Navy Faults Navigational Procedures in Crash of Sub

By ROBERT A. HAMILTON
Day Staff Writer, Navy/Defense/Electric Boat
Published on 4/9/2005

A Navy report on the submarine that hit a sea mount in the Pacific three months ago will conclude that there was a serious breakdown in navigation procedures that led to the accident, which killed one sailor and injured more than half the crew, Navy sources have told The Day.

The report, which could be released as early as this month, will cite problems with the USS San Francisco's chart preparation methods and, more seriously, the crew's failures to recognize specific warnings that the submarine was headed into trouble.

Soundings showed the bottom was more than 1,200 feet shallower than on the charts that were in use, a difference of more than 20 percent, the sources said. In addition, the ship's fathometer showed the water was shoaling, or getting more shallow with each reading, over an extended period of time, the sources said.

Either one of the warnings should have prompted the crew to slow the submarine down and proceed far more cautiously, the sources said. Instead, the ship plowed into an underwater mountain that was nearly a sheer cliff at a speed of about 30 mph.

In addition, the navigation team was not laying out the ship's projected track far enough ahead of the ship's actual position to determine whether it was sailing into safe water, a particularly dangerous practice in the island-studded area of the Pacific where the San Francisco was operating, the sources said.

One of the sources said he was on a submarine that nearly ran into another uncharted sea mount, but the navigation team recognized and responded to the early warnings and avoided grounding.

The San Francisco left its homeport of Guam on Friday, Jan. 7, headed for Brisbane, Australia. The next day, a little more than 400 miles southeast of Guam, as sailors were sitting down to lunch, it slammed into the sea mount in an area where official Navy charts list 6,000 feet of water.

Three of the four ballast tanks in the bow were shattered, the sonar dome and sonar sphere were smashed, and a bulkhead at the front end of the ship was buckled. But the crew got the ship to the surface and rigged it to make the trip back to Guam.

Machinist Mate 3rd Class Joseph Ashley was killed when he struck his head on a large pump. Almost two dozen others were injured so badly they could not perform their duties, though within days most were treated and released from a hospital in Guam. Most of the crew were treated for some injury.

At an admiral's mast in February, the captain was found guilty of putting the ship into danger and was relieved of command. Last month, six more crewmen were cited for putting the ship into danger or dereliction of duty, and received punishments that included demotions and letters of reprimand.

Almost immediately, attention focused on the fact that the mountain was not on the charts, and even some within the submarine community wondered whether the crew should be held responsible.

But the investigation showed that there were at least five notices to mariners, most recently in 2002, about a large patch of muddy water about three miles south of the sea mount that were not incorporated on the charts the San Francisco was using at the time, the sources said.

If the bottom had been as deep as the 1989 chart indicated, that muddy patch would not have appeared.

Certainly, incorporating notices to mariners on existing charts is arduous. On Feb. 5, for instance, the National Geospatial-Intelligence Agency, which produces map information for the military, issued a notice to mariners about the sea mount that the San Francisco hit.

But submariners said no matter how cumbersome, a failure to adequately update the charts with the notices can put the ship in danger, as the San Francisco incident proved.

The Navy has been criticized for not issuing updated charts if it knew of a possible hazard to submarine operations in the area. But updates are expensive and take time. The agency that would make the changes has been kept busy in recent years on other work, such as terrain mapping in Afghanistan and Iraq, where accurate maps are critical to land operations and cruise-missile strikes, the sources said.

There were other problems with the navigation practices on the San Francisco that might not have contributed to the accident, but which indicated a slackness that is unacceptable in the submarine force, the sources said.

The San Francisco was using a chart that showed the area in a large scale, which was convenient for the high-speed transit it was making but did not provide sufficient detail about other dangers in the area, the sources said.

And the submarine crew had not adequately projected the ship's intended track on its charts. One of the sources said it would not have been uncommon to have had the entire track to Brisbane laid out on the charts, and to brief the navigation team daily on the track for the next 24 hours, but the San Francisco had not met either of those standards.

Navy sources said putting your signature on that chart makes you personally liable for its accuracy, a responsibility that naval officers cannot take lightly.

In the crew's defense, it has been noted that the operational orders known as the Subnote, which was issued by Submarine Group 7 in Yokosuka, Japan, arrived at the ship only a short time before it was to leave.

The Subnote provides the submarine with several points where it must be and the time it must be at those points, provides an average speed of the transit and the submarine track. It also provides the submarine with a “moving haven,” an area where no friendly submarines will be operating and where the Navy will not be using subsurface hazards to navigation such as towed sonar arrays.

Having the Subnote get to the ship so late provided the ship little time to prepare, and the Subnote routed the ship through the area of the sea mount.

But that defense was dismissed at the non-judicial proceedings known as the captain's mast where the navigation team was punished, for several reasons, including the fact that if the submarine had insufficient time to prepare adequately, the captain should have asked for more time. And while the track is laid out in the Subnote, the crew must still follow safe navigation practices — if the Subnote called for it to transit an area of heavy boat traffic, for instance, the crew is expected to avoid hitting other craft, one of the sources pointed out.

The captain and navigation team were also held liable because San Francisco was making flank speed, or just about top speed for the submarine, through an area that it should have known was dangerous.

Even more serious than them breakdown in the chart preparation process, the sources said, were the warning signs that were not heeded, particularly the soundings taken by the ship's fathometer. Just minutes before the crash, the San Francisco came to the surface to check its location on the Global Positioning System.

The submarine is also equipped with the sophisticated Ring Laser Gyro Navigator, so it knew its position with a high degree of certainty.

Yet where the charts showed 1,000 fathoms of water, the sounding showed less than 800 fathoms — still a huge safety margin below the keel, but a difference that should have caused the navigation team to recommend proceeding with caution.

In addition, the navigation team had noted for a lengthy period that the water depth was shoaling, or becoming more shallow.

The team apparently believed it was a faulty reading — moving through the water at 30 mph, fathometer readings can be inaccurate — and the team kept hoping that perhaps the next reading would correlate with the chart.

In retrospect, it's clear that the readings were accurate, the water was shoaling, and the San Francisco was heading for what was nearly an underwater cliff.

The next day, a little more than 400 miles southeast of Guam, as sailors were sitting down to lunch, it slammed into the sea mount in an area where official Navy charts list 6,000 feet of water.
This is inexcuseable, on an administrative level. If charts are not maintained and updated constantly electronically, there is criminal contributory negligence higher up the chain of command. A corrected electronic version of the chart could have been and should have been transmitted and distributed world-wide to anyone who needed it in seconds...
On a ship or boat, the buck stops with the captain --- but only if the captain has ultimate control of where he is and when he gets there. I have the uneasy feeling that he was facing conflicting orders, one explicit the other implicit by reference, and his choice came back and bit him on the butt.

That notice is 58 pages long and covers hundreds of changes worldwide, including four — the sea mount, an obstruction and two depth changes — on the specific chart, number 81023, the San Francisco was using when it ran aground. And it is one of 15 notices issued so far this year.
It is so easy, after the fact to assume that the captain and his crew had the time and the resources to wade through 58 pages of data to find four changes that affected their immediate task, given his orders and the time frame they were given in which to execute those orders.

There's plenty of blame to go around, and procedural errors to be corrected.

Under submarine-force regulations, the navigation team might prepare the charts, but the captain, executive officer, navigation officer, assistant navigation officer, and senior electronics technician responsible for navigation would have had to review the voyage planning process, and signed the charts as acceptable... Navy sources said putting your signature on that chart makes you personally liable for its accuracy, a responsibility that naval officers cannot take lightly.

But the captain is probably the guy that writes the others' periodical evaluations? If anyone else in the crew gets into the hint of a habit of disagreeing with the captain on paper, I wonder how far his career would go...

Also, issuing 58 page reports containing map numbers and warnings about suspected uncharted sea mounts doesn't seem anywhere close to what is needed by a modern submarine. This seems as if it would be the kind of thing someone could write up a software tool for in a few person-weeks. The crew should have had a software map tool that points out suspected underwater hazards (sheesh).

I've never served but have relatives who have. And I have worked in government jobs. From a distance, this reeks of cover-my-@@@ for higher-ups, and scapegoating for the five operating under the captain and perhaps the second in command who in my mind have more than reasonable doubt as to whether they were ever given a realistic option to object. Six signatures to a procedure from the same line of command seems like at least four too many.

I am a sailor and a navigator, and this smells.
"But the investigation showed that there were at least five notices to mariners, most recently in 2002, about a large patch of muddy water about three miles south of the sea mount that were not incorporated on the charts the San Francisco was using at the time, the sources said."
Failure to ensure that notice to mariners are on your charts is a big no-no, but they were traveling south and this muddy patch had nothing to do with the accident. This is their most serious offense.
"On Feb. 5, for instance, the National Geospatial-Intelligence Agency, which produces map information for the military, issued a notice to mariners about the sea mount that the San Francisco hit."
This proves that the sea mount they struck was not on a prior notice to mariner, so they had no way of knowing it was there.
As to the depth, if you're going along at 500 ft, and the chart says 1000 fathoms and you're reading 800 fathoms, while it's a curiosity that is still 4800 feet deep, almost a mile below the keel. Charts are also pretty vague about precise depths at that depth. (sorry for the grammar) What really ticks me off, is that for under a $1000 you can buy a commercial GPS that gets it's updates off the internet and automates it without having to sort through pages and pages of notice to mariners. The same navigation system can actually warn you when your projected course (entered via waypoints) runs into objects that are known. It was a system failure, but the Navy has to have a scapegoat(s). (I'm ex-Navy).

To finish my rant, the Navy knew it had a problem that is why they developed this:
http://www.news.navy.mil/search/display.asp?story_id=17547

Submarine Force Forges Ahead with Electronic Navigation to Enhance Capabilities
By Chief Journalist (SW/AW) Mark O. Piggott, Commander, Submarine Force, U.S. Atlantic Fleet Public Affairs
NORFOLK, Va. (NNS) -- The submarine force is advancing toward its goal of “paperless” navigation with the Voyage Management System (VMS), an electronic navigation tool currently aboard all Navy submarines.

This summer, USS Oklahoma City (SSN 723) will be the first submarine to undergo final certification. The certification process involves certifying both the VMS system and the Sailors who operate it.

Developed by Sperry-Marine, VMS integration into the submarine force began in 1998 to introduce electronic navigation as a way to enhance accuracy and efficiency of navigation and voyage planning. Seven years later, all submarines in the fleet today carry some version of VMS, depending on the class of submarine and the installation date. Although crews have been required to still use paper charts as the primary means of navigation, VMS has served as a valuable back-up tool.

Electronic navigation offers numerous advantages over paper charts. VMS significantly reduces time and manual labor required for chart maintenance and voyage planning.

“Anyone who has had to correct a paper chart will tell you it’s a very tedious process – time consuming and painstaking,” said Chief Electronics Technician (SS) Mark Little, Tactical System Development Install (TSDI) Team assistant navigator. “With electronic charts, it’s very simple. You just start the computer, insert a CD to update the database and you are free to tackle other work.”

It is especially valuable when a ship receives an operational order that requires updates to the submarine’s course.

“When any OPCON transmits a ship’s sub note to a submarine, that will automatically be transferred from radio to the VMS system,” Little explained. “VMS takes care of much of the planning. All that’s required of the crew is to make small refinements and review it.”

With paper charts, the manually plotted ship’s location is always behind by the amount of time it takes to plot the bearings. “But with VMS, it’s a continuous, real-time plot all done by the computer,” Little said. “VMS never lags behind. It’s always real time using the ship’s position from the Global Positioning System (GPS) when surfaced or inertial navigators when submerged.”

VMS is designed with backup systems in the event of technical issues.

“You have two separate computers,” Little explained, “that are linked together but can also act independently of each other if one should not be available.”

According to Little, these computers also have spare hard drives. Additionally, each submarine will have a laptop available with the latest VMS program – version 6.4 – as another backup. However, he doesn’t anticipate problems with VMS reliability.

“The CNO (Chief of Naval Operations) has set guidelines on how long these systems have to run without a mission critical failure,” Little stated. “VMS far exceeds those guidelines.”

The National Geo-Spatial Agency has spent the last five years digitizing all nautical charts of the world’s waterways, with the exception of the polar ice cap. These electronic charts provide much more detailed and layered information than paper charts and virtually eliminate the risk for human error in navigation.

VMS has built in programmable alarms that will warn the navigation team in advance if they are veering off course or have planned a voyage track that takes them through hazardous areas, according to Cmdr. Mike Brown, Commander, Naval Submarine Force force navigator. Advances in technology and computer software for VMS in the last few years have dramatically enhanced the features and capabilities of the current version over older programs. With such improvements, the submarine force is now ready to take the next step toward digital charts as the primary navigation tool.

“It’s like comparing Windows 98 to the latest application available today,” Brown stated. Many of the new features are a result of not only advanced technology, but also feedback from the hundreds of commanding officers and their crews who have trained on and used these earlier versions.

“Until we reach the point where our submarines have the latest version of VMS, and the crews are certified to use the system, they will still have to use paper charts in addition to VMS for navigation,” Brown said. “We knew this was going to be a long process back when we started. It took time to develop and improve the tool, install and integrate into a submarine, as well as to train crews to operate the system.”

“Before we make the transition to be completely paperless, we needed to be sure our electronic navigation tool has the right capabilities," he added. "We’ve reached that with 6.4.”

Only three submarines currently have the latest version and they’re all homeported in Norfolk, Va. – Oklahoma City, USS Hampton (SSN 767) and USS Jacksonville (SSN 699).
“This is because Sperry-Marine is based locally, which has made it easier for the company’s engineers to install the system on these ships,” Brown explained.

Though the complete installation and integration of the VMS system aboard a submarine does not necessarily take long to complete, the certification process is demanding and thorough for the officers and Sailors who will operate the system underway.

“All the operators go through operator training, which is three weeks in length, along with wardroom training for all officers and specific training for the commanding officer, executive officer, navigator and assistant navigator,” Little said.

“Once they finish all the training, the ship’s crew will have to demonstrate proficiency on a shore-based trainer before they have to finally prove themselves at sea as the final step to certification,” he continued.

The goal ultimately is for the entire submarine force, including ballistic missile submarines (SSBN), the newly converted guided-missile submarines (SSGN), Los Angeles-, Seawolf- and Virginia-class fast attack submarines (SSN) to be certified for electronic navigation in the 2008 time frame. Submarine Force Commander Vice Adm. Chuck Munns believes the investment in time, technology and training toward this goal is well worth the effort.

“VMS helps commanding officers make better decisions and, ultimately, save valuable time and effort when we go completely paperless,” Munns said. “I’m proud of the fact that the submarine force is leading the way on this CNO priority of electronic navigation.”

For related news, visit the Commander, Submarine Force, U.S. Atlantic Fleet Navy NewsStand page at www.news.navy.mil/local/sublant.

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Navy Faults navigational procedures In crash Of Sub San Francisco's Crew Failed To Recognize Warnings, Report Says