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Boiler explosion detailed
By Andrew Scutro
Navy Times
Corroded tubing that ruptured during a safety valve check of boilers aboard the submarine tender Frank Cable was the "root cause" of the Dec. 1 steam explosion that seriously burned six sailors, according to a recently completed investigation report.
Two sailors later died of their injuries.
In addition to equipment failure, humans also come in for criticism -- and praise -- for actions before and after the deadly event at the pier in Guam. Navy Times obtained a redacted copy of the Manual of the Judge Advocate General report through a Freedom of Information Act request.
Earlier on the day of the accident, the Frank Cable had crew members' friends and family aboard for a Tiger Cruise, but what should have been a day of light duty turned disastrous.
Under what the report termed a "false sense of urgency," the engineering department sought to "complete some outstanding maintenance, specifically number one boiler safety valve lift checks," before the day was over.
As the maintenance check began in the early evening, with the visitors off the ship, 14 sailors were in the compartment with the boilers, or the "fireroom." Early in the test, with steam pressure increasing in the No. 1 boiler, and "no lifting of the safety valve," a section of the boiler system "split open, emptying the contents of the boiler inside the contents of the fireroom."
The sailors reacted quickly.
"Watchstanders immediately took action to secure the boiler to prevent further damage and exited the fireroom," the report states.
All but one sailor who'd been in the fireroom were injured. Six were burned seriously enough to be evacuated to Brooke Army Medical Center in San Antonio.
Machinery Repairman 3rd Class Jack Valentine died of his injuries less than a week later, on Dec. 7.
Chief Machinist's Mate Delfin Dulay died at Brooke Army Medical Center on May 1.
Among the criticisms leveled in the report are that local ambulances took "47 to 70 minutes" to fully respond to the casualties; that sailors' coveralls did not offer adequate protection; and that the ship's stretcher inventory was inadequate for a mass casualty event.
While the reviewing officer holds the opinion that the crew's response was "satisfactory," he points out that "most fireroom watchstanders did not don" Emergency Escape Breathing Devices.
'Errors in judgment'
In the recommendations submitted by the initial reviewing officer, the commanding officer and the chief engineer committed "errors in judgment" by allowing the safety valve maintenance despite reported deficiencies in the system and both "should be reviewed for administrative or disciplinary action."
The chief engineer and the executive officer are recommended for similar review for failure to train sailors in evacuating the main space that "may have led to more serious injuries."
Rear Adm. Joseph A. Walsh, commander of the Pacific submarine force, concurred with the initial report and recommendations, which include possible action against the crew leadership, who are not named in the redacted report.
Cmdr. Mike Brown, public affairs officer for the Hawaii-based sub force, said any potential administrative actions would be taken up by the Frank Cable's group command in Japan.
"The JAGMan investigation did not recommend any disciplinary action be taken, but it did refer (the matter) to Commander, Submarine Group 7, and they can determine if further action is necessary," Brown said.
Walsh makes several recommendations, including improved training and the formation of a board to "review the actions of all personnel involved in this tragedy and determine if personal awards or recognition is warranted."
He commends the sailors on the scene who "displayed courage and resolve in the face of extraordinarily difficult circumstances by staying their watch and securing the boiler before exiting the boiler room. Their heroic actions exemplified Navy core values of honor courage and commitment."
By Andrew Scutro
Navy Times
Corroded tubing that ruptured during a safety valve check of boilers aboard the submarine tender Frank Cable was the "root cause" of the Dec. 1 steam explosion that seriously burned six sailors, according to a recently completed investigation report.
Two sailors later died of their injuries.
In addition to equipment failure, humans also come in for criticism -- and praise -- for actions before and after the deadly event at the pier in Guam. Navy Times obtained a redacted copy of the Manual of the Judge Advocate General report through a Freedom of Information Act request.
Earlier on the day of the accident, the Frank Cable had crew members' friends and family aboard for a Tiger Cruise, but what should have been a day of light duty turned disastrous.
Under what the report termed a "false sense of urgency," the engineering department sought to "complete some outstanding maintenance, specifically number one boiler safety valve lift checks," before the day was over.
As the maintenance check began in the early evening, with the visitors off the ship, 14 sailors were in the compartment with the boilers, or the "fireroom." Early in the test, with steam pressure increasing in the No. 1 boiler, and "no lifting of the safety valve," a section of the boiler system "split open, emptying the contents of the boiler inside the contents of the fireroom."
The sailors reacted quickly.
"Watchstanders immediately took action to secure the boiler to prevent further damage and exited the fireroom," the report states.
All but one sailor who'd been in the fireroom were injured. Six were burned seriously enough to be evacuated to Brooke Army Medical Center in San Antonio.
Machinery Repairman 3rd Class Jack Valentine died of his injuries less than a week later, on Dec. 7.
Chief Machinist's Mate Delfin Dulay died at Brooke Army Medical Center on May 1.
Among the criticisms leveled in the report are that local ambulances took "47 to 70 minutes" to fully respond to the casualties; that sailors' coveralls did not offer adequate protection; and that the ship's stretcher inventory was inadequate for a mass casualty event.
While the reviewing officer holds the opinion that the crew's response was "satisfactory," he points out that "most fireroom watchstanders did not don" Emergency Escape Breathing Devices.
'Errors in judgment'
In the recommendations submitted by the initial reviewing officer, the commanding officer and the chief engineer committed "errors in judgment" by allowing the safety valve maintenance despite reported deficiencies in the system and both "should be reviewed for administrative or disciplinary action."
The chief engineer and the executive officer are recommended for similar review for failure to train sailors in evacuating the main space that "may have led to more serious injuries."
Rear Adm. Joseph A. Walsh, commander of the Pacific submarine force, concurred with the initial report and recommendations, which include possible action against the crew leadership, who are not named in the redacted report.
Cmdr. Mike Brown, public affairs officer for the Hawaii-based sub force, said any potential administrative actions would be taken up by the Frank Cable's group command in Japan.
"The JAGMan investigation did not recommend any disciplinary action be taken, but it did refer (the matter) to Commander, Submarine Group 7, and they can determine if further action is necessary," Brown said.
Walsh makes several recommendations, including improved training and the formation of a board to "review the actions of all personnel involved in this tragedy and determine if personal awards or recognition is warranted."
He commends the sailors on the scene who "displayed courage and resolve in the face of extraordinarily difficult circumstances by staying their watch and securing the boiler before exiting the boiler room. Their heroic actions exemplified Navy core values of honor courage and commitment."