and at the same timeusing the fathometer and radar to best advantage to insure that theship is not deviating from her intended track. This case, as inmost grounding cases, resulted not from ,lack of knowledge, or of oneerror or oversight of anyone person, but basically it stemmed fromthe failure to follow the basic fundamentals of safe piloting whichare well known.

D-22


CASE

Submarine grounding off Cape Canso, Nova Scotia.

PRINCIPLES

Safe navigation when piloting requires that:

a. All navigational aids be used;

b. An accurate dead reckoning track be scrup1,llously maintained;

c. Actual speed over the ground be determined.

NARRATIVE

Submarine was returning from a shakedown cruise enroute to NewLondon from Montreal, Canada. At 0617 a fix placed the Ship 600 yardson bearing 2180 from Cerberus Rock Gas and Whistle Buoy in ChedabuctoBay, course was 1280 , speed about 15 knots, visibility about 8 miles.On the basis of the fix, course was changed to 1190 to pass Grime ShoalGas and Whistle Buoy to starboard. The Commanding Officer went belowshortly before passing Cerberus Buoy at 0617.. The Navigator was theOOD. At 0636 the visibility reduced to about 800 yards and was soreported to the Commanding Officer. Visibility continued to reduceuntil at the time of grounding it was between 200 and 300 yards. At0653 and afterwards the fathometer was used to obtain soundings. At0654 speed was changed two thirds (approXimately 10 knots). At 0702the Navigator thought he heard Grime Shoal Buoy, and assuming that ithad been passed, changed course to 1900 , reporting to the CommandingOfficer that the sea buoy had been passed to starboard and the coursechanged to 1900

• At 0705 "All Stop" was orde.red. At 0707 two thirds.speed ahead was resumed, but at 0710 one third ahead was ordered andcourse changed to 1800 • Shortly thereafter "all stop" was ordered,then "All back emergencyll, and· at 0712 the boat grounded in about 10feet of water to about frame 40 on the keel in a rocky cradle formation, in the vicinity of Bass Rock (Lat 45° 21' N, Long. 600 West),approximately 3 1/4 miles northeast from Cape Canso, Nova. Scotia.While aground the ship rolled with each swell and pounded heavily wheninclined about 500 • At 0729 the ship backed clear and anchored •.


1. There was opportunity to check the speed by navigational fixeson vi·sible landmarks after passing Cerberus Rock Buoy before visibility was reduced at 0636.

2. All reports as required by U.S. Navy Regulations, 1920, werenot made to the Commanding Officer.

D-23


3. No radio bearing was taken of or received from Canso Radio CompassStation, which was approximately 4 1/2 miles to starboard.

4. The original course of 119 0 laid down from Cerberus Rock Buoyto Grime Shoal Buoy was proper for the visibility prevailing at 0617,and after 0636 when Visibility was reduced to 800 yards or less,there should have been no unusual difficulty in navigating aroundGrime Shoal Buoy safely. It was near slack water.

5. The grounding was primarily caused by changing too soon tocourse 190 0 on the false assumption by the Navigator that he hadheard and passed to starboard Grime Shoal Buoy, and also his failureto give heed to the reckoning of the ship and distance run fromCerberus Rock Buoy.

6. Contributory causes for the grounding were as follows:

a. Failure of the OOD to keep the Commanding Officer fully informed of changes in visibility and other incidents affecting safenavigation of the ship.

b. Failure of the Navigator to keep track of ship after passing Cerberus Rock Buoy before visibility was reduced.

c. Failure of the Officer of the Deck to stop immediately whenthe first sounding of less than 20 fathoms gave indication of danger.

COMMENTS

As, of course, is evident, this is a good example of thehazard of navigating from fix to fix without use of the DR to determinewhere the ship will be and when. In absence of information to thecontrary, the DR Posit represents the best position available to theNavigator and must be so used. How man~avigators when asked, ''Whereare we?", can reply, "The DR from the last fix puts us here, I'll geta fix to check it."??? All too often the reply is "Just a minuteIt'll get a cut" because no DR has been run ahead from the last fixand without the cut"the navigator in truth doesn't know where theship is or should be.

Of equal hazard to safe navigation as exemplified in this caseis the failure to keep the Commanding Officer fully informed. Not onlyshould OODs zealously keep him informed by reason of his ultimate responsibility for the ship in which he has a right to know just what istaking place, but also because the Commanding Officer is much moreexperienced and it is possible that he might better know what to do.Two heads are better than one.

D-24


CASE

Submarine ground.ing in a fog.

PRINCIPLE

When in fog in confined waters and the ship's position is indoubt, anchor.

NARRATIVE

In 1943 a newly commissioned submarine got underway from themouth of the Thames River, New London, Conn. Visibility was ab0ut 4000yards. About 31 minutes later, while still between Race Rock and Southwest Ledge, course was reversed to return to the anchorage becausevisibility had been reduced to zero in a dense fog~ The following precautions were'taken:-' the Commanding Officer took the conn, propulsionwas shifted to the battery, hull ventilation valves and bulkhead valvesshut, a watch stationed at each watertight door, a special fog lookoutstationed, lead line manned, anchor made ready to let go, and properfog signals sounded. Radar and fathometer were employed to try todetermine the ship's position. Both the Cormnanding Officer and theNavigator were cognizant of the state of the tide and the current tobe expected. Although desirous of anchoring due to doubtful ship'sposition, the Cormnanding Officer elected to continue navigating withcaution to the anchorage rather than anchor in the traffic lane be-tween New London and Race Rock. Finally, due to the uncertainty of theship's position and the sounding being obtained, the decision was made toanchor approximately 1 1/2 hours after cormnencing the return to theanchorage. As the anchor was about to be let go the ship grounded nearGoshen Ledge at the Mouth of the Thames River. Damage was minor.


1. All necessary precautions were taken when the dense fog setin except that of anchoring.

2.by hisport.

The Cormnanding Officer was solely responsible for the groundingfailure to anchor shortly after reversing course to return to

COMMENT

Shifting to the battery in a dense fog is good practice toreduce background noise in order to promote better listening conditions for the bridge watch. It has also been found advantageous touse the JT sonar to locate bell and whistle buoys under conditions oflow visibility.

D-25


CASE

Submarine grounding submerged.

PRINCIPLE

When approaching shoal water every available navigational aidshould be used.

NARRATIVE

Submarine was submerged at 58 feet on a training exercise. TheCommanding Officer had ordered the boat to remain near a referencepoint which was 2 miies to seaward of the 20 fathom curve. Limited usewas made of radar in order to avoid detection by opposing aircraft.For a similar reason soundings were being taken only every 30 minutesbut only with permission of the Conning Officer. At 0919 the positionof the ship was fixed with 3 visual bearings as about 2500 yards outside the 20 fathom curve; ships course 322 0 (toward shoal water) at4 knots. Without advising the Commanding Officer the Navigatordecided to continue to close the shore to further attempt to identifylandmarks. The 0930 sounding was overlooked. At 0933 a round ofbearings was taken; as they were plotted the Navigator realized thatthe ship had enterdunsafe water inside the 20 fathom curve. "Rightfull rudder, starboard stop" was ordered. The Commanding Officer,who had been in the Forward Battery and had felt the ship bump thebottom, rushed to the Conning Tower and gave orders to surface, butnot before the submarine had. struck bottom.

FINDINGS

1. The Navigator negligently hazarded the submarine in that:

a. The position of the ship was not fixed during a 14 minuteperiod while approaching shoal water.

b. The Commanding Officer was not advised that the ship wasapproaching unsafe water, nor was he advised of the difficulty inidentifying landmarks which were vital to the safe navigation of theship.

c. A dead reckoning track was not maintained nor were dangerbearings employed.

D-27


2. The basic navigational practices, i.e. proper DR track, use ofdanger bearings, and effective use of fathometer, are matters whichthe Commanding Officer should have insisted upon in training and indoctrinating the Navigator and OOD.

OPINIONS

1. The failure to note the absence of the 0930 sounding indicatedthe relative unimportance attached to fathometer readings as a navigational aid.

2. The failure of the Navigator to fix the ship's position for 14minutes after having directed the course toward shoal water was dueto his concentration on trying to identify navigational aids on adjacent land.

COMMENT

This was apparently a case of trying to do such a good job ofnavigating that the basic fundamentals of safe navigation were ignored.One of the best aids available to the Navigator for safe navigationis the Q}1 assisting the Navigator, be he the navigating QJt1 or the Q}1on watch. By. confiding fully in the Q,M as to what is .intended andreqUiring him to maintain the projected DR track, there are in effect2 navigators and a mistake or omission by one is likely to be discovered by the other. Too often young and zealous Navigators do allthe work themselves with the result that th~ Q}1 is practically ignored except to record bearings, with the result that the Q}1 couldcareless what is going on when in truth he should be the Navigator'sright hand man.

D-28


CASE

Scraping the bottom in shallow water.

PRINCIPLE

The bottom side sound heads should. be raised when operatingnear the bottom.

NARRATIVE

A submarine conducting S-3-G 1rehearsals in Narragansett Baysubmerged in water 117 feet deep and comm.enced the attack. Whilesimulating firing at the target, the escort was observed to changecourse toward. The submarine dove to 85 feet to avoid, at whichtime the fathometer indicated 4 fathoms under the keel. Eight minutes later a scraping noise was head under the Forward TorpedoRoom. A position at the time of surfacing showed that the submarinehad skirted the edge of a 90 foot curve. The sound head shaft wasparted above the spider and the spider twisted.

COMMENT.

In,practically all cases of grounding or striking the bottom,the sound head, if lowered, has sustained a considerable amount ofdamage. In several cases the sound head has been the only equipmentdamaged. Cornmon sense dictates that the bottom side sound head beraised when operating below periscope depth in shallow water.

D-29


CASE

Submerged grounding while conducting an approach.

PRINCIPLE

Navigational fixes should be plotted on the NAVPLOT when exercising at battle stations in the vicinity of shoaling water.

NARRATIVE

The submarine was conducting a practice torpedo firing exercise in a submarine operating area where water depth varies frommore than 700 fathoms to fathoms. The Commanding Officer and allship I s officers were fully aware of the potential dangers to submerged operations in this particular area. When the ship submergedto begin the approach, the position of the dive was fixed wherecharted water depth is approximately 500 fathoms. This fix was nottransferred to the NAVPLOT nor were any navigational aids or indications of shoal water noted on the plot.

The manner in which the approach developed required the submarine to steer courses in the general direction of the shallow portion of the area. The significance of this fact was not fullyrealized by the Commanding Officer. He had been informed of thewater depth upon diving and apparently assumed the approach would beconsumated prior to reaching the 100 fathom curve. While maneuveringthe ship to gain a firing position, the Commanding Officer made visualobservations of the target. Land marks in the vicinity were withinvisual range, but bearings were not taken to fix the IS positionnor were any requested by the NAVPLOT party during the approach. Thefathometer had been secured. Immediately after firing an exerciseunit from a keel depth of feet, the Commanding Officer orderedthe depth changed to 250 feet. He had announced his intension toperform this maneuver to the fire control party earlier in the approach. As the submarine leveled off at 250 feet, with a zerobubble and about 3 knots speed, an unintentional bottoming occurredwhich damaged sonar equipment and a propeller.

COMMENTS

A submarine battle station organization must provide for navigating the ship and fixing its position as required. When exercising in potentially dangerous areas, the last fix taken prior to

D-31


submerging should be placed on the NAVPLOT. In addition, curvesindicating shoaling water, landmarks and other aids to navigationshould be indicated. A NAVPLOT with this information will give earlywarning that the ship is approaching dangerous water and will alsofacilitate plotting any visual fixes which may be obtained during theapproach. When necessary to secure the fathometer to prevent sonarinterference, it should be left in standby and single ping soundingsobtained periodically. Once an exercise torpedo has been fired, and.especially if the submarine is increasing its depth, soundings shouldbe taken at frequent intervals.

This submarine sustained a casualty Which it had taken particular effort to prevent. Knowing the topography of the area, theCommanding Officer had stated a firm policy never to operate the shipsubmerged in that portion of the area inside the 100 fathom curve.This policy was fully understood by all officers. The Navigator hadalso stated the policy and explained it to all quartermasters. Thefact that the ship bottomed proves once again that good intentionsare not an adequate substitute for vigilance and prudence.

D-32


CASE

Submarine grounding while anchored near dangerous shoal water.

PRINCIPLES

1. A submarine should not remain in a hazardous position exceptwhen required by the nature of the mission and then for only as long asis absolutely essential.

2. True bearings of fixed objects must be taken frequently whenat anchor to determine any evidence of movement. The frequency of takingthese bearings should be determined by the conditions of hazard existingat the anchorage.

3. A Commanding Officer exerc~s~ng command when, even thoughashore, he is in communication with his ship and is receiving reportsand issuing orders. In this situation he must exercise the same decisiveness characteristic of a good Commanding Officer when actually onboard his ship.

4. The Executive Officer succeeds to command by virtue of theabsence of the Commanding Officer, as does the next senior officer inthe absence of both the Commanding Officer and Executive Officer, andas such must actually exercise command as dictated by the situation.

NARRATIVE

The submarine was ordered to an island in order to fuel and assist in the repair of a seaplane. The coastal area at which the evolution was to take place was poorly charted, the only chart On board being to the scale of 4 miles per inch. Since the bottom in this areashoaled rapidly and the landmarks were poorly charted, a small boatwas launched to precede the submarine and to take soundings. The submarine anchored but was unfavorably situated so it shifted to a secondanchorage, preceded again by the small boat. A third anchorage ~as

necessitated when it was found that the aircraft had insufficient fuelto move to the submarine I s second anchorage. The submarine thereforeshifted to a third anchorage very near the seaplane. This anchoragewas in 33 feet of water but with dangerous shoal water so near that theship could safely use only 12 fathoms of anchor chain.. (It is interesting that this anchorage was about 500 yards from the beach, a distance of 1/16 of an inch on the chart being used for navigation). Thesubmarine was flooded down aft to effect the fuel transfer. Difficultywas experienced in flooding down and a diver was put over the side toinspect the underwater body. He discovered the rudder inbedded in softsand to a depth of about two inches. The aircraft was then fueled and

D-33


departed to its mooring buoy. The submarine chose to remain in heranchorage preparing equipment and mooring tackle for use of the aircraft in effecting an engine change on the following day. This repairwas to take place in a sheltered cove along another coast of the island.

Bearings were taken throughout the night of objects on the beachto check any evid.ence of movement. The Command.ing Officer t s Night OrderBook called for bearings to be taken at least every two hours. Thesebearings were actually taken at a maximum interval of 3 1/4 hours and aminimum of 15 minutes. The bearings of these objects did not changethroughout the night. However, the rudder was felt to touch bottom atabout 2030-2100.

At 0930 on the following morning the Commanding Officer causedan inspection of the rudder to be made by a diver and the rudder wasagain found to be imbedded in sand to about the same depth as before.The Commanding Officer left the ship by small boat at about 1000 to discuss further details of the aircraft engine change on the shore. Atthis time wave height was about 4 feet and wind velocity 18 knots; bothwere increasing. Upon arrival at the beach, the Commanding Officer received a flashing light message from the Executive Officer that the shipwas dragging or had dragged her anchor. Weather and sea conditions haddeteriorated rapidly during the small boat's transit and the CommandingOfficer found he could not return to the ship because of surf conditionsat the beach. The small boat was not able to transmit any message visually back to the ship so the Commanding Officer proceeded to a radiostation 4-5 miles away. At about 1130 he established communicationswith his ship. Several radio conversations between the Commanding Officer and Executive Officer took place beginning at this time. These conversations describe the deteriorating conditions and in essence were asfollows:

1130 - Executive Officer reported he believed ship had stoppeddragging. Commanding Officer said that he preferred not to get underway until he returned but to do what the Executive Officer thoughtbest. The Commanding Officer would call again in 1-1 1/2 hours.

1300 - Executive Officer reported situation deteriorating. Anchor chain whipping some and rudder pounding on bottom. Would like toflood No.2 main ballast tank to ease strain on the rudder. Ship hasbeen rigged for dive with the exception of main induction, bridge hatchand checking by officers. The Commanding Officer gave permission toflood No. 2 main ballast tank and told the Executive Officer to standby,he would try to return to the ship, but to get underway without him ifhe thought it best.

D-34


The Commanding Officer left t he radio station and arrived at thebeach to find that the boat could not make it through the surf. He returned to the radio station and called the ship.

1400 - Executive Officer reported that the weather was worse andhe believed he should get underway. The flooding of No. 2 main ballasttank had not helped and the ship was pounding heavily. He had thereforeflooded down and bottomed. He planned on completing the rig for divecheck, pumping all variable ballast tanks dry, then blowing the mainballast tanks and getting underway. The Commanding Officer concurredin this course of action and again stated that he would prefer to beon board before getting underway. He would continue to try to get outto the ship but that the Executive Officer should go· ahead and get underway if he thought best.

1500 - Executive Officer reported weather worse, submarinepounding heavily and believed he should get underway. CommandingOfficer told him to get underway and not wait for him. ExecutiveOfficer reported that he would have the variable ballast tanks dryby 1530 and would attempt to underway on the high tide whichoccurred at that time.

1600 - Exec~tive Officer reported the ship rigged for diveand ready to get underway; he would attempt to get underway. TheCommanding Officer told him to go ahead.

At 1606 the Executive Officer ordered all main ballast tanksblown and attempted to get underway. He blew safety and negativeand heaved in on the anchor. At 1626 the anchor was aweigh but theship would not move. At 1630 the anchor was again dropped, chainveered to 15 fathoms, and the ship flooded down and bottomed. At1647 the Executive Officer reported by radio that the submarine wouldnot move. The Commanding Officer ordered him to flood d.own as much aspossible and was informed that this action had already been taken. TheCommanding Officer said that he was going to attempt to come out to theship in a rubber boat.

The Commanding Officer returned to the ship at 1800 and madeanother unsuccessful attempt to get und.erway. Several attempts weremade on high tides the following day, all being unsuccessful, and onthe day following that an ATF arrived which also was unsuccessful inher attempts to refloat the submarine. The submarine remained agroundfor a period of eight days during which time several attempts to refloather were made. The salvage force needed to finally free her consisted

D-35


of 3 ATF t s, 2 ASR t S and 1 YOO. The submarine was lightened by approximately 1,660,000 pounds before she was refloated.

Damage to the submarine t s underwater body and appendages wereextensive due to the nature of the coral shoals on which she had strand.ed.The ultimate cost of restoring the ship to a condition similar to thatexisting prior to the stranding was estimated at $19,275.

In reviewing this grounding, a significant finding of fact isthat true bearings of objects on the beach changed as much as 12.5degrees during the period 0930-1730 on the day of the grounding.Between 0900 and 1700 the wind velocity increased from 18 knots to25 knots and wave height increased from 4 feet to 12 feet. Testimony also revealed that throughout the entire period of uncertaintyas to whether the anchor was dragging, with extremely poor naVigationalaids for determining the ship's position or any change thereof, noattempt was made to use a drift lead to determine any motion of theship over the ground.


1. The professed inability of the aircraft to be maneuvered tothe location of the submarine at her second anchorage dictated theshift to the third and closer anchorage.

2. On the occasion of the third anchorage the CommandingOfficer'placedhis ship in such a restricted location that theproximity of dangerous shoal water prevented.him from using adequatescope of anchor chain.

3. Under the conditions of the ruddE;!r touching bottom, theproximity of dangerous shoal water, and the vulnerability to theweather from the position, having completed her immediate task ofservicing the aircraft, the submarine should have moved to·a lessrestricted anchorage or moved away from the island.

4. The Commanding Officer was negligent in departing the submarine with the following conditions existing:

a. Rudder bumping on bottom.

b. Weather freshening from the West.

c. The submarine a ship length from dangerous shoal waterto the East.

D-36


d. Insufficient scope of anchor chain in use.

5. The Commanding Officer showed indecision in his radioconversations between 1130 and 1400 with the Executive Officer inthat he gave him the impression that he desired to wait until he,the Commanding Officer, returned aboard, and then complicated thesituation with the expression, liDo what you think best".

6. The submarine dragged her anchor toward the beach intermittently from 0930 to 1720.

7 . The submarine went hard aground sometime between 1400 and1606.

8. The Commanding Officer was exerclslng command from the timeof establishment of radio communications between himself and the Executive Officer, even though he, the Captain, was physically off the ship.

9. The Executive Officer used poor judgement in not getting theship underway at the first indications of the anchor dragging at about1030, considering all conditions under which the ship was anchored.

10. The 1500 radio conversation is the first indication of morethan tacit approval by the Commanding Officer of the Executive Officer'sopinion that the ship should be gotten underway.

11. The delay, occasioned by completing pumping variables andchecking rig for dive, was not necessary in order to get the ship underway•.

12. At any tiine prior to t he deliberate bottoming of the submarine at approximately 1400, the ship could have been gotten underwayand .clear of the anchorage .

13. Both the Commanding Officer and Executive Officer passed upnumerous opportunities between 1130 and the time the ship went hardaground to take positive action to save the submarine from stranding.

14. There is doubt that the submarine could have gotten underway at or after 1500 following the conversation between the Captainand the Executive Officer.

The cause of stranding of the submarine was due to a combination of the following conditions:

D-37


a. Inadequate scope of anchor chain.

b. Increase of wind and sea conditions.

c. Failure on the part of the Commanding Offi cer to takepositive action when appraised of the conditions at the anchorage.

d. Reluctance on the part of the Executive Officer to movethe ship to safe waters.

COMMENTS

In many situations a task may be assigned a submarine, the emer-gency nature of which requires acalculated hazarding of the Thiscase could conceivably be considered in that category at the time whenthe submarine was forced to move to a d.angerous anchorage in order tofuel the aircraft. In view of the weather conditions which followed,there exists the possibility that the seaplane might have been destroyedhad she not been refueled and thereby able to seek shelter on the leeside of the island. However, once the refueling evolution had been performed, there was no further need to remain in this dangerous anchorage.With insufficient anchor chain out and the rudder already having touchedbottom, it is inconceivable that a commanding officer would choose toremain overnight rather than spending the night at sea or shifting toa safe anchorage.

It would be noted that the Commanding Officer's Night Order Bookrequired bearings of objects on the beach at least once every two hours.With shoal water only a few feet away, this time interval is grosslyinadequate. A prudent time interval in a safe anchorage would be everyquarter hour. If a vessel must be anchored in a hazardous situationsuch as this, in unsheltered waters, with shoals in close proximity and.an insufficient scope of anchor chain out, the situation would dictatethe taking.of nearly continuous anchorage bearings and the maintainingof a maneuvering watch able to get the ship underway on a moment'snotice.

It is difficult to understand why the Executive Officer did notimmediately the ship underway when, shortly after the CommandingOfficer I s departure at 1000, he discovered that the anchor was dragging. He had full knowledge of the shoal water, being also the ship'snavigator, and knew that the rudder had been found to be on the bottom when inspected at 0930. In the absence of the Captain the Executive Officer had in fact become the Commanding Officer. Rather thangetting underway and informing the Captain of his reasons, he chose to

D-38


take no action other than to inform the Captain by flashing light thatthe anchor was dragging or had dragged, a message for which the Captainhad no means of immediately replying. Good judgement would dictatethat, in the absence of the Captain and the Executive Officer, the DutyOfficer or senior officer on board would immediately the ship und.erway in such a situation.

In regard to this grounding, the Force Commander stated inpart" ... illtimate responsibility for the submarine's remaining atthe anchorage throughout the day preceding the grounding and untilabout 1015 on the day of the grounding, even though the aircraft wasrefueledand the rudder of the ship touched bottom on three occasions,must rest upon the Command.ing Officer. However, after the CommandingOfficer's departure from the ship at about , the exact delimita-tion of the deficiencies in performance by the Commanding Officer andExecutive Officer is complicated by the absence of an accurate recordof their radio conversations. None-the-less, it is clear that theExecutive Officer failed to adequately discharge the dU~ies placed onhim by authority superior to this' Commanding Officer and for this hemust individually be considered accountable. The Executive Officer asearly as 1030 recognized that the submarine was in danger. Prudencedictated that he exercise command and get underway immediately, inform-

the Commanding Officer, who was ashore, of the action. Or, havingdecided to inform the Commanding Officer before taking action he shouldhave recommended a definite course of action. This was not a situationwherein an Executive Officer must carefully consider the serious implications attendant upon relieving a Commanding Officer; it was rathera situation expressly provided for by Navy Regulations, section 1373,in which the Executive Officer had succeeded to command by virtue ofthe absence of the Commanding Officer."

D-39


CASE

Submarine grounding while approaching the measured mile offProvincetown, Massachusetts.

PRINCIPLE

1. Physical fatigue does not relieve the Navigator of his responsi-bility for the safe navigation of the ship.

2. The Commanding Officer's Night Orders are the guide lines forthe conduct of watchstanders; in addition to containing standingorders they must list specific navigational aids to be encountered.

3. The Officer of the Deck can not rely on any other person to connthe ship into safe water; this is his responsibility, and to execute itproperly he must personally know the ship's position at all times.

4. The Officer of the Deck retains the conn until properly relieved.

NARRATIVE

The submarine departed New London enroute to Provincetown viathe Cape Cod Canal, with the Commanding Officer and Navigator activelypiloting, a duration of about ten hours. Upon entering Cape Cod Bayat 0316, the submarine set course for the measured mile area offProvincetown. The Commanding Officer retired to his stateroom aftersending his Night Orders to the conning tower. These orders weregeneral, referred to the standing orders, and state<i Navigational datawould be furnished by the Navigator. The Navigator and Officer of theDeck read and initialed the Night Orders as written by the CommandingOfficer. The ship made one-third speed on one engine in order to arriv€at the measured mile during early morning twilight. The Navigator continued to pilot from the conning tower, and cat-napped there betweenfixes. There was no chart on the bridge for the OOD. During the transit across Cape Cod Bay, regular fixes were plotted and bearing recorded.The fixes showed a definite northwesterly set. No DR positions along theintended track were plotted, nor were danger bearings established in areaswhere shoal water was to be encountered. The proposed track passed southof unlighted buoy DELTA, leaving it to port. The Night Orders made nomention of this fact. Because during the major part of the transitthree of the four available naVigational aids were nearly in line,bearings were taken on only two aid.s. Radar was employed for rangingduring the transit, the greatE!r part of which was made during darkness,visibility ten miles, skies overcast, sea state one.

D-41


Five minutes before the ship was to enter shoal waters the fathometer was lighted off. Morning twilight began. Shortly thereafter,soundings showed the depth below the keel to decrease rapidly from 125feet. A fix taken prior to this showed the submarine to be well offthe intend.ed track. The Navigator was aware of this; the OOD was not.Unlighted buoy DELTA was sighted abeam to starboard. The Navigator,who was also Executive Officer, doubting the validity of his lastand upon being informed of the sounding and the buoy, ordered the ship.pack down and turned to the left, then twisted, without properly relieving the OOD. The twist to the left turned the ship towards shoalwater. Soundings were now zero. At about 0505 the submarine ranaground near Shank Painter Bar, suffering neither physical damage norpersonnel injuries.


1. The Commanding Officer's Night Orders were written in terms toogeneral for proper navigation through shoal water, and no additionsto the orders were made by the Navigator.

2. The Navigator erred by failing to plot DR positions along thetrack, and danger bearing.

3. The Navigator did not take action to return the submarine to thetrack when successive fixes showed a definite set, nor did he alert theCOD or inform the Commanding Officer.

4. The OOD erred by placing complete reliance upon the Navigatorand by failing to check the ship's position himself.

COMMENTS

Night Orders are the Commanding Officer's specific instructionsfor the safe navigation of the ship. They, and the proceduresfollowed, must embrace every aspect of proper navigation and goodseamanship. In this instance they should have included the listingof characteristics of navigational aids to be encountered, and adefinite position of arrival. They should have directed a twoengine propulsion combination on arriVing on station. The latter isan important consideration when maneuvering in dangerous or unfamiliarand restricted waters. Proper navigation involVes a multitude ofroutine practices by the Navigator and when piloting, the plottingof DR positions and danger bearings along the track are necessaryones. Additionally, early and prudent action to aviod apparentdanger as shown by plotted fixes, giving advice to return the ship

D-42


to the intended track, and informing the ODD and Commanding Officerthat the ship is off the track, are essential. The ODD's role certainly includes keeping himself adequately informed of the ship'sposition, and taking appropriate avoiding action on his own initiative when it is early enough to be effective. When the ExecutiveOfficer deems it adyisable to relieve the ODD of the conn, he shoulddo so in a proper, formal manner. And finally, good seamanshipdictates that when maneuvering in unfamiliar waters and doubtingthe ship l s position, one should remain in, or return to safe waterby stopping, and if necessary, clearing the dangerous area throughgood water just transited.

D-43


CASE

Submarine grounding while conducting submerged operations.

1. Responsibility and necessity for the Conning Officer to be fullyaware of the depth of water in which the submarine .is operating.

2. Responsibility of the Diving Officer for being fully aware of thedepth of water under the keel and keeping the conning officer so informed.

NARRATIVE

A submarine was conducting routine training operations with another submarine while enroute from Norfolk, Virginia, to San Juan, P.R.While making a submerged approach on the other submarine, the attackergrounded in 145 feet of water. At the time of grounding the submarinewas at battle stations for the submerged approach. The Cornm.andingOfficer was the Conning Officer. The depth of water at the point ofgrounding was clearly indicated on the chart in use as 24-25 fathoms.The conning officer, navigator and diving officer, among others hadprior and sufficient knowledge of the actual depth of water. Thefathometer was in operation on automatic ping until just prior tothe grounding. The approach was being conducted at periscope depthwhen the conning officer ordered 150 feet in an effort to reducecavitation noises. The diving officer acknowledged the depth changeand proceeded to carry it out. When at about 145 feet indicated depththe conning officer decided to go deeper and ordered a depth of 200 feet.Again the diving officer acknowledged the order depth and proceeded toward200 feet. At almost the same time the submarine touched bottom.

OPINIONS AND FDIDINGS

1. The conning officer erred in ordering a depth that was greaterthan the depth of water and was responsible for the unintentionalgrounding. The error is attributed to the conning officer's failureto keep in mind the actual depth of water in which he was operatingwhile conducting the approach.

2. The diving officer was responsible to a lesser extent forfailure to associate the ordered depth with the insufficient depthof water.

D-45


COMMENTS

It is of paramount importance that the Conning Officer of a submarine always keep in mind the actual depth of water in which he is conducting submerged operations. This becomes increasingly more importantwhen the depth of water is such that it restricts the submerged operationsto less than the operational capability of the ship.

The Diving Officer must always be acutely aware of the depth ofwater in which submerged operations are being conducted and mostparticularly when the dBpth, of water is restrictive. The diving officer has a further responsibility to inform the conning officer promptlywhen existing conditions should preclude an order being carried out.

D-46


CASE

Submerged. bottoming while conducting drills.

PRINCIPLES

1. Extreme caution must be exercised while conducting submergeddrills, particularly in shallow water.

2. Drills that could easily result in loss of depth control must beeither carefully supervised by competent personnel or modified to anextent that resultant loss of control in shallow water will be precluded.

NARRATIVE

A submarine conducting drills prior to change of command lostdepth ctmtrol and struck the bottom. After completing a "hand dive"in water of generally 130 feet, sloping to 168 feet, a "collision inthe conning tower" drill was conducted. Upon executing the drillthe Commanding Officer ordered speed increased to full to add a degree of realism, since the depth of water prohibited the flooding ofnegative to simulate added weight. The ship was at 53 feet with anordered depth of 56 feet. The bow planesman had some dive on the bowplanes. The stern planesman had ordered bubble of zero on the ship.Some time after the word "Flooding in the Conning Tower" was passed,the auxiliary electrician who was acting under instruction, securedthe conning tower AC isolation switch. This switch cut off AC powerto both the conning tower/and the control room.

The Diving Officer, on loss of AC power in the control room,personally turned on the emergency. plane angle indicators and ordered,"Shift to emergency indication." Thi!3 was misunderstood by bothplanesmen. The loss of indication had been interrupted by the planesmen to be loss of power. In their minds the Diving Officer's orderadded confirmation and they attempted to shift to energency power.The bow planesman had difficulty with the pin of the emergency handwheel and was assisted by the Chief of the Watch. The stern planesman was assisted by the trim manifold operator. Both planes were atfull dive. During the shifting operation the ship assumed a sharpangle, estimated at about 25 down, and dropped from 53 feet to thebottom.

D-47


During this time the Diving Officer took the following additional actions:

a. at about 65 feet, "Bow buoyancy"

b. at about 90 feet, "Blow the forward group," "All stopII,"Blow the after group", "All back full".

The order to "All back full" was rung up on the 1 and 2 ME's in Conn,and passed via the 7 MC in Control. Realizing that both these circuitswere dead the order was then given on the XJA phone.

The total time elapsed from AC failure to striking the bottomwas about 35 seconds. The resultant damage was estimated at about $17,600.

OPINIONS AND FnIDINGS

The grounding was considered as not resulting from negligence butrather from the poor state of training of the watch personnel.

The casualty resulted indirectly from the loss of AC power in thecontrol room while rigging for flooding in the conning tower. The slowreaction time and lack of supervision by those standing supervisory watches,plus the failure to test and to verify wiring accomplished pursuant toa SHIPALT reflects adversely on the state of training of the command.

COMMENTS

The proficiency of the ship r s company must be kept at a maximum.level at all timesA During training periods for unqualified men closesupervisiQ!!1,lunan,datory to prevent accidents.

In order for a command to be carried out it must reach its destination. Positive -communication throughout the ship is necessaryto carry out all orders without delay.

The Diving Officer must constantly be aware of the watch personnel in the control room, their abilities, and their whereabouts.He must closely supervise his planesmen, particularly under conditionswhen they may, by their actions, endanger the ship. When he givesan order, he must insure that the order is acknowledged correctlyand is carried out as given. If any misunderstanding is encountered,he shall correct the situation immediately. Proper procedure is amust.

Whenever a submarine has any equipment that is not functioningproperly,corrective action must be taken immediately. Until suchcorrective action is completed all watch personnel must be made awareof the malfunction, such as the improperly wired conning tower isolationswitch, and act accordingly.

D-48


The Diving Officer must always take into consideration thebubble angle on the ship, whether for depth control or for damagecontrol purposes. In this instance the control room depth gage wasreading 130 feet, but with the 25 down bubble the bow was at about170 feet, and struck bottom.

D-49


PART E - MISCELLENEOUS CASUALTIES

These cases are grouped together under the heading of "MISCELLAN

EOUS" because they run the gauntlet from minor to maJor damage, from

serious to not so serious errors of personnel, and because they are not

so numerous in any particular category to warrant such a separation.

They have been selected, not because they were either sensational or

minor in nature, but because they resulted in almost every case from

avoidable personnel failures and omissions. Each case is representative

of many similar ones that have occurred as a result of the same errors,

whether in port, underway, or undergoing navy yard overhaul. These

cases are also important because they show that good submarining

embodies much more than just avoiding collisions, keeping off the

shoals, or bouncing off the bottom rocks. The errors illustrated in

these cases should serve as sign posts to guide the uninitiated toward

the performance required to prevent their reoccurrance.

E-l


MISCELLENEOUS CASUALTIES

Fire

Near Collisions

Near Grounding

Exceeding Test Depth

Loss of Control Submerged

Man Overboard

Personnel Injuries

Accidental Submergenqe

Loss of Power

E-3


CASE

Fire in Main Ballast Tanks while ship in drydock.

PRINCIPLE

Ship I S force is responsible for fire prevention and other safetyprecautions while in drydock.

NARRATIVE

While in a floating drydock, a submarine had #2 MET painted withwhite plastic, the painting being completed about 1600. Welding workwas performed between 1600 and 1900 adjacent to #2 MET, from which thetank top had been removed. No fire watch was stationed. About 1930a fire started in #2 MET, rapidly becoming very intense due to thedraft created through the flood holes in the bottom of the tank and theholes (about 18 inches in diameter) in the top. Additional minor fireswere caused inside the ship and in the well deck of the ARD.


1. Hull section and associated piping inside of #2 MET must be renewed at a cost of approximately $900,000.

2. That had adequate fire hoses been available and promptly used thefire would have been contained and extinguished before serious damageoccurred.

3. That the regulation concerning the stationing of fire watches wasnot being enforced.

COMMENT

It is well known that fire is the most serious danger to be fearedwhile in shipyard overhaul, an ever-present danger that is amplifiedwhen welding and burning is in progress. In this particular case, thedanger was made greater due to the proximity of the white plastic paint(formula 89), which has a flashpoint of 4000F and a ignition point of4350F, thus constituting a serious hazard.

AlthOUgh burners and welders are supposed to obtain fire watchesbefore commencing work, ship1s force must be ever on the alert to prevent such violations as occurred in this case. To this end, all hands

E-5


should be indoctrinated concerning the dangers of fire and the necessity for continuous inspections by the Duty Officer, the Duty ChiefPetty Officer, the Below Decks Watch, and the Topside Watch.

In addition, adequate fire-fighting equipment must be on hand readyfor use at all times. This includes CO2 extinguishers and fire hoses,and personnel must be well trained in their use and location. It isnot enough that the fire watch merely be stationed where they can do.,little except pass the word if a fire starts--they must be equippedand trained to fight the fire in order to be effective.'

E-6


CASE

Near collision with moored submarines by Tender parting hermoorings.

PRINCIPLE

Duty Officer and Duty Section must be ready at all times to get theship underway.

NARRATIVE

The Tender was moored port side to pier 22 in Norfolk. Submarineswere nested across the slip in 2 pairs of 2 each, one pair astern ofthe other. During a northeaster, 50 knots of wind pulled out the pierbollard that held the Tender's forward lines. The other mooring linesquickly parted and the ship began to drift downwind to starboard,endangering the submarines at pier 21, even though both of the Tender'sanchors were let go. By quickly warning. the submarines when the dangerwas apparent, the submarines were underway to safety within 7 minutes,except for the forward inboard boat which did not have time to clear.This boat moved forward to the sea wall and averted collision with theTender which came to rest against pier 21 astern of the submarine.

COMMENT

This case is a perfect example of why the Duty Officer must stayaboard and not wander up the dock or go over in some otherboat. It is also a good example of why an alert topside watch isnecessary.

E-7


CASE

Near gro~ding due to loss of rudder angle indicator.

PRINCIPLES

1. Emergency rudder angle indicator should always be energized inconfined waters.

2. Speed used in confined waters should be selected so as to providea reasonable safety factor in case of a mechanical failure.

NARRATIVE

Submarine was roaring by Southwest Ledge Light enroute New LondonOp-area for local operations, attempting to pass a submarine ahead.Helmsman reported, "Lost steering". The Commanding Officer, who wason the bridge, ordered "All stop", and "All back emergency" as theship began to swing left. Maneuvering room then reported, "Fire inthe maneuvering room". Since the Commanding Officer had not obtainedthe backing turns he had ordered, he ordered the anchor let go. Byskillful veering, the ship was stopped to the~ of Southwest LedgeLight, heading in the general direction of the Griswold Hotel with athoroughly chagrined Commanding Officer and OOD on the bridge.

COMM:ENT

The principal lesson is that "hot-rodding" in confined waters isfolly. The few minutes gained are never worth the risk, and oftenthe risk is most unfair to the rest of the trusting souls in the ship.

The entire casualty was due to a loss of AC power. Instead oflosing steering as he reported, the helmsman lost only rudder angleindication. The emergency rudder angle indicator was not on as itshould have been. The fire in the maneuvering room was the result ofexcessive arcing igniting some cork when the "all stop" bell wasanswered in a hurry.

E-9


CASE

Exceeding test depth when depth gage was secured by mistake.

PRINCIPLES

1. Diving Officer must check by all means at his disposal when suddenlarge unexplained weight changes are needed or when ship apparentlyfails to respond to control.

2. Diving Officer must keep Conning Officer informed when off depthor when having trouble with depth control.

NARRATIVE

Submarine was conducting evasive maneuvers under surface units at·a depth of 250 feet, with shallow depth gages secured. A depth of100 feet was ordered, and upon passing through 150 feet the planesmanwas directed to cut in the shallow depth gage. Instead, he mistakenlysecured the sea valve to all depth gages. The gage vent valve leaked,however, so the gages continued to indicate a slow decrease in depthas the pressure vented off them, and of course this indication continued when the Diving Officer attempted to level off at 100 feet. Inan effort to stop the apparent ascent of the boat, the Diving Officerrequested speed, took a down angle, and began to flood water intoauxiliaries, but still the gage indicated decrease in depth. When theDiving Officer requested full speed with a six degree down angle, theConning Officer, who had heretofore been busy checking sonar information on the ASW ships--took note of the depth on the conning towerdepth gage and the boat was leveled off about 100 feet below its testdepth. More than 30,000 pounds of water had been flooded into thevariable tanks during the attempt to stop the "ascent".

COMMENT

The Diving Officer made no checks of other depth gages or-of pressure gages when the ship apparently insisted on rising despite largespeed with good-sized down angles and the intake of many thousands ofpounds of additional water. The ship had been operating properly inreasonable trim minutes before, and any such radical change in variableballast or measures to maintain depth should have given rise to checksto see if the depth indication was in fact valid. Had the DivingOfficer reported his difficulty with depth to the Conning Officer, it

E-ll


is likely that the Conning Officer would have immediately taken moreinterest in his own depth gage and thus would have detected the troubleearlier. It is also significant that the near casualty would not haveoccurred in the first place had the planesman been properly checkedout on the duties and equipment of his watch station.

E-12


CASE

Exceeding test depth.

PRINCIPLES

1. All depth gages must not be secured at the same time.

'2. When securing any depth gage at the diving control station, depthshould be checked with other gages to insure proper depth keeping.

NARRATIVE

Submarine tlA": While running at 90 feet rendering services toDDs, the submarine was rigged for depth charge. The sea valves todepth gages at the depth control stand were shut. On securing fromdepth charge the sea valves to the gages were not opened and theboat was thought to be still at 90 feet in good trim. The auxiliaryman noticed abnormal sea pressure on the air manifold sea pressuregage, upon which it was found that the boat was well below test depth.

Submarine "Btl: While running at 150 feet, depth was orderedchanged to 175 feet. Bow planesman secured shallow gage stop andstern planesman secured deep depth gage stop thinking he was securinghis shallow gage stop. Depth was then 175 feet. Later, afterventing deep depth gage, the stop was discovered shut. On openingthe deep gage stop the boat was found to be below test depth.

COMMENTS

1. During "Rig for Depth Charge" the depth gages that are notsecured should be checked against each other often and personnel incompartments with sea gages should be required to keep check on seapressure.

2. When shifting to deep depth gage it should be checked againstanother gage to insure its proper operation.

3. The ease with which this type casualty can occur is primarilydue to the piping nightmare that connects the depth gages at the control stpnd to the sea chest(s). Piping should be modified to locatethe stop for each gage immediately below the gage itself rather thanhidden in t~~ maze of piping behind the control stand.

E-13


CASE

Broaching due to loss of baw and stern plane angle indicators.

'PRINCIPLE

Emergency angle indicators are essential for safe operation.

NARRATIVE

The submarine was running at 110 feet providing ASW services forDDs. AC power was lost, thus baw and stern plane angle indicatorswere lost. The Emergency Plane Angle Indicators failed to work, withthe result that control of the boat was lost and it broached in thecenter of the DD group.

COMMENTS

1. Emergency plane angle indicators are provided for just such occasions as this, and must be maintained in proper operating condition.

2. The torpedo room watches should be trained to report when theplanes are jammed (as is undoubtedly what happened in this case), aswell as the position of the planes when requested by control due tofailure of the indicators in the Control Room.

3. Ina similar case of stern plane angle indicator failure, allindicators indicated planes on full rise. The boat, however, reacted as if they were on full dive. Investigation revealed thatthey were actually on full dive and that the mechanical linkage tothe normal and emergency plane angle indicator transmitter had carried away, putting both normal and emergency indication out.

4. Loss of plane angle indicators should not prevent operation ofthe planes if the false reading of the indicator is ignored and theplanes operated in the manner indicated by the action of the boatitself. The hydraulic gages provided at the baw and stern planeshandwheels will indicate when the planes are in the stops and inwhich direction.

E-15


CASE

Broaching from loss of control when backing submerged.

PRINCIPLE

Evasive maneuvers should be selected with due regard to the exercise depth and the experience of the ship control team.

NARRATIVE

Submarine was operating at 125 feet with DDs conducting coordinated attacks. Boat was using "all ahead full", then "back full l

'

when speed had built up to 12 knots. Control was lost and the boatbroached with a 320 up angle with negative flooded, "All ahead full ll

and full dive on both planes.

COMMENTS

1. Backing is generally a poor evasion tactic, particularly at 125feet •.

2. 125 feet is not sufficient depth to exercise at this type evasionwithout skilled planesmen and Diving Officer.

3. The difficulty of removing an unwanted upperative that special attention be given to preventengaged in this type exercise.

E-17

makes it imup angles when


CASE

Uncontrollable up-angle on first dive of the day.

PRINCIPLE

Trim changes from compensation should be entered as changes fromprevious trim to specified new trim.

NARRATIVE

Submarine made first dive of the day for an ORI approach.Boat took a 150 up-angle before it could be brOUght under control.Trouble was traced to after trim tanks being 10,000 pounds heavy.This had resulted from careless logging of previous day's trim of25,000 pounds to appear as 35,000 pounds. Compensation was effectedby giving auxiliaryman a new set of tank readings. The change inafter trim was negligible, resulting in the auxiliaryman floodingin approximately 10,000 pounds to agree with the desired ~inal trimreadings.

COMMENT

The best practice is to effect compensation d~rectly from thediving book which shows the former trim, amount of change, and the~esired trim. Such a system provides a double check on getting theproper trim. Compensation should always be accomplished throughthe Chief of the Watch, never by the Diving Officer's handing theauxiliaryman a slip with some figures on it.

E-19


CASE

Excessive angle.

PRINCIPLE

Knowledge of the boat by all hands is essential to its safeoperation.

NARRATIVE

During a wartime patrol, a submarine lIlost the bubble lf whilediving to such an extent that all hands in the control room losttheir footing and slid to the forward end of the compartment, fromwhere the air manifold operator was unable to climb back to hisstation. A crewman in the after battery was able to climb lIdownhill" to the air manifold, which he immediately manned, and blew theforward group.

COMMENT

This incident indicates the necessity for well-trained personnel who know the boat and each other I s jobs. Had this man been lessfamiliar with the air manifold the boat could easily have been lostwhile he hunted for the proper valve to open.

E-2l


CASE

Lookout left topside on diving.

PRINCIPLES

1. A count by the ODD of personnel on the bridge to insure all,are below on diving is essential.

2. To insure that all lookouts hear the work "Clear the bridge",it should be repeated by each lookout.

NARRATIVE

A submarine on fleet exercises submerged in early morningdarkness. As the conning tower upper hatch was shut, "You left meon the bridge" was heard over the lMC. All vents were shut, surfacing alarm sounded, and "All stop" was rung up. On surfacing a dimlight was seen well astern. The man !.was recovered in approximately9 minutes. Since it was standard practice for all lookouts towear life jackets the man was well supported in the water althOUghonly half of the jacket inflated and he was dressed in foul weatherclothing. The man had just relieved the starboard lookout and didnot hear the word "Clear the bridge" from the OOD, probably due to therain parka pulled tight around his head.

OPINION

Although the man should not have been left on the bridge, theimportant lesson is that with proper training, cool thinking, andcareful checking of equipment, such a casualty can be successfullyhandled with no major injury or harm.

COMMENTS

1. It is the responsibility of the ODD to keep track of the numberof personnel on the bridge and to insure that all get below beforeshutting the hatch. This can be a problem on dark, rough nightswith lookouts dressed in foul weather clothing. The ODD must shout"Clear the bridge" at least twice with his head turned aft; then,the lookouts can be counted by feeling them as they go down thehatch.

E-23


2. The casualty points up the need to have lookouts repeat loudly theword ltClear the bridget! when they hear it passed, and the need to havelookouts trained in the procedure to follow if they are left topsid.eon diving.

3. During routine dives the diving alarm should be sounded after"Clear the bridge lt is given and the lookouts are on their way below.

4. The bridge 1 and 7 Mes should not be turned off by the 01 untilthe bridge is under.

E-24


CASE

Man overboard.

PRINCIPLE

Heavy weather precautions are required for personnel going on themain deck.

NARRATIVE

During LANTSUBEX a submarine put one man on deck to repair a badlyleaking main engine exhaust valve. A heavy sea parted the fastening ringon his safety belt and washed him overboard. He Was wearing a lifejacket and was recovered in 6 minutes.

OPINION

This could easily have been a tragedy but for the precautions takenand the skill exercised in maneuvering and recovering the man.

COMMENTS

1. Risking a man's life for a repair ttat is not essential is neverwarranted.

2. When necessary to put men on deck the following precautions are inorder:

a. Life jackets should be worn and inflated. At night the jacketlight should be turned on.

b. Safety lines and equipment should be adequate and checked ingood condition.

c. Men should be tended from the bridge in addition to theirsafety line to the safety track. Such a tending line in this casewould have permitted recovery in 1 minute vice 6 minutes.

d. Men should work in pairs, never alone.

E-25


CASE

Man overboard.

PRINCIPLE

Same as preceeding Man Overboard case.

NARRATIVE

A submarine at night in heavy weather sent an officer and an EMC onthe main deck an to repair the overtaking light. A wave washed bothmen overboard, parting their safety lines. The EMC was recovered, theofficer perished.

OPINION

Not available.

COMMENTS

1. The repair of the overtaking light was of little importance compared to the risk involved.

2. It is probably safe to assume that the safety lines used werewholly inadequate for the use to which they were subjected. It isunknown whether life i jackets with lights were worn.

3. See previous Man Overboard case for precautions to be taken whensending men on the main deck.

E-27


CASE

Near submergence due to personnel error.

PRINCIPLE

The diving alarm should never be used on the surface for anypurpose except as a diving

NARRATIVE

A new submarine enroute to war zone was exercising at Battle StationsGun Action. The Commanding Officer sounded one blast on the divingalarm as a "Lay below" signal. The Chief-of-the-Watch opened the vents,but the boat was stopped before SUbmerging.

COMMENT

The diving alarm should be used for only one reason while on thesurface--as a signal to dive the boat. It is most doubtful if it evencould have been heard well enough topside to accomplish the desiredresult in this particular case. The ship's whistle or the QM's whistlecan be used effectively.

Under conditions of wartime crulslng it is not uncommon for thevents to get opened on the first blast--it can be expected to happenagain.

E-29


CASE

Accidental submergence while flooding down.

PRINCIPLES/

L Flooding down of a submarine must be done in a orderly manner withpositive control of the flooding at all times to prevent inadvertentsubmergence.

2. Flooding down should be done only when the boat is either positivelyrigged to prevent accidental submergence, or is in all respects readyto submerge if control is lost.

NARRATIVE

A submarine at sea flooded down to recover torpedo. With mainballast tanks flooded, and negative flooded, torpedo recovery partytopside, the order was given to, "Vent safetyll, which was dry. Whensafety was vented the boat submerged to 48 feet leaving all personneltopside swimming. Luckily the bridge hatch was shut before it wentunder and fortunately no main deck hatches were open. The boat wasquickly surfaced and all personnel recovered.

COMMENTS

L Evidently bridge personnel in ordering, llVent safety" thought thatthe floods w~re shut.

2. ,Flooding down should not be attempted except in accordance withPrinciples stated above. This requires the Diving Officer in Controlto handle the eVolution.

E-3l


CASE

Fouling of bridge hatch during dumping of garbage.

PRINCIPLES

1. All submarine personnel must be indoctrinated in the need to keepthe bridge hatch clear for shutting.

2. The upper conning tower hatch must be checked clear for shuttingimmediately after surfacing, after passage of personnel through the hatch,and after dumping garbage.

NARRATIVE

After dumping garbage, the Commanding Officer ordered a dive immediately. When the OOD pulled on the hatch lanyard it was found tobe wrapped around the hatch handwheel. The Quartermaster, in freeingthe lanyard., jammed the hatch dogs in the "Dogged" position, preventing the hatch from closing. Luckily the dive was stopped before thehatch went under. The mess cooks, in dumping garbage, had eVidentlywrapped the lanyard around the handwheel to keep it out of the waywhile bringing up garbage through the hatch.

COMMENTS

1. Since the lives of all on board may depend on the upper conningtower hatch being shut on diving, all personnel should be indoctrinated in the care and use of the hatch and its lanyard.

2. Many casualties of this nature have o6curred with various results.Frequently the hatch can be shut even though the handwheel or lanyard isjammed, and this should be the first effort, for if the hatch can beshut, it does not have to be dogged to prevent entry of water. It canbe held tight until it is firmly seated by water pressure as the boatsubmerges. As shown in this case, too often efforts to clear thelanyard result in preventing the hatch from being seated. Quartermasters should be thoroughly drilled in the proper procedure andmade aware of the primary need to first seat the hatch, then dog it.Realistic drills of this nature can be held safely by shutting emergency vents before sounding the diving alarm.

3. In a similar case a submarine anchored for the night in a riggedfor dive condition. On the first dive on the following day: the hatchcould not be shut due to dogs having been run out by personnel turning

E-33


the hatch handwheel in passing through the hatch during the night.Evidently the latch on the handwheel'(to prevent rotation of the handwheel when the hatch is open) was inoperative. Good practice requiresthat the hatch be checked often by the OOD, lookouts, and Quartermaster, not only to insure that the hatch itself is free for shutting,but to insure that no foreign material has been caught on the seatingsurface or is adrift nearby where it might foul the hatch.

E-34


CASE

Failure of Main Induction to shut following salvage inspection.

PRINCIPLES

1. Gagging and operating of hull openings and valves during salvageinspections should be done by Ship's Force.

2. After being gagged for salvage inspection or drill, hydraulic operated equipment should be operated in power to insure proper operation.

NARRATIVE

The submarine completed a two week upkeep period during which asalvage inspection was conducted. Prior to getting underway the boatwas sealed and a pressure in the boat attempted. Main Induction showed"Greenll but the pressure could not be built up. Visual check of themain induction valve revealed that it was about ~ inch open.

COMMENT

Many casualties have occurred due to failure to reposition properlythe gagging gear on exhaust valves and other power operated valves aftera salvage inspection., In every case the inspection team from the ASRis blamed. Since the submarine personnel are more familiar (or shouldbe) and of necessity more interested in the mechanical equipment involved, they should accomplish all gagging and ungagging of valves forthe inspecting party.

As shown in this case, it is always good practice to Rig for Diveand check out all equipment at the end of an upkeep period prior togetting underway. This should always include, as was done on thissubmarine, a pressure (or vacuum) test for watertightness of the boat.

E-35


CASE

Complete physical loss of stern planes.

NARR.ATIVE

In December 1956, USS MULE (ss-403) was retu.rning from a northernpatrol area in the midst of some of the worst weather ever experiencedin the North Atlantic. Winds of 70 knots and waves of forty to fiftyfeet in height were prevalent for weeks. The ship was experiencingrolls up to 57 degrees on the su.rface and 12 degrees at depths of 200feet. It had been two days since the ship had submerged and the divingalarm was a welcome sound of escape from the fury of the su.rface stonn.

After the initial llhanging Upll caused by the wave action the shipbroke through the su.rface and headed for the ordered depth of 120 feet.The Diving Officer had ordered a 10 degree down bubble, which was obtained at a depth of fI:) feet, but continued to increasetci 15 degreeson passing 70 feet, in spite of blowing negative and ordering rise onboth planes. The Conning Officer ordered right full rudder and all back:full to help catch the bubble which was now passing 20 degrees. Theforward group and bow buoyancy tank were also blown and immediately vented to catch the angle. The ship leveled off at 180 feet. A maximumangle of 26 degrees was experienced. An immediate check of the compensation was made to include readings on all trim tanks, WRrs and statusof torpedo tubes. All these checks indicated that conditions were normal and the llloss of bubblell was attributed to the sea lifting thestern on the dive and the planes not catching it in time.

The Conning Of.ficer then ordered the ship to be brought to theoriginal ordered depth of 120 feet with a 3 degree up buble. The shiptook a 7 degree up bubble and came up to. 35 feet. No combination ofspeeds or plane positions could prevent this from happening. Twoadditional diving attempts were made to reach and maintain the ordereddepth with the same happenings occurring. The following items wereinvestigated in attempting to find the cause for the uncontrollable angles:

a. Air induction and snorkel exhaust piping dry.

b. Iv:rechanical bow and stern plane indications checked against normal and emergency indications and torpedo room mechanical indicators.

c. All bilges checked for unusual amounts of water.

d. All fuel tanks vented to insure no. air pockets.

e. All variable ballast tank liquidometers checked against readingsat trim manifold.

f. All main ballast tank vents operated in hand power to insuretheir actually opening.

E-37


g. Diving planes tested in hand from full rise to full dive.

Only one of these checks produced a possible cause of the trouble.The stern planes were able to be moved from the full dive to the fullrise position without much effort on the part of the planesman regardless of the stroke setting. It was believed that the stern plane operating linkage must have broken. If this were the case though, the planeswould have been sucked into the propellers when the backing bell wasused during the initial dive. That the trouble was with the sternplanes was fairly well determined, but the exact extent of the casualtyto the planes could not be determined from any examination from withinthe ship.

The ship did not attempt another dive enroute to New London. OnarriVal, divers from E & E DePartment f':ound that the ste;rn planes andits connecting shaft had completely fallen off the ship and no evidenceof any of their parts was visible. Subsequent drydocking substantiatedthis finding. Bronze from the stern planes bushing was wiped into thepores of the foundation steel casting and hydraulic jacks plus heatingand cooling failed to remove these bushings. These facts indicate thatthe stern plane shaft had probably been snapped by the force of thefully exposed stern of the boat crashing down on the surface of the sea.

OPINIONS AND FINDDfGS

A board of investigation was not deemed necessary in this .case.A complete record of additional damage sustained by USS ATULE (ss-403)from ice and heavy weather during this northern patrOl was submittedto CNO under .ATULE serial 001 of 18 December 1956 via COMStJBI..ANT.

CO:MM.F.m

This was thefirst time that this casualty had been witnessed byanyone on board .ATULE and discussions with personnel from COMSUBLANl'Staff, Development Group, and the Base E & R Department could revealno one who recalled a similar casualty. It might be added that theseplanes had received a careful inspection for unusual wear in thedrydock at Portsmouth Naval Shipyard just four months prior to thiscasualty.

E-38


CASE

Loss of hydraulic power on diving.

PRINCIPLE3

1. Phones should be manned on diving.

2. Bow planes should not be rigged out until other more essentialoperations are completed.

N.A.RRATIVE·

The submarine was conducting a post-overhaul shakedown. Upondiving, an inexperienced EMFN tripped the forward auxiliary distributionboard disconnect switch instead of the air compressor strip switch. Thevents were opened, planes rigged out, and a periscope raised, leavingno hydraulic power to shut the :Qlain induction. The lMC and 7MC, motororder telegraphs, and bow plane tilting motor were lost, and the phoneswere not manned. 1I.All Back Dnergencyll was ordered by telephone, thevents were shut by hand, and the boat was blown up witho'L].t damage.

COMMENTS

1. Bow planes are not essential to safe diving and should neverbe rigged out until the vents are opened and the main induction shut.

2. Had the phones been manned, this casualty could have beenmore easily handled.

E-39


Injury of a diver with submarine propeller.

PRINCIPLE

In-port evolutions must be coordinated by the Duty Offlcerthrough the proper channels.

Divers at the Submarine Base" New London, were directed to changea screw on a submarine. The leading diver requested the ship to securethe stern ylanes" rudder, and screws. The OOD supervised the pullingof fuses to the stern plane tilting motors, the steering motor and theengaging of the jacking gear on the propeller shafts. It is not knownwhether or not the below decks watch, the duty controllermen, or theduty chief participated in these actions or were informed of thereasons for them.

With two divers waiting in the water near the screws, the leadingdiver requested the starboard screw to be jacked over thirty degreesby hand. This request was received by the Duty Chief, who ordered thejunior Duty Electrician to perform the task, but neglected to informthe D.1ty Officer. The junior electrician decided that hand-jackingwas too much work" however" and decided t<, turn the shafts with theuse of main power from the battery -- II just touching the shafts alittle" so they would turn the desired amount. With this in mind,he disengaged the jacking gear" and energized the motors" upon whichthe shaft started to turn at about 30 rpm. By the time he could movethe starter lever to the 1I 0 ff ll position the shaft had made two complete revolutions. One of the divers was immediately sucked into thescrew" whipped around" and thrown unconscious to the bottom when thescrew stopped. Fortunately, the screw also cut off his weight beltand face mask" so that he immediately popped to the surface where heregained consciousness from contact with the icy water. He hadslashes and bruises in ten places on his body. The other diver wasswept clear of the screw by the screw current and was uninjured.


1. The Duty Chief erred in not informing the OOD of the request tohave the shaft jacked over by hand.

2. The D.1ty Chief erred in not supervising the evolution" whichshould have been considered potentially dangerous" as it indeedproved itself to be.

3. The junior electrician erred in not carrying out his orders tojack the shaft over by hand.

E-41


4. The leading diver erred in having divers in the water while ashaft was being turned, in direct violation of the U.S. Navy SafetyPrecautions Manual.

COMMENT

This is an example of what can result from allowing operationsto get out of the proper channels. Had this been properly coordinated by the OOD, with the necessary personnel being informed of whatwas going on, and with the required operations conducted by properlyexperienced personnel, the accident would not have happened.

E-42


Personnel injury, electrical burns.

PRINCIPLE

Electrical circuits should be de-energized before any maintenance is performed.

NARRATIVE

Submarine had a ground in the main propulsion system. Inisolating the ground it was found to be in the cables from the battery to the cubicle. Permission was obtained to work on the groundand an officer was supervising the OPeration. After completing oneof the tests, the electrician in charge neglected to OPen the forward battery circuit breaker. He then entered the cubicle to replacethe disconnect links and was burned when arcing occurred.


The main propulsion electrician1s mate, who was the injuredman, although a well qualified and experienced submariner, displayedcarelessness in Violating a posted and~eli-promulgated-safety----n

precaution.

COMMENT

If there is one primary rule in electrical maintenance, it is"Kill the power before it kills you". This old adage is time provenbut there remain individuals who feel that the rule does not applyto them by reason of their experience and knowledge. Current can I ttell the difference between an FN and a CPO and couldn I t care lesswhich is the path to ground. It is impossible to devise an interlock for the human brain. The only answer is to use the brain, andin work such as this, two brains are better than one. There shouldbe a double check that the power is off before anyone is allowed toenter the cubicle. Proper training and eternal Vigilance will paydividends .-- in long life.

E-43


Malfunction of escape trunk door.

PRINCIPLE

Safety equipment must be kept in proper order and inspected.regularly to insure that it is in fact in proper order.

NARRATIVE

A submarine conducting escape training exercises while bottomedin about fI) feet of water found that it was impossible to shut th,eescape trunk door after the first group of escapees had left thetrunk.

Subsequent inspection revealed that the outer handle on theescape trunk door was installed 900 out of position so that theclosing arm operated from the forward torpedo room rotated the handleenough to extend the dogs about a quarter of an inch, thus preventingseating of the door.

COMMrnT

Had this been a "real" escape instead of just training escapes,only the first three men to escape would have been able to do so.

Proper operation of the salvage fittings and equipment of asubmarine is of such importance that special salvage inspections arerequired to .be made by personnel of the rescue vessels. These inspections should be meticulous and should be attended by shiplspersonnel. Too often, as in this, instance, shipls force fail toplake any inspections of their own to insure that everything is inreadiness should the need arise to make an escape.

E-45


CASE

Personnel injury, electrical burns from cubicle.

PRINCIPLES

1. A voltmeter should always be used to check the cubicle dead beforeattempting any work therein.

2. Two persons should be required to check the cubicle safe beforepermitting any work therein.

NARRATIVE

A submarine duty chief, an EMC ,_ attempted to clear the starboardcubicle (split CUbicle) to permit welding in it. All starboard leverswere placed to the uOffll position, the starboard motors excitation switchwas opened, and the disconnect to numbers 1 & 2 batteries (Guppy II)were opened. Workers using a portable light with a wire guard inadvertently fouled the guard between the battery bUs, causing an arc whichburned a worker. No other damage occurred.


1. The port battery lever was in the "an" position, thus causing theforward part of the starboard cubicle to be energized.

2. Use of a vo.ltmeter to check on the cubicle would probably haveprevented this casualty.

COMMENTS

1. No cubicl-e work should be attempted until the entire cubicle hasbeen disconnected and checked. "dead" with all battery d.isconnects open.

2. Any work involving danger to personnel such as this should not bepermitted until the conditions for safety are finally checked by twoseparate checks by two separate people, i.e., in this case the EMCand the Duty Officer.

E-47


CASE

Personnel injury (burns).

PRINCIPLE

Access hatches and doors should be securely latched when open.

NARRATIVE

A Quartermaster carrying a bucket of hot water to the Conning Towerset the bucket on the edge of the hatch, steadying it with his lefthand as he attempted to pull himself through the hatch. Ue took holdof the hatch I s lower handle and as he did the hatch shut, knocking overthe water and inflicting second degree burns as it spilled on the man.

COMMENTS

1. Safe practice requires that doors and hatches he properly latchedwhen opened so that the handles placed thereon may be safely used.

2. The springs on hatches should be kept adjusted so that when a hatchis undogged, it will fly open with sufficient force to latch opensecurely. '

3. All hatches and doors should be checked after being opened to insurethat they are in fact securely latched open.

4. In the case of WT doors on submarines, the latch should be adjustedso that the door is held tightly against the compressed rubber buffer by thelatch in such a manner that the door will be moved sufficiently by thebuffer when the latch is disengaged to prevent the latch from re-engaging.This permits the door to be rapidly shut with one hand when reaching into shut the door from an adjacent compartment.

E-49


CASE

Personnel injury using power wire brush.

PRINCIPLE

Safety goggles are essential when using rotating power equipment.

NARRATIVE

A seaman working topside with a power wire brush removed his gogglesand was subsequently injured when one of the wires flew off the brush andlodged in his left eye.


The seaman had been instructed to wear his goggles while using thepower wire brush. They were not the standard ventilated type and thusfogged up. This is presumably the reason they were removed.

COMMENT

Submarines should always have standard protective goggles on handand should insure that all personnel understand the necessity of wearing them at all times when using power brushes, grinding wheels, etc.Of equal importance is the necessity for personnel to wear goggles whenworking adjacent to a power wire brush. In one such case a man 15 feetfrom the wire brush was injured and lost his vision in one eye whenstruck by a wire fram the brush.

E-51


CASE

Personnel injury resulting from operating handle of engine inductionvalve.

PRINCIPLE

Sloppy practices result in trouble sooner or later.

NARRATIVE

During an ORI conducted by a SubRon Staff, a drill IICollision in theforward engine room ll was instituted, with the ship surfaced. During thedrill the main induction was shut, the hull induction and the two engineair inductions were shut, but the handle for the after engine room airinduction was hanging down loose. A pressure was put in the forwardengine room as part of the simulated casualty control. Subsequentlya pressure was put in the after engine room also, in order to permitthe door between the engine rooms'to be opened. Before the door wasactually opened, however, the drill was secured and the main inductionwas opened. Pressure which had evidently built up in the inductionpiping was immediately vented off thrOUgh the main induction. Thisaction lifted the after engine room air flapper valve, swinging the loosehandle. The handle struck the Engineer Officer a glancing blow on thehead, knocking.him unconscious for about ten minutes.

COMMENT

Had the handle been in its proper place this incident would nothave occurred. Lax practices such as this can be expected to lead totrouble.


I--~ -

CASE

Personnel injury, fractured arm while locking the main induction.

PRINCIPLE

Hand operation of hydraulic operated equipment requires that thehydraulic power first be secured.

NARRATIVE

In attempting to lock the main induction valve operating gear shutduring a dive the mess cook disengaged the locking pin before the valvehad been shut hydraulically. The handwheel spun rapidly, breaking themess cook's arm.

COMMENT

The first concern for the main induction operating gear is to insurethat it is SHUT. Once it is seen to be shut, then the action to lockit shut should be commenced.

The power exhibited by thehandwheel of a piece of hydraulic gearwhen hydraulic power is cut in with the mechanism in the "hand" positionis almost unbelievable. Positive safeguards must be used to preventhydraulic power from energizing hydraulic eqUipment in the "hand" positionwhen exercising at hand evolutions, i.e., "hand divel!.

E-55


CASE

Personnel injury: Electrocution in battery well.

PRINCIPLE

Extreme caution is essential when working in the battery well.

NARRATIVE

The submarine was in overhaul. An EMl was removing cell connectorsbetween cells #2 and #3 in the after battery well. The well temperaturewas 1000 to 1100 with the air conditioning out of commission. The manwas perspiring profusely and had stripped to the waist. Ground readingstaken the previous night on completion of the charge were minus 25 voltsand plus 30 volts. EVidently no readings were taken just prior to commencing the work. There was a known intermittent full voltage groundthat resulted from insulation damage to the cell voltmeter leads duringthe battery renewal of the previous overhaul. Bakelite sheeting wasused on the outboard row of cells with nothing between. The man accidentally completed the circuit from a terminal of cell #3 under his armthrough his opposite shoulder blade to a buss on the battery disconnectswitch. The circuit was completed to cell #123 by a full voltageround. on the voltmeter lead. The curr~nt flow was not enough to blowthe cell voltmeter lead fuses.

COMMENT

This casualty emphasizes the point that extreme caution is requiredwhen working with any electrical circuit, and especially when working insubmarine battery wells. It also emphasizes the extreme importance oflocating and eliminating grounds on such circuits.

E-57


CASE

Less of main power from batteries on diving.

PRINCIPLE

Restoration of casualties following a drill should include a checkfor proper operation.

NARRATIVE

Submarine was on surface conducting drills. One of the drills required that the after battery be isolated. Excitation was shifted forward and after battery main circuit breakers tripped. When excitationwas shifted, the holding coil on the battery paralleling lever properlytripped open. Following this drill, another drill was held that necessitated the isolation of the forward battery, so excitation, was shiftedaft and the forward battery isolated. On the completion of the drills,and when all casualties were reported restored, a dive from four engineswas made. Since there had been no bells answered on the battery duringthe surface drills and the battery paralleling lever had not been moved,there was no power from the battery on diving because the holding coilon the paralleling contactors was still tripped out. As can be imagined,this lack of battery power on a four engine dive caused great consternation.

COMMENT

Restoration of casualties following any drill in which the normalcruising conditions are disrupted should include a check for properoperation to insure a return to normal cruising conditions. In particular, disruptions to the cubicle as were required in this case necessitate a good propulsion check-out similar to that required on gettingunderway. Also, anytime the excitation switch is thrown for any reason,it should be automatic to throw the battery paralleling lever to theIIOFF" position in ord.er to pick up the holding coil.

E-59


CASE

Officer of the Deck washed overboard and lost at sea.

PRINCIPLES

1. Compliance with established safety precautions is essential tosurvival at sea.

2•. In a heavy sea, main ballast tanks must be·blown frequently toinsure maximum surface stability.

NARRATIVE

The submarine was cruJ.sJ.ng in a sea ~tate.of five and upwards, withwind velocity about 55 knots. and visibility varying to & minimum ofabout 100 yards. The upper conning tower hatch' and ma~n induction wereshut, air induction being taken through the snorkel,mast. The lowpressure blower was being run about once each watch as a. ql8.tter ofroutine. The Commanding Officer's night orders required the OOD andlookouts to be tied to the bridge with safety belts. The ship wasrolling heavily in this sea and wind qonditiqn and on one occasion tookan extremely large roll of about 80 degrees to starboard. On this rollthe bridge and fairwater were completely submerged for a considerableperiod,.the Ship showing a tendency to hang in this position. The starboard lookout was washed overboard but held by the safety line he waswearing and was later pulled back ontq the bridge. The port lookoutwas not wearing a safety line but wedged himself into a position suchthat he was not washed overboard. The OOD had a safety line ayailabl~

but was not wearing it and was washed overboara. A search of severalhours duration failed to locate the OOD and was finally abandoned afterthe time had elapsed beyond which a human could not survive due to exposure.


1. That the OOD was washed overboard when the bridge of the submarine became submerged during an extremely large roll and was drowned.

2. That the death of the OOD was not caused by the intent, fault,negligence or inefficiency of any person or persons in the naval service or connected therewith.

E-61


3. That the extreme angle of the roll and the tendency to· "hang"in a heeled over condition were contributing factors and that both wereaggravated by the filling of the interior of the fai:ryater with 'Water.

COMMENTS

The failure of the OOD to comply with instructions of the Commanding Officer to utilize available safety equipment resulted in the tragicloss of his life. This laxity also caused one of the lookouts to follow the OOD's example and only goodforturne prevented him from alsobeing lost. Safety lines should always be used in heavy weather. Theirusefulness in saving lives is strongly illustrated in this case by thefact that the starboard lookout was washed overboard, held completelysubmerged for a prolonged period, but was held fast to the ship by hissafety line and later pulled back onto the bridge.

With safety and negative tanks flooded, in diving trim and blowingup about once a watch, the submarine was in a normal cruising condition.An inclining experiment conducted prior to this casualty showed a metacentric height well above the minimum of the average submarine. However,approximately six hours had elapsed since the last time the tanks hadbeen blown dry and this probably had an adverse effect on the submarine'sstability. In high winds and with wave heights of 25-30 feet, the average angle of roll was 25 degrees. With this amount of rolling and thelong time since blowing main ballast tanks, considerable air could havebeen spilled from the tanks, resulting in reduced buoyancy and stability.This may have contributed to the excessive angle and consequent loss oflips. Main ballast tanks must be kept blown substa:t;ltially dry in heavyseas to insure maximum sta1?ility. The frequency of blowing tanks is amatter of judgement depending upon the amount of roll and other condi..tions. However, in heavy weather, a good procedure would be· to blow upat least twice a watch; it would not be excessive to blOw up once anhour in very heavy seas. If in doubt - run the blower. It may do somegood, and it certainly will do no harm.

Of interest in connection with the OOD not having his.safety beltsecured is the fact that the Commanding Officer had verbally directedhim to secure it just minutes before the accident.

E-62


CASE

Personnel injury, fractured skull, as a result of being struck by ahand crank thrown from the steering gear of an ASR.

PRINCIPLE

1. Safety precausions should be augmented while testing equipment where"danger of personnel injury exists. (Where rotating machinery is involved,personnel should stand well clear.)

2. Tests of equipment should be conducted under actual operating conditions,but not at times that might jeopardize the safety of the entire ~hip.

NARRATIVE

While at sea an abnormal condition existed in the steering gear of an ASR.The hand crank shafting crept when the manually operated clutch was inthe motor position. Valve grinding compound was placed in the clutch in anattempt to free the shafting. The hand crank was affixed to the operatingshaft and held there. With.the clutch in the motor position, the motorwas turned on. The binding in the clutch assembly was aggravated bythe presence of the grinding compound and as a result the crank wasthrown, lacerating the head of the man who was holding it and fractur-ing the skull of another who was sitting on the deck nearby. Fortunately the ship was in the channel enroute to port with a doctor onboard. First aid was administered on board and an ambulance was awaiting on arri~al.


Similar type accidents may be prevented in the future by neverengaging the hand crank unless the clutch is in the position for handoperation and the motor is off.

COMMENTS

Work on' an auxiliary means of steering normally should not be attempted while the ship is maneuvering in a channel. Positive safeguards must be employed to prevent equipment from being operated inother than the designed positions. Personnel should keep clear of therotating gear while testing the effectiveness of any repair.

E-63


CASE

Electrical fire as a result of improper "set_up" on cubicle in conjunction with failure of safety device.

PRINCIPLES

1. It is mandatory that Duty Officers and Duty Chiefs make inspectionsas required by Ship's orders.

2. Duty Officers, Duty Chiefs and cognizant department representativesmust be kept informed of all ship's work in progress and be aware ofany abnormal conditions.

3. Leading Petty Officers of departments should not leave the ship untilinforming responsiole on-board personnel of the status or condition ofmachinery and equipment undergoing repair or maintenance.

NARRATIVE

At 0830 on Monday, after proceeding from drydock, an attack classsubmarine moored outbOard of two submarines in a tender nest. Work onthe ship 1 s electrical equipment, interrupted by the undocking, resumed:At approximately 1100, as a measure to facilitate removal of arc chutesin the cubicle, the main motor field rheostat 'Was operated the flfullon" position, the starboard propulsion set-up cam shaft 'WaS placed in theflparallel" position, and the starboard main motor propulsion contactorswere closed. This set-up on the cubicle, made by a person or personsunknown, resulted in a starboard main motors parallel combination withcables and armature resistance equal to about .0112 ohms. The forwardand after main battery circuit breakers, opened on securing the maneuvering watch, were designed for instantaneous trip at 20,000 amperes.The application on mail battery voltage (500 volts) to the resist-loadresulting from the fiset-up" on the cubicle could result in an instantaneous current in excess of 40,000 ampers.

Shortly after 1100, the leading petty officer supervising the workin the cubicle departed without furnishing the duty chief, who happenedto be the chief in charge of main propulsion, the status.and conditionof the cubicle. At 1600 the duty officer was relieved. The on-comingduty officer did not inspect the ship with the off-going duty officer,nor did he inspect the ship with the duty chief. Both inspections wererequired by ship's regulations. He did however, conduct a complete inspection of the ship at 1700.

E-65

lhttp://archive.rubicon-foundation.org

At about 2330, incident to lining up for a battery charge, thecharging electrician attempted, unsuccessfully, to close the forward andafter circuit breakers remotely from the maneuvering room. It shouldbe noted that this electrician had just qualified as a charging controllerman that day and had stood only seven battery charging watches underinstruction. Of these seven, two were in-port charges. The electricianassumed that the remote mechanisms were faulty and ordered the breakersclosed manually by the assistant charging electrician. The breakers, inactuality, were prevented from closing by an electrical interlock. Whenthe assistant manually closed the forward breaker the electrical interlockwas overridden; however, the instantaneous overload current trip operatedproperly and tripped the breaker out again. When the forward breakerwas initally closed, the electrician in the maneuvering room was alertedby the whirring sound of rotating machinery and meter deflections onboard, noticed the "set-up" on the board, and attempted to call hisassistant and prevent him from closing the after breaker. During theinterim, the assistant, believing he had shut the forward breaker, proceeded to the after battery and attempted to close the after batterycircuit breaker manually. This time the instantaneous oVerload tripfailed to function and an excessive current passed through the afterbattery circuit breaker contacts, fusing them together and negating theprotection provided for overloads.

The intense heat generated by the overload current set fire to combustible material. Simultaneously, full after battery voltage was applied to the starboard main motors and the ship was propelled forward.The fire continued until the metallic points of the electrical contactin the circuit breaker were consumed and current ceased to flow. Insulation and cork in the area continued to burn for about 10 minutes thereafter. Damage was as follows:

1. After battery circuit breaker: Beyond repair.

2. Main power cables from main breaker to battery disconnect linkin battery well: Beyond economical repair.

3. Auxiliary power back-Up breaker: Beyond economical repair.

4. Bussing destroyed as follows:

a. From main breaker to auxiliary power disconnect links.

b. From auxiliary power disconnect links to auxiliary back-upbreaker supply.

c. From back-up breaker outlet to second set of disconnect links.

E-66


Additionally both sets of auxiliary power disconnect links, the antipump relay assembly for main battery breaker remote operating circuit,the anti-pump relay assembly for auxiliary power back up breaker operating circui~, and the automatic individual cell voltage scanner for theafter battery, were all damaged beyond repair. Various other electricalequipment in the vicinity required extensive cleaning and repair.

The relative lack of experience of this submarine's electrical gangmust be considered as a contributing factor. The following table illustrates by rate the relative inexperience of this ship's four leadingelectricians:

RATE MOS OB as of 5/18/59 PREV EXP IN SS

EMC 4 Qual on Attack Class

EMC 5 NONE

EMl 5 NONE

EMl 4~ Qual on GUPPY

An interesting sidelight at the time of the fire is that the ship had inits possession an engineering report from the bUilding contractor datedsix years prior to the casualty reporting the failure of the after battery breaker to operate properly, and recommending a remedy. No knowneffective action had been taken by any activity on the basis of thisreport.

COMMENTS

An almost unbelievable chain of events and circumstances coupled toovercome the installed safety features and permit this casualty. The"set-up" on the cubicle was not unauthorized and had been used in thepast to assist removal of arc chutes. However, on this occasion, noneof the duty personnel were aware of the set-up. Although the duty officerinspected the ship alone at 1700, be might have noted the "set-up" hadbe made the required inspections in company with the off-going dutyofficer and the day's duty chief. Similarly, had the duty chief, who wasalso in charge of main propulsion, kept himself informed of the statusof the work in progress in the cubicle and exercised proper supervision,the casualty might have been averted.


In conjunction with the foregoing, the inexperience of the chargingelectrician must be considered. The fact that there had been a historyof difficulty with the e~uipment involving remote closing of the batterybreakers caused him to assume incorrectly that they were malfunctioning.A more experienced electrician. would probably have noted the "set-up!!on the cubicle and cleared the board on hearing the initial whirringsound. Instead precious seconds were lost while attempting to contactthe assistant electrician.

In conclusion, it must be realized that there is a definite. shortage of experienced personnel on board many of our submarines tod13.y.There is no substitute for experience. The solution to this problemlies in close supervision, extreme. thoroughness, and increased a~tention

to duty on the part of the officers and leading petty officers who dohave submarine experience.

E-68


PARr F - MATERIAL CASUALTIES

The material casualty cases included in this part are illustrations

of the need for effective qualification and continual department training

of submarine personnel. All too frequently, these casualties occur be

cause either the OPerating personnel do not understand enough about their

equipment or do not adequately appreciate the need for following estab

lished procedures.

These cases, of course, are only selected samples of many casual

ties which have occurred in the past and are continuing to occur today.

The lessons to be learned are the need for knOWing your equipment, fol

lowing established procedures which are a result of years of experience,

and repairing a malfunctioning piece of equipment, no matter how insig~

nificant it may seem, as soon as possible after the malfunction occurs and

before a casualty can happen in which a series of minor equipment failures

can result in a major casualty.

F-I


CA.SE

Loose bolt in main motor contacting armature while making landing.

PRINCIPLES

1. Check and double check for loose foreign matter inside motorsand generators following shipyard overhaul periods.

2. Investigate innnediately any unusual noise in operating machinery.

NARRATIVE

A submarine was maneuvering while making a landing at a pier. Anunusual clicking noise was heard coming from #1 main motor. Investigation revealed the noise to be caused by a 9/16 X 1-3/4 bolt lying between a main field pole and the armature of the motor. Further inspection revealed no damage to the motor.

Prior to opening the motor all casing bolts were checked andfound to be in place. There was no access to the motor through whicha bolt of this size could have accidently entered. The motor had notbeen opened since the previous shipyard overhaul.

COMMENT

This was a close one. The probable disastrous results of heavybacking vibration l thus shaking the bolt into the airgaPI can be readilyimagined.

This case wasout at the shipyard.ears to spot troublecasualty.

caused by some officer who failed to get the boltIt was saved by~some officer who had trained his

and had acted quick enough to prevent future

F-3


CASE

Flooding of a main generator while bottomed.

PRINCIPLE

Known leaks into bilges should be continuously monitored.

NARRATIVE

A submarine bottomed at 0900 in 155 feet of water for a salvageexercise. Word was passed over the announcing system to II stand easyon stationstl

• In the Engine Room the snorkel exhaust line drain wasopened and water was noted by the watch to be draining continuouslyfrom this line into the bilge in a stream about the diameter of apencil. At 1100 this bilge was pumped.

No inspection of this bilge was made at the relieving of thewatch at 1145. The next bilge inspection was made at 1345 by theauxiliary electrician during his routine tour through the boat. Atthis time no water showed above the lower deck plates in that bilge.

At 1400 the Engineer Officer noted a very low ground readingon #2 generator, which was located in this boat down deep in thissame bilge. In:o:nediate inspection revealed that water in the bilgewas over the lower deck plates and had entered the casing of #2generator.

Subsequent in-port tests revealed a leak in the snorkel exhaustpiping in the superstructure.

FINDINGS .AND OPINIONS

1. The rate of leakage into the bilge concerned from the snorkelexhaust line drain increased some time after the 1100 pumping of thatbilge, such that the water level in that bilge at the 1345 inspectionwas just barely below the lower deck plates in the bilge.

2. A continuous monitoring of the leakage would have detected theincreased rate of leakage, resulting in timely pumping of the bilgeand prevention of the entry of water into the #2 generator caSing.

COMMEN'TS

One basic thumb rule in submarining is that the sea can be theboat's greatest friend by hiding the boat, but that the sea can alsobe the boat's greatest enemy by flooding the boat, and that HULLOPENINGS MAKE THE DIFFERENCE.

F-5


The status of all hull openings, whether by intent or by material failure, must be known by all compartment watchstanders and supervisory personnel. KNOWN LEAKS deserve meticulous attention!!!"Stand easy on stations tl should never mean to any submariner that heno longer'needbe concerned with leaks into the boat.

F-6


CASE

Main engine damage from blank flange in engine lube oil supplyline.

PRINCIPLES

1 • Enploy extremely thorough and careful procedures when startinga main engine after extensive maintenance periods.

2. Believe gages, meters, and indicators when these instrumentsshow that abnormal conditions exist.

NARRATIVE

A submarine was conducting initial test running of an enginefollowing it's overhaul by ship's force during yard overhaul. Forreasons l.inknown to the Engineer Officer and operating enginemen atthe time, the eng;i..ne lube oil low pressurealB.rn1 was "inoperative.The Erigine~r decided to conduct the test runs without it. The engine was started and idled for five minutes. The. lube oil pressuregage showed abnormally high lube oil pressure, but since the generator bearing was draining· oil normally, the Engineer Officer decidedto continue the idling for the five minute period.

The next day the engine was again idled, sti11without thebenefit of the lube oil low pressure alarm. The +ube oil pressuregage showed abnormally high lube oil pressure again, and again theEngineer Officer decided to continue the idling, since the generator bearing again indi.cated a normal oil drain from it. This time,however, the fittings on the line to the lube oil pressure gageruptured. The engine was stopped while these fittings were renewed,then idling was resumed. After a minute or two the engine stopped.

Inspection revealed that all main bearings had wiped, thatseveral main bearings had seized, and that several bearing supportwebs had warped from overheating. This inspection also revealed ablank flange installed in the lube oil supply line to the engine.


1. n:unage to the engine had caused it to stop.

2. Lack. of lubrication had caused the damage to the engine.

3. The blank flange had caused the lack of lubrication and hadcaused the abnormally high lube oil gage pressure.

4. The only thing wrong with the lube oil low pressure alarm wasthe fact that it lacked fuses.

F-7


5. Operating an engine without first testing the alarms and find-ing them satisfactory was a violation of the ship's orders.

6. As soon as an abnormal pressure was detected, the engine shouldhave been immediately shut down and examined to discover the cause.The engine should not have been restarted until the trouble had beencorrected.

COMMENTS

This case is an example of an advapced degree of negligenceand incompetence.

During a shipyard overhaul period, operating procedures tendto get out of channels. During an engine overhaul period, the engineundergoes ext~nsive disassembly and reassembly. Both of :these periodscall for very careful resumption, of o~ration upon completion. Whenboth of these occur simultaneously, then maximum care must be exer~

cised in restoring machinery to operation.

Even under regular operating periods thr.ottlemen are trainedto shut down their engines whenever conditions become abnormal, andnever to start their ~ngines unless all the protective alarms areoperative. In this case the conditions were as far, as possiQle fromregular operating conditions. Not only did the lube oil pressuregage show abnormality to its limit, but it even exceeded its limitand burst its fitt:ings. '

F-8


CASE

Damage to engine due to flooding during a snorkel start.

PRINCIPLE

After an aborted snorkel engine start, vent off entrapped exhaustgasses to prevent premature opening of "All valve on next snorkel start.

NARRATIVE

A submarine attempted to snorkel start #1 engine. The IIAll valvewould not open. After re-checking for proper rigging for snorkel, asecond snorkel start was attempted on #1 engine. The "A" valve openedprematurely on this attempt resulting in the flooding of #1 engine.As a result of the excessive exhaust gasses then inside the submarine,the submarine had to surface.


1. Examination of the #1 engine after surfacing revealed three bulgedliners, two bent connecting rods, and three cracked pistons.

2. At the time of the first attempt to snorkel start #1 engine,the "A" valve had not been placed in the power position.

3. At the time of the second attempt to snorkel start #1 engine,the exhaust drains had not been opened to vent off the exhaust pressure trapped in the line between the "BII and "All valves from thefirst aborted snorkel start.

4. This trapped pressure resulted in premature automatic openingof the "A" valve as snorkeling was again attempted on #1 engine,causing the engine to flood while turning over.

5. Once the engine became flooded while turning over, it becameinevitable that hydraulic compression damage would result in thatengine, regardless of any action taken by personnel.

COMMENTS

The failure of the cook on watch to place the lIA" valve inpower while preparing to snorkel is a serious one. The questionof reliability of personnel in performing submarine e~olutions isso basic that no more need be said here.

The failure to drain down or vent off the snorkel exhaust 'piping following an aborted start, or following any securing fromany reason, shows lack of understanding of the snorkel system andwhat happens to various parts of the system while snorkel starting,

F-9


If the personnel involved in the operation of #1 engine during theseattempted snorkel starts had known their plant, then they would neverhave tried to restart that engine as long as they lacked positiveindication that exhaust-gas back-pressure no longer existed in thesnorkel exhaust system.

The means by which the IIAll valve is opened during snorkeling.has been changing through the years, but the newest procedure usesthe already-existent snorkel safety circuit as an aid, essentiallyas follows:

a. The engine builds up a 17 psi back pressure in the exhaustline.

b. A bellows type switch completes the circuit to the llAll valve.solenoid.

c. The llAIl valve spool valve itself is positioned by the solenoid action above.

The change in operation of the "N' valve has been a source ofpotential danger to those submarines whose personnel have came fromsubmarines with different snorkel systems. This case emphasises theneed for individuB.11y tailored re-qualification programs for personnel new to the particular submarine to which they are assigned.

F-IO


CASE

Explosion of an oxygen flask inside a submarine.

PRINCIPLES

1. Keep oxygen flasks and flask fittings free of oil, grease, andother fuel material.

2. Inspect oxygen flasks regularly for tightness to prevent poten-tially explosive leaks.

NARRATIVE

A submarine was inspecting its oxygen flasks to determine thepressure of the oxygen therein. A few minutes after one of the flaskshad been gaged for pressure and secured, it exploded. No personnelwere in the vicinity of the explosion and negligible material damagewas incurred, except for the damage to the flask itself'.

COMMENTS

Oxygen flasks contain oxygen. Oxygen plus fuel plus heat produceburning. Rapid burning become an explosion. The greater the concentration of oxygen present the more certain the burning under given fueland heat conditions.

Submarine training should include these simple facts, as well asthe two following thumb rules for oxygen flasks:

a. Never use any fuel material, such as oil or grease, in anattempt to free up oxygen flask fittings.

b. Always test oxygen flasks for leaks by means of a pureneutral soap solution, using 'a solution kept on board specificallyfor the purpose.

F-ll


CASE

Flooding a main engine during an airless start after an airlesssurface.

PRINCIPLES

1. Do not leave an outboard exhaust valve open unless. certain thatthe engine has fired.

2. Do not attempt two airless starts at one time.

3. Following any aborted start, repeat the full exchange of prepara-tion signals between the Engine Room and the Maneuvering Room.

NARRATIVE .

A submarine was conducting an lIa irless surface, airless start,2 engines". The seniorthrottleman decided to start both enginessimultaneously, a practice that the ship had employed several timesin the recent past. Only three enginemen were stationed in the EngineRoom at the time, two throttlemen and 1 oiler.

One of thethrottlemen prepared one engine, the other preparedthe other engine. One rang up IlReady ll to Maneuvering Room:.and mannedboth throttles sinrultaneously. As one engine commenced to rotatedue to its generator being motorized, this throttleman momentarilylet go of the other engine's throttle to shut the exhaust drain valveon the rotating engine. As the other engine commenced to roll, thisthrottleman momentarily let go of the first engine's throttle to shutthe second engine's exhaust drain valve.

Meanwhile, the other throttleman was manning the outboard ex:laust valves. As he noted one engine back pressure build up heopened that engine's outboard exhaust valve. He then noted that theother engine's exhaust back pressUre had built. up so he opened thatengine's outboard exhaust valve.

Both enginemen then heard what sounded to them like cylinderrelief valves opening, and noted water spraying out of one of theengines •. They shut down both engines immediately, However, noengine order telegraph signal was transmitted to the controllermennor were the generator trip switches opened immediately.

The controllermen did not realize that anything had gone wrongin the Engine Room aside from failure of the engines to fire. Thusthey attempted to restart the engines. This time the enginemenopened the generator tri;p switches immediately.

F-13


Investigation revealed one engine flooded with the followingresultant damage:

a. Seven broken or cracked cylinder liners.

b. Six broken or cracked pistons.

c. Two broken or cracked cylinder heads.

d. Four bent connecting rods.

e • Bent lube oil supply line to main bearings.

f. Some babbit was knocked off all main bearings.

g. The lower deck liner bore .of one unit was damaged extensivelyrequiring rebuilding and reboring of that liner bore.

FINDlliGS AND OPlliIONS

1. The first engine had not fully fired off at the moment theengineman let go the first engine's throttle momentar~y to shut theexhaust valve for the second:. This resulted in the first enginedying before it had blown the muffler and tail pipe clear of -waterand while the tail pipe was still below the waterline after .theairless surfacing.

2. Most of the engine damage occurred on the attempt to restartthis first engine whic4 was now full of water. This damaging attemptto restart was due solely to the Engine Room's failure to signal"stop" to the Maneuvering Room and their failure to OPe.n the generator trip switches •.

3. Although the desire to perform an airlesssurfac-e with an airless start on two engines in a minimum of time is appreciated, attendant risks are not outbalanced by the rewseconds saved by startingtwo engines at one time.

COMMENT

The great difficulty of coordinating this two-headed evolutionshould be persuasion enough not to try it.

F-14


CASE

Main engine damage from inoperative lube oil ptunp.

PRINCIPLES

1. Do not operate machinery unless its safety devices are operative.

2. Report all casualties through the internal chain of command.

3. :Employ thefix-it-now policy on repairs.

A submarine's lube oil low pressure alarm for its #4 engine wasdamaged by the engineman in charge of the Engine Room. This was reported to the electricians for repair but was not reporte~ to the ChiefEngineman nor to the Engineer Officer. Repairs were attempted bui{were not successful. The engine continued to be operated as neededdespite the lack of the lube oil low pressure alarm.

Several weekS went by. Then, shortly after starting that engine,an unusual noise was heard in that engine. The lube oil pressure gageshowed zero lube oil pressure. The engine was stopped and examinationrevealed that the' shaft driving the attached lube oil pump had broken.Further eXamination revealed that all main bearings and four connectingrod bearings has been wiped, and that two cylinder liners were cracked.

FINDllfGS .AND OPINIONS

1. The engineman in charge of the Engine Room violated ship f s,orders and good engineering practice in that:

a. having knowledge that the low pressure lube oil alarm wasnot operating properly, he failed to report it to his seniors.

b. he operated #4 main engine with the safety devices inopera-tive.

c. he had not entered the necessary repair of the alarm in theCSMP nor any notation of necessary work to correct this condition inthe "Workbook.

2. The primary cause of the trouble was the deranged lube oil pump,but the inoperative lube oil alarm failed to warn the operating personnel before extensive damage was.done.

COMMENT

This case is an illustration of personnel failing to employestablished procedures. Loss of proper lubrication and overheating

F-15


are the two most common causes of engine damage. For this reason, alarmsto indicate impending damage from these failures are installed to warnthe operator. Lack of these alarms· places the operator in a precariousposition of having to note the gages continuously in order to be ableto obtain the same information. Had the engineman in charge of theEngine Room fully realized that one reason for requiring reports of allmaterial failures is that otherwise unreported failures might result ininadequate emphasis on repair, and inevitably much greater damage, thencertainly he would have reported the damaged alarm without delay to hisseniors. Trying to aviod blame in this case resulted in the additionalcost of thousands of dollars, hundreds of man-hours of additional workload, and, worst of all, loss of operational readiness of the engine.

/F-16


CASE

Wiping main motor bearing during alongside battery test discharge.

PRINCIPLE

Enploy routine maneuvering watch procedures while operating thepropulsion plant alongside.

NARRATIVE

A submarine connnenced a regular 6-hour battery test discharge alongside the pier at 0700. The evolution was being conducted by an EMl controllerman and the Engineer Officer as Officer of the Deck on the bridge.other personnel" both officer and enlisted" were available on board" butwere not called upon to assist.

In starting the discharge" the controllerman made several serious mistakes. He failed to start the main motor lube oil pumps" hefailed to energize and test the low lube oil pressure alarm" he failedto commence taking bearing temperatures" and he' failed to employ aroutine electrical log sheet.

At 0745 the controllerman was relieved. The new controllermandid not correct any of the mistakes of his predecessor.

At 0805 this controllerman was relieved. Th.e third controllerman commenced using an electrical log sheet and taking bearing temperatures as a result. At 0814 he noted the forward starboard bearingsreading was so high as to be off the scale. Noting then that the lubeoil pumps were not running" he started them. He also stopped thepropeller shafts" and reported this to the Officer of the Deck.

Subsequently the shafts were turned slowly to prevent shaftseizure until the bearings cooled to 1400 F. Examination revealedall main motor bearings wiped.

FINDINGS .AND OPINIONS

1. The bearings wiped due to lack of proper lubrication.

2. The high lube oil temperatures would have been read sooner hadthe electrical log been properly employed. This in turn would haveresulted in proper lubrication of the main motor bearings beforeserious damage could result.

3. The electrical log would have been employed and the low lubeoil pressure alarm energized had routine maneuvering watch proceduresbeen employed" with adequate personnel stationed in the ManeuveringRoom.

F-17


4. Conducting a battery test discharge alongside should requirestationing line handlers, an OOD, a bridge talker, a helmsman, twocontrollermen, a Maneuvering Room talker, an electrician in eachbattery compartment, with the Engineer Officer and his leadingelectrician's mate free to supervise the plant.

5. Routine procedures for relieving the watch, no matter whatwatch, should include proper methods of relaying the informationneeded to intelligently assume the watch.

COMMENTS

The real fault here was that no established procedure was employed. The use of non-standard procedures gets minds out of channels,and watch personnel will fail to do things which regularly they wouldnever fail to do.

Regular getting-underway procedure should be employed at any timethat the propulsion plant is operated alongside. This includes batterytest discharge, breasting out, and shipyard overhaul dock trials, aswell as the regular or emergency getting of the ship underway•

•

F-18


CASE

Damage to normal fuel oil tanks from excessive pressure of firemain.

PRINCIPLE

Enploy established procedures during all evolutions affecting thefuel system to prevent excessive pressures being placed inside fuel tanks.

NARRATIVE

A submarine was filling its fuel oil ~ks with compensating wateralongside following the drydock period during shipyard overhaul. Waterwas being taken from the shipyard fire main into the topside compensatingwater connection. Tanks being filled were being vented through their fuelfilling connection. Shipyard fire main pressure was 75 psi. The fuelking filling the tanks thought the shipyard fire main pressure was 15 psi.No one placed a gage on the fire main connection to determine what thepressure was. No one was assisting the fuel king in the filling operation.

As soon as the first tank became full, water commenced passingout the fuel filling connections from that tank. Shortly thereafterthe tank ruptured.


1. In. order for the water to leave the filled tank as fast as it iscoming in, it is necessary that the internal tank pressure equal theline pressure forcing the water in. This pressure (75 psi) was excessive, and the tank ruptured.

2. The immediate cause of the casualty is attributed to failureof personnel concerned to observe rudimentary precautions preparatoryto subjecting a compensating water system to an outside and unknowndock pressure.

COMMENTS.

The fuel tanks in the conventional submarine are built to withstand an internal pressure differential of 45 psi, are tested duringshipyard overhaul to 37 psi, and should regularly be fueled and defueled using 15-20 psi.

The established procedure for fueling ship requires a man atthe tank being filled, at the next tank to be filled, at the topside filling connections, and at the expanSion and collecting tankliquidometer location, with the fuel king and Engineer Officer supervising the entire evolution, free to observe and direct from any andall locations. The procedure requires that all personnel stationed

F-19


for fueling keep aware of pressure in the tanks and lines at their location by use of pressure gages placed at these locations specifically forthe purpose. The procedure requires that personnel stationed :for fuelingbe in continuous communication with each other directly by sound-poweredphones. Positive control of the incoming fueling pressure by means ofhull and topside stop valves is mandatory. The plan of fueling and thecomplete understanding of the system should be included in the prefueling conference with each of the fueling party~resent.

During shipyard overhaul periods, procedures tend to get out ofchannels. This in turn tends to cause people to try to use shortcutmethods and bypass established procedures. This lesson of e:xperienceagain demonstrates the wisdom of following established procedures.

F-ffi


CASE

Flooding main motors while alongside during overhaul sound survey.

PRINCIPLE

The below decks watchstander must continuously be alert for waterleaks into bilges, despite other diverting influences.

NARRATIVE

A submarine was conducting an overside sound survey incident toentering shipyard overhaul. At the request of shipyard survey personnel,the ship's force was operating individual auxiliary machinery on acalled-for basis. The particular person who was operating this machinerywas the below deck watchstander. He was doing this at the direction ofthe ship's Duty Officer. No one else was below decks inside the submarine.

Being involved in the sound survey, the below decks watchstanderfailed to conduct his routine hourly inspections of all compartments.After approximately three hours, however, he did make an inspection.Inspection of the motor room bilges revealed flooding had occurredto a depth of three feet, and that the main motors were flooded throughmissing bolts and faulty end bell seals.

FINDINGS MilD OPINIONS

1. Although the stern tube was leaking at this time more than wasusual, no flooding of the main motors would have occurred had themotor room bilges been pumped on each hourly inspection.

2. The ship's Duty Officer was violating the ship I s orders whenhe diverted the below decks watchstander from his hourly inspectionsof all conrpa.rtments.

COMMENT

This is another illustration of personnel not adequately understanding the need for following established procedure. The Duty Officershould have assigned an additional man from the duty section to operatemachinery for the sound survey, and under no circumstances should hehave employed the below decks watch in such a manner as to divert hisattention from his primary responsibility: Integrity and securityof the ship.

F-21


PART G - SUBMARINE ESCAPE HISTORY

The following notes concern sinkings of submarines from which

survivors have been able to report possible and definite causes of the

disasters and which seem to stress the importance of escape training in

peacetime and war. This chapter includes case histories of the sinkings

of submarines of various nations) and provides much information on es

cape procedures used by these countries.

G-l


GERMAN SUBMARINE U- 3

The U-3 sank in dock in Kiel (pre 1914). The crew failed toclose the after hatch and 25 men were trapped in the torpedo room.She was a very small submarine and floating cranes were able to liftthe bow and the men were released.

AMERICAN SUBMARINE 0 - 5

The 0-5 sank in Coco Solo, Canal Zone in shallow water, andhere again floating cranes were able to raise the forward end andtwo men were rescued after 36 hours.

DANISH SUBMARINE DYKKEREN

The Dykkeren was a small submarine of 150 tons and was rammedby a steamer and sank in 28 feet of water off ~openhagen in November,1916. The bulkhead abaft the conning tower was shut leaving nine menalive forward~ Only six had Draeger breathing apparatu~ available.The Commanding Officer decided to go into the Conning Tower with threemen and help them escape by th~ Conning Tower hatch. These three menused their Draeger gear and escaped successfully. The CommandingOfficer, however, was not successful in shutting the hatch and perished. It is probable that he failed to work his oxygen valve properly and became unconscious, as iater when his body was recovered,his oxygen was full. The remaining five men went into the torpedoroom while this escape was going on. Water gradually entered thetorpedo room and the storage battery, forming chlorine gas. By usingthe spare potash regenerators of the Draeger gear they did not suffermuch from the chlorine.

Salvage vessels arrived and a diver made contact by acousti y< <

Morse signals. After conferring with the three men who had escapedsuccessfully, the amount of damage could be assessed and it was decided to hoist the bow to the surface by means of salvage craft.Approximately four hours after the accident, air connections weremade and air at atmospheric pressure was passed to the man imprisoned in the forward compartment, which greatly helped their survival.Nine hours after the collision, the bow was hoisted above the water 'and the five men released.

E-41

The E-~l was rammed by the E-4 on 8 August, 1916 off Harwichin water 45 feet deep. When the E-41 was hit, an attempt was madeto shut the forward bulkhead door, but the water was rising rapidlyand everyone was ordered on deck. While the men were still goingup, the boat sank by the bow. The rising air pressure blew open theupper conning tower hatch and carried two sub-lieutenants to thesurface. The FIREDRAKE, hurrying to the spot, was able to pick uponly three officers and eleven men. One and a half hours later <

another survivor, Stoker Petty Officer BROWN, came to the surface.

G-3


E-41 (Cont'd)

The story of his escap~ is a tale of indomitable courage in the faceof difficulty.

As the boat was sinking he tried to shut the lower conningtower hatch, but water was coming through it, and he had to retireaft. He could find no one else alive, and found himself alone inthe engine room of the sunken submarine, which was dimly lit by asingle pilot lamp. His only hope of escape was by the torpedo hatch,arid, with water rising round him, he started to disconnect its gearing and unship its strongback. Twice or thrice he had to dive underwater to work the wheel of the gearing, and received several severeshocks from the switchboard. The water rose steadily, and the airpressure increased, but his most strenous efforts only succeeded i~

opening the hatch half-way. For close to an hour he wrestled withit and thrice it flew open, releasing a portion of the precious air;but the pressure was not sufficient and it closed grimly on him,crushing his hand badly before he could escape. In poisonous fumes,with only one hand and in the face of failures, he refused to giveup hope, and, as a last resource, he decided to flood the boat asquickly as possible. Opening a deadl1ght in the bulkhead, he allowedthe engine room to flood completely. With the water right up tothe coaming of the hatch,. he 'knocked out his pin. "I then raisedthe hatch, and escaped", he wrote. He rose 4 feet to the surface,and was picked up by the FlREDRAKE after a desperate, but neverdespairing struggle for an hour and a half.

GERMAN SUBMARINE U-51

On 14 July 1916, the U-51 was torpedoed and sank off the Jade,in approximately 90 :eeet of water. She sank down stern first in 10to 15 seconds. The torpedo hit between the central compartment andthe engine room. All the men in these compartments, and on thebridge, were killed by the explosion.

As dinner was being served, a large number of the crew weregathered in the crews' space. Water entered the living quartersimmediately, and the men retreated into the bow compartment. Amongthem was the Commanding Officer. Emergency lamps were taken. 18men thus collected in the forward compartment.

It was now discovered that 6 of the 18 had no Draeger gear.For this reason, it appears that the Commanding Officer decided notto make any attempt to get out. (It is thought that both he and theChief Engineer, who was also forward, had been dazed by the actualexplosion of the torpedo).

After about 4 hours, the air began to get very foul and theDraeger gear was used to breathe from. Before long, however, thisgave out and the conditions became very bad indeed. When nearly

G-4


GERMAN SUBMARINE U-51 (Cont'd)

all the men were dying, two act~lly made their escape, but it mustbe presumed that they equalized the pressure either by flooding orreleasing lIP air, or a combination of both. Both got out and reachedthe surface, but one was already dead. This was approximately 10hours after the boat sank.

When the submarine sank, 3 men were also left alive in theafter compartment. The after hatch had been slightly bent by theforce of the explosion, and they were unable to make an immediateescape. One of these 3 men was very dazed, and in a weakened condition. Finally, 50 hours after the accident, these three menescaped, presumably by flooding the compartment. All wore theirDraeger gear; two arrived on the surface, not only alive, but inapparently good condition; the third man was assisted towards thesurface, but apparently died on the way up, as they had to let himgo during the ascent, and he was never seen again.

The K-13 sank in the Garelock in 60 feet of water, in January1917, due to the engine room ventilators being left open. Thirty-twomen in the after part of the submarine were instantly drowned.Forty-eight others were alive in the fore part. The Captain of thesubmarine, Commander G. HERBERT, went into the Conning Tower withCommander F .H.M. GOODHART, who was afterwards killed during the ascentby hitting his head on the chart house roof. GOODHART, was theCaptain of another K-boat, anq was taking a trip with K-13.Theyintended flooding the Conning Tower to allow GOODHART to escape,and so inform those on the surface. Of the situation below. HERBERT·was to remain and shut the hatch after GOODHART le·ft. Compressedair was used to equalize the pressure. Commander HERBERT de~cribes

the escape as follows:--

"During the night we heard sounds as if someone was trying tolocate the ship with a grapnel, and about 6 or 8 a.m. we reportedto the divers, tapping, but could get no sense with the Morse Code.During the forenoon I asked Commander GOODHART if he would try andget out at low water, 12:30 p.m., with the necessary instructionsto those on top for giving us air and food.

Accordingly, after thinking things out, Commander GOODHARTdecided to try for it, and I agree.d that I should try and close thedoor after him. I arranged a code of signals to LT SINGER in orderthat he could drain down the Conning Tower after Commander GOODHARThad gone clear.

Commander GOODHART and I worked all forenoon taking away theprojector compass to give headroom, and also in connecting an H.P.valve to the whistle pipe to act as a blow. When everything was

G-5


K-13 (Cont'd)

ready, I charged the Conning Tower with air to make sure the bottomdoor and glands, through which electric cables passed, were tight.After rectifying this, which took roughly an hour, we were ready.

A small tin cylinder about 8 by 1-1/2 inches was then filled withinstructions to the people on the surface, and Commander GOODHART,putting this in his belt, proceeded into the Conning Tower with me.His last words were 'Well, if I don't get up the cylinder will'.He opened the flooding valve (fuel vent disconnected) and when thewater rose to our waists, I turned .on the H.P. air. Commander GOODHART knocked off the clips of the Conning Tower hatch. The ConningTower lid began to let water in and was soon wide open. CommanderGOODHART stood up in the dome, took a deep breath, and then made hisescape. We were both exceedingly out of breath at the time. Almostimmediately I put my hands up to feel for the lid, and without knowing, found myself carried through the opening into the shelter, theroof of which must have struck my head, from the bruises, and a cutI subsequently discovered.

All the time H.P. air was escaping fast from the Conning Tower,and I attribute my escape entirely to this, for without doing anything; I fdund myself shooting through the square hatch in the topof the wheel house. I breathed hard all the way to the surface andfortunately arrived up between two craft, one of which hauled meaboard" •

HERBERT came up 23 hours after the submarine sank. From HERBERT's report and knowledge of the boat, the divers were enabled toconnect up,H.P. air (another submarine (E":'50) supplied the air), andby this means the survivors in the boat blew out some tanks. Thisextra buoyancy, plus large wires which were passed under the bows,allowed salvage craft to get the bow to the surface; a hole was cutin the hull, and the survivors escaped 54 hours after the disaster.

Foul air might have killed them before this, had not the diversconnected a 4 inch flexible pipe to the ammunication hand up. Thiswas approximately 40 hours after the accident. A divers air pipe waspassed down this 4 inch pipe for refreshing the air inside.

There are two particular points of interestj one is that thesurvivors were saved by air being passed them, and that HERBERTdescribes in two different erports written shortly after his escapethat "I breathed hard all the way to the surface", and again "swimming vigorously for the surface, I was compelled to place my handsover my face and take a deep breath which to my surprise was air andnot water. Shortly after this, I broke surface." It is probablethat HERBERT's experi~nce was the excess pressure in his lungs exhaust-

itself on the way up. Nothing of course was known of excess pressurein those days. It is possible that there was so much H.P. air exhausting from the Conning Tower that he was actually coming up in a largeair bubble or air stream.

G-6


liB-57

The liB-57 struck a mine off Dover in the 1914-18 war, and sankin 128 feet of water. The boat flooded rapidly aft, filling up tothe forward Control Room bulkhead. The forward bulkhead leakedbadly. Twenty men were alive in the forward compartments. It wasdecided to distribute eight of these men in the Conning Tower, andthe remainder under the fore hatch. Only four-Draeger breathingapparatus were available.

They first attempted to equalize the pressure in the boat byusing H.P. air from the bottles and torpedoes, but this proved insufficient, and they had to flood the boat in addition.

It was not until approximately 1-1/2 hours after the accidentthat they succeeded in equalizing the pressure and opening thehatches.

The flooding-up period was terrible; chlorine gas caused badcoughing, and the constantly increasing difficulty in breathing withaching pain in the ears made conditions well nigh unbearable. Twomen could not stand it any longer and shot themselves. The Officerin Charge contemplated taking morphine, and the following is thisofficer's story of his escape:--

trThe water was in the boat at a height of about one foot abovethe floor plates, when I 'once more tried to. open the hatchway.Suddenly, against my expectation, by the increasing inside pressurethe hatchway cover was torn out of my hands and flung open. I justcould shout "hold on", and then was lifted, without any effort on mypart, •••• and remained for just a short moment up to the lips outof the hatchway cover without getting wet. I stood in front of adark black greenish wall, through which the outlines of the ConningTower were perceptible. Then the water broke all over me and I commenced to rise. To previously inhale deeply was impossible for me,due to the difficulty of breathing and the exertion while tryingto open the hatchway cover. For that reason I had not inflated thelife-belt and only closed its valve; so that no water might get intoit. While rising I had the senstation to constantly increase insize. I was curious to see how long I would be able to hold mybreath, and was astonished to observe that I had no desire to inhale,but to forcibly exhale so that I constantly had to blow air out ofmy cheeks. (Looking upon what had happened an easily understandablecase, because I had air at 3.5 atm overpressure in my lungs which,while rising, expanded gradually). I therefore commenced to stopmy trip to the surface by energetically moving my hands. How longit took until I came to the surface I do not know, and it has beenimpossible for me to even guess at that length of time. No two ofthe queue leaving the Conning Tower at any event had arrived at thesurface of the water before me, and within about two seconds more,all of the eight men had been shot out of the Conning Tower hatch-

G-7


DB-57 (Cont'd)

way like corks out of a bottle. A short time later the men fromthe fore compartment appeared. Of these, some, after a terriblescream, went down again. This I explain by the fact that theirbodies were internally bursted (by holding their breath). My surprise was great when at the surface my swimming vest was filledwith air to the point of bursting. (Reasoning out what had happened, a very simple case, exactly the same conditions influencingmy lungs). From one of the men saved I heard that the crew in thefore compartment had seen in the rising of the manometer an indication of the boat rising to the surface, and had commenced to hastilypack their clothing. When the manometer showed 6 meters they thoughtthat the boat had come to the surface and opened the hatchway coverthrough which - very much to their suprise - the water heavily rushedin. I was told by him that he had been in the compartment forward,quite a distance from the hatchway cover, and had to swim through theboat to the hatchway, leaving her as the last man.

On the surface we first tried to make our way for a buoy which,however, we missed by drifting away from it. Through a light swellrunning, it'was impossible to see the other men. We tried to keeptogether by shouting at each other. My watch officer, who againstmy advice had undressed entirely, after some time did not reply anymore and no doubt was benumbed (heart failure). The water had atemperature of about 4 degrees Celsius. I myself left in the boatonly my sea boots, cap and gloves, so that I did wear what duringcold weather one has of clothing aboard a submarine. After sometime the masts and fmmel of a guard ship came in sight. By jumpingout of the water and clapping the hands I indicated to her ourlocation. I was picked up by her already unconscious with six others,amongst them the Chief Engineer. How it came about that I 'becameunconscious I do not know. I only remember without any struggle orfear of death. I only know that with my clothing thoroughly soaked,I had to swim hard notWithstanding the life-belt in order to remainfloating.

My Chief Engineer was lifted on board by the guard ship as thefirst man. She lowered a boat and made a search for about an hourand twice picked up each time three men. During their second tripthey found me as the last one, with my head already in the water.The Chief Engineer was likewise unconscious and could not be revived.We did swim in the water about an hour to an hour and a half. If

POSEIDON

The POSEIDON was rammed and sunk off Weihai by S.S. YUTA at1212 on 9 June 1931 in 130 feet of water. 18 men were trapped in theafter part and perished. Of the remainder, 27 left the submarine bythe Conning Tower before she sank and 8 were trapped in the fore ends.Of these, five made successful escapes, 1 died making his escape and2 never came up.

G-8


POSEIDON (Cont'd)

The tube space and stowage compartment were flooded by meansof number 3 bowcap, draining to· the main line and into the compartmentby the W.R.T. suction. Pressure was equalized after 2-1/2 hours whentwo men escaped through the fore hatch, whereupon it shut again. Ofthese two, one came up with his mouthpiece cock Shut, and was dead onreaching the surface. Death was diagnosed as a burst lung although noautopsy took place. The other one used his D.S.E.A. nearly correctly,but the exhaust valve clip was removed too soon, resulting in a seriousloss of oxygen. In addition, his nose clip was knocked off on leavingthe submarine. This man suffered no ill effects although he lostconsciousness whilst supporting the dead man on the surface. On theway up he states that he kicked and swam in order to speed up theascent at the beginning (presumably he started with negative buoy'ancy) and exhaled through his nose during the later part of the ascent.

The compartment was flooded up again by the remaining 6 menand 3-1/4 hours after the disaster, the pressure equalized again and4 men managed to escape.

The first came up using his D.S.E.A. solely as a buoyancybag, full of air, with the mouthcock shut and the exhaust clip on,his oxygen having run out. This P.O. (WILLIS) gave the followingaccount of his escape:

"The hatch then flew open and the compartment was immediatelyfilled. I seemed to hang around the hatch for a few seconds and thenseemed to shoot up, having very violent pains in my chest at the sametime. A short time after getting out I opened by mouth; I could notstick it any longer. The pain eased and I went unconscious. I came

. to in the stern sheets" of one of the cutters". He afterwards had noill effects.

The next two men (one a Chinese boy) came up without removingthe exhaust clip at all, resulting in slight caisson disease in thecase of the Chinese boy and no ill effects in the case of the otherman. Nose clips were in place and there was no escape gas at themouthpiece.

The fourth man came up having used all his oxygen. Just before leaving he broke the small emergency outlet. He came up withthe mouthpiece in and the exhaust clip off, but suffered from severecaisson disease. He felt no symptoms until he reached the surfaceand boarded a boat. He then "went paralysed and had shooting painsin all his joints".

Of the two who never came up (one a Chinese boy), one had aset but no oxygen and is presumed to have drowned on leaving thehatch. The Chinese boy had no set and is presumed to have drownedin the compartment.

G-9


U.S.S. SQUALUS

The U.S.S. SQUAWS sank at about 0840 on 23 May 1939 in 220feet of water. The water temperature was 290F.

At 1040, 23 May, it was noted that the SQUALUS' expected surfacing report was orie hour overdue. The submarine SCULPIN was ordered to try to contact SQUALUS. The Submarine Salvage Ship FALCONwas also warned at this time to be ready to stand by.

At 1241 SCULPIN reported having sighted a red smoke bomb fromSQUALUS. later SCULPIN reported locating the marker buoy from·SQUALUS at latitude 420 53'N., longitude 700 37'W. This positionwas 3 3/4 miles westward from the reported diving position of theSQUALUS. This fact is pointed out in order to emphasize the extremevalue of the alert lookout kept by SCULPIN" and undoubtedly saveda tremendous amount of time which otherwise would have been spentsearching for the SQUAWS.

The Commanding Officer of the SCULPIN reported that he hadpicked up the marker buoy" which was the forward one of the SQUAWSand had held two minutes conversation over the buoy telephone withLT J.C. NICKOLS and LT O.F. NAQUIN, Commanding Officer of SQUALUSwhich was in substance as follows:--

WILKIN "What is your trouble?"

NICHOLS "High induction open" crew's compartment" forwardand after engine rooms flooded. Not sure about aftertorpedo room but could not establish communicationswith that compartment. Hold phone and I will put youon to the Captain."

WILKIN "How are things'l"

NAQUIN "Consider best method to employ is to send diver downas soon as possible to close high induction and hookon salvage lines to flooded compartments and freethem of water in attempt to bring her up; for thepresent consider that preferable to sending personnel up with lung."

At this point the marker buoy cable parted. ~ter investigation showed that a bight of the buoy cable had been caught on somesharp obstruction over the side of the SQUALUS.

SCULPIN then located the SQUALUS with her supersonic equipment.

At 1930 PENACOOK hooked her drag anchors on to the SQUAWS.

At 1245 a U.S. Coast Guard vessel arrived" bringing experts of theExperimental Diving Unit who had been sent from Washington"D.C. by air.

G-ll


U.S.S. SQUALUS (Cont'd)

No attempt was made to conduct diving operations during thenight. It had been ascertained that the personnel in the forwardcompartments of the SQUALUS were in no immediate danger. Satisfactory communications had been established with the SQUALUS since 1345by tapping in Morse code on the hull of the SCULPIN and hearing similar messages from the SQUALUS. Early messages indicated 33 men aliveforward. Conditions were reported satisfactory but cold.

On 24 May at 0415 Commander Allan R. MC CANN, USN and 12 diverson the Experimental Diving Unit arrived at the scene of operations.

At 0425 the U.S.S. FALCON arrived. Divers from FALCON weresent to SCULPIN to familarize themselves with the layout and eCluipment to be found on the SQUALUS, which was a sister ship.

FALCON, owing to wind and sea conditions, had some difficultyin getting to the right position but at 1014 the first diver wentdown and reached the SQUALUS at 1017. The descending line used wasthe buoy line which had been attached to the drag anchor by PENACOOKand this line was discovered by the diver to be only six feet aft ofthe forward torpedo room hatch.

At 1028 the rescue chamber downhaul wire was shackled to thedescending line and lowered to the diver who shackled it to the hatchat 1039.

The extr.emely skillful work of this first diver resulted inmarked expedition of the whole rescue operation and contributedgreatly to its ultimate success. In addition to shackling on thedownhaul wire, it was necessary for him to clear the bight of themarker buoy line, which lay across the hatch, and was still fouledsomewhere over the side. Had this buoy lirte been allowed to remain,it would have endangered the rescue chamber operations by possiblyfouling or preventing a tight seal on the hatch. The rescue chamber was hoisted over the side for the first trip at 1130 and reported on the submarine at 1212. The operators reported the SQUAWSto have a 7 degree list and to be down by the stern.

At 1240 the chamber had been secured to the submarine and theupper hatch opened. The lower hatch was opened and contact established with the submarine crew at 1247.

Provisions and dehydrating materials·were delivered to thecrew, the submarine was ventilated through the chamber for severalminutes, and several passengers taken aboard.

At 1256 the submarine hatch was shut.

At 1342 the rescue chamber reached the surface and survivorsevacuated.

G-12


U.S.S. SQUALUS (Cont'd)

The first three rescue trips were made expeditiously, andequipment functioned as designed throughout these trips. This wasthe first occasion in which the rescue chamber had been used forother than training purposes, and the results achieved have fullyjustified the vision, faith and hard work of those involved in thedevelopment of the equipment.

The fourth trip of the rescue chamber proceeded apparentlyaccording to schedule up to 2022 when, during the ascent with thelast survivors on board, the air motor which dri'les the downhaulequipment stalled and could not be restarted. An attempt was madeto continue the ascent by controlling with the brake instead of themotor, but at 155 feet, the reel again jammed and no further downhaul wire could be let out, even with the brake released. Thedo~ul equipment could not be moved either up or down, thereforethe decision was made to lower the chamber to the bottom and senda diver down to unshackle or cut the downhaul wire to free thechamber.

At 2122 the downhaul cable was cut by a diver. An attemptwas immediately made to heave up the chamber with the winch but thestrain on the retriever wire was abnonnally heavy and at 2125, theretriever cable stranded. The strain was quickly taken off and thechamber lowered to the bottom. After a conference it was decidedthat the best method of getting tpe chamber up wo~d'be to adjustthe buoyancy of the chamber as nearly as possible to neutral onthe negative side and the haul in the frayed retrieving wire carefully by hand in order not to part the remaining strand•. In usingthis method, the danger of acquiring positi.ve buoyancy of the chamber with resulting swift ascent to the surface, and the possibilityof its coming up under the FAICON had to be accepted. This methodwas entirely successful and the chamber surfaced and the last knownsurvivors were evacuated at 0025 on 25 May.

It was now decided to make a trip in the chamber to the hatchcommunicating with the after torpedo room in order to be absolutelycertain that there were no survivors remaining in the SQUALUS.FALCON therefore changed mooring and after a new downhaul cable hadbeen fitted the chamber commenced its last descent at 1719. It wasnecessary in this operation to equalize the pressure in the rescuechamber with that of sea pressure in order to enable the submarinehatch to be opened, without flooding the chamber. At 1815 the rescue chamber reached the submarine. When the after torpedo roomhatch was cracked, water commenced to flood into the chamber fromthe after torpedo room, proving that this room was flooded. Thehatch was secured and the rescue chamber started to ascend, and,at 2107, was landed on the deck of the FALCON. It should be notedthat, in the final operation, the two men in charge of the rescuechamber were in some danger. If they had become incapacitated for

G-13


U.S~S. SQUALUS (Contrd)

any reason, there was no way in which they could have been rescued,as the chamber could not be entered from the outside.

With the exception of the last rescue trip of the chamber, whenthe downhaul cable became jammed, each trip of the chamber to thesubmarine and back to the surface took approximately 2 hours and 15minutes.

The'last survivors reached the surface at 0025 on 25 May. TheSQUALUS sank at 0840 on 23 May, so that these survivors were submerged for a total of 39 hours and 45 minutes.

All survivors complained bitterly of the cold in the submarinewhile waiting to escape. The water temperature was 31G:F. and thecompartment air temperature was only 360 F. The air in the compartment was foul with CO2, but thi s could never have reached a very highlevel as this air was refreshed with each trip of the chamber.Chlorine was just beginning to make its presence felt when the lastsurvivors were taken aboard the rescue chamber.

H.M.S. THETIS

The THETIS sank off Liverpool on trials in June 1939, in a depthof 120 feet as the result of the rear door of a torpedo tube being ,opened underwater with the bowcap open.

Due to the unfortunate fact that the wiT door on No.' 25 bulkhead had clips and butterfly nuts instead of being quick closing,they were unable to close it quickly enough to prevent furtherflooding. Had this door been quickly and securely shut the submarine could have been brought to the surface by the crew's own efforts.

Both fore end and torpedo stowage compartment flooded, i.e. allcompartments forward of No. 40 bulkhead.

With the crew and trials party, there were no less than 103people left alive in the remaining parts 'of the submarine.

It was first decided to pass into the flooded part of thesubmarine for purposes of shutting the tube and so pumping 'out, usingthe escape chamber as an air lock. An officer first went in alonewith a D.S.E.A. set, but was unable to stand the pressure. A secondattempt was made by a different officer and P.O. They practicallyreached the full sea pressure (120 feet), but as the P.O. complainedabout his ear hurting the attempt was abandoned. This same officerwent in again with another P.O., but the second P.O. showed signs ofdistress as the pressure was built up, and the attempt was againabandoned. The officer at no time suffered unduly except from thecold water.

G-14


H.M.S. THETIS (Cont'd)

There is no doubt that this incident was most unfortunate, asit must have had an adverse effect on the survivors, making themlose confidence in a normal escape from the chamber at this depth.

A great deal of work was done in the subma;rine during thenight with the subsequent building up of C02 with the large numbersin the confined space remaining and breathing fast was alreadynoticed ten hours after the accident. After 14 hours some men,who had been working, began to feel sick.

After 17 hours the crew had lightened the submarine aft sufficient1y to get the stern up, but by that time most people hadheadaches and were breathing fast.

The angle of the boat, once the stern was up, was severe and,in order to get aft) men had literally to haul themselves up. Thisextra strain on men already distressed by the C02 can be appreciated.For example, one officer stated at this time that, by the time hegot aft) he had to rest for 10 to 15 minutes before having enoughenergy to don a D.S.E.A. set. 18-1/2 hours after the accident, breathing was becoming increasingly difficult, and the older men were in abad way.

Two officers went into the after escape chamber and made theirescape without any real difficulty. The after chamber was about10 feet below the surface at that time. They both used D.S.E.A.

After this successful escape the chamber was drained down,but unfortunately the water, due to the angle, drained into themain motors and start.ed an electrical fire with masses of smoke.The effect of this on the already foul air can be appreciated.

It must have appeared now to the survivors that, unless theymade hurried escapes, most of them would be unable to escape at all,due to the CO2 content in the air. It was probably this fact thatdecided them to make the fatal mistake of putting four people inat once in a chamber designed for two. They were flooded up, buteither they got jammed or panicked) for after a quarter of an hourthey were still in the flooded chamberj the hatch was shut, and themen pulled out.. Three were dead, and the fourth nearly so. (Allfour had D.S.E.A. sets).

Two were sent in after this, one of whom was a civilian whohad never used D.S.E.A. before. These two men made their escapewith D.S.E.A. sets in the normal manner without any great difficultyjthe after chamber still being only about 10 feet below the surface.No one else ever came out.

G-15


H.M. S. THETIS -( Cont I d)

There is little doubt that after the last two left, the remaining were in too bad a state, due to the foul air, to be any longer capable of making the physical effort of the escape.

After the boat had been salvaged and the submarine under waterfor nearly three months, the escape chamber mechanism was still inperfect working order.

There is every reason to suppose that, had the normal routineescape been made early enough before the air became foul, a largemajority would have reached the surface successfully.

The lack of a ready means of supplying air at atmospheric pressure was also a disaster. Had the crew removed the manhole to Z tankwhich was secured by bolts to the after compartment bulkhead and runthe compressor once the stern was on the surface, they could themselves have obtained air through Z vent which was above water, but bythis time approximately 18 hours after the disaster, they were tooovercome by the C02 to think or reason clearly.

u-40

The u-40 hit a mine off Dover in mid-October 1939 and sank in115 feet of water. The two forward compartments were immediatelyflooded and everyone in them drowned. Nine men were left alive inthe after compartment. They were left in darkness, but used torches.There was no officer who survived.

The men discussed when to escape and decided to do so an hourafter she sank. One survivor stated the air was getting foul, butthe others did not confirm this. Some ate biscuits while waiting,some nothing. Some put on a lot of clothes, some had only a suitof underclothes. There was no panic, a certain amount of good humor,and no tendency to blame anyone for the disaster. Valves were openedand the compartment took 10-15 minutes to flood. The men took precautions not to be knocked over by the inrush of water·when the hatchspring was released. The 9 men escaped in between 3 and 4 minutes.They did not use their pressure release stopcocks, but allowed thesurplus oxygen to escape out of their mouths as they ascended. The 9men reached the surface, but one was missed fairly soon, and no reasoncould be given for his disappearance. The remainder complained bitterly of the cold. All of them had lifebelts, which they inflated byblOWing them up when they were in the water. Four men huddled together in the water for warmth, 'but after a few hours exposure, oneafter the other died until only WEBER was left. Five men lost theirlives through exposure. The three survivors think that this was dueto cold, but it was probably accelerated by the inhalation of water asthe three survivors were intensely thirsty in the hospital. One statesthat, just at dawn, a small boat passed near him, but his cries werenot heard. He lost his courage and the cold was so unbearable thathe deflated his lifebelt with a veiw to drowning. He found the sensation so unpleasant that he changed his mind and swam upwards and

G-lb.


u-40 (Contrd)

inflated his lifebelt again. The three survivors were rescued aboutmid-day after being in the water between 9 and 10 hours.

Two of them lost consciousness before being picked up. Theywere in the hospital 4 to 5 days, and at the end of this time, theywere fit to travel, and a month later were in excellent health.

Only one in the water vomited after about two hours. He wasthe one who had eaten biscuits.

The hatch by which they escaped is closed against a heavyspring. The clips were undone, and when the pressure equalized thehatch opened itself with only a slight push.

They donned their apparatus before flooding the compartment,but they did not insert their mouthpieces and commence inhaling theoxygen until the last possible moment. This was' not because of .anyinstruction they received, but because they regarded the apparatusas rather an uncomfortable thing which one had to put on at thelast moment, only as a means of escape. When they got to the surface they disconnected their mouthpieces and relied entirely forsupport on their 1ifebelts. Their 1ifebe1ts were, in this case,entirely separate to their Draeger gear.

u-64

This submarine was sunk off Narvik by depth charge attachfrom the aircraft in 131 :feet, in April 1940. There were eight menleft alive in the submarine, and it is believed that they floodedthe whole boat, and escaped via the Conning Tower hatch, openingevery possible valve and means of letting in water. All eightmen survived, and came up without any apparatus.

The II-49 sunk in November ,194o, off the Dutch coast, inapproximately 70 feet of water. The only details known are from a conversation held ina P.O.W. camp in Germany as the sole survivor was subsequently killed in a car accident.

The H-49 was depth-charged, damaged, and went to the bottom.Leading Stoker, F. G. OLIVER was ordered by the ChiefE.R.A. to issue D.S.E.A. sets to all in the Motor Room. He did this and foundhe had left himself without a set. The next thing that he remembered was regaining consciousness on board a German trawler andfinding that he was the sole survivor.

UMPIRE

The UMPIRE was sunk by a collision off Sheringham 0030 on 19July 1941, in a depth of 60-65 feet. The submarine was listed heavilyto starboard on the bottom. "It made it possible to sit on front of

G-17


UMPIRE (Cont'd)

the engines on the starboard side" so the list was not less than 300 •

She was also bow down approximately 100 • She was holed forward.

Four men collected in the Control Room and 17 in the EngineRoom. Those in the Control Room decided to make their escape viathe Conning Tower. Water was pouring through the Forward ControlRoom bulkhead; probably through the ship's ventilation trunk. Thesefour men (two officers amonst them) allowed the pressure to builtup in the Conning Tower by venting through the lower hatch and allowing the pressure from Control Room to enter Conning Tower.

There was some chlorine present in the Control Room, but it wasnot bad in the Conning Tower. Pressure was equalized, and the Conning Tower hatch opened after approximately 40 minutes. The men inthe Conning Tower had neither D.S.E.A. sets nor lifebelts. Owing tothe shallow depth the pressure equalized before the water levelreached the Conning Tower. Of the four in the Conning Tower, thefirst to leave reached the surface and was alive and talked with oneof the survivors, but he was not picked up. Two others left andsurvived; the remaining man, anE.R.A., was in a very bad way beforethe escape was made, and it is the opinion of the survivor interviewed that he never left the Conning Tower, and was drowned in it.One of the survivors (the last to leave) said he held his breathall the time. The two survivors suffered no ill effects.

Meanwhile, in the Engine Room, preparations to escape by thetwill trunk were made immediately after the forward bulkhead doorwas shut. Of the 17 men, three had no D~S.E.A. sets.

None of the D.S.E.A. torches worked and difficulty was experienced opening the D.S.E.A. lockers, due to the strong pins.and wiresused to secure the lids.

Owing to the list, it was difficult to shut the forward bulkhead door, and tackles had to be used to do this in the dark. Flooding was normally carried out through the flooding valve provided,and the hatch was opened, when the pressure equalized, by the firstpair to escape. There was a small air lock left in the trunk priorto opening the hatch.

Unfortunately, it is not known how long the flooding took, butthe Engine Room survivors had surfaced less than 1-1/2 hours after thecollision.

As there were three men without sets, it was decided to sendthem up with men who had )sets. Of the first two to escape in thisway, both reached the surface alive, hanging on to their oppositenumbers with sets, but they were not picked up and clearly drowned.afte.r reaching the surface. The third man without a·set started with

G-18


UMPIRE (Cont'd)

hi s opposite number wi th a set, but although he was alive when heentered the trunk, he was not with his opposite number on the way up.What happened to him is not known. All the remainder, except one,in the compartment, made various escapes with the D.S.E.A. and survived, but some of those who came up successfully only used theirsets as buoyancy bags. How many is not known. One definitely losthis mouthpiece by fouling the hatch as he went out; others losttheir mouthpieces when they struck the wiT mast during the ascent.One man on the way up became entangled with this mast, and had somedifficulty getting clear. The one man with a D.S.E.A. who failedto survive was a civilian who knew nothing about submarine escape,and was in a low state of morale before leaving. Due to the angle,the D.S.E.A. ladder in the twill trunk was more of a hinderancethan anything else.

The escape from the Engine Room was an excellent example ofgood leadership, cool thinking, and the correct working of thetwill trunk method. For example, the Chief E.R.A., after some hadescaped, went up into the trunk, right to the hatch, to see that allwas clear and then returned back into the submarine to tell theothers. It is difficult to give 'an exact analysis, but of the 7men who attempted to escape with neither D~S.E.A. nor buoyancy bag,five reached the surface alive. The others undoubtedly drowned bylack of some sort of buoyancy on the surface. Of the 14 attemptingescape with D.S.E.A~, 13 were successful, but some of these usedD.S.E.A. as a buoyancy bag only.

The P-32 sank off Tripoli August 1941, in a depth of 210 feet.Probably mined forward, the submarine was submerged at the time.The lights went out immediately and the boat plunged straight tothe bottom. When they reached the bottom the forward bulkhead doorto the Control Room was already shut and jammed by the force of theexplosion. Some ratings were still alive forward, but the door wasjammed and could not be opened. Shortly afterwards these men wereheard screaming, and then silence, so it, was presumed the compartment flooded forward fairly quickly. The remainder of the crew wasstill alive; 24 in all. They went into the Engine Room, but owingto the congestion, three (1 officer, and 2 men) went to the ConningTower to make their escape from there.

The D.S.E.A. sets were all broken out, and after the forwardEngine Room bulkhead door was shut, the men in the Control Roomheard those in the Engine Room start flooding up; but none survivedfrom the Engine Room.

It is fairly certain that the reason for this failure to escape was the Engine Room D.S.E.A. hatch being clipped down from the

G-19


P-32 (Cont'd)

outside. In some submarines it was the practice during the war toclip down these hatches to prevent the hatches leaking due to IIjump"when depth charges exploded very close.

The submarine was listed about 200•

The officer, P.O., and E.R.A. climbed into the Conning Tower.P;ressure was equalized by flooding. As soon as the pressure equalized, the hatch was opened and they escaped. The E.R.A. escapedfirst, then the P.O., and then the officer. All three wore D.S.E.A.sets. The E.R.A. reached the surface but was dead; he was alive and

. had his wits about him before leaving the Conning Tower. On the, surface he still had his mouthpiece in, but the exhaust valve was'

shut; his eyes were bulging and his face grey, and when attemptswere made to remove his mouthpiece, blood came out.

None of the three had any trouble or experienced any real distress when flooding up.

The P.O. (KIRK) was a tall, rather timid man, with averagephysique. He used hi s set as follows:--

III did not have any air in my set, but I fitted it on, and,remembering my drill, when the sea pressure inside the Conning Towerhad equalized outside I filled my bag up by taking air in throughmy nose and closing the mouth cock. The E.R.A. then -went up and Itook in a breath of air, put my clip on and followed him straightaway. I had to hold my breath, but I had to open my mouth and tookin 2 or 3 mouthfuls of water. However, the next mOment I broke surface. I did not breathe oxygen in the Conning Tower at all".

KIRK had his mouthpiece cock shut before he started the ascentdurin,g the ascent and on his arrival at the surface.

The officer worked his D.S.E.A. set correctly and used theapron for the ascent.

The P.O. was in the water for 1-1/2 to 2 hours before beingpic~ed up.

PERSEUS

This submarine was running on the surface, in December 1941,in the Channel between zante and Cephalonia in the Mediterranean,Yfas apparently mined and sank rapidly to the bottom in approximately 170 feet of water.

There was one survivor. The story of the survivor is as follows:--

G-20


PERSEUS (Cont'd)

"Exactly at 10 0' clock there was a very considerable explosionand the ,boat went over to about 250 to starboard and in a matter ofabout 3 seconds was vertical, bow down. I was in the after bulkheadgoing to the stokers' mess. Stores, etc., were falling all round.In about 5 seconds she fell straight back to the horizontal position,slightly stern down. She then hit the bottom and went still furtherover to about 300 • You could not stand on the deck at all; you hadto hang on overhead. Before she reached the bottom all the lightshad failed and the battery was out. I was in complete darkness.The bulkhead door shut itself. '

For ~bout ten minutes I was feeling my way about trying tofind a D.S.E.A. torch or the secondary lighting. Eventually, in thestarboard bilge I found a D.S.E.A. torch. Water was seeping in 1;l.11around •••••• I went into the stokers' mess and found three fellowsunder the lockers. All the overhead woodwork had collapsed. Themen were slightly injured but fairly sensible. I went through themess bulkhead to the Motor Room; t4ere all the switches had comedown and one L.T.O. was completely burned. I then went through thebulkhead to the Engine Room and by the time I got there it must havebeen anything up to 20 mInutes.

In the Engine Room water was over the tops of the engines andjust seeping back into the Motor Room. There was no one alive abovethe water. The boat was slightly down aft. The Engine Room bulkhead door itself was shut and tight, but it had no clips.

I proceeded back aft and shut the Engine Room door and putthe dogs on it. I examined the L.T.O. but he was definitely deadand I left him; I didn't both to find out who he was. I shut theMotor Room door and in the mess the three young stokers had extricated themselves and were sitting on the deck which was at a bigangle. I told them to get back aft which they did and we shut thecompartment door and clipped it.

At this time I thought we had better consider flooding. Ittook half an hour to ,clear all the stores and boxes, etc., that hadfallen from the space under the D.S.E.A. trunk. The pressure thenwas still very slight, almost normal. There was no smoke, I attempted to use the flooding up valves, but they were useless. On thestarboard side of the PERSEUS was the underwater gun which was in afavourable position for flooding by opening the breech•. The watercame in at considerable pressure up to my waist in three minutes.We got the D.S.E.A. sets out, but did not put them on. When shewas flooded half way up I shut off and we got the trunk dow, andsecured it. I flooded up again and by this time breathing was painful. I continued flooding until no more water would come in. It wasthen well up to my chest. During flooding up I could hear a hissing

G-21


PERSEUS (Cont'd)

noise and assumed it was air going out of the hull. With the helpof a spanner I undid No. 4 H.P. air group to the underwater gun andlet air come into the compartment, as I was afraid that, with thehull leaking, we would be flooded before we could get out. I succeeded in getting air in all the time from the after group.

I still had my D.S.E.A. set, out of the water, but I did notput it on. I dived down and got inside the trunk and found therewas about two feet of air inside. I undid the four dogs and waterbegan to seep in through the rim of the hatch. I gave the hatch aheave and nearly went out in the bubble. The other three fellowshad their sets on and I saw their exhaust cocks were open and theywent out. They had to be pushed out and they had to help themselvesbecause of the angle. I then put on my set and adjusted the noseclip and dived down. Immediately I got inside the trunk there wassuch a blast of air that I knocked the set off. I returned to thecompartment and put the mouthpiece and nose clip on again, and puta little gas itl the lung, because I had lost it all. I had the exhaust cock open and everything was working properly, although therewas one disadvantage" a drum of enamel had burst open and it was allon the surface of the water inside" so that immediately you diveddown you were covered in it. However this time I held the set onwi th one hand and in the other held the torch. I eased myself out,feeling for the jumping wire" and steadying myself by putting myfeet in the rim of the hatch. I let myself go, holding the apronout most of thetirrie. It took about two minutes to come up.

I felt no ill effects at all. It was a bright moonlight nightand there was nobody in sight at all. The other three could nothave reached the surface. I had to swim about 7 miles to the shore.I kept the set on all the time and it kept me up very well. II

(Note: The whole of this escape should be treated with reserve, as there are various incidents difficult to account for.Three different authorities who all saw this man separately aredoubtful of the whole story. There is no other means of checkingthe facts and it is possible that this man, who was only taking passage in PERSEUS, may have been on the bridge or in the Control Roomand got out before she sank. At the same time there is no directevidence that his story is not in substance correct.)

The X-3 sank on 4 November 1942 at 1350 in Loch Striven in adepth of water of 114 feet, due to a leaking engine valve. The wholecrew, consisting of three officers, all made successful escapes afterthe submarine bottomed.

G-22


X-3 (Cont'd)

Immediately after the submarine dived, it was realized thatwater was coming into the boat and she was brought to the surface ata very steep angle of about 800 , but only stayed on the surface aboutfive minutes before sinking rapidly by the stern. All possible methods of surfacing after sinking failed. The motors continued to rununtil the boat bottomed. Very shortly after hitting the bottom,chlorine appeared and all three donned their D.S.E.A. sets. LT LATESwas the first to enter the W&D hatch and the flooding of the W&D wasdone by opening the equalizing cock in the top hatch. The forwardhatch of W&D was shut and LATES shut the after hatch before flooding.The method of flooding the W&D was very slow as the pump was notworking. LATES was exposed to a shower bath and he felt cold, miserable and frightened. He was breathing from his set very fast and hisoxygen ran out in about 20 minutes, he thinks. He was nearly unconscious, but he opened the forward door of the W&D and went back intothe Control Room, where he lost consciousness.

GAY, the second survivor, stated that when LATES came back intothe boat, he looked very frightened, was almost hysterical, was shaking allover and complained of being unable to get any oxygen tobreathe. Immediately after that, LATES lost consciousness. The othertwo officers placed another set over the one that LATES was wearingand stuck the mouthpiece in his mouth. He was only breathing theatmosphere from the boat for about half a minute. GAY now enteredthe W&D but flooded it up this time with the forward door open. Theboat itself was flooding more rapidly now. It had been flooded onits own from the momeni of the accident. LORIMORE and GAY hadopened an induction valve and this apparently did increase the rateof flooding. They also tried to break the glass of some scuttles toincrease the rate of flooding but this was unsuccessful. GAY pushedopen the hatch of the W&D as soon as the pressure was equalizedwhich took approximately 20 - 25 minutes from the time they bottomed. (Note: From the account of surface vessel the first survivors appeared approximately 30 minutes after the submarine sank).

GAY breathed from his set the whole time, Le. from the timethe ship bottomed until he made his escape. He carried out thedrill completely; he drained his lung and the bag before he putoxygen into it. He was therefore breathing pure. oxygen for about25 minutes before opening the hatch. All this time the water wasgradually filling up until it was level with his face and he was ina continual shower of water the whole time. He experienced a slightfeeling of breathlessness before he actually made his escape, butattributes it to his exertions whilst trying to open the hatch.After opening the hatch he climbed out of the W&D and intended toremain there in order to pull LATES out, as he was unconscious, butunfortunately, he did not hold on to anything and immediately startedto float up. He pulled his apron out and came up at the standard450 angle. His exhaust valve was open all the way up. He remembers

G-23


X-3 (Cont'd)

breathing in from his bag at the beginning of the ascent but notafter that. He had a nose clip on and his mouthpiece in all thetime. He stated "It was lovely going up". He had no pains in hischest at all. At the surface he carried out the routine drill andfelt no ill effects except soreness of his shoulder muscles. Theseremained sore for about three days and he attributes this to musclesoreness following his exertions to open the hatch and crawl out ofthe W&D but it might have been due to a mild case of bends.

After GAY had left, LORIMORE thrust LATES into the W&D.LATESrecovered consciousness at this point. He came to with the sensations of terrific pressure on his ears and stinging of his eyes dueto chlorine. He was wearing two D.S.E.A. sets and as he was thrustthrough the forward door of the W&D, the mouthpiece of the set hewas breathing from was knocked out of this mouth. Somehow he passedthrough the upper hatch of W&D and he then opened his eyes and struggled, swimming to the surface. On the way up he held his breath aslong as he could and then released the air from his lungs throughhis mouth. He thinks he released too much as, just before he reachedthe surface, he wanted to breathe in and did in fact get some waterin his mouth, but almost simultaneously broke surface. It is considered by the physiologists that LATES' condition was one of syncopeproduced by overbreathing and this view is supported by the fact thatboth his sets were found to contain oxygen after he had been rescued.It should be noted that none of the three survivors suffered fromany marked or permanent ill effects.

UNTAMED

The UNTAMED sank about 1400 on 30 May 1943 in 160 feet of wateroff Campbeltown. There were no survivors. The UNTAMED was subsequently salvaged and examined.

Disaster was due to faulty operation of the "Ottway" log, causing extensive flooding forward. Two men were trapped in the crewsspace which had been flooded in an attempt to escape.

For about four hours attempts were made to surface the submarine which were entirely inadequate and, in many cases, incorrect.Preparations to escape were not made until this period had elapsedand it is presumed thatthis was due to the fact that at this timethere was access only to a limited number of D.S.E.A. sets, and because the D.S.E.A. flooding valve, which was especially fitted forflooding the compartment, was defective.

The more obvious alternative methods of flooding were not used,resulting in a very low rate of flooding through the main line. Alsoa drain into the after ends was left open resulting in that compartment having to flood up as well.

G-24


UNTAMED (Contrd)

It is estimated that flooding must have taken at least an hourby which time the danger of C02 poisoning must have been acute.

Evidence has shown that escape by the Conning Tower was considered but discarded as being too difficult.

Examination after salvage showed that all available D.S.E.A.sets were in good working order and had been worn correctly. 10 menin the Engine Room were without sets.

From a tabular statement showing the state of D.S.E.A. setsafter salvage, half the sets were full and half empty, or nearlyempty, and in most cases the mouthpiece cocks, and exhaust valveswere shut. From this it would appear that the effects of CO2 werenot appreciated until it was too late and most of the crew succumbedwithout attempting to use their sets as a breathing apparatus in thefoul atmosphere.

WELIMAN X

As the result of an accident the WELLMAN craft sank in 186feet of water with one man aboard - a Norwegian named PEDERSON.The boat sank with a steep angle down by the stern. After vainlyattempting to surface the craft, this officer set about escaping.The boat was flooding rapidly. He started up the direction indicator which kept air circulating and put on the Momsen Lung, chargingthe lung up with oxygen by 'means of the flexible connection provided. He smelled chlorine so started to breathe from the lung,but as the water rose he floated up with it thereby breaking theconnection to the main oxygen supply. He then broke the oxylet an-dtried to open the hatch but the pressure had not yet completelyequalized. He dipped under water and connected the flexible connection and so got more oxygen into the lung. But the supply soonran out and a few minutes later there was nothing left to breathefrom. Again he·tried to open the hatch and this time he succeeded.He states theiate of ascent was slow and began to feel himselfpassing out through lack of oxYgen, at what he thought was about30 feet. (He states "It had grown quite light".) He' lost consciousness.

Loss of consciousness was almost certainly due to a lack ofoxygen, plus asphysixation due to almost drowning. He was underwater a considerable time before escaping and when he lost consciousness his mouthpiece fell out of his mouth.

The officer surfaced approximately 20-25 minutes after theboat sank. When picked up (there was a boat immediately on the spotwhich picked him up the moment he surfaced) he was floating facedownwards and unconscious. Approximately 30 seconds after surfacing,

G-25


WELLMAN X (Cont'd)

he was breathing, although poorly. He had his Momsen lung on, butthe mouthpiece was out of place.

Artificial respiration, combined with the Novox~esuscitator,

soon restored normal rhythm, which was only disturbed by frequentvomiting. This may have been due to chlorine, but most probablywas due to the salt water swallowed. There was no smell of chlorine,either on the patients breath, or in his vornit. The vomiting continued for half an hour after PEDERSON was in bed, and by this timehe was only bringing up a little blood-stained mocous, probably dueto rupture of small blood vessels caused by strain of retching. Hewas of course from cold and shock, but his recovery wasrapid and apparently complete. Thanks to his magnificent physique,and the fact that he was able to receive immediate skilled attention, he was, two days later, back at work' entirely confident andtreating the whole matter as part of the days work.

U-533

The U-533 was sunk by alc in the Persian Gulf on 17 October1943. The submarine dived as soon as she sighted the ale, and thefirst depth charge exploded when she was at approximately 75 feet.All the went out. At 180 feet, approximately, another depthcharge exploded near the hull apd she sank. This holed the submarine arid she flooded throughout very quickly.

One officer and one man got out. They were in the ConningTower at the time, and they suddenly found themselves up to theirnecks in water. The officer opened the Conning Tower upper hatch.at once and they both shot to the surface Without any gear.Whether or not they had lifebelts on is not known. Both reachedthe surface, but the officer was unconscious. The rating supportedhim on the surface for nearly an hour, but he did not con-sciousness. The rating himself states he lost consciousness fora short period, but came to on the sur:face.•

This rating then swam to the coast and. was swimming for 28hours (prisoner's word only for this).

The depth from which they came up is uncertain, but it wascertainly 180 feet or deeper. Both men were under pressure for averY short time indeed, before they sta~ted ascending.

U-741

The submarine was diving at 150 feet, approximately, off theIsle of Wight and was sunk by depth charges and sank to 190 feet.

G-26


U-741 (Cont 'd)

The submarine was badly holed and started flooding quickly.The bulkhead door at the after end of the Control Room was shut butleaked badly. The pressure aft in the boat had already increasedconsiderably before the survivors started to flood up. There was acertain amount of chlorine pre sent.

The method of flooding was via the diesel exhaust valve andthen through the inboard drain, approximately a 4 inch diameterpipe.

There were 12 men in the after part after the accident; allhad Draeger breathing apparatus.

There was possibly 310 C02 present before the accident as thesubma:r:ine bad been submerged from 12 to 15 hours previous to theaccident and for some unknown reason bad not been using the purifiers. (This is only the survivorts statement and cannot be reliedon implicitly; they may have been running some of that time withouthi s knowledge).

The order to don their Draeger gear was not given until therewas considerable pressure in the boat, and it was not until some ofthe· men passed out (obviously with C02 poisoning from the high partial pressure) that the remainder donned their equipment and startedbreathing oxygen. All were panting for breath before donning theirapparatus.

The submarine was listing approximately 400 •

About 10 minutes after the disaster they started flooding.(Note: there was some pressure already in the compartment beforeflooding started). Flooding lasted approximately ~ minutes, until the hatch could be opened. Approximately 15 minutes after theflooding started several men started to shout and scream and saidthey had no air and became unconscious. (It is not certain whetherthey were getting oxygen poisoning or had run out of oxygen--it ismore likely oxygen poisoning).

At this time there must have been a very high concentrationof C02 as the survivor stated he tried taking his mouthpiece out tobreathe from the air pocket to save oxygen, but he felt his throatcontracting and it was impossible to breathe after taking only avery few breaths. The water in the compartment was waist high bythis time.

A stoker P.O. ftrst started to try to open the hatch, but assoon as he commenced making the extra exertion he could not getenough air and fell back into the water.

G-27


U-741 (Cont'd)

At this time, when the pressure was practically at its maximum, anyone who started doing work passed out. (It must be remembered that all were wearing Draeger gear--capacity approximately30 minutes).

As the pressure started to reach its maximum, several mencomplained of ear trouble and became very excited about it. Thesurvivor cleared his ears by blowing, with his fingers holding hisnose.

Towards the end the men became very quiet and only four orfive could talk at all; one after the other they passed out. (Didthey go out with oxygen poisoning or lack of oxygen due to thebottle being expended? It is probable it was oxygen poisoning, ashad it been lack of air, it is more likely they would have draggedtheir mouthpieces out of their mouths to breathe in from the airpocket. From one survivor's report, they did not do this, butpassed out with their mouthpieces still in their mouths).

The survivor, realizing that the men were passing out possiblybecause their oxygen was running out, managed to get hold of a second unused set which he donned. He managed to get the hatch open.There was no twill trunk in this hatch and therefore there was alarge air bubble that was released as the hatch opened. He shotout in this bubble and ascended very fast indeed; in fact, when hereached the surface he bounced out of the water to waist level.Before leaving he noticed his oxygen was nearly finished (this mayhave been that the bag was merely collapsed due to the pressure andhe had not put enough in). As soon as he left the hatch and startedto ascent he felt the oxygen bag expanding and he at once started tobreathe more freely. He felt that he could breathe more freely assoon as he was oi:lly a few meters away from the boat. He had hismouthpiece in his mouth all the way up. When he reached the surfacehe was a+m0st unconscious and had great difficulty in keeping himself afloat. He later had pains in his ears. He was sick in theboat which picked him up, but he himself attributes this to the fueloil he swallowed, as there was a lot of this in the compartment during flooding up.

One other survivor reached the surface alive and shouted, butsank just before the Corvette's boat reached him. He was also wearing a Draeger. Probably he forgot to blow it up and shut the valve,and it consequently dragged him under.

STRATAGEM

She was sunk by depth charges in the Straits of Malacca inNovember 1944, and sank rapidly to the bottom in 150 feet of water.

G-28


STRATAGEM (Cont'd)

The submarine was diving at the time and had already been submerged for about 6 hours. The following is the account of an officerwho escaped:--

"Almost immediately a depth charge exploded somewhere extremely close under us, lifting the stern and causing us to hit bottomhard. This charge extinguished the greater part of the lighting,although one or two of the emergency lights held. About five seconds later a second charge exploded, as far as I could calculate,right amidships, extinguishing the remaining lights. By this time,I had a torch in operation and could see water flooding through thedoor at the after end of the torpedo stowage compartment. Immediately, I gave the order "Shut water tight doors" and turned to makesure that the three ratings in the tube space were brought out ofthat compartment before the door was shut. By the time this doorwas shut, the water was flooding very much faster and had risenabove the deck boards in the stowage compartment. It now was aboveour knees. It was flooding through the door so fast that the ratingswere unable to shut this door. The position of the stop (retainingdoor in open position) on this water tight door was such that toremove it one had to stand in the doorway as the port side of thedoor was blocked by stores. Hence, due to the furious rate of flooding, this could not be removed. "In what appeared to be an incredibly short time, I was keeping above water by clinging onto a hammockwhich was slung from the deck-head. The crew in my compartment began to sing, but I ordered this to stop and told the crew to get outand put on their D.S.E.A. sets. The first I managed to reach had adefe'ctive valve on the oxygen bottle and I could not move it. Thesecond was in working order and I put this over the head of one ofolder ratings who was panicking and in tears due to the pressureeffect on his ears. The pressure in the boat at the time was immenseand the chlorine content in the air considerable. The water allround us must have been full of oil as we were all drenched with it,although I did not notice it at the time. The air could be heardto be escaping through the hull forward and the water was stillrising fast. At this time Leading Seaman GIBBS was in the escapehatch trying to slack back the clips. He shouted to me that hecould not move the third clip. Speaking was nearly impossible dueto the pressure. I swung up into the trunk alongside GIBBS andtried to remove the clip. After what seemed like an hour, and whatI suppose was really a minute, I managed to move the clip by hammering it with my fist •. By this time there was no hope of usingthe escape trunk as the water was already up to the metal combingwhich houses the twill trunking. I took off the last clip and as Idid so the hatch commenced to open. Immediately this clip was free,the hatch was blown open and Leading Seaman GIBBS was shot out sosuddenly that I cannot remember him going. The hatch slammed shutagain and hit me on the top of the head, but immediately blew openagain and I was shot out in a bubble of air".

G-29


STRATAGEM (Cont'd)

Ten of the men in the compartment, which contained fourteen atthe time, are known to have left the submarine alive, although onlyeight were picked up. The Ship's Cook was later seen to be floating,face downwards, on the surface, but was obviously drowned; it is notknown whether or not he wore a D.S.E.A. During the flooding up andprior to escape this man was fit and active and his morale was good.Another rating came up with a D.S.E.A., but it is practically certain he had the mouthpiece cock shut. He was in a very bad way onthe surface and would have drowned had not one of the other survivors on the surface blown up his D.S.E.A. bag by opening theoxygen bottle. Another who wore a D.S.E.A. set is believed to haveleft the submarine with it, but was never seen on the surface, thiswas probable the man, aged 55, who was in a very bad way before theescape and could not have been expected to survive in any case.Three others were seen to be handling sets before the hatch wasopened but it is not known whether any of these survived or if theydid, whether they had time to don their sets or not.

The Japenese destroyer dropped two more charges after thesubmarine was hit, but these were not so close and did not do anymore damage although they p~obably acceleraten the flooding.

"Throughout the above experiences the behaviour of the crewin my compartment was magnificent".

H.P. air was escaping all the time during the accident and itis known that they had an excess pressure in the submarine over thesea pressure. The effect of pressure was described by the officeras follows (the pressure at this time must have corresponded to adepth of 160 feet):--

"Speech was practically impossible; one could make movementswith one's mouth but no noise came. One's head was swimming andyou could not think quickly. You could not hear anything except aringing sound, and it felt as if one had been holding one's breathfor a long time".

The time between sinking and escape was probably 15 min-utes.

Of the 14 men in the compartment onlyseriously from the suddenly rising pressure.well under the increasing pressure.

one apparently sufferedThe men behaved very

The officer stated his ascent seemed very fast and he felt theair being forced out of his lungs as he ascended. Apart from a painin his chest some 48 hours later and fairly severe bends, whichlasted for 3 days, he was none the worse. Once the hatch openedthe men escaped very quickly.

G-30


STRATAGEM (Cont'd)

A sailor who survived also felt the air being forced out ofhis lungs as he ascended.

Both the officer and man interviewed considered that, whilethey were under high pressure, they would not have carried out simpleorders or worked valves, etc.

U-1199

This submarine, which had been Schnorkel-cruising for 3 to 4days, was badly damaged by depth charges and bottomed at 73 metres(240 feet), with a list of 350 to 400 • She sank off the Wolf Rock.At this time the whole crew of 47 were alive and orders were givento abandon ship and stand by with life-saving equipment. CLAUSSENwas in the Control Room together with the Commanding Officer, theEngineer; and Control Room personnel, all of whom, with the exception of the First Lieutenant, had Draeger gear, but no swimsuits.It was a standing order that anybody on watch carried his Draegergear even if he only went from one compartment to another.

No bulkhead doors were shut and flooding was rapid throughthe damaged hull and through the outboard vents of the trimmingtanks which were opened for the purpose. There was no chlorine.

CLAUSSEN was first in the Conning Tower followed by otherscrawling up the ladder and the time between his entering the ConningTower and opening the hatch was a matter of seconds rather thanminutes. He was unable to give any estimate of the time betweencommencement of flooding and his escape, but it must have been several minutes.

During the flooding he had been breathing oxygen from his setand was totally submerged before being able to open the hatch; therebeing no air-bubble in the Conning Tower.

At this time he was wearing his Draeger gear with mouthpiececock open. He had opened the oxygen valve slightly when first donning the gear, opening it further as pressure increased, but hadforgotten to close it again later. It is probable that he also forgot to open the exhaust valve. Before leaving the craft, he experienced a senstation of great pressure which caused a ringing or humming in his ears and, after having lifted the hatch, felt very weakand quite incapable of further physical effort. This weakness persisted for the first few feet of his ascent which was rapid, butfeeling his chest to be intolerably expanded he held his nose andtwisted the mouthpiece to allow gas to escape from the corner ofhis mouth, which relieved both discomfort and weakness. This wasa spontaneous action and not the result of training. He continuedto release gas during the remainder of the ascent, and noticed that

G-31


U-1199 (Contrd)

he was rlslng more slowly. At the surface the set was deflated andhe subsequently blew it up by mouth to give himself buoyancy. Hewas on the surface for about 10 minutes before being picked up.

He experienced pains in his chest and in his knees for 2-3days, but had no trouble with eyes or ears and brought up no blood.He had been trained in the use of Draeger gear at the usual depthof 18 feet.

Of the 46 men alive and provided with sets when the boat bottomed, only one man escaped successfully, although flooding wasrapid, and some were actually on the ladder of the Conning Towerjust behind the sole survivor.

The most probable explanation of this fact is that all collapsed with oxygen poisoning, having been breathing from their setsfor some minutes under pressure. CLAUSSEN's loss of strength anddifficulty in muscular movement seem likely to be advance symptomsof collapse fram oxygen poisoning; a view which is strengthened byhis rapid recovery on releasing pressure by the mouthpiece.He, in fact, escaped only just in time. It may be that CLAUSSEN'ssuggestion is correct (that the man following him got stuck andprevented others from emerging), but again the effects of breathing oxygen under pressure would so weaken the crew that the additional effort of clearing this obstruction might produce collapse.

The ascent was, in effect, accomplished with buoyancy only.CLAUSSEN allowed air to escape from his lungs continuously and although he stated that he felt a desire to inspire he was unable todo so. It is, however, a fact that buoyancy was lost during ascentby escape of gas through the twisted mouthpiece and this would helpto avoid the risk of burst lungs and of vascular embolism in thelast of the ascent.

This submarine was sunk on 26 March 1945 at 0520 by depth charges. She was submerged at the time at a depth of 50 meters, i.e. 160feet, and sank settling on the bottom at a depth of 60 meters, i.e.190 feet. The submarine had been submerged for the previous 24 hours,all of which were spent on the bottom. The Engineer Officer and P.O.in the Control Room were responsible for testing the air. The airwas still quite good in the boat at the time of the attack. It ispresumed that the C02 absorption unit had been working, but the report does not state so definitely.

PFLOCK was on watch in the Control Room and was beside thedepth gauge. They were at 50 meters depth when attacked and theEngineer Officer told him they were then 10 meters above the bottom.

G-32


U-399 (Cont'd)

The second depth charge made a large hole in the stern andwater commenced to pour in. The crew did not all have their lifesaving equipment with them and PFLOCK himself had none. He made hisway into the Conning Tower where there were two others, also without breathing sets. The water rose very rapidly and he told one ofthe others to open the hatch. While he was opening the hatch thewater was up to their shoulders. They were" all three very nervousand scared stiff. Just before the hatch opened the water was almostto the top. PFLOCK took one deep breath and shot out. The othertwo men never left the boat as far as he knew. He thinks they justheld on to the rail and never made an escape.

On the way up to the surface he did exactly what he had beentold. He held his arms out wide to slow down his rate of ascentand allowed the air from his lungs to escape through his mouth. Allthe way up he had no desire to breathe in. He had no sensationsduring the ascent probably because he was so scared. He does notthink he was in the Conning Tower more than two minutes before hemad.e his e seape •

After reaching the surface he was in the water about 3/4 ofan hour before being picked up. It was March and the water was verycold. Coldness was the only sensation he had. He swam to the Corvette, but had to be hauled on board from the lifeboat, he was soweak. After getting on board he began to feel pain in his chestand was taken to the Sick Bay where they gave him artificial respiration, after which he began to feel better. He couldntt lie downproperly because of the pains in his back. Breathing also remainedpainful for some time. He suffered no eye trouble or visual disturbances.

Just before he escaped and when under high pressure he statesthat he could not have done anything at all. He was very scared,and fully resigned to death. He has no idea how long it took himto ascent to the surface, but it seemed a very long time.

Note: There is little doubt there must have been at leasttwo per cent of CO2 in the boat before it flooded, and yet PFLOCKtook a deep breath of highly compressed air just before leaving theboat. He was scared and stupid and would have been expected to doall the things conducive to drowning. This is a typical example ofa man who is terrified making his escape and yet he knew he had tobreathe out, from his training, which he did.

XE-ll

The XE-ll was rammed and sunk by a trawler on 6 March 1945,in Loch. Striven in 204 feet. Two mEm escaped and su;rvivedj neitherof them wore D.S.E.A. at any time. The men surfaced five minutes

G-33


XE-II (Cont'd)

after the trawler's propeller holed the submarine. The submarine wassubmerged at the time of the accident and had been submerged about 20minutes with no air purification working during that 20 minutes. Shewas hit forward and listed temporarily to about 400 then the trawler's propeller hit and holed the submarine aft. The CommandingOfficer ordered the W&D top hatch to be opened, this was unclipped,but naturally could not be opened owing to water pressure. She sankto the bottom stern down nearly vertical (survivor's estimate) waterpouring in aft all the time.

When she hit the bottom she straightned out and settled without any appreciable list. E.R.A. SWA'ITON at time of accident was inthe Control Room. The First Lieutenant was in W&D when she hit bottom and ·SWATTON was halfway intoW&D.The two W&Dhatches leadingforward and aft were open all the time. By the time the pressurehad equalized BWA'ITON and the First Lieutenant were both in ~he W&Dwith their heads in the air lock. The top hatch was already unclipped. Owing to the very large hole aft,' the pressure eqUalizedin a few minutes, possibly not more than 3 minutes. A shower camein round the lip of the top hatch when the pressure was practicallyequal, but this shower did not prevent the women breathing ·in theair pocket right up to the mtch' being opened. There was still anair pocket when hatch was opened, which at the end, was approximately 4 inches.. They had to force their heads back to breath in it.SWATTON pushed hard to open the hatch but doesn't remember taking adeep breath before coming out. Neither had any li~ebelt. SWATTONnever felt any pain in his ears at any time, neither did the FirstLieutenant complain.

SWATTON was a poor swimmer.

He was conscious and thinking fairly clearly all the way up(he states that he was actually thiriking more clearly than he hadever thought before in his .life). He remembers the water passing

. from very dark green (almost black) to light green on the way up.He consciously thought that he might want to breathe out on the wayup because of the big pressure at which he had been. He did sowell all the way up by puffing through his lips, about half way uphe felt he would like to breathe in but decided definitely to holdhis breath until he surfaced. In actual fact he refrained frombreathing in and thinks he'never stopped breathing out all the wayup, at no time did he feel a desperate urge to breathe in. Hedidn't notice that he was breathless on breaking surface.

It must be remembered that this man had done a course of diving. The interesting point is that suddenly, on the way up, itdawned on him that he must breathe out, this was probably an unconscious reaction to the rising pressure in his lung added to his

G-34


knowledge of the subject. He swam slightly on the way up. No waterentered his mouth or nose on the way up, neither does he rememberany air going out of his nose. SWATTON, on surfacing, felt noeffeGts at all, nor did he feel any later. He was picked up almostimmediately after surfacing.

The First Lieutenant left the submarine immediately afterSTtlA'ITON, in fact practically simultaneously, they arrived on thesurface together.

This manls evidence bears out that confidence inspired by knowledge and training is of the first,importance.

As regards the First Lieutenant he states in his evidence:--

llJust at this time, immediately after hitting the bottom, Ihad given up all hope of getting out and resigned myself to keepcalm until the end. Pressure was becoming acute and I kept clearing my ears. Suddenly water poured into the W&D. I was not fullyconscious because,I cannot remember clearly what did happen, but Iimagine we had bottomed and levelled off. I thought the hatch hadopened itself with the pressure, but E.R.A. SWATTON pushed it open.I was aware of being shot up. I was aware of going through thewater and I imagined I was coming up to the surface ll

•

SWATTON stated that the F~rst ~ieutenant Who reached the surface almost simultaneously with himself, was unconscious and hegrabbed him as he was sinking. He was still unconscious when he wasbrought on board the trawler but was brought round. by artificialrespiration and later in the afternoon he was alright and was none.the worse afterward.

U-1195

This submarin~ was sunk in April 1945 in the Channel off theNab. She VTas submerged at approximately 75 feet when she was holedby depth charge forward. She rested on the bottom in 96 feet.Nearly all the crew was alive--approximately 50 in all.. These splitinto two parties, one lot of 33 went into the after part, the remaining ·17 went into the Control Room.

Taking first the escapes from aft. There was an officer incharge. All the clips were taken off the escape hatch and thehatch secured by a piece of rope. This could then be cut when thepressure equalized and the hatch would open itself. (Iri Germansubmarines the hatches are shut against a spring). This hatch hada twill trunk which they rigged.

G-35


The submarine was listed to approximately 400 • All the menhad Draeger gear except 4 or 5. The officer in charge had a Draegerset, but the oxygen bottle was not working. Those without Draegersets were given life jackets and one man dinghies and were to maketheir escape first. As soon as these preparations were complete theystarted to flood the after part of the boat i.e. from the after ControlRoom door to right aft. They flooded the boat through the Dieselexhaust drain by opening main exhaust valve and then the drain to thisexhaust--approximately a 4 inch diameter pipe. Fortunately the officerhad a watch and he states quite clearly that from the time of floodingto the escape it was 20 minutes. He stated the flooding seemed veryslow and was bad for their morale.

During the flooding the batteries in this part of the submarine started giving off chlorine so that they shut the door tothis compartment which helped to isolate the chlorine.

At first, apart from the coughing due to the chlorine, allwent well, but as the water and pressure rose the situation startedto deteriorate.

The men with Draeger sets stared breathing from them as soonas flooding up started - the men's eyes were running. They werebreathless and "snapping for air like fishes".

The officer was very worried as to how to get the men into thebottom of the twill trunk owing to the excessive angle of the submarine. When this officer recknoned the pressure was equalized hesent a Stoker P.O. to open the hatch. This man was wearing a lifejacket, but no Draeger gear. The P.O. succeeded in opening thehatch, but was drowned in the process and was left gripping thecoaming or rail and it took three men to finally pull him back intothe compartment.

The escape then started. Those without escape gear, but withlife jackets went first. The officer stationed himself at the bottomof the trunk and literally thrust each man down and under the twillas they had difficulty in getting do~n and under due to the buoyancyof their life jackets. He was under water each time he did thisbobbing up to breathe from the air pocket between each escape. Except for the Stoker P.O., the four who went out thus, withoutDraeger, reached the surface successfully and survived. One withDraeger gear then went up.

The officer went up next. As his oxygen bottle was hot working he blew up his Draeger bag with his mouth while his head was inair at the top of the compartment. He then took a deep breath andtried to get out but was caught up due to his gear fouling the twill,owing to the angle. He repeated the procedure a second time andagain got caught. The third time he went right under by holding on

G-36


to the deck and then got safely through the trunk. For the ascent hehad his Draeger blown up as a lifebelt, the mouthpiece in his mouthwith the mouthpiece cock shut. He states he put the mouthpiece inhis mouth as the mouthpiece cock was leaking and he did not want theair to go from his Draeger bag.

He swallowed a little water during his struggles to get underand through the trunk. He reckons he must have been a minute struggling under water before he got clear. He held his breath aftergetting out for what he guesses was about half the way up; but allthe time he let air escape out of his mouth as he had been taught.His minute of struggling plus the air he had deliberately let escapefinally made him want to breathe in before he reached the surface.Although he wanted to breathe in very badly he managed to keep hismouth firmly shut. Some water came in through his nose which finally stopped him trying to breathe in. He distinctly felt the expanding pressure in his lungs on the way up. Ite was in the water about10 to 15 minutes before he was picked up. His eyes and lower partof his chest hurt him after rescue. The pains in his chest made himfeel that he could not get enough air, but these pains wore off afterabout 20 minutes. His nose was permanently running for about 3hours. He had no other pains and no visual disturbances; althoughhis eyes still hurt him when it is cold.

When this officer reached the surface there was another survivor, in a dinghy, in a very weak condition who was suffering withhis chest. This man had been breathing from a Draeger set beforehe made his escape and as far as is known he had the mouthpiece inwhen making the ascent. This man, before the escape, had lost allhope and was very demoralized and had to be shouted at before hewould do anything.

After SCHICK had made his escape, the Ship's Cook, wearingonly a schwimmveste, became jammed at the bottom of the twill trunk.

FRUHWALD was sitting on top of the starboard diesel. The remainder in the compartment surged forward in a panic around the twilltrunk. He heard the Chief E.R.A. shout that the only means ofescape now was through the after torpedo hatch. He then made hisway aft to the torpedo hatch, found it open, and made his escape.He considered that the Chief E.R.A., who had no apparatus, was overcome by the surge forward of the remainder (these were .all inexperienced and rather panic striken young stokers).

He noticed during the flooding up that a powerfully built manwho was sitting right forward and not wearing a breathing apparatussuddenly collapsed.

On leaving the hatch he shut his exhaust valve and ascendedvery rapidly in spite of the fact that he held his arms and legs outto slow him down. The bag expanded, forcing air out of his mouth

G-37


U-1195 (Cont'd)

past the mouthpiece. He thinks that he breathed in during the ascent. On reaching the surface the mouthpiece came out of his mouthand the bag deflated, so he blew it up as a buoyancy bag.

He considered that NEIDERHAUSEN, who assisted him in floodingthe compartment and w.ho remained aft the whole time during theflooding up, made his way to the after torpedo hatch as soon as thepressure equalized, opened the hatch, which was submerged due tothe list, and escaped, as he was already in the Corvette when FRUHWALD was picked up. (Note: Due to the list the air pocket in thecompartment would remain when the after hatch was opened).

A wiT operator who escaped out of the twill trunk with SCHICKdid not put on his set until the moment of escape and was very illafter being picked up. FRUHWALD suffered no ill effects.

Seventeen men, including the Captain and First Lieutenantwent into the Control Room and started to make their escape fromthere. Three of the seventeen had no Draeger gear, but these threehad lifebelts.

They flooded up through Q tank (presumably by kingston andinboard vent) also via the ballast pump. The three without setswere sent up into the Conning Tower to escape first. The remainderwith their Draeger were collected in the Control Room. The lowerhatch leading from Control Room to Conning Tower was open. Therewas a certain amount of confusion. During the flooding up a lot ofoil fuel came in withthe water and bothered the men' s· eyes.

The flooding was upset by rivets overhead in the pressurehull leaking. The escape of air due to leaking rivets overheadmeant that there was no air pocket left in the Control Room whenthe pressure had equalized and the only air pocket left was about4 to 6 inches at the top of the Conning Tower. Thus everyone inthe Control Room·was completely submerged.

The three without se:ts were left with their heads in thistiny air pocket in the Conning Tower. They opened the hatch andwent up. (The survivor whom the Committee examined, GMOEHLING anEngineer, was most intelligent and lucid. He had also taken considerable interest in escape during his Draeger training).

One of these three described in detail how he and the otherswere breathing very rapidly in this tiny air pocket immediatelyprior to opening the hatch. He also stated he was unable to take adeep breath before leaving as there was so little air left (and thatlittle contained-C02 at a high partial pressure). In this high concentration of C02 he states he found it very hard to hold his breath.But (and this is most interesting) although he had been panting hard


U-1195 (Cont'd)

and found it difficult to breathe before the hatch opened, as soonas he started ascending he no longer WANTED TO BREATHE IN.

As he ascended he let air escape out of his mouth as he hadbeen taught to do. He states "he just opened his mouth and awayit went." He let out air all the way up.

After leaving the boat at first he felt he was going too slowly, he therefore let more air into his life jacket (not the Draegerset which he was not wearing). He. then went up faster and at no timedid he attempt to check his ascent. He felt no ill effects afterreaching the surface. He stated quite clearly that he had no desireto breathe in on the way up; on the contrary he had too much air andwanted to get rid of it.

Fortunately the survivor interviewed was responsible for theair purification and had taken this just before the accident occurred. It was then 2'/0. They had been submerged from 2 to 3 hours before the accident.and the air purification plant had been switched'off· (to avoid noise during the attack).

From ~he ~ime the flooding started untilthe hatch was openedwas about 10 minutes. No one, as far as thi s man remembers, complained of the rapidly increasing pressure.

Out of the Conning Tower and Control Room 6 reached the surface and survived. Three without Draeger gear, three with it. Itis of considerable interest that these three with Draeger gear weresubmerged completely for what must have been several minutes beforethey could coine out of the Conning Tower. Of the original 50 survivors alive in the submarine after she sank, 14 survived. Of these7 came up with no Draeger gear, 1 came up using the Draeger only asa lifebelt, with mouthpiece cock shut .and the remaining 6 had Draeger gear. Six had survived from the Control Room and the ConningTower, 6 from the twill trunk hatch aft and two from the afterhatch with no twill trunk at all.

Note: This survivor stated that the Draeger school has appreciated mixtures must be breathed at big depths (nitrogen and oxygen).The deeper the more accurate must be the mixture. He was asked if hefelt he could come up from 306 feex (if necessary) with no apparatusand replied Yes, provided he was only under pressure first for avery short time prior to the ascent.

U.S.S. TANG

The submarine sank after being hit by one of its own torpedoescircling after an attack on the surface off Formosa in October 1944.She sank quickly by the stern and remained for 15 minutes at least

G-39


r

U.S.S.TANG (Cont'd)

at a very acute angle, the stern resting on the bottom, the bot sticking out of water. The upper'Conning Tower hatch was open as shesank; those in the Control Room managed to shut the lower ConningTower hatch, but it was strained by the explosion and leaked. Theconfusion at this stage with men and gear falling around, due to theacute angle, was great.

All but two of these in the Conning Tower were probably drownedalmost at once. One of these, found himself breathing in a ring airpocket. He struggled out of this, and reached a larger pocket atthe fore end of the Conning Tower. These pockets were, of course,due to the acute angle. Very shortly after his accident, this officer ducked out from his air pocket and made a free ascent throughthe Conning Tower hatch without breathing apparatus or lifebelt.This officer had been taught to exhale during a free ascent at theSubmarine School. He came up from 50-60 feet,and described hisascent as follows: "I began to swim up using both hands as hard asI could - the whole idea was to get up - I wanted air and lots of it.I had no sensation of being under pressure, but thought about lettingthe air out and knew as I came up I would have to force the air out so I heaved it out all at once - and then just as I thought I wouldhave to swallow some salt water I burst ov.t on the surface and begansWimming ll

• He was none the worse, had no pain in his chest, andswam around for about 8 hours, before being picked up. The secondman alive in the Conning Tower was dazed and frightened. He wasto have held on to the officer's trouser legs as he ducked out,but appears to have let go, and probably drowned without attempt-ing to <escape.

Meanwhile many men were alive (probably 45) in the ControlRoom and compartments forward, and in the Engine Room and afterBattery Room. The compartments abaft the Control Room fioodedfairly rapidly, and the men opened the door and got forward withthe water already half up the door. Approximatelyl5-30minutesafter the accident, a rating in the Control Room opened a.tank ventby hand, and the submarine sank to the bottom and levelled off without any very serious angle. The depth was now 180 feet. The menmade their way forward tinti145of them (at least 2 with brokenlimbs and many others injured) were collected in the Forward Torpedo Room. One of them, a Negro, had had his face smashed in whenthe door into the Forward Torpedo Room was opened. The emergencylights were working.

Not long after this an officer and some men tried to passthrough the door aft, but as they cracked the door" dense smoke andfumes poured in through the door. This smoke was serious for sometime. Men complained of irritation of throat and lungs and eyes, andtt some seemed actually choking to death in it"; one survivor statedt1this smoke did more to kill the men who didn't get out than any

G-40


u.S.S. TANG (Cont'd)

other thing". In twenty minutes or so, however, these conditionsimproved. There is little doubt that there was a bad battery firein the Forward Battery Room which continued right up to the end asthe lower part of the bulkhead at the after end of the Torpedo Roomgot hotter and hotter until the paint began to peel. There had previously been another fire forward when the forward plane rigging andtilting motor burned out completely, lasting about 10 minutes.

There was probably a continuously build-up of pressure fromthe flooded portion aft, as the escape proceeded, through some drainsin the battery compartment via a sanitary tank and from this throughdrains into the Torpedo Room. This must have been assisted by theincrease in pressure when men were admitted from the flooded part;by the fact that the explosion had fractured the air lines; and bythe draining of the chamber into the compartment during the escape.Some survivors are said to have noticed the heightened pressure, butthere is no definite evidence of it.

The first attempt was made about 4 hours after the accident,and the last escapee 6-7 hours after the accident; in all it isprobable 5 attempts to escape were made. In the first attempt toescape four entered the escaPe compartment taking a rubber boat withthem. There was a difference of opinion among them as to the drill,rigging and' trunk, life line, etc.; there was also some difficultyin getting this l;ine out.'" One man didn't wait for the line and wentout, this man had already been injured about the head in the firstcrash and is reported to have used his lung and taken two pistolsand a bayonet with him. lie was not seen again and whether he reachedthe surface or not is unknown. Some 40 minutes later as there wasno signal from the trunk those inside drained it down. The threeremaining must therefore have been under pressure equal to 180 feetfor 40 minutes. The failure of these three men to escape after 40minutes in the trunk must have discouraged those in the compartmentespecially as one of them stated he didn't care to attempt to escape again.

At the next attempt 5 went in, very much crowding the escapecompartment, but the lifeboat was omitted. After another 40 minutesand no signal, those in the Torpedo Room drained the compartment andfound 3 had gone up; one of these men had already been 40 minutesunder pressure during the first escape. But 2 men remained: one wasin a stupor, the other was very exhausted and had got forward of thelife line which had pinned him to the trunk; the line was cut adriftand he was brought bac;k into the submarine. Of the three who did escape, one survived, one was seen at the surface drifting away, andthe third was never seen again.

The failure of these 2 and their exhausted condition togetherwith the delay of 40 minutes must have still further discouraged

G-41


u.S.S. TANG (Cont1d)

those waiting to escape, as evidenced by survivors' statements "after the first two attempts there were very few men who cared totry an escape although they knew what was going to happen to thembelow" - another states - "after 2 hours over half of the men didnot care to attempt it". The rising partial pressure of CO2 andthe smoke added naturally to their discouragement. For example asurvivor states - "the constantly increasing pressure, smoke andheat seemed to effect everyone's thinking, after the difficultiesof the first escape and the smoke all formed enthusiasm died downand many didn't care whether they escaped or not". (Apparentlythere was no panting, or difficulty in getting breath). To add tothese terrible conditions the Japanese were dropping depth chargesfrom time to time II •

A third party of one officer and three men then attempted theescape. Some difficulty was found in opening the door but this wassoon overcome and the pressure was equalized by flooding, when thefirst man went to charge his lung from the oxygen manifold therewas no oxygen, thi s greatly di scouraged the other three. For about15 minutes under the full pressure they attempted to rig a new lifeline, but the first man (the officer) who had blown up his lung fromhis own lungs began to feel dizzy, he stated as foliows at this time:__ "I felt very exhausted like I couldn't get any oxygen into my lungsI began to get dizzy so I knew I had better get out while I could,it took me about 15 minutes to rig the trunk" and prepare the lifeline as a buoy. I would have let the ring go up to the surface andthen gone up the line but I was so near passing out I went up withit. The other men could have escaped if they had only stepped outof the hatch, but they didn't want to try without oxygen althoughI explained how they could".

After this man got out he lost the mouthpiece of his lungabout 20 feet from the submarine due to the men below jerking theline, he then made a free ascent, he states as follows:--"After 20feet - I lost my lung, so I blew the air out all the way to thesurface trying to equalize the escaping air the way the lung wouldhave done, on reaching the surface I was exhausted and sick ll

• Hegot t9 a life buoy, which another survivor had with him and 'Waspicked up about 3-4 hours later~

The fourth attempt was made by4 men. One of these had already been in the trunk for 40 minutes under pressure and caughtin the life line, another had also made a previous attempt. Allthese four escaped and probably reached the surface alive some 45minutes after the. previous men surfaced, although one of them disappeared soon and it isn't known what happened to him.

The last escape is very confused, and there may be more thanone escape involved. Three men appear to have reached the surface,

G-42


U.S.S. TANG (Cont'd)

and all of them died. One had been apparently diving looking afterthe wounded manj he was nearly unconscious and had to be supportedas his lung didn't give him enough buoyancy. The survivor who heldhim up stated:--"He kept gasping as if he couldn't breathe andwouldn't understand anything. His condition grew worse until hestopped breathing.

The second man (a Negro, possibly the man who has his facesmashed) had no lung, and probably no lifebelt. His arms were seenflailing the water for a few seconds, and he was then seen floatingaway drowned.

The third man had a lung, and probably used it. He seemedvery weak at first, but recovered after holding on to the buoy forsome time. He talked to another survivor, and did not complain thatanything was wrong with him. He was picked up by the Japanese, 1-1/2hours later, and thrown into a boat. He now began to froth at themouth, and became blue, although he continued breathing for 10 minutes at least. He was then separated from the other survivors andnever seen again.

SUMMARIZING THESE ESCAPES: In the Conning Tower, there were2 survivors, of whom one made a free ascent from 60 feet, and theother probably never attempted to escape. In the Forward TorpedoRoom there were 45 survivors, of whom probably 13 tried to escape 8or 9 reached the surface, and 5 survived. One of the survivors madea free ascent without difficulty. Of these who died on the surface,one was probably already injured, one had been exposed to the pressure of 180 feet of water for a long time twice, and all had beensubjected to rising pressure and smoke inside the submarine forseveral hours.

COMMENTS

It is evident from analyzing the few known facts of attemptedand successful submarine escape that strong leadership and a willto survive is essential. Equally important is a detailed knowledgeof escape equipment, procedures) and the physiological phenomenonencountered at increased pressures and during changing pressures.Understanding the effects of gasses particularly under increasedpartial pressures, and a means of combating them may well mean thedifference between success and failure.

Analysis of survivors' reports combined with experience gainedthrough experimentation, training and continued searching for bettermethods of escape have brought about many changes in the SubmarineEscape Field. Probably the major improvements are better equippedand more efficient Submarine Rescue Vessels and the adoption ofBUOYANT ASCENT as the primary means of SUBMARINE INDIVIDUAL ESCAPE.

G-43


PART H - ADMINISTRATIVE FAILURES

These cases have been included in the Casualties Booklet because

often times their result is the same as a major casualty, i.e. loss of

time, operating man-hours, money and, in some cases loss of prestige

for the Navy. All too frequently, administrative failures are caused

by laxity or a failure to appreciate the need for following existing

regulations. The attitude that, "if it works, the system's O.K.,11

is not the attitude of a Submariner. We are proud of our high ma

terial and operational standards and we work hard to maintain these

standards. To allow our reputation to become suspect because of lax

or inefficient administration is inconsistent.

H-l


CASE

Loss of public funds due to poor administrative procedures onboard ship.

PRINCIPLES

L The requirements for the security of safes on board ship must becomplied with at all times.

2. The cognizant Bureau requirements regarding the administration ofa ships depsrtment must be complied with at all times.

On this occasion, a submarine was making a partial commissaryreturn covering two months and seven days of an operating quarter.Money for Cash Sales of Meals to Officers "had already been collectedfor the first two months and was in the custody of the CommissaryOfficer. This money was kept in a cigar box in the Duty Officerssafe in the yeomans office. The combination to this safe was knownby all Duty Officers.

On Monday afternoon, while the ship was in port, the Commissary Officer removed the box from the safe preparatory to collecting mess bills for the last seven days of the period. Themoney, about $289.00, was missing.

The last time that the Commissary Officer had seen the moneywas about 1400, the preceeding Friday, while the ship was returningto port. At that time, he took the money, clipped it together andplaced it in the bottom of the cigar box with the records of mealssold on top. The box was then returned to the safe.

That night the Duty Officer entered the safe to obtain an envelope, containing money for a member of the crew, which has been putthere for safe keeping. The envelope was not found. Next morning,Saturday, the Commissary Officer entered the safe and found the envelope, and returned it to the proper man. Over the weekend, otherDuty Officers may, or may not, have had occasion to enter the safe.

Investigation revealed that the Duty Officers had, on numer~

ous occasions, left the safe open and unattended. It was also customary to keep money belonging to the crew in the safe for safekeeping. This information was common knowledge among the officersand many members of the crew. In addition, although the Bu8andarequirements that the Commissary Officer have a combination sat'efor his exclusive use were known to the Commissary Officer, theyhad not been complied with for a period of at least 28 months.This, in spite of the fact that $47.00 had been lost from the safejust a short time prior to this incident. This loss was attributedto laxity on the psrt of Duty Officers in locking the safe.

H-3



1. Money was lost due to safe being left open by an undeterminedofficer without being constantly attended while open.

2. Requirements of BuSanda Manual, Volume VIII, Par. 82131.4b in regard to having a combination safe for the exclusive use of stowage offunds collected for the sale of meals from the general mess were notcomplied with by the ship.

3. The Commissary Officer used poor judgment in keeping such a largesum of public funds on board over an extensive period of time.

4. The security of safes on board was poor since, at the time of theloss, no routine procedure exi sted for checking safes shut l3.nd severalwitnesses stated that the safe in question had been left open and unattended on" numerous occasions.

COMMENTS

This case illustrates how accepting an administrative discrepancy because it has "always been that way" leads to trouble. TheCommissary Officer used the Duty Officers Safe to stow public fundsbecause it had been done that way for over two years._'I'he_cxew-cknew _that they could stow money for safe keeping in the Duty Officers safebecause it had also been done in the past. The Duty Officers werelax in locking the safe because they had done thisin the past withno untoward incidents. The Commissary Officer kept large sums in thesafe, despite a recent loss, because it was 'easier than trying to turnit in monthly to a disbursing officer. The above open safe with moneyin it and a thief on board combined at last to result in trouble thatdid not need to happen had routine administration procedures been observed.

H-4


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US Navy Submarine Casualties Booklet 1966

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