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 School
U. S.Naval Submarine Base
New London, Connecticut
1966
Changes 1 &2 entered
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LIST OF EFFECTIVE PAGES
Table of Contents
List Of Effective Pages
PART A A-l through A-33
PART B B-1 ~ h r o u g h 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 is
probably unmatched by any other conveyance of modern warefare. Indeed,
the millions of hours of sUGh operations have been marred by so few
accidents that it is quite probable that submarines have a better
safety record than has the family bathtub. There have been some
casualties and near-casualties, however, each of which contains valuable
lessons for the prevention of similar incidents in the future.
This Casualty Booklet is written to fill a long felt need to provide
young officers and men entering the submarine service with the stern
lessons of the past. These lessons not only provide the background
and reasons behind many well-established methods and procedures, but also
the misfortunes, often tragic, of departing from proven procedures and
basic fundamentals that are essential for safe operations.
The following narratives were derived from various sources, including
reports of official investigations, when available, and from information
submitted by persons who were on the scene when the casualty occurred.
The "Opinions and Findings" are paraphrased versions of the remarks
made by any investigating or reviewing officers; no change has been
made in the substance of these qpinions. The comment paragraph re-
presents the lesson to be learned and other helpful or associated
information, composed in the cold, clear light that is so characteristic
of "hindsight". These comments in themselves are mute testimony to
"Hindsight is damned easier than foresight
ll
, and it is hoped that they
will be viewed in the objective light in which they are intended: to
stimulate more foresight. .
Contributions to this booklet are welcomed and invited; such con-
tributions should be addressed to the Officer in Charge, U.S. Naval
Submarine School, U.S. Naval Submarine Base, New London, Connecticut.
PART A - MAJOR DISASTERS
The enviable safety record that u. submarines enjoy is not the result
of mere chance. It is the result of a continuing effort toward better
design and well-trained officers and men. The major disasters that have
occurred since 1920, excluding wartime losses by enemy action, are a
stern reminder that the road has not been an easy one.
While many of the disasters were the result of some failure,
it is striking to note that in every case some action could have
been taken which might have averted the tragedy. Regardless of the im-
provements made to the submarine itself, the key to its survival remains
with the officers and men who man it, for their training may mean the
difference between sinking and survival.
The disasters of the "early daysl! may be considered "ancient history".
They are not only for the valuable lessons therein, but also
to provide the modern submariner with an appreciation of submarine
development in the last 40-odd years.
A-I
*
*
*
YEAR
1915
1917
1920
1921
1921
1923
1923
1925
BOAT
F-4
F-l
S-5
R-6
s-48

0-5
S-5l
INDEX
BRIEF
Failed to return from a submerged run off
Honolulu, 15 March. No survivors (21 lost).
Cause of not determined. Located
by oil slick and air bubbles in 305 feet
.Raised 29 August after salvage diVing that
set record for depth.
Rammed by F-3 in fog off Point Loma, Cali-
fornia. Sank in 600 feet, five survivers
from nineteen lost.
Sank during full power trials off Delaware
Capes, Stern blown to surface, and after
36 hours of cutting hole in stern, above
water line, all hands escaped; last man
emerged 51 hours after the sinking.
Sank in nest by flooding through torpedo
tube. Two men lost.
Sank off Bridgeport, Connecticut in 67
feet, during builder's trials, by flooding
through ballast tank manhole cover. Bow
was brought to surface and all escaped
through torpedo tube.
Sank alongside tender by flooding from
sea valve when bonnet was removed.
Rammed and sunk off Alantic entrance to
Panama Canal. Three lives lost. Two men
trapped in torpedo room were rescued when
bow raised 31 hours later.
Rammed and sunk off Block Island by the
City of Rome at night, 25 September.
Three survivors, thirty-three lost. Sub-
sequently raised. Salvage efforts re-
counted in On the Bottom by Ellsberg.
A-3
-I
YEAR
1927
1939
1941
BOAT
s-4
SQUALUS
0-9
s-26
R-12
COCHINO
INDEX
BRIEF
Rammed and sunk off Provincetown, Massa-
chusetts in 102 feet, no survivors, by
Coast Guard vessel Paulding. Subsequently
raised.
Sank on 23 May in 220 feet, off Isle of
Shoals during trials. Boat flooded aft of
control ro'om through main induction. 33
survivors rescued by rescue chamber from
FALCON. Subsequently raised and re-named
SAILFISH.
Lost off Portsmouth, New Hampshire with all
hands, during trailf? Located in 440 feet,
diver found evidence that hull had failed to
withstand pressure.
Rammed and sunk by PC escort at night, 24
January, three survivors.
Sank suddenly while running on surface off
Key West, Florida, six survivors.
Sank off Norway after battery explosions.
All hands saved by TUSK except for one
civilian technician who was washed over-
board from TUSK.
* - Not included in case histories herein.
A-4
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 enable
qUick closure.
3. Training must stress that each member of the crew is responsible
for carrying out his assigned tasks to the exclusion of other work.
NARRATIVE
While diving off the Delaware Gapes during a 72-hour endur-
ance run, t h ~ S-5 failed to level off and imbedded her bow in the
mud bottom at 160 feet. Water had entered through the open main
induction valve and had passed through the induction piping (ven-
tilation system) to the torpedo room (forward). The inboard valve
in the torpedo room could not be shut because of the pressure of
water pouring through it. Other inboard valves on the same line were
shut; those in the control room and engine room immediately upon
diving as per diving procedure; that in the motor room only after 80
tons of water l;tad entere.d through it. The water in the motor room
was dumped into the battery compartment (forward) by cracking water-
tight doors. The control room was abandoned when chlorine began to
seep in from the battery compartment, but not before a 70
0
down angle
had been put on the boat by blowing the after main ballast and fuel
tanks. Two passing merchant vessels sighted the stern protruding
above the surface, and on investigating, cut a hole in the stern
which allowed the entire crew to escape. The boat sank shortl;r afte.r-
ward and was never salvaged.
OPINIONS AND FINDINGS
1. The man detailed to shut the main induction on diVing left his
post to aid a shipmate in another duty just after the diving alarm
was sounded. He realized his error too late, and his hasty efforts
to shut the valve resulted in its jamming open.
2. Although procedure called for shutting the four valves inboard of
main induction upon diving:
A-5
a. This was not the actual practice in the torpedo room because the
inboard valve was not readily accessible.
b. This was not the actual practice in the motor room, where the
valve was not normally ~ h u t until the boat was leveled off after sub-
merging.
COMMENTS
It is most interesting to note that this same failure to carry out
prescribed 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 through
thorough training and constant awareness on the part of every person
aboard that his duty is an essential part of successful operation of
the ship.
A-6
CASE
Sinking of R-6 while moored in harbor, 26 September 1921.
PRINCIPLES
1. Torpedo tube do not completely insure that both tube
doors 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, com-
menced to load it into a tube. On opening the inner door, the torpedo
room flooded tbrough the tube, trapping the two torpedomen, who were
lost. The entire boat flooded rapidly,. but all other personnel aboard
escaped. other submarines in the nest cut their lines to the R-6 to
prevent damage to themselves, and she sank in 30 feet of water. She
was later salvaged and recommissioned.
1. The torpedo tube was flooded and its outer door was open when the
torpedomen 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 fool-
proof interlock, there is no substitute for checks by personnel of the
devices themselves and of the hazards they seek to prevent.
A-7
CASE
Sinking of s-48 by flooding after section of ship through ballast
tank manhold, 7 December 1921.
PRINCIPLES
A thorough check of all hull openings is mandatory when departing a
shipyard.
NARRATIVE
s-48 departed the Lake Torpedo Boat Company at Bridgeport, Con-
necticut} for New London on builder's trials. Although manned by a
civilian crew, she carried five naval representatives to perform the
witness t e s t s ~ The boat, which had made several dives on preceding days,
submerged in Long Island Sound off Bridgeport Harbor. As the after main
ballast tanks filled} a man-hole cover in the hull between
the engine room and number 5B main ballast tank unseated and the ship
began to flood rapidly. Personnel in the after part of the boat escaped
forward as she bottomed in 80 feet of water. The boat completely flooded
aft of control room/after battery compartment bUlkhead. By blowing all
forward main ballast, fuel, and variable ballast tanks, and dropping
both anchors, a 40
0
up-angle was obtained. All hands escaped through a
torpedo 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 formal
naval investigation. The Lake Company discovered upon salvage that
the manhole cover which failed had not been secured properly. Nuts
holding the cover had not been tightened and the pressure of water
entering the ballast tank outboard of the engine room stripped the
bolt threads.
COMMENTS
Every time a submarine completes repair or inspection of fittings
involving watertight integrity, a more-than-perfunctory check is in
order before the boat puts to sea. Failure to do so is an invitation
to disaster. Such fittings must be tested under pressure prior to
sailing. On all dives, these fittings must be watched carefUlly, with
personnel standing by to isolate possible damage. Had this latter
precaution been observed, flooding probably could have been confined
to the engine room, considerably minimizing the damage attendant to
flooding the e n t i r ~ after half of the ship.
A-9
CASE
Sinking of S-38 while moored alongside tender, 19 July 1923.
PRINCIPLES
1. Maintenance work affecting watertight integrity must be supervised
by competent personnel.
2. All submarine personnel, no matter what their experience, must be
familiar with the basic systems within their assigned province before
they are permitted to perform any task involving such systems.
NARRATIVE
S-38 was moored alongside U.S.S. ORTOLAN, a minesweeper acting as
tender, in Anchorage Bay, Alaska. During upkeep routine, the bonnet of
the after trim tank sea valve was removed, causing the motor room, in
which the valve was located, and the stern room to fiood. The boat
settled by the stern, the after platform deck of the conning tower
fairwater becoming awash. Further sinking was prevented by use of
salvage air pressure, confining the flooding to aft of the engine room,
and by quick action of ORTOLAN in cutting after mooring lines and
getting additional bow lines OVer. S-38 was towed to shoal water,
where salvage divers plugged the hole and pumped her 9ut in about
18-hours. While there were no serious personnel casualties, the boat
had to be tawed to a shipyard and much time was lost in reconditioning
her.
1. The sinking of S-38 resulted when an inexperienced man removed
the nuts holding the bonnet of the after trim tank sea valve while
he was attempting to clean the valve.
2. The man was not properly instructed in his duties, nor was he
under competent supervision at this time.
COMMENTS
The flvalve-twister" is the arch enemy of submariners.. This case
is a classic example of the extreme result of allowing an inexperi-
enced, untrained man to tamper with a system of which he has insuf-
ficient knowledge.
A-ll
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 mistaken
for a fishing vessel.
2. Because her lights do not comply with the Rules of the Road, a SUb-
marine is almost certain to be held at fault if involved in a collision.
3. As a result of 1. and 2. above, a submarine must
avoid placing his ship in a situation where even the risk of collision
exists.
NARRATIVE
While proceeding off Block Island on night surface operations, S-51
was sighted broad on the starboard bow by City of Rome. Visibility was
excellent and the liner had the submarine's masthead light under contin-
uous observation during the 22-minutes prior to the collision. Although
it was a crossing situation with S-5l as privileged vessel showing a
large port the City of Rome assumed she was overtaking
a small tug or fishing craft. Despite the merchant captain's doubts
about the light held in sight, neither ship took any action until in
very close proximity.
When several City of Rome commenced to alter
course to the left to pass the supposedly overtaken vessel. A few
seconds later, the red side light of S-51 became visible slightly to
the right of the masthead light. Too late the true situation was
realized. City of :Rome I s rudder was put right full and the engines
backed full, but the .ship rammed the S-5l just forward of the conning
tower on the port side. The boat flooded and sank immediately in 132
feet of water. Three men in the conning tower escaped and were picked
up, five officers and men were lost. None of the sur-
vivors had any knowledge of the submarine's navigation at the time of
the collision.
OPINIONS 'AND FINDINGS (U.S. Federal Court)
1. The City of Rome 'Was flagrantly at fault for failure to:
A-13
a. Yield the right of way as the burdened vessel in a crossing
situation;
b. Reduce speed when in doubt as to movements of 8-51;
c. Sound proper whistle signals when coming left just before the
impact.
2. 8-51 was equally at fault for running with improper lights, a
principal cause of the disaster.
COMMENTS
This case is the original classic example of the deceptive appear-
ance of a submarine at night. More than thirty years have passed since
the S-51 incident, and submarines are still in the same predicament
regarding lights, and no doubt alwaya will be. Also, because of her
low freeboard, a submarine sometimes presents a deceiving appearance,
particularly during low visibility. For this reason submarines should
take early action to avoid collision, and should avoid being placed in
the "privileged!! status. Once in the "privileged" role, however, every
effort should be made early too exchange identification with the other
vessel, and to determine its intentions. It is well worth the trouble
that it takes to rig the l21'T signal-searchlight to have it available
when needed for this exchange of identification.
A-14
CASE
s-4 rammed and sunk by the PAULDING, 17 December 1927.
PRINCIPLES
1. A careful look around at periscope depth is mandatory prior to
surfacing.
2. Naval vessels should be alerted to the presence of submarines in
their operating areas.
NARRATIVE
,
s-4 was running standardization trials on the range off Provincestawn,
Massachusetts. Visibility was fair to poor. Late in the afternoon she
surfaced at the end of a submerged run. The Coast Guard Cutter PAULDING
(an ex-Navy destroyer) which was conducting exercises in the area rammed
s-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 flooded
completely, except for the forward room where six men managed to isolate
themselves. The boat sank immediately in 102 feet.
At first PAULDING did not know that she had struck a submarine as
she was not aware that s-4 was ;i.n the area. Her suspicions were checked
by radio with the Boston Naval Shipyard, after Which extensive rescue
efforts were initiated.
A diver from the FALCON, who descended twenty-two hours after the
collision identified tapping s i g n a ~ s as coming from the torpedo room
where six men remained alive. A storm rendered rescue efforts impossible
and there were no survivors.
COMMENTS
Since there were no survivors, the situation aboard the s-4 can
only be conjectured, Apparently the submarine failed to see the PAULDING
due to law Visibility or failure to take a good look around prior to
surfacing. At any rate this case is the basis for the responsibility
for avoiding collision resting with the submerged submarine.
A-15
The 8-4 tragedy had strong repercussions, coming as it did on the
heels of the 8-51 sinking two years previous. The pUblic outcry that
followed provided much of the impetus behind the developmental efforts
which led to the submarine escape appliance and the submarine rescue
chamber. The 8-4 was raised, repaired and used for training divers in
submarine salvage and in use of the rescue chamber. In addition,
legislative investigators saw the need for and insured passage of a
bill authorizing hazardous duty pay for submarine personnel
A-16
CASE
Less of SQUALUS from flooding through main i n d u c ~ i o n valve, 23
May 1939.
PRINCIPLES
1. A visual. check of the main induction valve mechanical indicator is
mandatory 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 c o n t i n ~
uing builder's trials off the Portsmouth Naval Shipyard. She was rigged
for dive and so reported to the Commanding Officer. The boat sUbmerged
at 16 knots, main engines on propulsion. Prior to opening the vents, a
"green board" with .2 inches pressure in the boat was obtained. When
passing 50 feet, the commanding officier in control received a report
that the engine rooms were flooding. All main ballast tanks were blown
but 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 progres-
sed from the engine rooms to the after end of the ship as well as to the
after battery compartment through open doors and ventilation flappers.
The control room was secured immediately and flooding stopped at its
after bulkhead. The entire after end of the ship was flooded, drowning
twenty-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 remained
alive. SQUALUS was raised after several months, reconditioned and re-
stored to duty as SAILFISH.
Inspection on salvage showed the following valves were NOT shut;
main induction, forward engine room air induction, after engine room
air induction] ventilation hull supply in the after battery and the
ventilation hull exhaust in the after battery compartment. The outer
doors of the upper torpedo tubes aft were cracked and their inboard
vents were opened. It was customary to flood these above-the-water-
line tUbes in this manner on the first dive daily.
A-17
The watertight door between the after battery compartment and the
forward engine room had been reported on the latch before diving and
was eVidently dogged just after the flooding started, but not before
some water entered the after battery compartment through it. Unsucess-
ful attempts had been made to shut the forward engine room ventilation
supply bulkhead flapper and the exhaust hull stop on the ventilation
system.
A post-salvage examination of material aboard SQUALUS disclosed that:
a. All operating gear was in the correct position for diving except
for the main engine induction valve gear which was latched wide OPEN.
b. The single lever on the hydraulic manifold which controlled both
the main engine induction and the main ventilation induction valves was
in the SHUT position.
c-. The main ventilation induction valve operating gear was in the
SHUT position.
d. Upon test with hydraulic power supplied by hand pump the main
engine and main ventilation induction valves operated properly.
e. With the main engine induction valve gear in the latched OPEN
position, the gear could be moved a sufficient amount toward SHUT to
break the red light contact, the latch still in position to hold
the gear OPEN and giving neither red nor green light on the hull opening
indicator.
f. The main engine induction valve indicator was located
directly below the main ventilation valve indicator light next
to 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 operating
gear of the main engine induction valve.. This mechanical failure was
not discovered in time because of an electrical failure in the valve in-
dicator 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 the
main engine induction valve and the main ventilation induction valve.
A-18
2. The hull opening indicator board should be rearranged to group the
hull openings which are shut on "Rig for Dive" separately from those
which are shut during the diving process; the main engine induction and
main ventilation induction valve lights should be together on a separ-
ate board in the control room.
3 The ventilation supply and exhaust hull valves and engine air induc-
tion hull valves should be qUick-closing. These valves should be equip-
ped with electrical indicators which indicate on a separate board in the
control room.
4. The latching arrangement for :the engine induction and main ventila-
tion induction valves should be redesigned to insure positive operation
for locking and release for both OPEN and SHUT positions.
5. Ventilation duct bulkhead flapper valve housings should be pres-
sure-proof.
6. All deck hatches of all submarines should be fitted to receive the
rescue chamber.
COMMENTS BY SECRErARY OF THE NAVY
"_ ~ . When the operating lever was moved to the proper position to
shut both the main engine induction valve and the main venti.lation
induction valve (hereafter referred to as "Valve At! and "Valve B" re-
spectively), the red lights, indicating that they were open, Went out
and the green lights came on, showing to the operating personnel that
both. of these exterior valves were shut.. The barometer showed an in-
creased air pressure in the boat, further indicating that all exterior
openings were shut. Such was the testimony of eye witnesses in the
control room. Reliance was placed upon these devices. Water entering
the boat was the first sign that some exterior opening was not shut.
Either these witnesses, however, honest in their convictions, were
mistaken in their observations, or the instruments upon which they
relied were not in proper working order, for it is established that
Valve A either did not shut or, if it did, did not remain shut.
- - Water entered the submarine through Valve A, the piping behind
it, and the outlets therefrom into the hull. The pipe lines from
Valve A lead to the forward and after engine rooms. Those from Valve B
lead to the after battery compartment.
Hull stop valves are provided at the four points of entrance
into the hull of these systems of piping, i.e., one in each engine room
and in the after battery compartment. These stop valves back up Valves
A and B by closing the air piping at points of entry into the hull.
Specifications for these hand operated hull stop valves require that
A-19
they be capable of being shut in 15 seconds and practice shows that they
can be shut in much less time (6 or 7 seconds). Had these hull stop valves
been shut prior to submergence of Valve A, which normally will occur in
not less than 35 seconds after commencement of the dive, only the pipe
lines! and not the compartments, would have been flooded.
- - The two hull stop valves backing up Valve A cannot be shut when
sUbmerging until the engines to which they supply air are The
engines While in operation require such a large quantity of air that in
a few seconds a partial vacuum would be created in the engine rooms
with serious and probably fatal injuries to personnel, if the air supply
lines be shut with the engines running.
- - The and orders on the submarine required closure of
two hull stop valves backing up Valve A after the engines were stopped
when diving. Likewise, they required, on rig for diving, that the two
hull stop valves backing up Valve B be tested for free closure, that they
be shut on the diving alarm, and that they be reopened when normal sub-
merged condition was reached.
- - However, in view of the evidence adduced, and the endorsements
hereon, the Secretary of the Navy holds that the sinking of the sub-
marine was primarily due to the mechanical failure of the operating gear
of the main engine induction valve and also to the non-closure of four
hull stop valves.
- - The record shows that the closure of all hull stop valves was
prescribed as routine procedure in the facts remain,
however, that these four hull stop valves were open when the ship made
her last dive and that evidence was adduced that it was not the practice
always to shut these valves.
- - AlthOUgh the failure to shut the two hull stop valves in the
main engine air induction system may have been the result of special
circumstances known only to the personnel who died at their post of
duty in the forward and after engine rooms, there is no adequate ex-
planation of the failure to shut the two hull stop valves in the after
battery compartment. This, together with the fact that a substantial
doubt remains as to the habitual practice Of shutting the hull stop
valves) indicates that the training) supervision and indoctrination
necessary to insure the timely closure of these important hull stop
valves, while diving, was lacking in emphas is It
A-20
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 years
in the reserve fleet, 0-9 proceeded from Portsmouth Naval Shipyard to
her operating area near the Isle of Shoals for a test deep dive. She
submerged and was never heard from again. She was located in 440 feet
of water and a diver descended to identify her. He landed on the wreck
and definitely identified it as the 0-9, reporting also that the hull
appeared to have been crushed. No attempt to raise her was made.
1. 0-9 was presumed to have suffered a casualty SUbmerged which caused
her to exceed her test depth.
COMMENTS
The test depth of the 0-9 was 212 feet. Her sinking :trougllt about
the requirements that initial dives following overhaul be limited to
relatively shallow water, i.e*, 150 feet, and that the deep dive be
made after the initial dive and in water not much greater that the
test depth of the boat, and that for all test dives a vessel capable of
underwater communication be standing by.
A..21
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 of
a formation.
3. The usual deceptions of night vision are compounded when running with
ships darkened.
NARRATIVE
A formation of five darkened ships enroute from Balboa, Canal Zone
to patrol stations was arranged as follows: two columns of two sub-
marine eac4, interval 1,500 yards, distance 1,000 yards; PC 460, guide
and OTC, 1,500 yards ahead of the sUbmarines, with a column on each
quarter; course 169OT, speed 10 knots. s-26 was astern of S-21 in the
starboard column.
At 2152, PC 460 signalled to S-21: "Changing course to 1500T to
avoid ship ahead". All submarines followed this change in varying
amounts at varying times. s-26 suffered a steering casualty and made
a late turn in hand steering. She came to 1100T to compensate for her
loss of station resulting from the delay in turning. After the ap-
proaching vessel was clear, the formation returned to base course.
s-26, which had restored normal steering, was somewhat to the right and
2,000 yards astern of S-21 and steered 1650T to regain station. At
2210, the PC signalled to S21: IIThis ship is 14 miles west of San
Jose Light X Submarines proceed on duty assigned X This ship will
make wide turn to the right." The message carried no addresses and
only S-21 received it.
At 2213, PC 460 turned right with small rudder at 14 knots to
leave the formation. She crossed the bow of S-21 at about 400 yards
and 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 the
PC) on her port bOW, crossing from port to starboard. She immediately
changed course left to 150OT. s-26 then observed the PC to be turning
directly toward her. Left full rudder was put on, the screws were
A-23
backed emergency, and the collision alarm was sounded. The blinker tube
white light was flashed at the PC. Just before the flashing light was
seen, PC 460 sighted 8-26 dead ahead. With her bow pointing at the star-
board side of 8-26, aft of the conning tower, the PC increased rudder
to right full, and attempted to back. Her engines failed and at 2223
she struck 8-26 amidships on the starboard side. Within seconds the
submarine sank in 300 feet of water. Two officers and one man were
saved, while the remainder of her complement, three officers and forty-
three men, perished.
OPINION8
1. 8-26 was to the "west of her proper station as a result of the steer-
ing casualty when the course change was made to avoid the approaching
ship.
2. 8-26 should have taken prompt action to regain station.
3. When PC 460 left the formation, she did not have a correct estimate
of 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 she
had foreseen.
5. PC 460 erred in not taking a steady course divergent from the for-
mation for a long enough time to clear the formation before starting
the turn to the right.
6. PC 460 failed to recognize the existing danger that collision with
8-26 was imminent When she sighted 8-21 (first ship in column and ahead
of 8-26) close aboard instead of at an intended safe distance.
7. By the time danger of collision was imminent, the swing left by 8-26
contributed to the severity of the collision. Had she swung right, the
collision might have been avoided, or at least minimized.
8. By swinging right with full rudder, PC 460 made the collision prac-
tically certain. The use of left full rudder probably would have avoided
the collision and certainly would have minimized the damage to 8-26.
FINDINGS
1. The responsibility for the collision rested with PC 460 for bad
jUdgement and poor seamanship in handling the formation and in taking
A-24
departure from it, as well as for poor seamanship in maneuvering when
collision was imminent.
2. The responsibility for the collision rested also with 8-26 for her
failure to regain promptly her proper station in the formation and for
poor seamanship in maneuvering when collision became imminent.
COMMENT8
This case points up the danger of assigning surface ships to operate
with, and maintain formation with, submarines when the former are not
familiar with the limitations and vulnerability of the latter, and the
fact that due to their low freeboard and small silhouette they are most
difficult to see from a surface ship at night. A similar accident oc-
curred in the British Royal Navy in World War II with the same result.
arcs and Commanding Officers of surface ships must understand the
capabilities of submarines in order to work with them with safety in
formation. This understanding should be the basis for the choice of
formation, interval, distance, speed, and positions for the submarines
assigned.
Every seaman is aware of the difficulties of night Vision, par-
ticularly the inability to jUdge distances absence
of running lights further complicates the problem. The conning officer
must allow a much greater safety margin when leaving formation course
and 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 "seamanI s eye"
available to the PC once 8-21 was seen clearly and should have been
used at that time as the basis fQr changing course radically away
from the formation.
Any ship which reverses course while running close ahead of a
formation is inviting adversity, even under conditions of perfect
visibility. 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 for a practice torpedo approach off Key
West, the Commanding Officer was turning over the bridge watch to a
junior officer when the collision alarm was sounded from below. Word
was passed up that the forward battery compartment was flooding. The
Commanding Officer immediately ordered all main blown and the
bridge hatch shut. While he was speaking OVer the MC-system, the boat
submerged. About fifteen seconds elapsed from the time the alarm was
sounded until the boat was under the surface. The Commanding Officer,
Officer of the Deck, one other officer and three men were washed from
the bridge. All other personnel, including two Brazilian officers
undergoing training, were lost as the R-12 sank in 600 feet of water.
1. While pronouncing the cause of the sinking as unknown, the Court
of Inquiry gave the opinion that the boat flooded through an open
torpedo tube.
COMMENTS
The most striking feature of this case is the speed with which it
occurred, leaving no time for corrective action. It is illustrative of
the fact that once major flooding has begun, it is impossible to maintain
or regain positive buoyancy unless the boat is stopped by the bottom in
her 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 catastrophe
unless prompt action is taken.
Personnel must be keenly aware of the danger of hydrogen evolution
when snorkeling.
NARRATIVE
While operating in Arctic waters, COCHINO secured charging batteries
and submerged at 0500, 25 August 1949. The reqUirements for a normal
charge had. not quite been met. She ran sUbmerged on the batteries
until about 1030 when she commenced snorkeling. A heavy sea (State 4)
made depth control extremely difficult and she alternately broached and
exceeded snorkel depth often.. After snorkeling for about ten minutes,
the forward engine room reported considerable water entering through the
snorkel induction s.ystem. An investigation by the executive officer
revealed no serious flooding.
At ;1.046, t1!e high vacuum cut out secured the two snorkeling engines
in the forward engine room. Two minutes later, a series of explosions,
described as a muffled thud by witnesses, occurred in the after battery
compartment in the after port corner near the series-parallel switch.
The ship surfaced imediately and the after battery compartment was
rigged for fire. Maneuvering removed the load from the after battery.
Shortly after 1100, the ammeters in the maneuvering room indicated
that battery number four was discharging into battery number three at
the rate of 3,500 8,!llperes. The controllerman went forward immediately
to inform executive officer (in charge at the scene) of the immediate
necessity to pull the battery disconnect switches. By this time, though,
the compartment had been abandoned because of smoke and gas, and had
been sealed. In rigging this space, the disconnect switches had not been
pulled nor had the covers been placed over the battery well intakes.
A muster was by the officer at this time to
insure no personnel remained in the after battery compartment while
preparations were made to reenter it through the after door of that
space. The .forward engines were started to clear smoke, and as the
executive officer, wearing a rescue apparatus, cracked the
door both engines began to accelerate. Fuel was secured to both engines,
but number one continued to accelerate. An explosion took place within
the ?fter battery compartment, while, simultaneously, another occurred
near 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 to
secure it with only one turn. The forward engine room was evacuated.
A few nimutes later, two chief petty officers returned to the forward
engine room, extinguished several small fires and secured the compartment
except for the engine sea water cooling systems and the door to the after
battery compartment.
At the same time that the attempt was made to reenter the after bat-
tery compartment prior to the second explosion, a man was washed overboard
after going topside through the after torpedo room hatch. He was engpged
in carrying out an order for all personnel not on watch or fighting the
fire to iay topside. The Commanding Officer maneuvered the ship and
rescued him.
About 1145, the Commanding Officer ordered all excess personnel
topside to go below via the conning tower. They remained below until 1208,
at which time all personnel forward were evacuated because of smoke and
gases.
At 1215, another violent explosion (the third) rocked the after bat-
tery. Shortly afterward, the hospital corpsman1s reports of treatment of
the injured being conducted in the after torpedo room became more alarming
and his requests for medical supplies became more urgent. The Commanding
Officer requested TUSK, in company, to come alongside to remove the in-
jured and the excess personnel. This was attempted but found impossible
because of the heavy seas, but at 1410 the medical supplies arrived from
TUSK by rubber boat.
At 1420 one officer and a civilian technician attempted to transit
to 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 apparently
drowned. When TUSK personnel_were attempting to administer artificial
respiration,. two huge waves swept eleven crewmen and the civilian over-
board. Five crewmen were recovered but the others could not be located
during a two-hour search.
During the afternoon, three attempts were made to enter COCHINO's
forward torpedo room from topside to clear it of gpses. An attempt was
made to vent the after battery compartment through the high external
salvage valve but this valve would not open. The men suffering from
gas were being revived and The generai situation was being
discussed with the hope of solutions to the problems. At
1537 aUXiliary power was lost when a short circuit tripped out the
forward battery auxiliary circuit breaker. At 1610 the engines were
stopped when the clean fuel oil tank became empty.
A-30
Auxiliary power was restored about 1800 and shortly thereafter
CCCHINO get underway, steering for the nearest land with the screws
only. .Rudder steering was restored about 1900. For the next four
hours, COCHINO proceeded astern of TUSK. Personnel who had been evac-
uated from below were sheltered in the sail.
At 2306
J
the fourth and explosion occurred (probably in the
forward engine room) and filled the after engine room with fire and
gases. The latter space and the maneuvering room were abandoned at once.
Around midnight, the remaining personnel below, all in the after torpedo
room, were ordered topside.
Ten minutes later, TUSK came alongs and transfer of personnel to
her was commenced. At 0036J because of a starboard list and low free-
board aft, the Commanding Officer ordered CCCHINO abandoned. The Com-
manding Officer at 0043 and three minutes later CCCHINO sank
in 170 fathoms of water
. OPINIONS AND FINDINGS
FINDINGS OF COURT OF INQUIRY
1. The initial of explosions were probably hydrogen flashes
touched off by a spark in the Vicinity of the series-parallel switch in
the after battery compartment.
2. The excess hydrogen probably existed in "and near the battery for
about five hours and "had not been purged or been brought into a dan-
until sno::l:'keling was commenced"..
3. Responsible officers erred in failing to note the dangerous concen-
tration of hydrogen when it occurred and in not taking corre9tive action,
particulariy in the light of Bureau of Ships Instruction covering such
matters.
COMMENTS AND RECOMMENDATIONS OF TEE CONVENING AUTHORITY
Although agreeing that tIle probable cause of the first relatively
minor explosions was hydrogen (not positively determined), the Force
Commander, as convening authority, did not concur in the recommendation
to censure certain officers for their errors. It was "obvious that
currently available hydrogen detection equipment was inadequate to in-
dicate promtly the dangerous situation
ll
which existed.
A-31
He stated that the ship might have been saved had the muster about
1100 not been taken and had, instead, an immediate attempt been made to
enter the after battery compartment to open the disconnect switches.
Although conclusive evidence was not the convening authority
believed that COCHINO sank as a result of flooding ot both engine rooms
following a derangement of sea water piping and valves in the forward
engine room after the final explosion at 2306. The ship might have re-
mained afloat, he stated, had the after engine room been secured prior
to its abandonment.
The Force Commander followed his direct comment on the court's pro-
ceedings.with a series of recommendations to CNO for submarine material
changes as a result of the disaster. The following were based upon the
premise that the first explosions were caused by hydrogen:
1. The storage battery, its ventilation and its electrical
arrangement in the well should be redesigned to make it safe from con-
centrations of hydrogen regardless of submarine internal atmospheric
conditions accruing from wartime operations, snorkel or otherwise.
2. Increased safety should be provided against short circuits and
grounds involving cells, cabling, switches and other electrical elements
of different potential within the well.. The part played by the series-
parallel switch in the COCHINO disaster indicates that all switches might
require shielding with a gas-tight enclosure, perhaps employing the
principle of the safety screen.
Series-parallel switches should be modified to protect against
maloperation, whether from personnel error or material failure. This
should include positive interlock between switches and between each
switch and its battery disconnects. An "OFF" position should be pro-
vided on each switch.
4. Operating personnel should have improved instruments to enable
their determining'safe conditions of resistance to ground, hydrogen
concentration, and ventilation air flow.
The following changes were recommended based upon possible means of
controlling an initial casualty such as coeHINO's and of providing for
continued operation of the ship:
1. Remotely controlled battery disconnect breakers should be in-
stalled providing full operation from the maneuvering room and with
control of tripping from either side of the end bulkheads of battery
compartments.
2. Protection should be provided against faults and grounds in the
take-off leads for aUXiliary power, ship1s lighting, emergency lighting
and other directly connected loads. Such occurrences may have been
A-32
involved in the COCHINO case as they were in previous uncontrollable
submarine electrical fires.
3. Submaripes should be provided with more qUickly operable rescue
breathing apparatus. The ideal type should be rechargeable' on board.
4. At least two fire extinguishers should be provided which can be
recharged on board.
5. A suit and smoke helmet should be carried by sub-
marines.
6. The main propulsion plant should be modified so that main gen-
erators could provide power for excitation, the plant auxiltaries, and
for ship control" indpendent of the battery.
A final recommendation involving training of personnel requested
that the Bureau of Ships prepare a single publication covering the
modern submarine electrical plant with emphasis on the compromises
which have been accepted, operating procedures, safety precautions and
electrical casualty procedures.
COMMENTS
Since the majority of our boats in the postwar era were conversions
involving addition of Guppy batteries or snorkel or both, the.lessons
learned were many and important.
of the origin of the first explosion in COCHINO it seems
apparent t.hat there were several points during the aftermath at which
corrective action could have saved the ship. for completely
rigging compartments for emergencies is. most evident, as is the re-
qUirement for electrical isolation in cases of casualties of electrical
origin. The ratio of the ounce of prevention to the pound of cure has
not been altered by advances in technology.
Most of the recommendations by the Force Commander have borne
fruit and are now considered standard: open-tank ventilation, remote-
operated 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 not
lost, as almost certainly would have been the case had she been operating
alone. Loss of life was an indirect result of the casualty. Such has
not been the case with most other battery explosions.
The man overboard problems encountered by both submarines involved
were aggravated by the heavy seas. The rescue of the man lost from
A-33
COCHINO during a in the catastrophe is worthy of note. The
safety-line track alteration 'Was an outgrowth of these incidents.
The maxim that trouble breeds trouble 'Was proved time and again
throughout COCHINO's last hours. Lessons to be drawn from the minor
difficulties encountered are almost too numerous to permit complete
listing. A bridge sound-powered telephone proved invaluable as the
IMC-7MC systems were knocked out shortly after the first explosion.
With no power for her searchlights, COCHINO 'Was reduced to using a
battle lantern for night communications, a situation which has 'been
remedied by the Aldis Lamp. The rapidly-being-forgotten art of
semaphore was used by day but 'Was limited by. wind and the signalmanIS
exposed position. The medical supplies, other than those in the
after battery compartment,- were limited to first aid kits in the
torpedo rooms. Present practice calls for more such supplies in
stowages forward and aft. Several of the life jackets were found to
have been by the bunksprings upon which they have been
stow:ed.. Althoug'll many occasions called for use of a knife, only two
were available, the personal possessions of two crewmen. With
the control room and conning tower abandoned, steering 'Was
except from the afte:r torpedo room with a makeshift lever to move the
steering pump control valve. Steering with the screws only was inef-
feCtual. The emergency steering method employed by COCHINO is now part
of the standard repertory of after torpedo room crews.
While material improvements have lessened the of the
type casualty which caused COCHINOf sloss, submariners should have a
healthy respect for hydrogen and its dangers whether at sea or in
port, 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 ~ o l l i s i o n 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
occursII
B-1
CASE
-'--
Collision between submarine (submerged) and AKA.
PRINCIPLES
1. Description of target disposition to fire control party by Com-
manding Officer during attack on multiple targets is essential.
2. Use of number two periscope in state five sea inside the screen is
preferable to use of ST scope
.NARRATIVE
A submarine penetrated f?creen for attack on fOI'!!J,ation of two columns
of 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 with
starboard 45 angle on the bow. The submarine then commenced attack. on
end ship in column. After this attack the Commanding Officer made a look
.around and steadied on the AKA. Somehow, the picture was lost, and
thinking the AKA to bean the starboard quarter vice the port bow, h ~
ordered "Left full rudder, all ahead fulli!. At 400 yards range the mis-
take was realized and the order was given to "Take her down
u
A col-
lision resulted before the submarine could gain' depth. The submarine
surfaced immediately since a previous look around bad shown the AKA to
be only ship near.
OPINIONS
1. The Commanding Officer erred in failing to make clear the tactical
situation 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 apparently
aware of the possibility of having to go deep, as he had so informed
the fire control party, but he had done nothing about it.
Once the SUbmarine is close to the screen or inside of it, the use of
number 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 periscope
depth.
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 the
danger 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 avoiding
collision.
2. Precautions must be taken when returning to periscope depth from
deep submergence.
NARRATIVE
The 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" , the
submarine fired "down-the-throat" at "ALFA" which was bearing 004OT,
1,300 yards,angle-on-the-bow starboard 10, speed fifteen knots. The
submarine came to 0900T at fuil speed in order to pass under the target
and then fire a stern shot when lIALFA" has passed overhead (the sub-
marine',s JT lost lIALFAlIonthe starboard bow when going deep and in-
creasing speed). About 1513 IIBRAVQlI reported a sonar contact to "ALFN'
who, in turn, ordered all ships to turn to the starboard to 250OT. At
1514 the submarine's TDC operator reported the generated target to be
passing overllead. The submarine slowed to two-thirds, came to course
029
0
T. The JT operator reported regaining contact with lIALFAlI bearing
the WFA sonar reported one ship at 2150R arid another at 250OR.
The Commanding Officer ordered 58 feet. At this time the reported JT
bearing checked within a degree of the TDC solution although the CPA
was indicated as only 260 yards. Thirty to forty-five later a
second JT bearing Was obtained which required a two or three degree
correction in the TDC. Then, at 1516, with lIALFAH on a heading of
about 2300T, coming right to 250OT,making turns for seventeen knots,
and with the submarine on aheading of at two-thirds speed, 58
feet depth, the two ships collided. The result was damage to the sub-
marine's shears and periscope--$44,000. lIALFA'sll damages were estimated
at $110,000.
The JT bearing of reported to be was Iilost likely
lICHARLIE" and the WFA bearing of was a spurious one, probably a
minor lobe, giving the Commanding Officer the indication that lIALFAlI
B-5
was passing down his starboard side leaving the other two ships aba:ft his
port beam.
2. The COIll!JlS.nding O:f:ficer apparently :failed to require a care:ful all
around 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 the
exercise.
4. Use o:f the high periscope and better in:formation :from the sonar plot
might 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 sub-
marine's Commanding O:f:ficer.
COMMENTS
Use o:f the high periscope a:f:fords two advantages - an earlier look
and more sa:fety to the submarine by providing a greater d.epth o:f water
over the pressure hull; thus reducing. the seriousness o:f collision.
This greater depth alsoreducea the p o s s i b i ~ i t y o:f broaching when in a
poorly controlled ascent or heavy seas.
Agreement between a sonar nearing and the TDC generated solution
should not be relied upon to the extent o:f omitting a care:ful all around
search by sonar.
B-6
CASE
Collision between submerged submarine and destroyer.
PRINCIPLES
The primary responsibility for avoiding collision rests with the
sUbmerged submarine.
NARRATIVE
A submarine was attacked by two destroyers when carrying out night
screen penetrations. The submarine came to periscope depth to counter-
attack, fired at destroyer llBRAVO
lf
ahead and then shifted to lfALFA
lf
which was crossing astern at between 300 - 500 yards with an estimated
30 - 40 port angle-on-the-bow. The submarine lost sight of llALFA'slf
hull but still saw her lights and was receiving reports of range of 500
yards and steady. He estimated angle-on-the-bow to be 90
0
port. Moments
later the report "300 yards and closing
ll
was received, and at the same
time the hull again came into view. This gave a new angle-on-the-
bow of 0
0
and showed collision to be imminent. The Commanding
Officer ordered down scope, standard speed and 70 feet. Collision oc-
curred before the orders could be carried out with the exception of
lowering the scqpe while at 60 and the gaining of a slight down
bubbl", 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 from
the stern planesman inadvertently putting the planes on rise when the
roll from collision occurred. The submarine was immediately rigged
for collision, the running lights turned on, a red flare fired, and
was then brOUght to the surface. The damage was valued at $190,000
to the submarine and $27,700 to the destroyer.
OPINIONS
The submarine's Commanding Ofi'icer was operating aggressively and
the collision was a result of his haVing erred in estimating the de-
stroyers angle-on-the-bow.
COMMENTS
After a submerged collision'has occurred, the greatest -danger
usually exists when surfacing quickly. The first step prior to
SUrfacing should be to get the submarine to a safe depth until it is
known to be safe to surface, using the procedure prescribed for a dis-
abled SUbmarine. The fact that approximately a minute and a half
passes between the order to fire a red flare and the time the flare
is 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 Com-
manding Officer, the officer of the deck and the Navigator.
NARRATIVE
During a routine transit of a harbor, the Navigator informed the
officer of the deck that it was safe to pass a mooring buoy on the port
hand. The commanding officer suggested that the ship would pass too
close to the buoy, whereupon the Officer of the Deck ordered a change
of course to the right. At the same time the Commanding Officer asked
the Navigator if there wasn't shoal water by the pier toward which the
ship was heading. The Commanding Officer's remark alarmed the Officer
of the Deck and he ordered left full rudder. The Commanding Officer
upon seeing the buoy passing down the ship's port side issued the order
"starboard stop". Shortly thereafter, the ship struck the buoy, dam-
aging the port screw which had become entangled in the chain of the
mooring buoy.
1. The Officer of the Deck and the commanding officer had not used
the Tide and Current Tables prior to getting underway, since the
Commanding Officer considered tides to be of little consequence.
2. No chart was on the bridge since the Commanding Officer believed
the simplicity of the harbor warranted no such aid, although the of-
ficer of the deck had not been instructed in the hydrographic char-
acteristics of the harbor.
3. The Commanding Officer had not required the navigator to keep a
continuous and accurate plot of the ship's position and to keep the
Officer of the Deck informed thereof.
4. There was no complete exchange of navigational information between
the Navigator, the Commanding Officer and Officer of the Deck, lack
B-9
of which resulted in the Officer of the Deck erroneously believing
there 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, but
the Officer of the Deck was uncertain of whether he did or did not.
COMMENTS
There is no substitute for following the sound navigational pro-
cedures for piloting as laid down in DUTTON's-procedures which were
flagrantly violated in this case. Of utmost importance are the
preparations 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 chart
and the conning chart. Of equal importance is the practice of taking
frequent cuts while on soundings, as required by Navy Regulations.
It is essential that there always be a positive understanding of
who has the Conn. Failure to establish this fact is usually the
fault of the Commanding Officer. CINCLANrFLT Instruction 3530.2A
is 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 rounded
Sarah'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 the
submarine on course 225 degrees true, speed eleven knots. Current was
shown by the tables to be 1.2 knots to the north (flooding). The course
was maintained until the buoy was about 150 yards away, at which time
the OOD began small course changes to the left. The ship struck the buoy
amidships and damaged the starboard screw.
FINDINGS AND OPINIONS
Collision resulted from the OOD's failure to determine by true
bearings the relative motion of the buoy.
COMMENT
Although not available from the record, it would appear that no allow-
ance was made for current in setting the course of 2 2 5 ~ ; it also is
probably safe to assume that the OOD was totaily unaware of the cur-
rent conditions.
The OOD (as the one in this case sadly learned) shares the respon-
sibility with the NaVigator for the safe navigation of the ship. Too
many 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 ex-
pected, the depth of water in which operations are to be conducted--in
short, they blindly rely 100% on the Navigator to keep them advised. of
such essential information. The prime responsibility of the OOD for
the safety of the ship must never be slighted in the least--if he
blindly acts merely as a "mouthpiece" for the NaVigator, he is not
doing 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 of
sightings and course changes, and assure that the former is informed
of the ships navigational position at all times.
3. Risk of collision with any object can be ascertained by observing
its 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 was
plotted to clear Buoy 2A by 300 yards, but did not allow for any cur-
rent. Visibility was between 3,000 and 4,000 yards. The Navigator and
the Commanding Officer left the bridge upon clearing Sarah's Ledge Buoy.
SUbsequently, the OOD sighted Buoy 2A dead ahead at a range of about
2,500 yards, but neglected to inform either the Commanding Officer or
the Navigator. When the range had closed to 900 yards the OOD changed
course to 225T, then a bit later to 2 3 3 ~ , and finally to 2 2 0 ~ .
While on this last course and at a speed of 11 knots the submarine's
bow 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 Officer
upon sighting the buoy and of course changes made to avoid it. More
radical course changes should have been made once it became apparent
that there was a danger of collision with the buoy.
COMMENT
The magnitude and direction of the current in the area where this
accident occurred is readily obtainable from standard publications, but
the Navigator failed to determine and use such current information in
advising the initial course.
B-13
Further, the OOD should be informed on the existing current, and in this
case he apparently was not. Poor initial course or not, however, it is
mandatory for an OOD to observe the true bearings of objects which he
approaches, and it is well-known that something must be done if the
bearing 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 course
change of only 8 degrees was made, beginning at a range of 900 yards,
until the buoy was hit. Apparently the OODbelieved that some danger of
collision with the buoy existed. when he commenced these minor course
adjustments, but his action was not sufficiently positive; he should have
used rudder orders to positively and immediately head the ship clear
of the buoy rather than to use trifling course changes. It is of
interest that this casualty is almost identical with the previous case
involving the same buoy--a buoy which has at least 1,000 yards of
navigable 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 ship
in restricted water.
NARRATIVE
The submarine was tied up outboard of another submarine which in turn
was outboard of a destroyer. The inboard submarine got underway,and the
outboard submarine breasted out to facilitate the maneuver. While breasting
back alongside the destroyer, the submarine Commanding Officer observed
that his ship was getting forward motion, therefore, he ordered "starboard
back 1/3". The helmsman repeated the order correctly,but actually rang up,
II starboard ahead 1/3", which maneuvering answered. The JA talker on the
bridge correctly repeated the order to maneuvering but was unable to re-
ceive in acknowledgement. As the ship's headway increased,the Commanding
Officer ordered, "starboard back 2/3",but the helsman rang up star-
board ahead 2/3, and again the JA talker was unable to get through the
maneuvering. As the ship gained headway rapidly, the Commanding Officer
ordered, "all back 2/3" over the }MC, but it was too late to prevent a
collision of the submarine 'With the DD. Fortunately, the damage to both
ships was slight.
OPINIONS
1. The primary cause of the collision was the failure of the helmsman to
ring up the proper orders.
2. The secondary cause of the collision was the f a i ~ u r e of the JA
telephone circuit.
COMMENT
All communication and control circuits should be tested prior to get-
ting underway. Anytime a ship is breasted out to permit another to move
it should be considered a getting-underway operation--because under such
conditions it frequently becomes necessary to get underway. Further,
telephone talkers should be trained to notify the Conning Officer im-
mediately when they apparently are not getting orders through-it will
often 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 acutely
aware of bells ordered and the response actually received to the orders.
2. Deviation from established maneuvering practices in confined water
must not be permitted.
3. Watch stations for all special evolutions must be manned by the very
best personnel available, and such manning should never be secondary to
leaving 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 on
the bridge, wind and weather conditions good. The watch in the maneuver-
ing room consisted of an unqualified officer observing, a chief elec-
trician's mate, and two third class electricians, rated as the ship's
number two and number five controllerman respectively. The maneuvering
room talker was a seaman apprentice standing his first watch on this
station; 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 fact- that only 55% of
the ship's complement was on board, the remainder having been left in
port 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, starboard
ahead full; port back 2/3; port stop; all ahead full; all ahead flank.
At this point the submarine struck the concrete mole (260 yards from
the end of Pier 4) stern-first, and all stop was ordered.
Considerable damage resulted to the after tube nest, necessitating
navy yard availability for repair.
It was SUbsequently learned that the port shaft had been on pro-
pulsion as directed by the Conning Officer, but the starboard shaft
had never turned over owing to the fact that the starboard generator
trip switch had never been cut in. The bridge was first informed by
maneuvering that there was no power on the starboard shaft about 10
B-17
to 15 seconds before the ship struck the mole; bridge personnel had
not observed the fact that the shaft was not turning at any time.
1. The maneuvering room watch was not of the efficiency and experience
required in maneuvering a ship in confined waters. The Officer stationed
therein vms not qualified, and the telephone talker was not only not
qualified but was assigned duties (keeping the bell book) which should
not have been required of a well-qualified talker. The Commanding Officer
was negligent in failing to have a fully watch in the maneuver-
ing room.
2. The Commanding Officer was negligent in failing to have a full and
efficient maneuvering watch stationed in the engine rooms, i.e., only
one engineman was stationed therein.
3. The Commanding Officer was culpably negligent in failing to recog-
nize that the starboard shaft was not turning over and in failing to
issue proper countering orders in time to avoid the casualty.
COMMENT
The number of violations of proper sea-going practices contained in
this case is equaled only by the interesting variety of same.
Compliance with the standard practice of testing shafts before getting
underway 'Would have prevented the accident. It is also possible that
the failure would have been detected in time to take corrective action
had the well-established practice been followed of always using, "all
back 1/3" as the initial bell (until it is definitely determined that
the 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 Officer
becoming aware that the starboard shaft was not answering. Whether
the maneuvering room watch was not aware of the failure of the shaft
or whether they were aware of it and failed to take action or report
it to the bridge is not known from the records available. It is hard
to believe that the failure was unknown to the maneuvering room
personneL Had they known of it, correct action should have been to
answer the bells on the battery and report the casualty to the
B-18
Of course, the underlying cause of the entire debacle is the fact
that critical maneuvering stations were manned by inexperienced personnel
and in inadequate numbers due to so many of the crew having been left in
on that particular day, but it is interesting to note that the existing
ship's engineering orders were also so inadequate that the maneuvering
stations were properly manned in accordance with those o r d e r s ~ Why were
so many men left in that day? The exact reasons are probably diverse and'
multitudinous, but it is probably safe to assume that the decisions to
leave in the various persons was made without coordination between the
Executive Officer, the departments concerned, and the Watch, Quarter
and Station Bill.
B-19
CASE
Collision between submerged submarine and DDE.
PRINCIPLE
Attention must never be concentrated on a single target to the ex-
clusion of others.
NARRATIVE
A submarine commenced an approach against a DDE, acting as the
target, which was escorted by two other DDEs. At problem time 31, the
nearest escort was observed by periscope to be heading toward at a range
of 1,400 yards, therefore the submarine went to a depth of 100 feet.
Sonar tracked the closing escort until it had passed overhead and had
merged with the submarine screws, at which time the submarine Command-
ing Officer believed the escort to be well past and came to periscope
depth for a shot at the primary target. Just as he was getting his
final bearing on the target, a jolt was felt, and the Commanding Of-
ficer, realizing that he had been run dawn, went to 100 feet. He
subsequently made proper surfacing signals and surfaced, whereupon he
discovered his periscope severly damaged. No damage was suffered by
the DDE. It was subsequently determined that the escort had sent the
contact signal !lCCC
ll
upon commencing his run in after initially passing
over the submarine, but he got no acknowledgement for the signalj it
was also learned that the JT sonar operator had reported screws close
aboard and closing just before the submarine got to periscope depth
for its final observation, but this report was not acknowledged by
anyone in the conning tower.
1. If the contact signal from the escort had been acknowledged this
accident could perhaps have been avoided.
2. If the sonar had continued to track the escort instead of dropping
him as soon as he appeared to have passed overhead, the run back in
could have been detected.
3. If the report of closing screws received from JT had been acknow-
ledged the accident could have been avoided.
B-21
COMMENT
This incident is clearly a case of the Conning Officer becoming so
engrossed in the primary target that he neglected to keep up with the
other targets. Not only did he fail to use his sonar to ascertain that
it was clear for coming to periscope depth, but he neglected the ele-
mentary precaution of a quick look around in low power before he allowed
himself to become absorbed in his final bearing on the target. Such
negligence 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 to
getting underway.
NARRATIVE
The OOD got a submarine underway from a nest in order to permit
inboard ship to underway. While attempting to come back alongside
the tender, the OOD noted the rudder angle indicator showed the rudder
to be left full. This rudder angle had not been ordered, and in the
resulting confusion the OOD lost control of the situation and rammed
the tender.
The rudder angle indicator has been disconnected by a torpedoman
in the after room without .notifying anyone of his action.
COMMENT
Proper preparations for getting underway, which includes the checking
of such indicating and control circuits, would have prevented this
casualty.
Further, the OOD apparently was not watching his rudder angle in-
dicator as he should, else the casualty would have been discovered
immediately upon getting underway rather than in attempting to come
back alongside. The bridge r u d d ~ r angle indicator is for the use of the
OOD, and he should cultivate the habit of checking it after each order
to the helm.
B-23
CASE
Submerged collision with attacking destroyer.
PRINCIPLE
Safe operations at periscope depth with attacking surface ships re-
quire some means of quickly getting negative buoyancy.
NARRATIVE
intertype
Negative
linkage.
A radar picket submarine was conducting
unrestricted counter-attacks by destroyers.
commission due to a failure of a flood valve
exercises involvling
tank was out of
While approaching a DD at periscope depth, the submarine was detected
by the DD, who immediately turned toward to counter attack. The submarine
attempted to get down to a safe depth by using speed, but her air-search
radar mast was struck by the destroyer's screw before she could get
under.
COMMENT
During such operations as this it is important to be able to get the
boat to a safe depth quickly. With negative out of commission, it
would have been possible to use safety tank as a negative tank by
leaving a bubble in it and venting it out through the main vent in case
it 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 of
getting down out of the way of the attacking ship. It would also have
been possible to have blown negative flood open before starting the
exercise, and then to have run with it to the mark at periscope depth--
flooding could then have been accomplished quickly by simply opening
negative tank vent. This procedure would have had the disadvantage of
the boat's trim changing as the depth was changed, but for the critical
depth for periscope observations this would have been unimportant, and
at deeper depths it could have been handled very easily by shifting
variable water.
B-25
CASE
Collision with sea wall on getting underway.
PRINCIPLE
1. Orders to maneuvering room should be paralleled by phones during
maneuvering watch.
2. #2 line should not be taken in until the first back bell is properly
answered.
NARRATIVE
In getting his submarine underway from a pier in Key West the OOD
ordered, "take in all lines, all back 1/3, one long blast". Helmsman
rang up all ahead 1/3 by mistake. The order was not paralleled by the
bridge phones. With no lines over and the shistle interfering the ship
collided with the sea wall before corrective action could be taken to
check headway.
COMMENT
If the first ordered bell had been all back 2/3 or all back full
as is standard practice on some boats, considerable damage would have
resulted. #2 line should always be held to check the headway if a
mistake such as this occurs. The long blast should not be sounded
until the first back bell is answered properly and the lines have been
taken in to obviate any interference with the orders from the bridge.
This has the additional advantage of having the boat actually moving
when the blast is sounded, permitting neighboring ships to identify
the ship getting underway. If reliance is placed on the soundpowered
phones and talkers are properly trained, this type casualty can be
prevented easily. Indeed, the only reason for manning the phones is
to 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 of
a ship.
2. Acute awareness of a vessel's motion is necessary for satisfactory
shiphandling.
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 watch
was 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 your
phones. I will use mine when I need to". When the lines were in, the
OOD ordered, "all back 2/3". The helmsman erroneously rang up "all
ahead 2/3". The order was properly transmitted over the telephone cir-
cuit, but maneuvering answered the annunciators vice the telephone order
as they were under the impression that the OOD was not yet using the
phone circuit for orders. Further, all stations in maneuvering were
manned with a total of two junior men with no supervisionj these inex-
perienced men saw nothing unusual in an initial ahead bell when
practically against a sea wall.
The OOD belatedly noted that the ship was moving ahead rather than
astern and ordered all back full. Again the helmsman rang up all
ahead full. By this time the ship had hit the pier, sliced several
yards into it, and crushed two telephone booths. The next order, "all
back emergency" went out over the 7MC and the lMC and was correctly
answered.
1. The OOD erred in not placing a competent talker on the bridge and
establishing proper communications between maneuvering and the bridge.
2. Maneuvering erred in not demonstrating submarine sense and aware-
ness in failure to doubt the annunciator error, especially during
B-29
unusual maneuvering and personnel situations and when conflicting motor
orders are received by phone.
3.
and
and
The OOD erred in failing to handle
personnel situation and in failing
preliminary screw wash.
properly an unusual maneuvering
to be aware of the ship's motion
4. The helmsman erred in ringing up the wrong bells, and in failing to
show 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 the
need arises. Though it is not an every-day occurrence, it certainly
is not an unusual evolution and the duty section must be trained to
accomplish it safely. Further, the fact that it is a maneuver con-
ducted with something less than the first-string maneuvering watch
makes it even more imperative than usual that standard organizational
practices and the accepted practices of good seamanship be meticulously
observed. Had the bridge talker been properly stationed, and his
phones and other ship control circuits tested, this accident might have
been avoided. Had the OOD followed the standard practice of initially
ordering a 1/3 bell in backing away from a pier it is entirely possible
that he would have caught the wrong bell in time to prevent the col-
lision. Holding of #2 line until the first backing bell has been
answered is another aid to prevent this type accident, but is of little
Use when the initial bell is for 2/3 instead of 1/3.
B-30
CASE
Collision of submarine with channel marker (Eastern Triangle) in
main ship channel, Key West.
PRINCIPLES
Maneuvering in confined waters requires that the best use be made
of personnel and equipment available.
NARRATIVE
The submarine was proceeding out of Key West, with the Commanding
Officer and Division Commander on the bridge. While on the last leg
of the channel passing signals were exchanged with a YF ahead which
was being overtaken. Course was 165
0
, speed was increased from stand-
ard (12 knots) to full (13.5 knots). The OOD ordered course 163
0
to
give the YF a wider berth in passing. The Commanding Officer told the
OOD that this course was too far to the left and the GOD directed 50
right rudder. At this time the boat was about 600 yards from Eastern
Triangle and about 300 yards astern of the YF. Both the Commanding
Officer and the Division Commander observed and informed the OOD that
he was getting wrong rudder as indicated by the rudder angle indicator.
GOD then ordered 10
0
right rudder and received 10
0
left rudder. At
this point the Commanding Officer relieved the OOD, ordered right full
rUdder, traIl back emergehcy", and sounded the collision alarm. The
submarine struck one leg of E a s t ~ r n Triangle "a glancing blow at a
speed of about 4 knots. The triangle scraped down the port side to
about abeam of the bridge, at which time it toppled over out of the
channel. No damage resulted to the submarine.
OPINIONS
1. Helmsman became confused and applied rudder opposite to that ordered
by OOD. The close confines of the channel and the nearness of the
Eastern Triangle made time of the essence and the corrective action
came too late.
2. The OOD could have diagnosed the situation earlier had he been
watching 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 question
were poor practice. Although such speeds may be customarily used,
this casualty is prima facie evidence that there is no room left for
human or mechanical failures with any margin of safety. Submarine
officers can do well to cultivate the habit of checking the rudder
angle indicator immediately after each order given to the helm. Not
only does this practice provide timely warning to prevent accidents
such as this one, but valuable experience will be gained in observing
how 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 com-
munication circuits;
b. Training of lookouts to report screw wash after each order to
the screws;
c. Stationing an experienced officer in the maneuvering room to
supervise proper operation of the main control cubicle.
NARRATIVE
Submarine had twisted into position and was approaching the pier for
a starboard-side-to landing. Shortly after giving !!all ahead 1/3" to
get the sh,ip moving into the sliP., AC power was lost Circuits of
i n ~ e r e s t which became de-energized were as follows:
Annunciators
Shaft Revolution Indicators
1 and 7 MC
Controller Wrong Direction
Alarm
The OOD ordered "all stop" without knowing AC power was lost. This
bell was answered by maneuvering via the sound powered phones. The
officer in maneuvering attempted to query the bridge using the 7 MC
then realized the loss of AC power. While maneuvering began to re-
store AC power, things began to happen rapidly on the bridge. "Port
back 2/3" was the next bell; the reverser on the port side was still
in the "ahead!! position from the previous "all stopH bell, and with
the controller wrong direction alarm out and the annunciator still on
the "ahead 1/3" bell to further confuse him, the port controller man
answered with "ahead 2/3
11
"All back 2/3
11
Was ordered, answered cor-
rectly on the starboard side. Then in rapid succession came Hall
back full", back emergency", CRUNCH! On the order l1 all back full!!
the phone talker in maneuvering (an ICFN) corrected the port control-
lermans (an EMl(SS who then answered the bell correctly. The officer
in maneuvering failed completely to see the mistake. On the bridge
the 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 the
port screw. The collision with the sea wall caused moderate damage
to the bow of the ship.
The direct cause of the submarine striking the sea wall was due to
the port controllerman giving "ahead 2/3" on the port shaft when "back
2/3" was ordered.
COMMENT
The primary reason for having an officer stationed in the maneuver-
ing room is to insure that the orders to the screws from the Conning
Officer are answered correctly. He should not let himself get involved
in other details to the extent that this responsibility is neglected.
Had the mistake of the port controllerman been caught immediately the
collision would not have resulted. A contributing factor to the mistake
by 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 qUickly
check the screw wash can be realized only be developing the habit of
checking the screws after orders to maneuvering. This habit should be
backed up by training of the lookouts to report screw wash after each
order to the screws. Had either the OOD or lookout checked the port
screw wash, the accident could have probably been prevented. This
accident conclusively proves that the assignment of lookouts to the
maneuvering 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 of
surface vessels.
2. The collision alarm should be sounded as a steady sound to prevent
its being confused with the surfacing alarm.
NARRATIVE
Two destroyer escorts, ALFA and BRAVO were conducting target services
for a submarine. AlthOUgh the directive for the exercises called for an
initial 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, zig
zagging on base course 270
0
, speed 20 knots. On receipt of the "Execute"
the submarine dove, disappearing from ALFA's radar at range 6,150 yards,
bearing 268
0
The Commanding Officer of the submarine commenced his approach and

between 0814 and 0822 made seven observations, three with #1 scope and
four with #2 scope. Only two of these were complete setups on the
target, destroyer escort BRAVO, which was maintaining station 1,500
yards, bearing 090
0
from ALFA. TOC obtained no solutions; plot gave
the conning tower a solution of 2500, but plot's speed solution of 20
knots was not received by the Conning Officer. At 0816% submarine
changed course to 150
0
and increased ;peed to standard. At 0819 SUb-
marine slowed to 1/3, and at 0820% ordered full speed, left full rudder
to 040
0
While swinging on this turn and raising #2 scope the sub-
marine collided with destroyer escort ALFA, keel depth 62 feet; no
flooding resulted. At the collision, the Commanding Officer shouted
"take her down" through the open lower conning tower hatch, and the
hatch was shut from the control room. While clearing the conning tower
of the excess personnel, someone - whose identity could not be estab-
lished later - gave an order to "shift steering below" and steering
and annunciator control was shifted to the control room. However, no
one in control remembers lining up the annunciators prior to shifting
annunciator control below.
Immediately thereafter, a report was received from the Diving
Officer, "I can't get her down - she is coming up". The Commanding
Officer concluded that the submarine was being dragged to the surface
B-35
by the colliding destroyer escort. He ordered a red flare fired by the
torpedo 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 Com-
minding Officer proceeded to the bridge where he found the submarine
to be clear.
In the control room the crew had begun rigging for collision when the
order "take her down" was received. The Diving Officer ordered 1!flood
negative" and sounded the collision alarm, giving, he stated later, three
blasts. Planes were put on full <dive, but with control room annunciators
on "all stop" when steering was shifted to control, all stop was answered
by maneuvering while the ship broached.
At this time the Diving Officer reported not being able to get the
boat down. On looking at the air manifold he discovered tanks being
blown, and deciding the boat would be .safer on the surface, ordered
bow buoyancy blown. No report was made to the Commanding Officer.
SUbsequently, it was disclosed that the air manifold operator though
he heard the DiVing Officer pronounce the word "blOW", and saw him make
a characteristic signal with his hand, Whereupon the air manifold
operator blew safety, negative, and main ballast tanks in that order.
The DiVing Officer denied haVing given the order to "blow", or having
made any hand si gnal.
1. The submarine Commanding Officer did not have sufficient information
to make a proper attack, and he should have discontinued the attack
before bringing his ship into danger of collision.
2. Throughout the exercise the attack party and personnel in general
of the submarine exhibited a lack of initiative, agressiveness, and
knowledge and an unsatisfactory state of training and readiness. By
taking no steps to correct this, in effect the Commanding Officer con-
doned this poor performance.
3. Neither Commanding Officer nor crew of the submarine reacted pro-
perly to the collision. Proper orders were not carried out, unauth-
orized orders were given, and only good luck appears to have prevented
the situation from turning into disaster.
B-36
/
4. The Commanding Officer of ALFA, as OCE, erred in not complying with
the prescribed condition instructions for the exercise, but this did not
contribute directly to the collision.
COMMENT
In this situation, with the submarine submerged throughout the ex-
ercise, it was clearly the responsibility of the submarine to keep clear
of the two surface vessels. By failing to take positive steps to avoid
the escort destroyers the Commanding Officer became solely responsible
for the collision. Although sonar was used to track ALFA, and provided
the Commanding Officer with relative bearings, no use was made of the
sonar information. Had accurate true bearings been used instead of the
relative bearings which naturally gave a high bearing rate when the sUb-
marine was swinging, the real picture of the position of ALFA would have
been apparent.
By not providing the fire control party sufficient information, a
timely solution could not be obtained. The handling of the periscopes
was inexpert, involving several shifts .between scopes, extra observations
in 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 and
the submarine, resulting in ultimate loss of ALFA by the submarine.
When collision occurred, the Commanding Officer acted properly in
ordering Iltake her down
tr
, and had his order been carried out the sub-
marine would have been taken out of danger of further collision with
surface ships within seconds.
Throughout the run, the submarine fire control party prOVided the
Commanding Officer with almost no assistance, although they were properly
stationed and did have a certain amount of information to work with.
Knowing that further collision was possible, the Commanding Officer
used questionable judgement in opening the lower conning tower hatch to
evacuate a few men from the conning tower. After the submarine had
broached, 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 the
air manifold to blow all tanks on receipt of the single trblow
tr
and the
waving of a finger signal was premature, and indicates that the man
was not thinki.ng clearly. This coupled with the fact that negative was
blow 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 surface
alarm. Three blasts should not be used on any alarm except on the
diving alarm as a signal to surface.
In the midst of the confusion in control, firm and positive action
should have been taken by the Diving Officer. Whether this confusion
existed despite his best efforts or because he failed to exercise
proper leadership during the emergency is not clear. Regardless, his
decision to remain on the surface after finding that the tanks were
being blown should have been communicated to the Commanding Officer
immediately because it was directly contrary to the latter's order.
When informed by the Diving Officer that he could not get the sub-
marine down, the Commanding Officer was faced with the decision of
continuing to try to go deep or of surfacing and avoiding further
collision on the surface. He made no decision and issued no orders
other than to raise #1 scope. If the ship was rising so fast that
possibility of getting it down again was remote, the Commanding Officer
should have issued orders to get it on the surface in the qUickest
possible time. If such was not the case, he should have taken steps
to see that the Diving Officer was doing everything possible to sub-
merge.
B-38
CASE
Collision between a nest of four submarines and a floating res-
taurant.
PRINCIPLES
1. A trained alert topside watch is essential.
2. Attention to tidal conditions and moorings when berthed in unfamiliar
harbors is essential.
3. The duty section must be organized to provide a section maneuvering
watch capable of getting the ship underway.
NARRATIVE
Four submarines were moored to a pier in Wilmington, N.C.; just ahead
was a floating restaurant. They were advised for a relatively strong
current, the tables placing it at about 3 knots. The inboard ship had 4
breast lines doubled" and =/fr2. and #3 were doubled as springs. In addition
the outboard ship had a line through the bullnose to the pier. The
moorings were inspected by the four Commanding Officers, the owner of the
restaurant, and a local Navy Liaison Officer, all of whom considered
them adequate. The pier had been used 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. The
cleat holding the #4 breast line of the inboard boat was pulled out,
bolts and all. The topside watch who was inspecting the lines at that
very moment iwmediately sounded the alarm and attempted to put over
another #4 breast line. This line was not enough. The nest, which was
rapidly swinging away from the pier, pulled the cleat over; then the
line parted. =/fr2. and #3 lines were around 12" pilings and they broke
the pilings. At this point the nest was swinging around the #1 line of
the inboard boat and into the restaurant. The line was cut free with
an ax and as all four ships backed on eight screws, the nest was able
to clear the restaurant with only minor damage to it. The boats then
dropped their anchors in midstream and rode to the current. Later they
broke the nest and returned to other moorings.
1. The lines were adequate.
2. The current was greater than that predicted in the Current Tables
for that area.
B-39
3. Prompt and effective action was taken.
COMMENT
From the time of the cleat pulling loose until the submarines were
anchored in midstream was approximately fifteen minutes. The prompt
and effective action taken by everyone concerned, from the topside
watch, alert at his post, to the conning of eight propeller shafts was
a credit to the Submarine Force. Much praise and gratitude was ex-
pressed by the citizens of Wilmington and the owner of the restaurant
for the skillful and alert action by the boats.
The key man here was the topside watch Without his warning and
the immediate response thereto by the duty sections, a very serious
casualty would have occurred. Below docks the training paid huge
dividends. Stations were manned in a matter of seconds. Teamwork
and coordination was outstanding. As one engineman was starting an
engine, two more were lining up the fuel and water systems. Men
aroused from sleep were topside immediately, handling lines without
taking time to dress.
This is a good example for the need of continual training to prepare
for the casualties that happen in spite of all precautions. It has
been and always will be the forte of the Submarine Force to maintain a
readiness to cope with any difficulty and gain control before the situa-
tion 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 180
0
, speed 14 knots in
formation of two columns. Submarine "A" was formation guide and lead
ship of the left hand column of three ships; guide of the right hand
column of four ships was 1,000 yards on the starboard beam of "A".
The Squadron Commander was arc and embarked in "A". Cruiser was on
course 273
0
at 13 knots. About 2330 sight and radar contact was reported
to the Commanding Officer of submarine "A" of a ship bearing 137
0
, .
19,700 yards. This was the cruiser. About 2338 the masthead, range,
and side lights of the cruiser were in sight bearing 137
0
, 14,500 yards
and, so reported to the Commanding Officer. At about 2345 the Command-
ing Officer was notified that the range was 6,500 yards and that the
bearings had remained constant. The Commanding Officer came to the
bridge about 2348 and. took the conn, assigning the OOD to take bearings
on the cruiser. Neither the Commanding Officer or OOD reported the
contact to the Squadron Commander.
On the cruiser the group of submarines had been reported to .the
Commanding Officer at 2340 as seven lights from a fishing fleet bearing
3160, 12,000 yards. The only other report to the Commanding Officer
was made at 2358 when "vessel at 860 yards" was reported. The cruiser
maintained course and speed until about one minute before collision
when 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 vessel
in the crossing situation until the range closed to about 1,050 yards
and the bearing had been determined to have decreased to 126. At
this time the Commanding Officer ordered "all ahead fUll", and increase
-of about l ~ knots. On sighting the bow of the cruiser close aboard a
few seconds before the collision, the Commanding Officer ordered "all
stop", "all back fUll", "all back emergencyII in rapid succession.
About 2400 the two ships collided at an angle of about 300, the sub-
marine's bow striking the cruiser about 75 feet aft of the stem, r e ~
lative speed between the ships about 20 knots. The bow of the sub-
marine forward of frame 11 was bent 900 to starboard, but there was
B-41
no damage to the pressure hull. The cruiser suffered four flooded
compartments and five partially flooded. One man was killed on the
cruiser.
1. The cruiser was burdened, the submarine the privileged vessel.
2. Neither vessel was aware of the naval character of the other nor
was any attempt to indicate their naval character, nor did they com-
municate with each other during their approach. A mutual exchange of
signals might have avoided the collision.
3. The collision was due to the fault, negligence and inefficiency of
the ODD and the Commanding Officer of the cruiser.
4. The Commanding Officer of submarine "A" erred in not informing the
OTC embarked in his ship of the situation.
COMMENT
Because of their deceiving appearance at night, submarines should
always exchange calls with ships met at night; failure to do so invar-
iably results in the submarine being considered a small fishing vessel.
The sinking of the 8-51 in 1925 resulted from a collision with the
City of Rome in an almost identical case. It was fortunate indeed that
this case did not result in a similar tragedy.
Not only can exchange of identification be effected with the signal
light, but the single letter international code signals can be used to
warn the burdened ship to keep clear if there is doubt as to her inten-
tions.
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 Des-
troyer Berth 2, Ribault Bay, Mayport Carrier Base, Florida. Approx-
imately 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 the
St. John River, time approximately l ~ hours after maximum ebb (1.8
knots) See accompanying diagram.
Submarine twisted her stern out, holding #1 line. The Commanding
Officer, 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 a
port 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 relieved
the OOD of the conn, requested tug assistance, and tried to twist and
back clear, but the submarine was set down against the stern of the de-
stroyer. By reducing the way on the submarine before contact was made,
the impact and resulting damage was slight. #5A fuel ballast tank was
ruptured and the propeller guard of the DD was bent.
FINDINGS
1. The submarine Commanding Officer had considered current and had con-
sulted Tide Tables 1956 and Current Tables 1 9 5 6 ~ U.S. Coast and Geodetic
Survey.
2. Normal sources of naVigational information do not cover the situation
existent in Ribault Bay.
OPINIONS
1. The assumption that a tug was unnecessary was a reasonable one based
on 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 due
to the overhang of the carrier moored at the carrier berth ahead of the
submarine.
3. The submarine experienced difficulty in twisting the stern out and
that the Commanding Officer attributed the difficulty entirely to the
fact 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 the
DDs) 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 cur-
rent) a high backing bell might have carried the submarine clear; such a
maneuver would have resulted in considerable damage had it failed.
6. The information concerning the current in

seminated to the Submarine Force
basin should be dis-
COMMENT
Local authorities should always be consulted about the particular tide
and current conditions, even though the landing upon arrival may have
been uneventful.
---
1500
I
SCALE IN FT.
500 1000
---
---
/
/
-J
----
---
CARRIER BASIN
----
/
/
/
/
/
L'--
...----
:.--' ..............
~
..............
B-44
CASE
Collision between submarine and overtaken merchant ship in narrow
channel.
PRINCIPLE
1. Excessive speed should not be used in narrow channels.
2. Helmsmen should be alerted to situations requiring particular at-
tention of the helm.
3. Commanding Officers should take timely and positive actions to
insure safe and smart handling of their ships.
NARRATIVE
A submarine proceeding down a narrow ship channel attempted to pass
a merchant ship. The submarine was llsucked in
ll
and collided starboard
side forward of the conning tower with port quarter of the merchant
ship. Channel llspeed limit" was 10 knots, merchant ship speed was 12
knots. The submarine had ordered speed of 16 knots to pass. The
bridge gyro was inoperative and the helmsman had not been altered to
the passing situation. A pilot with no previous experience in sub-
marines was at the conn and closed the merchant ship under her stern
using 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 knots
in this channel is hard to justify.
2. Failure to alert the helmsman as to the need for smart handling of
the helm in this passing situation shows a lack of prudent; seamanship.
3. Proceeding in a channel with the bridge gyro inoperative requires
the C o ~ n d i n g Officer to be particularly alert.
4. The Commanding Officer exercised poor judgement in permitting the
pilot to con the ship into a position of imminent danger close aboard
the merchant ship before taking personal and positive action toward
insuring 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 avoid
taking down angles of such degree as will jeopardize the stern.
2. When collision and flooding occur submerged, the natural tendency
to blow to the surface must be repressed if there are surface ships
in the area.
3. Under otherwise exc ellent sonar conditions the I'knuckle" created
by a vessel turning at moderate or high speed can almost completely blank
passive 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/or
bridge is isolated through communication casualty or damage.
NARRATIVE
A Guppy submarine was operating in the Virginia capes area in a
three-Submarine Delta formation, which was opposing a group Of seven
destroyers. Depth of water was in excess of 100 fathoms; the time was
mid-afternoon with good visibilitYj water was isothermal to 200 feet or
greaterj 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 exercise
torpedoes Were fired at several destroyer targets, and the submarine
was, in turn, intermittently counter-attacked by various destroyers.
These attacks and counter-attacks had occupied more than an hour and
the submarine, along with its companions, were being forced below peri-
scope depth more and more frequently. Destroyers were simulating
Ahead-ThroWn Weapon and Depth Charge attacks and were noticeably inten-
sifying their efforts. Because of the desire to maintain such formation
as would provide mutual torpedo fire protection, the submarine was
limited 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 a
JK!QC equipment. The latter two equipments were interim installations
and were obsolescent at the time (1955). The most experienced sonar
operator manned the BQR3 eqUipment in the conning tower. The two other
B-47
equipments were manned by less experienced, but competent operators in
the sonar room and forward torpedo room. The submarine was at battle
stations throughout the exercise.
A destroyer had just completed an excellent run, forcing the
submarine to 100 feet. At a speed of 18 knots, the destroyer had
passed directly overhead from astern, then moved ahead and to the right,
fading from contact near the position of one of the other submarines
of the Delta (3000 yards distant). Loss of contact was estimated at
3500 yards (later confirmed by the destroyers track chart). A second
destroyer, which was being tracked by the fire control party prepara-
tory to taking it under fire, was positioned on the submarinets port
quarter at a range of about 2300 yards and on a roughly parallel course
at 13-15 knots. QB sonar had been directed to search all around and
report all contacts, preparatory to resuming periscope depth and the
attack.
After careful search, both sonars reported no contacts other
than the target on the port quarter. The Commanding Officer of the
submarine ordered IIM1 ahead standard; watertight doors on the latch;
60 feet, smart1y.1I The submarine responded promptly, and at the
point of passing 75 feet, number two periscope was raised and trained
on the bearing of the target. As the periscope broke water, the Com-
manding Officer observed the target checking perfectly, and began to
look all around. At that instant, .BQR3 reported "screws closing,
close aboard; bearing (port bow). 11 The periscope was trained on that
bearing and the Commanding Officer saw only 1Igray paint
tl
The peri-
scope was instantly lowered and the Commanding Officer ordered "take
he down, fast; use negative.
f1
Hearing negative flood, and feeling a
good angle coming, on the boat, the Commanding Officer advised the
Diving Officer not to take more than 120 down as that would endanger
the stern. .
About 4 seconds after the sighting (periscope had just seatea),
collision occurred. Keel depth was about 63 feet and was almost
instantaneously increased to 80 feet, and the submarine heeled about
50 to starboard. On impact, fairly heavy streams of water began
entering the conning tower around the p e r i s c o ~ e (about the strength
and volume of six or eight heavy garden hoses). Several of the ;fire
control party recollect the impression of arcing, though this was not
positively confirmed. -The Commanding Officer immediately ordered
II Sound the collision alarm; shut the lower conning tower hatch;
shoot red flares, aft.1! Noting the sudden increase in depth, he
reasoned that rupture may also have occurred below the conning tower,
C1ad ordered tlB10w main ballastl! (via 7MC system). (Note: This order
was not acknowledged and was apparently not received in control; the
Diving Officer had also noted the descent and had given the same
order. As the descent checked, he countermanded the order; and the
Commanding Officer did not repeat his order, since it was apparent
that it had not been heard and was not necessary.)
B-48
The Diving Officer reported that he could hold the boat at 100
feet and was ordered by the Commanding Officer to do so. The Com-
manding Officer then announced by underwater telephone to all stations
that the submarine had been struck and requested all surface vessels
to clear the area of red flares for an emergency surfacing. He also
requested the Submarine Group Commander to advise when the area was
clear and to conn him if necessary on the surface, in the event that
the 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 manned
without the difficulty which had been anticipated. Before com-
munications with control could be established, an emergency party
had been sent on deck through the forward torpedo room hatch and
was actually on deck before being ordered below. After surfacing,
it was necessary to rig an emergency antennae and to replace a dam-
aged running light, following which the submarine proceeded to port
without further i n c i d e n t ~
Damage to the submarine was extensive in the sail area and to the
foundation and supports for all retractable masts as well as the fixed
installations on the sail. There was no damage below the sail and there
were no injuries to personnel.
OPINION AND FmDINGS
A Board of Investigation was convened in this case and was of
the opinion that the collision was not the result of negligence on the
part of any person involved. It felt that the submarine was aggres-
sively handled and operated within the terms of the advanced exercise
being conducted. It was of the opinion that the collision was the re-
sult of an error of decision on the part of the Commanding Officer of
the submarine, understandable and formed on the basis of misleading
negative sonar information. The Board noted, further, that the col-
lision might well have been prevented by the installation. of a scanning
type of sonar. Failure of the submarine to detect earlier the des-
troyer was attributed to the presence of a "knucklell in the water
surrounding the boat. Recommendation of the Board was that no disci-
plinary action be taken against any person involved.
COMMENT
Review and retrospect raises several points of interest in this
case. The decision of the Commanding Officer to resume periscope
depth was an aggressive action in keeping with the spirit of the ex-
ercise. It was formed on the basis of generally good to excellent
sonar conditions and performance of the submarinets equipment and
operators, and the fact that another destroyer was tracking per-
fectly at a range greater than 2000 yards. Sonar operators were ex-
perienced and reliable; each had engaged in numerous exercises of
this type. Finally, it was reasoned that the counter-attacking destroyer
B-49
might well have taken up attacks on the other submarine which was posi-
tioned in the area where contact had faded.
The election to resume a periscope depth of 60 feet for #2 peri-
scope observations was based on the sea state and the need for a good
clear look. The Commanding Officer estimated that 61 feet was the
minimum at which such a look could be effected. The additional foot
was intended for the Diving Officer to prevent I "undershooting
ll
It
is noted that a destroyer draws about 19-1/2 feet at the propeller
tips and the sound dome. The submarine sail is 49 feet and the #2
periscope 66 feet above the keel. Thus in order to avoid any possi-
bility of collision (with periscope lowered) the submarine must re-
main below (:J3-1/2 feet. Use of a deeper depth for the first look
l
howeverl would have at least lessened the damage.
Modern practice is to set Condition IlBAKER
II
preparatory to coming
to periscope depth. This condition includes shutting water-tight doorsl
bulkhead flappers I and the lower conning tower hatch. This case is a
good example of' how shutting the lower hatch places reliance for com-
munications to the Diving Officer on a reliable system. Sound powered
phones are less subject to failure than the MC system and should
always be used. To be useful
l
however
l
in emergencies such as this
l
they must be used habitua11YI just as they are in passing orders to
maneuvering during the maneuvering watch.
Of interest in this case was the completeness of the. logs and
records during emergency. The QM notebook and UQC log were maintained
under rather adverse conditions after collision, and proved invaluable
to 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 sub-
merged operatipns.
2. The necessity for an effective visual search when at periscope
depth cannot be overemphasized.
NARRATIVE
While operating at periscope depth preparat9ry to a landing ex-
ercise, a submarine exceeded the boundaries of her assigned area.
After evading a passing DE she sighted a previously unnoticed destroyer
close aboard with a very small angle on the bow. She went deep but
was struck by the DD while passing 66 feet. Without exception, all
electronic masts and both periscopes were bent or broken. The mast
and periscope shears were bent and buckled. Total da.m.a.ge required
three months repair at a cost of over $140,000. The submarine con-
tinued to 90 feet after the collision and surfaced about 45 minutes
later. There were no personnel casualties. On the destroyer, the
periscopes were sighted about 25 feet to starboard abreast the
stem. At this time the ship was swinging right and the order,
lILeft Fu.U- Rudder" was given. Collision on the starboard quarter
was felt as the ship commenced swinging left.
OPINIONS .AND FINDINGS
1. The Commanding Officer erred in not conducting an effective
periscope search.
2. The navigation of the submarine was poor in that the ship was
allowed to proceed out of her assigned area.
3. The Commanding Officer of the destroyer erred in swinging his
stern into the submarine after sighting the periscopes.
COMMENT
This casualty could have been averted by proper periscope
technique. The importance of keeping a clear picture of the surface
situation under all circumstances cannot be overemphasized. Had
the Commanding Officer taken a thorough look around at any time in
the previous ten minutl:ts he would have discovered the presence of
the d e s ~ r o y e r and probably been able to avoid. This case graphically
illustrates the pitfalls encumbent with over-concentration on any
particular surface contact.
B-51
Furthermore, had the submarine properly remained in her assigned
area, the avoiding action would never have been necessary. Leaving
the assigned area when submerged is an error of gross proportions,
the safety of the submarine being of paramount importance in any
peacetime maneuver.
B-52
CASE
Collision of submarine with YTF.
PRINCIPLE
Operations at periscope depth close aboard a surface ship are
hazardous regardless of the seeming simplicity of the exercise.
NARRATIVE
The exercise being conducted was designed to test the effective-
ness of submarine sonars at very close target ranges. It involved
the submarine submerging at 1500 yards and passing the target (an
.NJ!F, lying to) very close aboard while at periscope depth. During
thus run the submarine was approaching at a depth of 55 feet with
zero bubble at about 5-1/2 knots until within 200 yards. At this
point the Commanding Officer ordered negative flooded and a depth of
90 feet. The submarine struck the ATF while passing 66 feet, denting
her skin and buckling one frame. Both periscopes and the periscope
shears were bent, along with severe damage to the electronic masts
and antennae and related equipment. The total cost of submarine
repairs was over $100,000. No personnel casualties were sustained.
COMMENT
Besides this case there have been numerous near-collision cases
during similar operations with a surface ship either lying to or
anchored. All bear up the point that every precaution must be taken
to prevent a collision such as happened in this case. Apparently
the diving team was not aware or readY for the possibility of going
deep if in the time available before collision only 11 feet of
depth could be gainedl
In another case a snorkeling submarine barely averted a colli-
sion with a sound survey boat when the latter parted its anchor
chain and began drifting.
B-53
CASE
Collision of submarine with buoy 2CB off Virginia Beach, Va.
PRINCIPLES
1. action must be taken w):len approaching an object whose
true 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 current
and of the current being experienced.
NARRATIVE
A submarine stood out of Chesapeake Bay on course 121
o
T, speed
nine knots; visibility at the time was about ten miles, wind velocity
was about five knots from the east, and sea state was one. The in-
tended track had. been laid down 6n an apprOpriate chart and had been
inspected by the Connnanding Officer. At about 2211, the flashing light
of buoy 2CB was sighted bearing 123OT; this buoy was in sight both from
the bridge and by periscope, but was not reported to the Connnanding
Officer or the Navigator. A fiX at about this time indicated the ship
was nearly a quarter of a mile southwest of the intended track, and
the officer of the deck, observing the bearing of the buoy to be drawing
to the left, requested a better course from the quartermaster in order
to avoid the buoy. At about 2226 the Navigator got a fix which showed
the ship nearly a half mile southwest of the intended track, and at
2228 the course was changed by direction of the NaVigator to 1160T in
order to leave the buoy to starboard. At 2239, with buoy 2CB dead
ahead at a range of 2500 yards, the OOD on his own initiative changed
course to 1l00T; the NaVigator was informed and concurred in this change.
The Officer of the pointed out to the NaVigator that the ship was
being set badly. The Na.vigator concurred, and admonished the OOD
"D:m't hit the bUOY," whereupon the NaVigator went below. At 2246 the
OOD, observing that the buoy was still draWing to the left, changed
course to 105T; about one minute later, noting that the five degree
course change was not going to cauSe the ship to miss the buoy in the
eXisting set, he ordered left full rudder and all back emergency. At
2248 the starboard sid.e of the ship struck the buoy near frame 40,; the
buoy cable scraPed along the side until it became entangled in the screw
and rudder, causing damage amounting to more, than $21,000 .00.
In the ensuring investigation, the following additional facts were
brought 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 set
nor was it operating, and set and drift had not been computed; further,
no reference had been made to on-board naVigational publications to de-
termine the predicted set and drift. For some thirty-seven minutes the
buoy was under continual and was known to be maintaining
very close to a constant true bearing during this period.
B-55
1. That the collision of this ship with buoy 2CB was directly
caused by:
a. Failure of the OOD to take prompt, positive and sufficient
action as the ship approached the buoy, and
b. Failure of the Navigator and Executive Officer, in the ab-
sence of such action by the OOD and with the authority invested in him
as Executive Officer, to take such action himself.
2. That collision of the ship with the buoy was indirectly caused
by the following items:
a. Failure to determine expected set and drift from appropriate
publications and failure to compensate for them.
b. Failure of the Navigator to maintain a proper dead-reckon-
ing track.
c. Failure of the Navigator to inform the Commanding Officer
of the set being experienced and of the fact that the ship had deviated
from 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 course
for a period of 37 minutes in exactly the correct direction and amount to
offset the effect of current and thus maintain a collision course on this
stationary buoy. There was at least six miles of navigable water in all
directions around the buoy, therefore there was no justification for such
small, and obViously inadequate, measures to avoid the buoy.
Further, with plenty of water to p ~ s s the buoy on either side it
would have been more prudent to leave the buoy to port, thus the set would
have moved the ship away from the danger rather than toward it.
This case is strikingly similar to two other cases described in this
book (See pages B-ll and B-13). The comments contained in those cases
regarding the determination and use (by both Navigator <and OOD) of cur-
rent data, the need for maintaining an accurate DR track, <and the neces-
sity of complete exchange of information between the Commanding Officer,
the Navigator, and the OOD at all times are equally applicable in this
case.
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 prob-
ability of pooping and its effect.
NARRATIVE
A submarine had been cruising on two engines for two days in
very rough seas. Officers and crew were weary from seasickeness and the
continuous effort required to remain on their feet at their watch sta-
tions. During a false lull in the seas, the OOD opened the main in-
duction and increased speed to standard on four engines. Suddenly a
huge comber passed over the boat from the stern and immersed the bridge
in a tremendous volume of water. Water poured through the main induction
and the conning tower hatch until the forward engine room was nooded to
the floor plates, the after engine room to a depth of three feet, the
pump room a similar amount, and the after battery deck to a depth of about
one foot. Shut bulkhead flappers in the maneuvering room prevented
entry of water into that compartment. All five generators were flooded
and grounded, the trim pump armature was burned out, and the drain pump
starting panel was rendered inoperative. Water was prevented from enter-
ing the after battery well by building a dam around the battery well
hatch with dungarees and by bailing water into the storeroom. Water was
drained from the ventilation lines by removing inspection covers from
the line in the engine rooms, as the ship was down by the stern. After
considerable jury-rigging and washing down with fresh water, the water
was finally removed from the ship and its machinery, and propulsion
was resumed.
OPINION AND FINDINGS
Only rapid action prevented a major casualty from developing.
COMMENT
This casualty occurred on a neet boat; most boats nowadays can
snorkel, thus permitting them to operate the diesels on the surface with
the main induction shut. When danger of taking water down the conning
tower hatch andlor the main induction exists, the following precautions
are applicable:
C-3
1. The helmsman should be alerted to shut the brid.ge hatch at
the first indication of water entry.
2. The control room watch should be alerted to the possible
necessity of quickly shutting the main induction.
3. The inboard ventilation hull induction valve should be shut
to prevent entry of water into the ventilation lines and to prevent
damage to the ventilation blower impellers.
4. And, of course, courses and speed should be chosen to
minimize sea conditions whenever possible.
c-4
CASE
Partial flooding due to pooping seas (II).
PRINCIPLE
Operations in rough seas require especial alertness on the part
of the OOD.
NARRATIVE
The submarine was cruising surfaced in heavy seas when she was
pooped by a large wave. Approximately six tons of water was flooded in
through the main induction and a lesser amount through the conning tower
hatch. The ship was rendered inoperative, on a war patrol, for twenty-
four hours while repairs were effected.
COMMENT
Whenever possible, courses should be chosen to ~ n ~ ~ z e the pos-
sibility of pooping. Under cond.itions of heavy weather, the OOD must
be alert for such a casualty, however, and should order the main in-
duction shut immediately when pooping appears imminent. Similarly,
under such conditions he should run with the upper conning tower hatch
shut; when necessary to open it for some reason, it should be tended
by a man instantly ready to shut it upon entry of water. With most
modern submarines it is possible to use the snorkel for engine air in-
duction, thus reducing the probability of being pooped. Bulkhead
flappers should be kept shut in such dangerous weather unless required
open due to battery charging, etc. (See Case 1).
C-5
CASE
Partial flooding while surfacing.
PRINCIPLE
Heavy weather requires extraordinary precautions during surfacing
operation.
NARRATIVE
The ship surfaced at night in very heavy seas. Under conditions
of darkness and visibility which made it impossible for the Commanding
Officer 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 routine
manner, with the blower running. First indication of trouble was solid
streams of water entering all comparments through the ventilation supply
louvers; the supply blower then grounded out all lighting circuits. Ship
was sealed up and major damage was luckily avoided.
COMMENT
When surfacing under such conditions it is prudent to let the
main induction remain shut until the Conning Officer has definitely de-
termined that he has blown up sufficiently and that his heading is
optimum to avoid being pooped. Generally, he can blow up enough before
the vacuum in the boat gets excessive, but if it is necessary to get in-
take air to complete the blow then he will do well to use the conning
tower hatch for the purpose , with a man stationed at the lanyard to im-
mediately shut it in case of water entry.
It is a l ~ o good practice never to open the inboard induction for
ship's ventilation until completely blown up, thus reducing the degree
of water entering comparments through t he ventilation system and/or
grounding 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 bridge
personnel, on the bridge, or in the conning tower.
NARRATIVE
A key ring containing keys, a knife, and a smaJ.l crescent wrench
became detached from the belt of a lookout while clearing the bridge
during a routine dive. These hung in the upper conning tower hatch
mechanism. When the quartermaster attempted to dog the hatch it be-
came jammed and could neither be opened nor shut. By quick action the
dive was stopped before much water had entered the conning tower.
COMMENT
Bridge personnel should never have clothing hanging
from 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 the
bridge or in the coming tower which might move with water flow or large
boat angle to foul either the bridge hatch or the lower conning tower
hatch.
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 the
submarine; at 25 feet the after battery reported flooding through the
after battery hatch.
Alert action by the crew minimized the' effects of the flooding by
stuffing mattresses in the doorway leading to the berthing space, by
opening the refrigerator cold room hatch to drain away the water to pre-
vent it getting in the battery well, and by efforts to stop the entry
of the water by securing the hatch.
Subsequent investigation disclosed the cause of the flooding to
be the hatch lanyard hung between the hatch gasket and seat.
OPINION
L The hatch had been shut from topside, therefore its fouling by the
lanyard could not be seen.
2. A seaman secured the hatch with depth charge dogs on rig for dive
without noticing the fouled lanyard.
3. The officer checking rig for dive entered the trunk with a flash-
light and examined the hatch wheel, but failed to note the fouled
lanyard.
4. The hatch was shut tightly enough to give a green light, yet nearly
fifty gallons of water flooded through the seating.
COMME:NTS
The best submarine practice is to secure hatches from topside
after inspecting hatch seal and gasket, after which checking from below
decks is done.
C-ll
All personnel should be trained to include in their check of
hatches, when rigging for dive, a careful inspection to see that gaskets
are not cut, no foreigh matter is on the seats, lanyards are hanging
free 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 assurance
is available that the boat is either ready to submerge safely or has
sufficient positive buoyancy and will not submerge.
NARRATIVE
The submarine was alongside the pier with the underway section
on watch, less the topside lookouts acting as Deck Watch, and OOD on the
pier near the brow. In order to perform work on the bow superstructure
it was desired to put an up angle on the ship and thus bring the bow out
of the water. The ship was rigged for surface, except that safety and
negative were flooded, which fact was unknown to the Commpnding Officer,
OOD, and others who should have known. The after torpedo room hatch was
open with the bitter end of #4 line leading below decks where it was to
be stowed on departure during extended operations. The line had been
doubled up improperly with the result that one section had parted.
Ballast changes were initiated by two officers neither of whom informed
the Commanding Officer or OOD of what was being done ,nor had they taken
proper regard for the safety of the ship prior to adding this ballast.
Initial trimming was from forward to after trim. When this failed
to bring the bow sufficiently out of the water, #6c and.#6D were vented
by hand. When notified by the officer at the scene of the work (via 7
MC) that the boat would have to be flooded down further aft, an officer
below decks (who did not realize safety and negative were flooded) pro-
ceeded 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, that
6A and 6B were to be flooded, and on receiving an acknowledgement, or-
dered 6A and 6B vented hydraulically. Actually, all 4 sections of
#6MBT were then vented. The extra ballast taken on by this action plus
the fact that safety, negative, and after trim were already full was
sufficient to cause the stern to sink below the water. The after tor-
pedo roam and the store roam below it were completely inundated through
the open and fouled hatch.
The primary cause of this flooding was the lack of clear cut
responsibility and understanding, caused partially by the haste to
complete repairs and depart on assigned mission, among those persons
carrying out the various evolutions of trim and repair. Ballast
changes were initiated by two officers who neglected to inform the
C-13
Commanding Officer, OOD, or others of what they were doing, and further
who did not take prudent measures with regard to the safety of the ship
prior to taking on additional water ballast.
#4 line was not doubled properly and had been led through the
after torpedo room hatch, fouling same. The ship was not completely
rigged for the evolution being carried out and the above named excep-
tions were not known by officers who should have had this knowledge.
COMMENT
One of the greatest dangers of evolutions such as this is that an
officer may assume and carry out personally, all the necessary actions.
This frequently results in no central authority being cognizant of the
complete picture and in the remaining officers and crew taking little
active interest. Such evolutions should be planned and carried out
methodically to provide maximum safety, utilizing the experience and
talents of the entire watch section. The incident related is one of
the best examples of complete disorganization compounded by what ap-
pears to have been complete disregard for the principles of basic seaman-
ship with regard to mooring lines.
Many so-called small errors in judgment or procedures were enough
to 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 prior
to any flooding, or to determine the condition of watertight integrity
existing within the ship in case the ship should submerge unexpectedly.
3. Failure to check TP-TR circuit for indications of hull open-
ings 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 commenc-
ing flooding by blowing forward tanks, safety, and negative tanks.
6. Failure to insure slow and controlled f l o o d ~ g .
7 Failure of the OOD to be on the bridge and in charge of the
flooding. Whether or not the tanks were rigged to be blown, and a
man standing by the manifold, is not known.
8. Fortunately there were no personnel casualties. One man in
a forward upper bunk remained in his bunk in the air pocket until the
stern 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 pres-
sure be equal to sea pressure.
NARRATIVE
A submarine in upkeep was changing a bottomside sonar head by
withdrawing it inboard with the sea chest door shut. Upon removing the
last securing bolt, water started flooding, indicating that the sea
chest door was not holding. The compartment was sealed and air pres-
sure introduced. Flooding was not stopped, however, until considerable
damage 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 should
have been sealed and a pressure placed in it before the final stage of
the work was started. The slight pressure required to equalize sea
pressure at keel depth, surfaced, is not in the least bothersome to
most 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 prior
to checking o:f rig :for dive :from below.
2. Operating gear :for hatches, doors, valves, and other :fittings should
be checked on "rig :for dive" by manua.l1y testing the position o:f the
gear in addition to a visual check.
3. Torpedo loading hatches should be secured with depth charge dogs
whenever the hatch is shut.
NARRATIVE
A submarine made an initial trim dive, placing one-hal:f inch o:f
pressure in the boat. During the obtaining o:f trim, negative tank was
re-:flooded and blown three times. This raised the pressure in the boat
to about 1 1/2 inches. Upon getting a trim the boat was sur:faced. A
report was innnediately received that the :forward torpedo room was :flood-
ing. 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 the
bottom 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 the boat with the :forward room
still :flooded. No personnel were lost, but a six-week availability was
required in the Navy Yard to e:f:fect repairs in the :forward torpedo
room.
OPmIONS
L The shipt s rig :for dive procedure was not coordinated to insure that
the 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 who
checked the rig :for dive did not check the hatch dogged.
3. Material (torpedo-handling equipment) stowed in the loading hatch
probably prevented a clear look at the hatch and its condition.
C-17
4. Depth charge dogs instaJJ.ed on the hatch would have prevented the
hatch from blowing open as it did.
COMMENT
The officer who checked the rig for dive in the compartment had
shut the hatch and dogged it himself the last time torpedoes were loaded
which was the last time the hatch was known to have been opened (one
or two days before). The hatch was evidently una.ogged by some one to
store additional material or by someone rigging for dive who thought he
was dogging it. This latter could have occurred after the hatch was
checked from below.
Had the ship in surfacing followed the procedure of starting the
blower at 35 feet, instead of waiting for orders from: the commanding
officer, the pressure in the boat might have been reduced sufficiently to
prevent blowing the hatch open. Possibly the ship might have been blown
up high enough out of the water to prevent water from entering the ship
through the loading hatch. This would not, however, in any fashion
rectify the fact that the loading hatch was not dogged.
The use of padlocks on the FBT air manifold and the flood valve
operating mechanisms seriously impedes the use of these tanks during
emergencies when their buoyancy is required immediately.
<Had this accident occurred in relatively deep water it is
doubtful that the ship could have been stopped before striking the
bottom, 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 es-
sential to the safety of the ship.
2. The performance of all watchstanders must never be allowed to be-
came perfunctory.
NARRATIVE
A submarine moored alongside a pier completed a battery-charge at
2300. At 0730 the following morning a crewman returning to the ship
(Nor of the duty section) discovered about. forty inches of water in the
engine room bilges. Considerable damage had occurred to the high pres-
sure air compressors due to the flooding. Subsequent investigation
disclosed that the battery charge engineman had failed to shut the main
engine sea and stop valves when the main engine was secured. The engine
room had flooded through an open vent valve on the engine salt wa.ter
circulating pump. It was further determined that the last inspection by
the duty officer or the duty. chief had occurred at 0200.
OPINIONS AND F I N D ~
.1. That shipI s orders and below decks check-off lists were sufficiently
clear and complete to have prevented this casualty has they been prop-
erly complied with.
2. That required hourly inspections by the below decks watch were
careless and perfunctory.
3. That both the duty officer and duty chief petty officer erred in not
conducting the required inspections after 0200.
COMMENT
The pattern of overall standard o-r per-rormance :eor this watch
section was demonstrated by the enginemen who deliberately left the sea
and stop valves open (despite shipI s orders which required them to be
shut when not in use) on the excuse that the engine would be again used
when the ship got underway the following morning. Similarly, the below
deck watches apparently were not making proper inspections, else they
C-19
could not have missed the rising water in the bilges. This is not sur-
prising, however, considering that the example set for them by both the
duty officer and duty CPO was so abjectly poor. Most ship's orders re-
qillte.,an itl:Spectic:n by t he duty officer and chief petty officer at in-
of hbt more than four hOUl's, a1terilating every two
These inspections should be so scheduled as to provide the best
coverage of the ship--not to avoid inconvenience to the inspectors.
Further, inspections of lower flats are properly conducted only by going
down 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 ap-
preciated by all hands.
NARRATIVE
Prior to, or at the beginning of a yard overhaul a submarine is
subjected to a noise survey. The submarine in question was moored at
the Ordnance Pier, the shipyard had readied its equipment, and since in-
ternal noise -must be at a minimum, all hands of the duty section except
the OOD and Below Decks Watch were berthed on the pier.
The sound survey proceeded apparently satisfactorily with the OOD
and Below Decks Watch moving through the boat operating the specified
equipments
The survey was completed, having run somewhat behind SChedule,
and the maneuvering watch (all hands) was stationed for the down river
passage and entry into the shipyard. An unusually low ground exist.ed
on both main propulsion motors.
OPINIONS AND FINDmGS
L The flooding of the main motors is attributable to a combination of
circumstances wherein the motor room bilges were allowed to flood to
an abnormal depth. The damage to the main motors 'Would not have oecun-ed
had the casing been watertight.
2. Had ship's orders relative to below decks watch standing been carried
out, the c.asualty would not have occurred.
3. The inspections made this night by the below decks watch, the duty
chief, and the duty officer were, in varying degrees, perfunctory to
the extent that the -amount of water entering the ship was not revealed.
4. Sabotage by individuals on board incident to the sound survey is
a remote possibility.
5. The quality of the inspections made, t he fact that water leaking
into the ship, pumping of bilges, and radically ~ e s s e n e d ground reading
C-2l
on the main motors were not reported to responsible officers, and the
fact that those who did observe that water was leaking into the ship took
no action to stop the flow are indicative of an unacceptable low stan-
dard of in-port watch keeping.
COMMENTS
The main motors were both partly innnersed in river water, which
entered the "water tight II lower half of both motor endbell casings
through four missing bolts at the bottom of each motor.
Under reconstruction, water entered the motor roan when the be-
low decks watch, having finished running the main motor circulating
water pumps, climbed up from the lower flats and in so doing stepped on
and broke off the small vent pipe' and valve atop the main motor cir-
culating water starboard strainer.
There were no personnel injuries but replacement of two lower
field coils in each motor was required.
When the shipyard completed repair of the motors they were once
again assembled minus the four bolts, exactly as had been done one or
two overhauls previously, because of the almost impossible location of
the bolts.
That the motors had never flooded before was due entirely to the
general watchfulness of the ship's personnel over the Years.
This flooding'incident is intended to illustrate the vulner-
ability of a submarine undergoing overhaul: - first, the paramount
concern of the duty officer and below decks watch is the safety of
the ship, rather than a complete absorption in the performance of
shipyard tests to the point that ship's procedures and safety routines
are obviated; second, the ship is the final authority on the satis-
factory completion of yard work which is generally no better nor
more 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 liSecure
Snorkeling!!.
2. Personnel must be trained to think and observe prior to taking ac-
tion.
NARRATIVE
The submarine was snorkeling under normal conditions when
"Secure Snorkeling" was ordered over the lMC. The Diving Officer left
the mast raised and the snorkel induction valve open so that he could
equalize the pressure in the boat. The cook on watch without looking
at the indicator immediately locked the snorkel induction in its
Il open!! position, thinking that he was locking it shut.
When the pressure was equalized the Diving Officer ordered the
snorkel induction valve shut and the mast lowered. With a wet-snorkel
installation the mast lowering flooded the housing and continued through
the snorkel induction piping to the main induction piping. Neither
the nor the Diving Officer had checked the snorkel
board to see if the snorkel induction valve had shut.
Upon the first indications of water in the Engine Room, the
personnel took action to prevent further flooding of the Engine Room
and the ventilation system.
OPINIONS
1. The ship I s procedure for IlSecuring Snorkeling" should be followed
to completion once it is put into effect. The action needed to
equalize the pressure in the boat should be sepat'ate and be accomplished
either prior to or following the IlSecure Snorkeling!! procedure.
2. Personnel must be trained to think prior to acting and also to act
only with concrete knowledge of what they are accomplishing, not
merely a hazy idea. Alertness on the part of either the cook, Diving
Officer, or Chief-of-the-Watch could have averted this casualty.
C-23
COMMENTS
The Diving Officer should the pressure within the boat
as. a step separate from the "Secure Snorkeling" procedure. This will
preclude the possibility of confusion arising out of a departure from
the confines of a set procedure.
The need to "equalize" at all is fUrther debatable. The vacuum
drawn is relatively small and usually won't bother the operation of
the 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 of
flooding exists.
NARRATIVE
An SSK was snorkeling on two engines in the North Atlantic in
January, in a state 7 sea, at an ordered depth of fifty feet, at dead
slow speed. A following sea forced the ship down to a depth of 70
feet. Seconds later the Diving Officer became aware that the head
valve had not shut. The auxiliaryman moved the hand lever on the
snorkel head valve operating gear, but the llHold Open" air did not vent
off, hence the head valve would not shut. The snorkel induction valve
was shut at this instant. A large quantity of water had entered the
engine room through the engine air induction piping. This, together
with the fact that the boat had been trimmed 20,000 pounds heavy to
hold depth, resulted in a rapid descent. The Diving Officer blew
negative, requested speed, and ordered full rise on the planes. The
resultant up angle caused the water in the engine room bilges to
flow aft, flooding out both generators. By using standard speed
and 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 the
proper operation of the head valve operating gear hand lever, with
the result that the air could not be vented off and the valve would
not shut. The head valve operating mechanism was repaired, the bilges
were pumped, and one generator was restored to an operating condition.
Snorkeling was resumed.
COMMENT
When snorkeling in such heavy weather, sudden large variations
in depth and frequent cycling of the head valve are common, sometimes
resulting in momentary doubt as to whether or not the boat is in fact
under control. There should be no hesitancy on the part of the
Diving Officer to use all means at his disposal, including speed and
the blowing of safety and negative tanks, to prevent such large depth
C..25
changes. Nor should he hesitate to shut the snorkel induction valve
when the head valve is submerged and there exists the slightest doubt
concerning its proper operation.
Depth control when snorkeling at fifty feet in extremely heavy
seas is most difficult at best, and as shown in this case is nearly im-
possible at low speeds. Higher speed would have provided better depth
control, and with the prevailing sea conditions the increased screw
noise probably would have.been insignificant from a detection or
listening 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 local
operations the boat appeared to be in good diving trim. It then became
somewhat heavy aft. The Diving Officer took the necessary corrective
action by pumping from after trim tank to sea. The boat became heavy
aft again, with the Diving Officer taking action once again. This
condition recurred at least eight times. A total of 17,000 pounds of
water was pumped from after trim to sea, yet the Diving Officer made
no investigation into the possible cause.
At this point the After Torpedo Room watch reported ~ l o o d i n g ,
with additional information that the water level was already several
inches above the deck plates. The collision alarm was sounded, the
word "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 the
signal ejector were open. These were at once shut and the After Room
was pumped dry. There were no casualties to personnel nor damage to
material.
OPINIONS
1. An informal investigation determined that the signal ejector has
been fired just prior to surfacing to recover a torpedo. Through
negligence it had never been properly secured, with the result that
the compartment started flooding, slowly while on the surface and
more rapidly when again submerged.
2. It was also found that the After Torpedo Room watch had not dis-
covered this condition until his feet felt wet, whereupon he looked
down from his seat to see the water over the deck plates.
C-27
COMMENT
Unquestionably the torpedoman on watch was guilty of gross
negligence, both by not securing the signal ejector and by not dis-
covering the casualty until such a late state of development.
It was also a most serious omission on the part of the Diving
Officer not to have checked into the cause for the repeated heavy-
aft 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 sig-
nal ejector by the pneumatic expulsion system. He shut the outer door,
drained the gun, and started to open the inner door. At this moment
the SEIS exploded, blowing open the outer door and springing the inner
door so that it would not shut. The room was partially flooded by the
time the submarine was surfaced and the hole plugged.
COMMENT
This accident was the direct results of failure to adhere to
well-established safety precautions. The required precautions are
posted in the vicinity of all signal ejectors. There can be no valid
excuse for failure to follow such well known and simple procedures
as that of determining that the signal e j ~ c t o r is clear before shutting
the outer door and opening the inner door. Numerous casualties, in-
cluding serious injuries to personnel, have resulted from. this same
failure.
C-29
CASE
Flooding in the Forward Torpedo Room.
PRINCIPLE
Positive action should be taken by the Diving Officer upon
any unaccountable weight change.
NARRATIVE
The ship had been submerged at 300 feet for about 6 hours. The
watch in the Forward Torpedo Room was near the tubes. Sonar was manned
in the Conning Tower. The Diving Officer noted the boat getting heavy
forward and sent the messenger to check bilges and No. I sanitary.
In about one minute "Flooding in the Forward Torpedo Room" came over
the 7MC.
The packing on the bottomside WFA head had given w ~ allowing
sonar bilges to flood, slowly and unnoticed at first. Just as the
messenger arrived in the forward torpedo room, the packing which had
been leaking slowly gave way and began leaking rapidly. Pressure
was put in the compartment, and the ship came to 80 feet to slow
flooding and surfaced shortly thereafter. Only slight damage :was
sustained.
COMMENT
Had the Diving Officer taken no positive action when the
weight change was realized, the casualty would, no doubt, have
been much more serious. Also, the watch is in the compartment for
safety in peacetime as well as for torpedo readiness in c o m b ~ 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 water
system.
NARRATIVE
A submarine operating with DE's went to 300 feet quickly. An
inspection plate (4 inch diameter) on the forward engine 'room salt
water cooler carried away with the main engine circulating water sea
and stop valves open. When the engine room was reported flooding,
all main ballast tanks, safety and bow buoyancy were blown. The
trim and drain pumps were put on the bilges. The throttle man in
the forward engine room dove under the water in the lower flats to
secure the main engine circulating water sea valves. The Commanding
Officer in the conning tower had ordered "All Ahead Flank" and the
collision alarm sounded on receipt of the flooding report. Boat 'Was
surfaced with a 20 up angle about 1200 yards from the closest ship.
The amount of flooding was about 25 tons of water which flooded the
bilges of the engine room to a depth of about 5
1. Flooding was caused by the studs on the cover plate carrying
away due to metal fatigue.
2,. The main engine water sea valves should have been
shut after diving as required by the engineering orders.
3. Reach rods should be installed to permit the shutting of sea
valves from the upper level.
4. Studs, bolts, etc. should be checked for proper material in
all systems exposed to sea pressure.
COMMENT
"First and foremost is the utter uselessness of having orders
and instructions aboard which are tacitly ignored and only serve the
purpose of covering the number. Violation of established procedures
prescribed in Department Orders serve only to breed contempt for all
C-33
orders. In this case those ord.ers prescribed that suction Ild dis-
charge stop and sea valves were to be secured upon diving, but that
unknown to the Commanding Officer, Executive Officer, or the Engineering
Officer, the men on watch in the engine rooms did not do this
unless the boat were to go below 100 feet. The fallacy of such
reasoning is apparent when one considers all factors which may force a
submarine to go deep without being able to advise the engine room
watch. 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 watch
promptly got the word to the conning tower that the room was flooding,
rather than wasting valuable time in investigating the cause of flood-
ing. This together with the action in getting the sea valve closed
enabled the Commanding Officer to take prompt and correct action to
save the shipll
(Squadron Commander)
C-34
CASE
Flooding of compartment while in drydock.
PRINCIPLE
Extra precautions must be taken and more frequent inspections made
than normally required while ship is undergoing overhaul.
NARRATIVE
A submarine was undergoing regular shipyard overhaul and was in
drydock. Extensive rearrangement work was in progress in the motor room
and considerable piping was broken. The main motors had just been re-
turned to the ship, having been inspected, overhauled, and cleaned.
At about 2000, shipyard personnel requested premission of the OOD
to put a hydrostatic test on one of the NFO tanks. Permission was grant-
ed and an ENl assigned the task of assisting in lining up the compensat-
ing water system to fill the tank. with water. At about 2030 the OOD made
an inspection of the boat and all was normal. At about 2400, t h ~ OOD was
notified that a considerable amount of water was in the lower flats of
the motor room. The water level was just above the centerline of the main
motors. Explanation of this flooding is as follows: During the day the
ENI had noticed that the main motor circulating water connection to the
compensating water line was broken, but the compensating water line flange
waS secured with a blank flange. Consequently, he did not check that
portion of the compensating water line when preparing to fill the NFO tank.
Subsequent to his sighting of the flank. flange, but prior to the attempted
filling of the NFO tank, the flange had been removed by the shipyard per-
sonnel and not replaced. Thus, instead of the water running from the com-
pensating water line into the NFO tank, it was flowing into the motor room
via the main motor circulating water connection to the compensating water
line.
The cost of rectifying this error was approximately $5,000.00.
COMMENT
Because of the various stages of disassembly of the many systems
and items of machinery during a shipyard overhaul, and because of the
relative unfamiliarity with the ship by shipyard personnel, the possi-
bility of casualties is multiplied many times over the normal possibility.
Ship I S force must be more alert, make more frequent inspections, and above
all 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 a
minor 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. The
maneuvering room watch reported the port stern tube leaking and an
indication of packing being forced out. A few minutes later the
packing blew out and water began to rise rapidly in the motor roam.
The Commanding Officer ordered depth changed to 100 feet to lessen
the pressure and maneuvering reported that the drain pump was keep-
ing up with the flooding. In changing the depth to 100 feet the
Diving Officer was faced with the problem of keeping an up-angle
so that the water would not enter the main motors (the casing lower
half of which are nominally "water-tight", upper half II splash-proof"
and obviously of not rising above 100 feet until the area was deter-
mined clear for surfacing. This he successfully accomplished.
The packing was replaced on the surface by locking the port
shaft and putting a pressure in maneuvering room while repacking.
It was believed that the port
resulting in chewing of the packing.
not harmful, but at deep submergence
to 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 the
early discovery of this casualty and prompt operation of the drain
pump. Together with properly controlled change in depth, this minor
casualty 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 re-
quired by the ordinary practice of seaman, or by the special circum-
stance of the case" (borrowed from International Rule 29).
NARRATIVE
While attempting to avoid a hurri cane, a Guppy II submarine :was
proceeding downwind at standard speed on three engines, adjusting speed
to gradually overtake the state 4 to 5 seas and using rudder to maintain
an even keel. The ship rode comfortably in this condition for several
hours. Thus no precautions against pooping seas were made; upper Conning
Tower hatch was open to provide communication to the helm, personnel on
the bridge were not lashed to prevent being washed overboard, the Conning
Tower ventilation (via periscope well) was not shut, and the well drains
were open.
Shortly following the relief 'of the watch the ship was pooped and
broached. The bridge personnel were submerged in water (An officer on
another submarine about,two miles away was washed over the side and was
saved by his safety belt.) The flow of water and list to st::u-bo::u-d pre-
vented the helmsman from shutting the hatch and water flowed into the
Conning Tower and Control Room. The lower hatch was shut but only
after about 2 inches of water had. accumulated in Control. Shutting the
lower hatch caused the Conning Tower to flood to about one foot. Water
continued to spray into Control even after the hatch was dogged. Water
filled the periscope wells and flowed into the ventilation supply lines
discharging into Control, Radio (over the TBL), and Forw::u-d Battery until
the Conning Tower ventilation flapper was shut. The After Battery was
kept dry by action of the cook who heard. the water flow in the supply
line 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 for
some three minutes as a result of the submersion and general confusion
resulting therefrom.
Conning Tower: Isolated..
C-39
Control Room: Water on deck, people slipping and falling; Com-
manding Officer attempting to establish communication with the bridge
to 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 battery
well. The steward. receiyed. a minor shock while attempting to remove
this water with a toweL All bunks were drenched. via the individual
ventilation outlets. Most of the water was absorbed. in linens and
bedding in order to stop entry into the battery well through the leak-
ing deck hatch.
COMMENT
This is a good example of the danger of underestimating the sea
state and its potential. The boat was very fortunate not to lose the
entire bridge watch. Do not wait for the Commanding Officer to come
up to tell you to take heavy weather precautions. As the Officer of
the Deck, initiate whatever steps or precautions are deemed required
for 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 pro-
vide any real security.
NARRATIVE
In complying with the "Cold Weather Bill" a boat blew expansion
tank partially dry and then opened the tank vent (inboard). This was
done to allow the compensating water line topside to drain down into
expansion 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 auxiliary
generator. The charge was interrupted, tile field excitation of the aux-.
iliary generator was opened, and then the charge was resumed. At 0400
another full voltage ground appeared. This ground was traced to the
lighting circuit and found to be on the lights in the auxiliary gen-
erator. This circuit was isolated and the charge cont inued.
Upon completion of the charge, the forward engine room throttle-
man went aft to blow down expansion tank. He discovered the flooding
of the lower level which had caused the grounds on the auxiliary gen-
erator, and which had gone unnoticed by the below decks watch, the
duty chief, and the duty officer over a 6 hour period.
COMMENT
The appearance of a full voltage ground. is not to be taken
lightly, they do not appear without reason. While it is expedient to
isolate the offend.ing circuit or equipment, that is only half the
story. The cause of the ground must be determined also. In any
case, all such grounds should be reported to the duty officer and duty
chief.
Below decks inspections made in a perfunctory manner can only
lead 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 submerged at 310 feet during an SSK exercise, a
barely intelligible message was shouted on the 7MC to the effect that
the motor room was flooding. Few of the personnel in the control room
understood the message and no amplifying word was received. The flood-
ing in the motor room was actually caused by a ruptured gasket in the air
conditioning circulating water strainer; however, the shape of the open-
ing caused the water to spray 360 and with considerable force. The
electricianI s mate on watch d.id not know where to secure the sea valve,
so before qualified personnel could reach the scene, casualty #2 oc-
cured; 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 reports
were forthcoming, so main ballast was blown from about 300 feet to the
surface. At this point thehelmsman/controllerman (K-l class submarine)
reported casualty #3:. loss of cubicle control. This casualty was later
determined to have occurred from improper operation, probably occasioned
by excitement. The order was then sent to the motor room to take cubicle
control. The electrician's mate/controllerman on watch previously men-
tioned, in attempting to disconnect the remote cubicle controller prep-
aratory to taking local control, caused casualty #4 to occur. Instead
of disconnecting the remote cubicle controller, he opened the adjacent
and identical appearing switch, the main motor field switch.
By this time, the circulating water to the air conditioning sys-
tem had been secured and flooding stepped. A relatively small quantity
of 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 having
very little stability while in this "high and dry" condition. This
large roll with the attendant of loose gear further confused
the issue.
c-43
Finally the cubicle was cranked down to STOP (with no field on
the motors) accompanied by a great deal of heavy arcing.
Althoughthe actual damage from this series of casualties was
slight (burned insulation and pitted contacts in the cubicle), major
casualties almost occurred. Three good lessons in the avoidance of
compounded casualties are apparent:
1. Clear and concise casualty reports, followed by amplifying
reports, must be made in order that the Conning Officer can take in-
telligent action.
2. Men on watch must know their watch thoroughly enough to cor-
rect minor casualties on the spot and be able to perform their duties
under stress.
3. No loose gear should be tolerated That can complicate a
casualty 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" the
electrodes themselves, but only test the solenoid circuit to insure that
it vnll operate to shut the head valve.
NARRATIVE
A submarine enroute to refresher training after yard overhaul
was snorkeling at 63 feet in a calm sea. Previously she had snorkeled
successfully at 62 1/2 feet, and was attempting to determine the maxi-
mum depth at which snorkeling was possible. Shortly after reaching
63 feet, flooding was reported in the forward engine room. The ship
surfaced, concurrently for collision. Greatest depth reached
was 65 feet ,1-5 to 30 seconds flooding time. The forward room
was 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 when
the electrodes became wet. Upon disassembly of the snorkel control
panel it was found that a pin broken on the electrode selector switch
and bent switch shaft allowed the switch to actually be in a blank po-
sition instead of the indicated. F-P-S position. Using the push buttons
to test the head valve prior to snorkeling was not a test of the elec-
trodes themselves; but rather of the air solenoid circuits. The best
practice to check the head valve is by actually dunking it before com-
mencing snorkel operations.
c-45
CASE
Partial flooding of an engine room alongside.
PRINCIPLES
,1. Compliance with routine measures of water-tight integrity
and standard operational procedures are essential to the safety of the
ship.
2. Watchstanders must never become casual in their performance
of duty.
NARRATIVE
While moored alongside a pier a submarine renewed the zincs in
three fresh water coolers, a procedure which required opening of the
salt water drains for the coolers. Several hours later it was dis-
covered that two of the drains had been improperly left open. They
were shut and the third was tried and believed to be properly shut.
The engines were tested and secured at 2050, but, contrary to exist-
ing instructions, the two main sea suction valves and the associated
engine stop valves were left open in anticipation of their possible use
the following morning. About 2200 the engine room bilges were pumped
dry by the below decks watch. During the night various inspections were
made bY'the below decks watch, but it is doubtful if he at any time ac-
tually went into the lower flats for his inspection. THE DUTY OFFICER
AND THE DUl'Y CHIEF MADE NO INSPECTIONS BETWEEN THE HOURS OF 2400 and
0700. At about 0700 the water level was discovered to be about 8
inches above the lower flat deck plates. It was also discovered that
a main generator had flooded due to water entering its casing through
oil separator ring drain and vent holes. Subsequent investigation in-
dicated that the flooding had occurred through the salt water valve on
the fresh water cooler, and that such flooding must have been in pro-
gress since 2200 in order for such a quantity of water to have entered.
1. That ships orders and organizational procedures had no
major inadequacies.
2. That below decks inspections, if conducted at all, were
performed 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 deliber-
ately left open, in direct violation of existing instructions, simply as
a convenience for the operation of the engine on the following morning.
It is another example of perfunctory performance on the part of a below
decks watch who attempted to conduct his inspection of the lower flats
without entering the lower flats, and who failed to discover either the
improperly opened sea and stop valves or the rising water resulting
therefrom. And it is another example of the standard of watch per-
formance being established by the duty officer and the duty chief --
neither of whom made an inspection of the ship between the hours of 2400
and 0700.
c-48
CASE
Partial flooding of Motor Room alongside.
PRINCIPLES
1. Adherance to fundamentals of submarine water-tight integrity
is essential to the safety of the ship.
2. Casualness or perfunctory performance on the part of any
watchstander must never be permitted.
NARRATIVE
A submarine was moored alongside a New Lond.on pier in the winter
with its cold weather bill in effect. Incident to this bill, the main
motor cooler drain valves were open and a notice to this effect was
posted in the Maneuvering Room. At about 2100 the battery charging
controllerman started the main motor circulating water pumps without
closing the drains to the main motor coolers, resulting in salt water
entering the motor room bilges through the open drain valves; the water
attained a depth of about eight inches above the bottom of the after
end bells of the main motors before being discovered. This partial
flooding resulted in damage to number 1 and number 3 main motor, due
to water entering the motors through warped. end-bells and faulty end-
bell gaskets. Restricted availability at a naval yard was required
to effect repairs at .a cost to the government of $58,000.00. The en-
suing investigation revealed the facts that the required below decks
inspections had been made-- one of them approximately 5 minutes after
the circulating water pumps had been s t ~ t e d - - b u t that inspections of
the motor room had been conducted from the upper deck le.vel by simply
peering through the hatch rather than by actually going into the lower
compartment.
1. That the flooding of the motor room bilges was due to the
failure of the controllerman to shut the cooler drains before operating
the main motor circulating water pumps.
2. That the failure of a watertight seal of the after main
motor 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 reviewing
authority classed his performance of duty as negligent. It is worthy
of note, however, that the flood.ing could have been detected before the
water level got high enough to do damage had the below decks watch made
his inspection properly: by going into ,the lowe;r flats instead of
p ~ e r i n g down from above. This standard of watch-standing was set by the
example of the duty officer, who himself conducted his inspection of
the motor room from the upper level in violation of basic submarine
practices. The reviewing authority remarked in his forwarding endorse-
ment, itA duty officer's responsibility does not entail merely making
inspections or ascertaining that the required number of inspections are
made. His responsibility extends to ensuring that watchstanders are
properly discharging their duties. Likewise, his own inspections must
be thorough. It
C-50
CASE
Flooding of motor room bilges and main mbtor casing while in
port.
PRINCIPLES
1. The performance of watchstanders must never be allowed to be-
come perfunctory.
2. Good submarine practice dictates that sea and stop valves be
shut on salt water systems which are not in use.
NARRATIVE
A submarine completed work on the main motor circulating water
system and assigned an electriciant smate to flood and vent the water
system. Immediately upon completion of this assiginnent, the motor room
bilges were pumped dry. About two hours later the Duty Officer noted
a reading of 5000 ohms on the maneuvering room ground detector, and de-
tailed a man to localize the ground. Incident to locating .the ground,
the electrician's ~ t e discovered, still an hour later, that the motor
room bilges were flooded to a depth of about five i:p.ches a1?ove the deck
plates. It was subsequently determined that the port main motors were
flooded internally to a depth of about twenty-two inches, and that the
water had entered the bilges from the stern tube flushing lines and
through the port high point vent which had not been completely shut upon
completion of the circulating system venting. The water had thence en-
tered the motor casings through a universal pipe union which was not
properly connected between the port motor casing .drain manifold and the
suction side of a hand pump.
In t.he ensuing investigation, it developed that no one had en-'
tered the below ,deck spaces of the m o t ~ r room from the time the vent-
ing had been completed until the ground.-chasing electrician discovered
the flooding-"a period of over three hours. During this period, the
Duty 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 the
hatch.
OPINIONS AND FnIDINGS
1. That the below decks watchstand.er was negligent in his per-
formance 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 rather
than 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 depart-
ment instruction in regard to shutting the stern tube flushing sea and
stop valves during periods when the submarine was in port.
b. He did not exercise adequate supervision to insure shut-
ting of all of the stop valves on the port main motor casing drain
manifold, when good submarine practice d.ictated that they be shut when
not actually in use.
3.
in that he
to wit, he
That the Duty Officer was negligent in his performance
failed to make a proper and thorough inspection of the
failed to enter the motor room d.uring these tours.
of duty
ship;
4. That the Commanding Officer was not cognizant of certain un-
acceptable conditions and practices aboard his ship. He did not condone
the malpractices brought out by the investigation. However, since these
malpractices existed, it is evident that he failed to keep himself in-
formed to an extent which would permit him to direct correction of these
unacceptable conditions and practices.
COMMENT
This case is another example of the principles to be learned
from several similar flooding casualties in this boo}r. Salt water sys-
tems should be secured when not in use. Ship's orders should direct
this 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 on
the inspection checkoff list. BILGES CANNOT BE PROPERLY INSPECTED BY
PEERING 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 be-
low decks watch was relieved and the oncoming watch shortly thereafter
discovered the motor room bilges flooded to a of about 28 inches
(one inch above the deck plates). An immediate check revealed that the
flooding was by fresh water and was coming through the drain pump prim-
ing tank, the two fresh water filling valves to this tank being open.
The valves were secured and bilges pumped dry. Water had entered the
main motor casings and the resistance to ground on the series and shut
fields of the main motors were essentially zero.
1. Mathematical computations made by using the amount water
introduced water pressures, size of piping, and other factors, estab-
..... .l...:lu<;;u. that the minimum time during which this flooding took place was
4.5 hours and the maximum time could have been up to hours.
2. That the duties and responsibilrties designed to prevent
such occurrences as well as damage from such occurrences are con-
tained in the Ship's Organization.
3. That the Duty Officer did not conduct complete inspections
of the ship as required by the Ship's Organization.
4. That the Duty Chief Petty Officer did not properly perform
duties as required by the Ship's Organization.
5. That the quality of below decks watchstanding performed by
all parties involved is below the required standard.
COMMENTS
This is still another" illustration of the results of poor watch-
standing performance and general laxity. The fresh water filling valves
were 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 at
the required time intervals allowed the flooding to progress without
their discovering it, and was reflected in the below decks watchstanders
who failed to make proper inspections of bilges. In his statement, one
of the watchstandrs said. that on each inspection, he "missed checking
the bilge in (the) maneuvering room . . . because the hatch was shut II
It is interesting to note that the man who finally discovered the
flooded condition did not dD so by entering the lower level, but by
peering through the hatch and seeing the water after it was above the
deck plates. This is too late to discover the flooded bilge, as
evidenced by the fact that all main motors had already flooded by this
time. In regard to this case, the Force Commander stated " ...it is
apparent that the cause of this casualty was a complete disregard of
basic fundament ls in submarine watch standing. It is axiomatic that
the degree of alertness exhibited by watchstanders is in direct pro-
portion to that demanded and exhibited by officers, from the Command-
ing Officer right on down to the most junior. Ultimately, it is a
Commanding Officer's responsibility to ensure that watchstanders are
discharging 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 speed
that is consistent with the conditions of reduced visibility.
NARRATIVE
This submarine was entering the Cape Cod Canal from the west at
night. It was snowing; visibility was between one to two miles. The
temperature was 32 degrees. Speed was 14 knots (standard on two en-
gines). A minor casualty had necessitated the shift of s t ~ e r i n g to the
control room. Width of the channel was about 200 yards. The weather
had deteriorated to where indentification of buoys was extremely dif-
ficult even with the 12 inch signal light. The section maneuvering
watch was stationed and the anchor detail was standing by in the control
room. Lights were sighted ahead, believed to be the masthead and range
lights of a merchant ship whose presence at the eastern end of the
Canal had been previously reported. The lights, bearing on the star-
board bow, appeared to give the ship a small port angle on the bow.
The Commanding Officer believed collision imminent and changed courSe
to the right preferring to ground than to collide. These lights were
actually located on the beach and were not those of a ship. The sub-
marine ran aground, shearing the sound head and holing the chain locker.
It was considered that in view of the overall conditions con-
fronting the Commanding Officer, the USe of standard speed of 14 knots
was highly imprudent in the section of the canal in which the submarine
grounded, and that speeds were available to the Commanding Officer which
would have assured adequate maneuverability without placing the sub-
maripe in a situation where the supposed sighting of oncoming traffic
would leave the options of collision or beaching.
COMMENT
The speed used should be consistent with the conditions of
visibility, weather, and maneuvering room. A change can always be made
to the movement report. A good general rule for shiphandling, includ-
ing 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 a
mistake by anyone in the ship control team, including the Conning
Officer himself, without damaging the ship.
CASE
grounding while approaching Norfolk, Virginia.
PRINCIPLES
Safe and thorough navigation when approaching land includes
the 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 be-
cause the port is familiar.
NARRATIVE
This submarine was returning to her home port the Virginia
Capes operating Areas. She was in training having recently
completed a shipyard overhaul. After passing the Chesapeake Bay
Lightship, course was set for Norfolk. During the passage it was
necessary to alter course to avoid shipping. At one time the ship had
to stop and back to avoid closing a merchantman ahead. At this point
the Commanding Officer came to the bridge. The OOD retained the conn,
however, while -the Commanding Officer gave his instructions and
maintained overall supervision. The ship made a circle to the right
and then proceeded to the harbor entrance . It :was again necessary to
alter course to -avoid a fishing boat. The wind was about 30 knots
the northwest; the sea state was 3 or 4; visibility 6 miles. The
Navigator was stationed principally on the bridge but on several
ocassions went to the conning tower to obtain cuts through the peri-
scope. 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 assigned
to the Navigator. The radar operator was an ET3' who been aboard
only one month. The helmsman was also extremely inexperienced and,
in fact, just a short time before the grounding, was admonished by the
OOD for being 12 degrees off course. At this time (approximately
1930) the ship was being rigged for surface and the maneuvering watch
was 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 backed
clear on her own power and returned to port. Material damage was minor.
OPINIONS ~ i \ N D FINDINGS
1. A known current across the line of advance was not taken into ac-
count.
2. The last azimuth to determine gyro error was taken three days
prior to the grounding, at which time an error of over a d.egree was
found to exist. The steering of courses, uncorrected to compensate
for this gyro error, tended to take the ship off the proper track in
the direction in which it was ultimately grounded.
3. A prominent navigational aid was in sight throughout the approach
to the harbor. Bearings on this light were not observed or plotted.
4. The" Board investigating this grounding was handicapped in pip-
pointing the precise act or omission which resulted in the grounding
of this submarine by reason of the multiple violations of law, regu-
lations, customs, good judgement, and normal organization and admin-
istration which preceded this inexcusable grounding.
COMMENTS (BY COMSUBLANT)
In this instance the performance by this submarine demonstrated
an overall inability to properly approach and cope with the diffi-
culties attending the accomplishment of a routine task.
"The Commanding Officer, in hi.s basic responsibility for safe
navigation, 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 helms-
man, there is no evidence that the ship's 'organization required, or
that anyone took, affirmative action to supplement the normal under-
way watch, although radical maneuvering was in process and the op-
erating conditions were considered difficult".
"The navigation of this submarine leading to this grounding will
not bear even casual scrutiny as to the procedures and difficulties
imposed by the limited facilities for navigation on the Guppy type
submarine, plus the congestion to be expected..it is even more
imperative that the Navigator provide himself with competent assistants
to man whatever stations to which.he cannot personally attend and that
he make maximum use of the fathometer readings, radar observations and
loran navigation".
D-6
CASE
Grounding submerged while particpating in ASW services.
PRINCIPLES
1. The Commanding Officer and Navigator are responsible for the safe
navigation 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 sub-
marine.
NARRATIVE
This submarine was furnishing ASW services to de$troyers in an
operating area off St. Thomas, V.I. Shortly after submerging, the
OCE ordered a base course change from 180
Q
T to OOOQT. The Commanding
Officer had the conn. The Navigator was not informed of this change.
At the time of the course change the submarine was about a mile south
of the northern boundary of the operating area. Just beyond this
boundary was the 100 fathom curve which shoaled rapidly. After run-
ning north for awhile the Commanding Officer realized that he was leaving
the operating area and he changed course to 270
Q
T on his own accord.
This was also not reported to the Navigator, nor to the OCE. While
conducting full evasion, the submarine went another 400 yards north of
the track and struck a submerged pinnacle. This pinnacle was outside
the assigned operating area. Meanwhile, on the surface ships, the OCE
had realized that the submarine was getting out of the area and at-
tempted to order a course change. Although this course change was not
received by the SUbmarine, it would have been too late anyway.
1. Initially, the Cornma:nd.ing Officer should have called the at-
tention of the OCE to the fact that the ordered base course would take
the submarine out of her area.
2. On recognizing the danger of the base course, the OCE failed to
take positive and immediate action to direct the submarine to surface
to prevent grounding.
3. The Navigator failed to keep a running plot of the ship's posi-
tion 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 area
boundaries and the imminence of danger.
COMMENTS
The Commanding Officer is still primarily responsible for the
safety of his ship. If given a base course that would run his ship
into danger by an OCE or OTC it is his duty to acquaint the superior
with the fact. The only way to maintain a knowledge of position sub-
merged is by keeping an accurate DRT track with the limits of the area
marked on the DRT. If doubt arises as to position or safety, then a
yellow flare should be fired and the position requested from a surface
ship.
D-8
CASE
Submarine grounding while backing away from a pier in Port au
Prince, Haiti.
PRINCIPLES
1. All available information, such as Sailing Directions, Fleet G U i d ~ s ,
and Briefing Pamphlets should be studied prior to entering a port.
2. When entering strange ports, in particular foreign ports whose
harbor maintenance is sometimes dUbious, exceptional caution should be
exercised.
NARR.ATIVE
A submarine visited Part au Prince, Haiti, for a recreational
weekend. No unusual difficulty was experienced in entering .port.
It was noticed, however, that of three buoys listed on the chait to
indicate shoal water in the vicinity of the pier only one was present.
On the completion of the weekend, the submarine got underway. Five
minutes later, she had backed onto a 16 foot shoal spot and was
aground. Damage was minor consisting of bent propeller blades.
1. The Commanding Officer did not familiarize himself with available
information concerning the area which indicated that extreme caution
should be used in entering and departing the harbor of Port au Prince.
2. Had the ship allowed more margin of safety by staying in deeper
water closer to the pier while backing out the grounding would have
been averted.
3. Determination of the exact location of the only buoy present of
the three shown on the chart would have disclosed that the buoy mark-
ing the 16 foot shoal spot was missing.
COMMENT
It pays dividends to be extremely careful when entering foreign
ports. And when only one of three buoys is in fact present the defin-
ite identification of the buoy is mandatory and the locations of the
other shoal buoys should be avoided like a plague. When information
is lacking and you have eased your way into a port it is a common
practice of good seamanship to go out the way you came in. You know
that 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 all
aspects 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 Key
off Key West. The Commanding Officer decided to make a hand dive
prior to the final submerged photo recon run. A fix was taken at 1244
and the Commanding Officer estimated that there would be 15 minutes
before the arrival at the initial point for the reconnaissance. At
1253 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 made
by the ship in 18 months. The Commanding Officer became interested
in the course of the hand dive and left the Conning Tower to go to Con-
trol. A LTJG, acting as Assistant Navigator was piloting in the Conning
Tower. He obtained a fix at 1256 and recommended to the Commanding
Officer a course change from 300
0
T to 040T The Commanding Officer
did not order the course change. The Assistant Navigator made no
further recommendations or warnings to the Commanding Officer. The
ship had been making two thirds speed submerged during the dive, and
shortly thereafter, increase to Standard on orders of the Commanding
Officer. The Assistant Navigator was not aware of the speed change.
At about 1306, 13 minutes after diving, the ship ran upon a shoal in
about 32 feet of water. Damage was limited mostly to the sound head.
1. The ship grounded in broad daylight, in good visibility and with
an 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 and
the exchange of information concerning the safe piloting of the ship was
inad.equate.
4. The Commanding Officer made an error in judgement as Conning Officer
in 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 the
ship'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 changing
course and the location of nearby shoal w a t e r ~ .
COMMENTS
In this instance, it is a case of trying to do too many things
at once. The decision to make a hand dive (the first in 18 months)
without prior practice and immediately before another mission, coupled
with the facts that the submarine was approaching shoal water and that
the Commanding Officer left the Conning Tower to a LTJG, yet retained
the conn is indeed remarkable. Here the ship was well aware of the
fact that they were approaching the beach. The provision of limiting
ranges, 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 when
firing the f'orward tube nest.
NARRATIVE
A submarine conducting a mine plant at periscope depth was
operating in 160 f'eet of' water. The Diving Of'ficer, after flooding an
abnormal amount of water into forward trim tank, noticed Bow Buoyancy
and the Forward Group vents shut. He ordered them opened, vfuereupon
the boat took an irmnediate down angle, hitting the bottom and shearing
off both sound heads.
COMMENT
Several submarine "good practices" were violated in this in-
stance. First of' all, it is and has always been customary to open
Bow Buoyancy and the Forward Group Vents when firing the forward tube
nest. Indeed, a good majority of submarines run submerged with the
main ballast tank vents open. The job of Diving Officer f'or a mine
plant is not an easy one, but the problems connected with it can be
greatly reduced by advance planning. Had this Diving Officer antici-
pated the trim changes f'or various points during the mine plant, he
would have noticed that Forward Trim was getting too much water bef'ore
he reached the danger point. Even then, had he cycled the vents
quickly at f'irst rather than just opening them he could have maintained
depth control with speed while pumping the excess water out of Forward
Trim.
D-13
CASE
Submarine grounding off Hog Island, Virginia.
PRINCIPLES
1. All course changes and all navigational aids sighted must be re-
ported to the Navigator.
2. When approaching a landfall full use of all navigational equipment
should be used.
NARRATIVE
The submarine just out of the yard was enroute from New London
to Norfolk. Its position was fixed by three Loran lines at 1837R which
agreed within three miles of a celestial fix obtained at 1816R (this
celestial fix was not used). At OOlOR, a two line Loran fix was ob-
tained and was the basis for a course change from 231
0
T to 239T at
0048R on the advise of the Navigator. The Commanding Officer was
notified 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 avoid
shipping, then returned to base course. This was reported to the
Commanding Officer but not to the Navigator. Also on the midwatch,
rad.ar contact was obtained at a range of 24,000 yards on the starboard
bow, this was evaluated by the OOD as rain squalls.
While preparing to relieve the watch (04-08), the oncoming
JOOD observed the radar scope in the conning tower and saw what he
thought to be land extending from 210
0
T to 280T. No one else was
notified of this fact, nor were they aware of it.
At about 0350R, during the change of OODs, a light was sighted
forward of the starboard beam, but was neither identified nor re-
ported to either the Commanding Officer or Navigator. The Navigator
was at this time in the control room attempting to get a Loran fix.
At 0410R a white flashing light was sighted on the starboard
bow, timed as flashing every four seconds, but was not identified.
At 041lR a fathometer reading was obtained' which showed five
fathoms of water under the keel.
At about 0413R a lookout reported disturbed water from about
010 to 170 relative. The JOOD verified the report, but the OOD
could not substantiate the report, therefore he took no action to
reduce speed from 16 knots or to change course.
D-15
At 0415R, various personnel on board felt a series of bumps as
the ship ran upon a shoal. The Commanding Officer was called by the
Chief of the Watch. The Navigator had been up and about during the
midwatch and from 0300R until the grounding he had been trying to fix
the position of the ship. Neither the Commanding Officer, nor the
Navigator received the reports of lights sighted or the five fathom
report. With the exception of the sounding at 041lR the fathometer
had not been used since midnight. No flooding or damage resulted
and the ship was backed clear.
1. Loran fixes were found to be inaccurate.
2. A carefully computed DR, taking into acoount-the two course
changes to the right to avoid shipping, was not plotted or advanced.
3. The fathometer was not used througho1Jt the night when it would
have been of great assistance.
4 Radar operators, QMs, and the OOD failed to recognize land on
the radar scope.
COMMENTS
Some of the principle errors contributing to this grounding were
the failures of the CODs to report course changes and the sighting of
navigational aids to the QOIll!l1aIldirig Officer and Navigator. The OOD
also failed to take action when grounding was imminent. Another factor
was the failure to use the fathometer and the establishment of a min-
imum 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 the
Navigator of a submarine be at least the third officer and not below
the rank of Lieutenant.
CINCLANTFLT
'
s endorsement in part statedI! grounding not
serious if measured in terms of damage .... however, it was exactly the
type of incident which the training and organization of personnel
aboard ship is designed to prevent. Furthermore, this grounding did
not occur as the result of a single isolated instance of poor jUdg-
ment, negligence, or carelessness, nor did it occur as the result of
the shortcomings of a single individuaL Rather, it occurred as the
result of the failure to act properly in a number of instances by a
number of different inaividuals . The sum total of which leads to the
conclusion that in this ship, at least, the training and indoctrina-
tion of personnel concerned was insufficient to assure the safe
navigation 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, Navi-
gator, and OOD in piloting, specifically in preparation and famili-
arization with the track to be followed and navigational aids.
NARRATIVE
A submarine was leaving port via a restricted channel with
the Commanding Officer and OOD on the bridge using one HO chart
and the Navigator in the_ Conning Tower using a different
The Navigator's chart contained a printed, line indicating
the channel, but no track line had been laid on it before the ship
got underway. The Fleet Guide for the area indicated a track which
cleared all shoal water by 300 yards.
As the submarine approached an unnumbered beacon marking the
port side of the channel, making standard speed on 2 engines, the-
Navigator recommended a change of course. The OOD had sighted the
buoy marking the limit of the channel well before approaching the
intended turning point, but he failed to realize the danger to the
submarine and did not inform the Commanding Officer or the Navigator
of the buoy's location. The Commanding Officer ordered a fu:1other
change of course on which it appeared that the submarine would pass
the beacon 200 yards to port. The Navigator then ordered another
course; the OOD ordered right 15 rudder; and the Coniroatiding Officer
ordered Right Full Rudder. While coming right the submarine bumped
several times then ran hard aground. Extent of damage: $10;000.
1. The Navigator erred in selecting the dashed track line of the
chart when it clearly showed a well marked shoal within 50 yards,
and since the available channel width was 800 yards. He also failed
to advise the Commanding Officer of a safe course to be steered, to
use all aids to navigation at his disposal, and to maintain an ac-
curate plot of the ship's position.
D-17
2. The OOD failed to inform himself of the track line to be
traversed in exiting the channel.
3. The Commanding Officer failed to consult the Navigator about
the track to follow; he failed also to take congnizance of the navi-
gational advice in Fleet GUide, or to take judicious notice of all
available aids to navigation. And, when the ship had reached a
position of in extremis he failed to resort to emergency measures
to change heading and/or headway of the sUbmarine.
4. As in most cases of this nature, a contributing factor was
the confusion regarding whether the Commanding Officer or the OOD
had the conn in the last few moments before grounding.
COMMENT
The ship would not have been endangered had the officers
taken early and sufficient action for safe navigation prior to reach-
ing in extremis.
On most submarines it is feasible to on the bridge
with little difficulty, and such a procedure, had it been followed
in this case might well have prevented this unfortunate grounding.
Plotting on -the bridge has many advantages that should be weighed
before the Navigator is to retreat to the comfort of the
conning tower. The ship' s position, track, DR posits
instantaneously available to the Commanding Officer and the OOD and
the exchange of information that is vital to the safety of the ship
is greatly enhanced. Perhaps the most important advantage is that
the,Navigator has a much better perspective of the ship's position
and nav:j..gational aids. In almost every case, the piloting should be
done on the bridge except when manifestly imposible due to weather
or when using radar as the primary means of obtaining navigational
information.
D-18
CASE
Grounding submerged off St. Thomas.
PRINCIPLES
1. Accurate navigation is a necessity, especially when operating in
the vicinity of shoal water.
2. Area boundaries should be placed on the DRT along with other
caution points or shoal spots.
3. When operating in the vicinity of shoal water, Bottom Con-
tour Charts should be consulted..
NARRATIVE
This submarine was furnishing services for advanced ASW exer-
cises off St. Thomas. The initial position for the exercise was
the center of the northern boundary of the assigned operating area.
Approximately one mile to the north of this area was the 100 fathom
curve which shoaled rapidly. The Navigator of the submarine got a
which placed him in the area and. then transferred it to the DRT.
He neglected, however, to include on the DRT the boundaries of the
area or the 100 fathom curve. In an attempt to evade a sonobuoy
pattern, the submarine took a course of 285T. This took them out
of the area (of which fact they were and 20 minutes after
diving 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 was
that the submarine maneuvered outside her assigned operating area.
2. The proximate cause was the failure of the Navigator to lay
the area boundary on the DRT plotting sheet.
COMMENTS
The first lesson is a simple one. If performing extensive
maneuvers SUbmerged, you must keep t rack of where you are, not only
of where you have been. In plotting on the DRT, navigation is
practically useless unless area boundaries, shoal spots and the
like are included on the plotting sheet.
D-19
A secondary lesson to be learned here has been pointed out
numerous times since this particular occurrence. This lesson is
to make use of those items tucked away in the Forward Battery known
as Bottom Contour Charts. Many Hydrographic Office charts are
characterized by a sparcity of sounding information. This is especial-
ly true when the depth is greater than 50 fathoms. One reason is that
surface ships are little concerned if their bottoms are not imperiled.
Yet with the advent of increased operating depths for submarines this
becomes an extremely important factor. The Bottom Contour Chart
for this particular area showed a 20 fathom pinnacle 5 miles south
of the actual grounding position which was itself south of the 100
fathom curve. The HO chart is use by the submarine showed over
1000 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 going
in to commission in 1944 was returning to New London from Block
Island Sound. The night was dark with overcast sky but visibility
was such that navigational lights could be seen for at least 6
miles. At 2045 a fix using bearings on 3 lights was obtained and
the pit log mileage recorded; this was repeated at 2100. Additional
fixes were obtained until 2152 when a fix.was obtained using Cerberus
Shoal Buoy, Little Gull Light, and what was throught to be Race Rock
but what was in fact the station ship south of Fishers Island. This
fix was sufficiently accurate, however, in that it indicated that the
run to Race Rock was 3.9 miles. Course 270 was set to pass Race
Rock abeam to starboard. At 2155 course was altered to the left to
clear .a "navigational light" that later turned out to be the Station
ship previously mentioned. At 2159 after a run of approximately 1.5
miles from the 2152 fix, thinking that Race Rock had been passed to
starboard, course was changed to 300. Identification of the Station
Ship as Race Rock had been made by the Navigator because of the
shape discernable through binoculars. At this time because of the
war, Race Rock was not exhibiting its normal characteristics and was
showing instead a fixed white light. It had in fact been sighted
at 2142 by the Commanding Officer when he came to the bridge, but
he had not identified it nor had anyone else on the ship. At 2204
a darkened object was sighted ahead, identified as a tug and tow
passing port to starboard, and the submarine was maneuvered to avoid.
This tug and toW was in fact low head lands of Fishers Island with
the apparent eastward motion caused by the submarine's set to the
westward by the current. At 2207 course was changed to 340
0
T to
head for Southwest Ledge ~ i g h t . At 2216 calls were exchanged with
the RECP on Mt. Prospect on Fishers Island with the mistaken belief
that 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 the
submarine.
2. Had a fix been obtained using navigational lights that were in
sight showing proper characteristics and had radar ranges and bear-
ings of Race Rock been taken and plotted, it would have been apparent
that the light was Race Rock.
3. Use of the PPI rad.ar scope would have clearly shown the outline
of Fishers Island in time to have prevented the grounding.
4. The Connnanding Officer, Navigator, and OOD did not check the
characteristics of the lights of the Station Ship as compared with
those of Race Rock.
5. The fathometer was not used to ascertain that the ship was in
safe water, nor was the DR: track followed to insure that the ship was
kept in safe water.
6. Determination of the current was not made although the informa-
tion was readily available, notwithstanding the fact that both the
Connnanding Officer and Navigator were well aware of the dangerous
and 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 an
accurate DR track from fixes obtained landmarks, a
previously laid intended track with ranges, distances, danger and
turning bearings and ranges clearly marked, and at the same time
using the fathometer and radar to best advantage to insure that the
ship is not deviating from her intended track. This case, as in
most grounding cases, resulted not from ,lack of knowledge, or of one
error or oversight of anyone person, but basically it stemmed from
the failure to follow the basic fundamentals of safe piloting which
are 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 New
London from Montreal, Canada. At 0617 a fix placed the Ship 600 yards
on bearing 218
0
from Cerberus Rock Gas and Whistle Buoy in Chedabucto
Bay, course was 128
0
, speed about 15 knots, visibility about 8 miles.
On the basis of the fix, course was changed to 119
0
to pass Grime Shoal
Gas and Whistle Buoy to starboard. The Commanding Officer went below
shortly before passing Cerberus Buoy at 0617.. The Navigator was the
OOD. At 0636 the visibility reduced to about 800 yards and was so
reported to the Commanding Officer. Visibility continued to reduce
until at the time of grounding it was between 200 and 300 yards. At
0653 and afterwards the fathometer was used to obtain soundings. At
0654 speed was changed two thirds (approXimately 10 knots). At 0702
the Navigator thought he heard Grime Shoal Buoy, and assuming that it
had been passed, changed course to 190
0
, reporting to the Commanding
Officer that the sea buoy had been passed to starboard and the course
changed to 190
0
At 0705 "All Stop" was orde.red. At 0707 two thirds.
speed ahead was resumed, but at 0710 one third ahead was ordered and
course changed to 180
0
Shortly thereafter "all stop" was ordered,
then "All back emergencyll, and at 0712 the boat grounded in about 10
feet of water to about frame 40 on the keel in a rocky cradle forma-
tion, in the vicinity of Bass Rock (Lat 45 21' N, Long. 60
0
West),
approximately 3 1/4 miles northeast from Cape Canso, Nova. Scotia.
While aground the ship rolled with each swell and pounded heavily when
inclined about 50
0
At 0729 the ship backed clear and anchored.
1. There was opportunity to check the speed by navigational fixes
on visible landmarks after passing Cerberus Rock Buoy before visi-
bility was reduced at 0636.
2. All reports as required by U.S. Navy Regulations, 1920, were
not made to the Commanding Officer.
D-23
3. No radio bearing was taken of or received from Canso Radio Compass
Station, which was approximately 4 1/2 miles to starboard.
4. The original course of 119
0
laid down from Cerberus Rock Buoy
to 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 around
Grime Shoal Buoy safely. It was near slack water.
5. The grounding was primarily caused by changing too soon to
course 190
0
on the false assumption by the Navigator that he had
heard and passed to starboard Grime Shoal Buoy, and also his failure
to give heed to the reckoning of the ship and distance run from
Cerberus Rock Buoy.
6. Contributory causes for the grounding were as follows:
a. Failure of the OOD to keep the Commanding Officer fully in-
formed of changes in visibility and other incidents affecting safe
navigation of the ship.
b. Failure of the Navigator to keep track of ship after pass-
ing Cerberus Rock Buoy before visibility was reduced.
c. Failure of the Officer of the Deck to stop immediately when
the first sounding of less than 20 fathoms gave indication of danger.
COMMENTS
As, of course, is evident, this is a good example of the
hazard of navigating from fix to fix without use of the DR to determine
where the ship will be and when. In absence of information to the
contrary, the DR Posit represents the best position available to the
Navigator and must be so used. How when asked, ''Where
are we?", can reply, "The DR from the last fix puts us here, I'll get
a fix to check it."??? All too often the reply is "Just a minute
It'll get a cut" because no DR has been run ahead from the last fix
and without the cut"the navigator in truth doesn't know where the
ship is or should be.
Of equal hazard to safe navigation as exemplified in this case
is the failure to keep the Commanding Officer fully informed. Not only
should OODs zealously keep him informed by reason of his ultimate re-
sponsibility for the ship in which he has a right to know just what is
taking place, but also because the Commanding Officer is much more
experienced 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 in
doubt, anchor.
NARRATIVE
In 1943 a newly commissioned submarine got underway from the
mouth of the Thames River, New London, Conn. Visibility was ab0ut 4000
yards. About 31 minutes later, while still between Race Rock and South-
west Ledge, course was reversed to return to the anchorage because
visibility had been reduced to zero in a dense f o g ~ The following pre-
cautions were'taken:-' the Commanding Officer took the conn, propulsion
was shifted to the battery, hull ventilation valves and bulkhead valves
shut, a watch stationed at each watertight door, a special fog lookout
stationed, lead line manned, anchor made ready to let go, and proper
fog signals sounded. Radar and fathometer were employed to try to
determine the ship's position. Both the Cormnanding Officer and the
Navigator were cognizant of the state of the tide and the current to
be expected. Although desirous of anchoring due to doubtful ship's
position, the Cormnanding Officer elected to continue navigating with
caution to the anchorage rather than anchor in the traffic lane be-
tween New London and Race Rock. Finally, due to the uncertainty of the
ship's position and the sounding being obtained, the decision was made to
anchor approximately 1 1/2 hours after cormnencing the return to the
anchorage. As the anchor was about to be let go the ship grounded near
Goshen Ledge at the Mouth of the Thames River. Damage was minor.
1. All necessary precautions were taken when the dense fog set
in except that of anchoring.
2.
by his
port.
The Cormnanding Officer was solely responsible for the grounding
failure to anchor shortly after reversing course to return to
COMMENT
Shifting to the battery in a dense fog is good practice to
reduce background noise in order to promote better listening condi-
tions for the bridge watch. It has also been found advantageous to
use the JT sonar to locate bell and whistle buoys under conditions of
low visibility.
D-25
CASE
Submarine grounding submerged.
PRINCIPLE
When approaching shoal water every available navigational aid
should be used.
NARRATIVE
Submarine was submerged at 58 feet on a training exercise. The
Commanding Officer had ordered the boat to remain near a reference
point which was 2 miies to seaward of the 20 fathom curve. Limited use
was made of radar in order to avoid detection by opposing aircraft.
For a similar reason soundings were being taken only every 30 minutes
but only with permission of the Conning Officer. At 0919 the position
of the ship was fixed with 3 visual bearings as about 2500 yards out-
side the 20 fathom curve; ships course 322
0
(toward shoal water) at
4 knots. Without advising the Commanding Officer the Navigator
decided to continue to close the shore to further attempt to identify
landmarks. The 0930 sounding was overlooked. At 0933 a round of
bearings was taken; as they were plotted the Navigator realized that
the ship had enterdunsafe water inside the 20 fathom curve. "Right
full rudder, starboard stop" was ordered. The Commanding Officer,
who had been in the Forward Battery and had felt the ship bump the
bottom, rushed to the Conning Tower and gave orders to surface, but
not 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 minute
period while approaching shoal water.
b. The Commanding Officer was not advised that the ship was
approaching unsafe water, nor was he advised of the difficulty in
identifying landmarks which were vital to the safe navigation of the
ship.
c. A dead reckoning track was not maintained nor were danger
bearings employed.
D-27
2. The basic navigational practices, i.e. proper DR track, use of
danger bearings, and effective use of fathometer, are matters which
the Commanding Officer should have insisted upon in training and in-
doctrinating the Navigator and OOD.
OPINIONS
1. The failure to note the absence of the 0930 sounding indicated
the relative unimportance attached to fathometer readings as a navi-
gational aid.
2. The failure of the Navigator to fix the ship's position for 14
minutes after having directed the course toward shoal water was due
to his concentration on trying to identify navigational aids on ad-
jacent land.
COMMENT
This was apparently a case of trying to do such a good job of
navigating that the basic fundamentals of safe navigation were ignored.
One of the best aids available to the Navigator for safe navigation
is the Q}1 assisting the Navigator, be he the navigating QJt1 or the Q}1
on watch. By. confiding fully in the Q,M as to what is .intended and
reqUiring him to maintain the projected DR track, there are in effect
2 navigators and a mistake or omission by one is likely to be dis-
covered by the other. Too often young and zealous Navigators do all
the work themselves with the result that t h ~ Q}1 is practically ig-
nored except to record bearings, with the result that the Q}1 could
careless what is going on when in truth he should be the Navigator's
right hand man.
D-28
CASE
Scraping the bottom in shallow water.
PRINCIPLE
The bottom side sound heads should. be raised when operating
near the bottom.
NARRATIVE
A submarine conducting S-3-G
1
rehearsals in Narragansett Bay
submerged in water 117 feet deep and comm.enced the attack. While
simulating firing at the target, the escort was observed to change
course toward. The submarine dove to 85 feet to avoid, at which
time the fathometer indicated 4 fathoms under the keel. Eight mi-
nutes later a scraping noise was head under the Forward Torpedo
Room. A position at the time of surfacing showed that the submarine
had skirted the edge of a 90 foot curve. The sound head shaft was
parted 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 of
damage. In several cases the sound head has been the only equipment
damaged. Cornmon sense dictates that the bottom side sound head be
raised 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 exer-
cising at battle stations in the vicinity of shoaling water.
NARRATIVE
The submarine was conducting a practice torpedo firing exer-
cise in a submarine operating area where water depth varies from
more than 700 fathoms to fathoms. The Commanding Officer and all
shipI s officers were fully aware of the potential dangers to sub-
merged operations in this particular area. When the ship submerged
to begin the approach, the position of the dive was fixed where
charted water depth is approximately 500 fathoms. This fix was not
transferred to the NAVPLOT nor were any navigational aids or indica-
tions of shoal water noted on the plot.
The manner in which the approach developed required the subma-
rine to steer courses in the general direction of the shallow por-
tion of the area. The significance of this fact was not fully
realized by the Commanding Officer. He had been informed of the
water depth upon diving and apparently assumed the approach would be
consumated prior to reaching the 100 fathom curve. While maneuvering
the ship to gain a firing position, the Commanding Officer made visual
observations of the target. Land marks in the vicinity were within
visual range, but bearings were not taken to fix the IS position
nor were any requested by the NAVPLOT party during the approach. The
fathometer had been secured. Immediately after firing an exercise
unit from a keel depth of feet, the Commanding Officer ordered
the depth changed to 250 feet. He had announced his intension to
perform this maneuver to the fire control party earlier in the ap-
proach. As the submarine leveled off at 250 feet, with a zero
bubble and about 3 knots speed, an unintentional bottoming occurred
which damaged sonar equipment and a propeller.
COMMENTS
A submarine battle station organization must provide for navi-
gating the ship and fixing its position as required. When exercis-
ing in potentially dangerous areas, the last fix taken prior to
D-31
submerging should be placed on the NAVPLOT. In addition, curves
indicating shoaling water, landmarks and other aids to navigation
should be indicated. A NAVPLOT with this information will give early
warning that the ship is approaching dangerous water and will also
facilitate plotting any visual fixes which may be obtained during the
approach. When necessary to secure the fathometer to prevent sonar
interference, it should be left in standby and single ping soundings
obtained periodically. Once an exercise torpedo has been fired, and.
especially if the submarine is increasing its depth, soundings should
be taken at frequent intervals.
This submarine sustained a casualty Which it had taken parti-
cular effort to prevent. Knowing the topography of the area, the
Commanding Officer had stated a firm policy never to operate the ship
submerged in that portion of the area inside the 100 fathom curve.
This policy was fully understood by all officers. The Navigator had
also stated the policy and explained it to all quartermasters. The
fact that the ship bottomed proves once again that good intentions
are 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 except
when required by the nature of the mission and then for only as long as
is absolutely essential.
2. True bearings of fixed objects must be taken frequently when
at anchor to determine any evidence of movement. The frequency of taking
these bearings should be determined by the conditions of hazard existing
at the anchorage.
3. A Commanding Officer command when, even though
ashore, he is in communication with his ship and is receiving reports
and issuing orders. In this situation he must exercise the same deci-
siveness characteristic of a good Commanding Officer when actually on
board his ship.
4. The Executive Officer succeeds to command by virtue of the
absence of the Commanding Officer, as does the next senior officer in
the absence of both the Commanding Officer and Executive Officer, and
as such must actually exercise command as dictated by the situation.
NARRATIVE
The submarine was ordered to an island in order to fuel and as-
sist in the repair of a seaplane. The coastal area at which the evolu-
tion was to take place was poorly charted, the only chart On board be-
ing to the scale of 4 miles per inch. Since the bottom in this area
shoaled rapidly and the landmarks were poorly charted, a small boat
was launched to precede the submarine and to take soundings. The sub-
marine anchored but was unfavorably situated so it shifted to a second
anchorage, preceded again by the small boat. A third anchorage
necessitated when it was found that the aircraft had insufficient fuel
to move to the submarine I s second anchorage. The submarine therefore
shifted to a third anchorage very near the seaplane. This anchorage
was in 33 feet of water but with dangerous shoal water so near that the
ship could safely use only 12 fathoms of anchor chain.. (It is inter-
esting that this anchorage was about 500 yards from the beach, a dis-
tance of 1/16 of an inch on the chart being used for navigation). The
submarine was flooded down aft to effect the fuel transfer. Difficulty
was experienced in flooding down and a diver was put over the side to
inspect the underwater body. He discovered the rudder inbedded in soft
sand 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 her
anchorage preparing equipment and mooring tackle for use of the air-
craft in effecting an engine change on the following day. This repair
was to take place in a sheltered cove along another coast of the island.
Bearings were taken throughout the night of objects on the beach
to check any evid.ence of movement. The Command.ing Officer t s Night Order
Book called for bearings to be taken at least every two hours. These
bearings were actually taken at a maximum interval of 3 1/4 hours and a
minimum of 15 minutes. The bearings of these objects did not change
throughout the night. However, the rudder was felt to touch bottom at
about 2030-2100.
At 0930 on the following morning the Commanding Officer caused
an inspection of the rudder to be made by a diver and the rudder was
again 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 dis-
cuss further details of the aircraft engine change on the shore. At
this time wave height was about 4 feet and wind velocity 18 knots; both
were increasing. Upon arrival at the beach, the Commanding Officer re-
ceived a flashing light message from the Executive Officer that the ship
was dragging or had dragged her anchor. Weather and sea conditions had
deteriorated rapidly during the small boat's transit and the Commanding
Officer found he could not return to the ship because of surf conditions
at the beach. The small boat was not able to transmit any message visu-
ally back to the ship so the Commanding Officer proceeded to a radio
station 4-5 miles away. At about 1130 he established communications
with his ship. Several radio conversations between the Commanding Offi-
cer and Executive Officer took place beginning at this time. These con-
versations describe the deteriorating conditions and in essence were as
follows:
1130 - Executive Officer reported he believed ship had stopped
dragging. Commanding Officer said that he preferred not to get under-
way until he returned but to do what the Executive Officer thought
best. The Commanding Officer would call again in 1-1 1/2 hours.
1300 - Executive Officer reported situation deteriorating. An-
chor chain whipping some and rudder pounding on bottom. Would like to
flood No.2 main ballast tank to ease strain on the rudder. Ship has
been rigged for dive with the exception of main induction, bridge hatch
and checking by officers. The Commanding Officer gave permission to
flood 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 if
he thought it best.
D-34
The Commanding Officer left t he radio station and arrived at the
beach to find that the boat could not make it through the surf. He re-
turned to the radio station and called the ship.
1400 - Executive Officer reported that the weather was worse and
he believed he should get underway. The flooding of No. 2 main ballast
tank had not helped and the ship was pounding heavily. He had therefore
flooded down and bottomed. He planned on completing the rig for dive
check, pumping all variable ballast tanks dry, then blowing the main
ballast tanks and getting underway. The Commanding Officer concurred
in this course of action and again stated that he would prefer to be
on board before getting underway. He would continue to try to get out
to the ship but that the Executive Officer should go ahead and get under-
way if he thought best.
1500 - Executive Officer reported weather worse, submarine
pounding heavily and believed he should get underway. Commanding
Officer told him to get underway and not wait for him. Executive
Officer reported that he would have the variable ballast tanks dry
by 1530 and would attempt to underway on the high tide which
occurred at that time.
1600 - E x e c ~ t i v e Officer reported the ship rigged for dive
and ready to get underway; he would attempt to get underway. The
Commanding Officer told him to go ahead.
At 1606 the Executive Officer ordered all main ballast tanks
blown and attempted to get underway. He blew safety and negative
and heaved in on the anchor. At 1626 the anchor was aweigh but the
ship would not move. At 1630 the anchor was again dropped, chain
veered to 15 fathoms, and the ship flooded down and bottomed. At
1647 the Executive Officer reported by radio that the submarine would
not move. The Commanding Officer ordered him to flood d.own as much as
possible and was informed that this action had already been taken. The
Commanding Officer said that he was going to attempt to come out to the
ship in a rubber boat.
The Commanding Officer returned to the ship at 1800 and made
another unsuccessful attempt to get und.erway. Several attempts were
made on high tides the following day, all being unsuccessful, and on
the day following that an ATF arrived which also was unsuccessful in
her attempts to refloat the submarine. The submarine remained aground
for a period of eight days during which time several attempts to refloat
her were made. The salvage force needed to finally free her consisted
D-35
of 3 ATF t s, 2 ASRt S and 1 YOO. The submarine was lightened by ap-
proximately 1,660,000 pounds before she was refloated.
Damage to the submarine t s underwater body and appendages were
extensive 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 that
existing prior to the stranding was estimated at $19,275.
In reviewing this grounding, a significant finding of fact is
that true bearings of objects on the beach changed as much as 12.5
degrees during the period 0930-1730 on the day of the grounding.
Between 0900 and 1700 the wind velocity increased from 18 knots to
25 knots and wave height increased from 4 feet to 12 feet. Testi-
mony also revealed that throughout the entire period of uncertainty
as to whether the anchor was dragging, with extremely poor naVigational
aids for determining the ship's position or any change thereof, no
attempt was made to use a drift lead to determine any motion of the
ship over the ground.
1. The professed inability of the aircraft to be maneuvered to
the location of the submarine at her second anchorage dictated the
shift to the third and closer anchorage.
2. On the occasion of the third anchorage the Commanding
Officer'placedhis ship in such a restricted location that the
proximity of dangerous shoal water prevented.him from using adequate
scope of anchor chain.
3. Under the conditions of the ruddE;!r touching bottom, the
proximity of dangerous shoal water, and the vulnerability to the
weather from the position, having completed her immediate task of
servicing the aircraft, the submarine should have moved toa less
restricted anchorage or moved away from the island.
4. The Commanding Officer was negligent in departing the sub-
marine 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 water
to the East.
D-36
d. Insufficient scope of anchor chain in use.
5. The Commanding Officer showed indecision in his radio
conversations between 1130 and 1400 with the Executive Officer in
that he gave him the impression that he desired to wait until he,
the Commanding Officer, returned aboard, and then complicated the
situation with the expression, liDo what you think best".
6. The submarine dragged her anchor toward the beach in-
termittently from 0930 to 1720.
7 . The submarine went hard aground sometime between 1400 and
1606.
8. The Commanding Officer was exerclslng command from the time
of establishment of radio communications between himself and the Execu-
tive Officer, even though he, the Captain, was physically off the ship.
9. The Executive Officer used poor judgement in not getting the
ship underway at the first indications of the anchor dragging at about
1030, considering all conditions under which the ship was anchored.
10. The 1500 radio conversation is the first indication of more
than tacit approval by the Commanding Officer of the Executive Officer's
opinion that the ship should be gotten underway.
11. The delay, occasioned by completing pumping variables and
checking rig for dive, was not necessary in order to get the ship un-
derway.
12. At any tiine prior to t he deliberate bottoming of the subma-
rine at approximately 1400, the ship could have been gotten underway
and .clear of the anchorage .
13. Both the Commanding Officer and Executive Officer passed up
numerous opportunities between 1130 and the time the ship went hard
aground to take positive action to save the submarine from stranding.
14. There is doubt that the submarine could have gotten under-
way at or after 1500 following the conversation between the Captain
and the Executive Officer.
The cause of stranding of the submarine was due to a com-
bination 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 take
positive action when appraised of the conditions at the anchorage.
d. Reluctance on the part of the Executive Officer to move
the 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 This
case could conceivably be considered in that category at the time when
the submarine was forced to move to a d.angerous anchorage in order to
fuel the aircraft. In view of the weather conditions which followed,
there exists the possibility that the seaplane might have been destroyed
had she not been refueled and thereby able to seek shelter on the lee
side of the island. However, once the refueling evolution had been per-
formed, there was no further need to remain in this dangerous anchorage.
With insufficient anchor chain out and the rudder already having touched
bottom, it is inconceivable that a commanding officer would choose to
remain overnight rather than spending the night at sea or shifting to
a safe anchorage.
It would be noted that the Commanding Officer's Night Order Book
required bearings of objects on the beach at least once every two hours.
With shoal water only a few feet away, this time interval is grossly
inadequate. A prudent time interval in a safe anchorage would be every
quarter hour. If a vessel must be anchored in a hazardous situation
such as this, in unsheltered waters, with shoals in close proximity and.
an insufficient scope of anchor chain out, the situation would dictate
the taking.of nearly continuous anchorage bearings and the maintaining
of a maneuvering watch able to get the ship underway on a moment's
notice.
It is difficult to understand why the Executive Officer did not
immediately the ship underway when, shortly after the Commanding
Officer I s departure at 1000, he discovered that the anchor was drag-
ging. He had full knowledge of the shoal water, being also the ship's
navigator, and knew that the rudder had been found to be on the bot-
tom when inspected at 0930. In the absence of the Captain the Execu-
tive Officer had in fact become the Commanding Officer. Rather than
getting 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 that
the anchor was dragging or had dragged, a message for which the Captain
had no means of immediately replying. Good judgement would dictate
that, in the absence of the Captain and the Executive Officer, the Duty
Officer or senior officer on board would immediately the ship und.er-
way in such a situation.
In regard to this grounding, the Force Commander stated in
part" ... illtimate responsibility for the submarine's remaining at
the anchorage throughout the day preceding the grounding and until
about 1015 on the day of the grounding, even though the aircraft was
refueledand the rudder of the ship touched bottom on three occasions,
must rest upon the Command.ing Officer. However, after the Commanding
Officer's departure from the ship at about , the exact delimita-
tion of the deficiencies in performance by the Commanding Officer and
Executive Officer is complicated by the absence of an accurate record
of their radio conversations. None-the-less, it is clear that the
Executive Officer failed to adequately discharge the d U ~ i e s placed on
him by authority superior to this' Commanding Officer and for this he
must individually be considered accountable. The Executive Officer as
early as 1030 recognized that the submarine was in danger. Prudence
dictated that he exercise command and get underway immediately, inform-
the Commanding Officer, who was ashore, of the action. Or, having
decided to inform the Commanding Officer before taking action he should
have recommended a definite course of action. This was not a situation
wherein an Executive Officer must carefully consider the serious im-
plications attendant upon relieving a Commanding Officer; it was rather
a situation expressly provided for by Navy Regulations, section 1373,
in which the Executive Officer had succeeded to command by virtue of
the absence of the Commanding Officer."
D-39
CASE
Submarine grounding while approaching the measured mile off
Provincetown, 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 for
the conduct of watchstanders; in addition to containing standing
orders they must list specific navigational aids to be encountered.
3. The Officer of the Deck can not rely on any other person to conn
the ship into safe water; this is his responsibility, and to execute it
properly 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 via
the Cape Cod Canal, with the Commanding Officer and Navigator actively
piloting, a duration of about ten hours. Upon entering Cape Cod Bay
at 0316, the submarine set course for the measured mile area off
Provincetown. The Commanding Officer retired to his stateroom after
sending his Night Orders to the conning tower. These orders were
general, referred to the standing orders, and state<i Navigational data
would be furnished by the Navigator. The Navigator and Officer of the
Deck read and initialed the Night Orders as written by the Commanding
Officer. The ship made one-third speed on one engine in order to arriv
at the measured mile during early morning twilight. The Navigator con-
tinued to pilot from the conning tower, and cat-napped there between
fixes. There was no chart on the bridge for the OOD. During the tran-
sit across Cape Cod Bay, regular fixes were plotted and bearing recorded.
The fixes showed a definite northwesterly set. No DR positions along the
intended track were plotted, nor were danger bearings established in areas
where shoal water was to be encountered. The proposed track passed south
of unlighted buoy DELTA, leaving it to port. The Night Orders made no
mention of this fact. Because during the major part of the transit
three of the four available naVigational aids were nearly in line,
bearings were taken on only two aid.s. Radar was employed for ranging
during 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 fath-
ometer was lighted off. Morning twilight began. Shortly thereafter,
soundings showed the depth below the keel to decrease rapidly from 125
feet. A fix taken prior to this showed the submarine to be well off
the 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 last
and upon being informed of the sounding and the buoy, ordered the ship
.pack down and turned to the left, then twisted, without properly re-
lieving the OOD. The twist to the left turned the ship towards shoal
water. Soundings were now zero. At about 0505 the submarine ran
aground near Shank Painter Bar, suffering neither physical damage nor
personnel injuries.
1. The Commanding Officer's Night Orders were written in terms too
general for proper navigation through shoal water, and no additions
to the orders were made by the Navigator.
2. The Navigator erred by failing to plot DR positions along the
track, and danger bearing.
3. The Navigator did not take action to return the submarine to the
track when successive fixes showed a definite set, nor did he alert the
COD or inform the Commanding Officer.
4. The OOD erred by placing complete reliance upon the Navigator
and by failing to check the ship's position himself.
COMMENTS
Night Orders are the Commanding Officer's specific instructions
for the safe navigation of the ship. They, and the procedures
followed, must embrace every aspect of proper navigation and good
seamanship. In this instance they should have included the listing
of characteristics of navigational aids to be encountered, and a
definite position of arrival. They should have directed a two
engine propulsion combination on arriVing on station. The latter is
an important consideration when maneuvering in dangerous or unfamiliar
and restricted waters. Proper navigation involVes a multitude of
routine practices by the Navigator and when piloting, the plotting
of DR positions and danger bearings along the track are necessary
ones. Additionally, early and prudent action to aviod apparent
danger as shown by plotted fixes, giving advice to return the ship
D-42
to the intended track, and informing the ODD and Commanding Officer
that the ship is off the track, are essential. The ODD's role cer-
tainly includes keeping himself adequately informed of the ship's
position, and taking appropriate avoiding action on his own initia-
tive when it is early enough to be effective. When the Executive
Officer deems it adyisable to relieve the ODD of the conn, he should
do so in a proper, formal manner. And finally, good seamanship
dictates that when maneuvering in unfamiliar waters and doubting
the ship l s position, one should remain in, or return to safe water
by stopping, and if necessary, clearing the dangerous area through
good water just transited.
D-43
CASE
Submarine grounding while conducting submerged operations.
1. Responsibility and necessity for the Conning Officer to be fully
aware of the depth of water in which the submarine .is operating.
2. Responsibility of the Diving Officer for being fully aware of the
depth of water under the keel and keeping the conning officer so informed.
NARRATIVE
A submarine was conducting routine training operations with an-
other submarine while enroute from Norfolk, Virginia, to San Juan, P.R.
While making a submerged approach on the other submarine, the attacker
grounded in 145 feet of water. At the time of grounding the submarine
was at battle stations for the submerged approach. The Cornm.anding
Officer was the Conning Officer. The depth of water at the point of
grounding was clearly indicated on the chart in use as 24-25 fathoms.
The conning officer, navigator and diving officer, among others had
prior and sufficient knowledge of the actual depth of water. The
fathometer was in operation on automatic ping until just prior to
the grounding. The approach was being conducted at periscope depth
when the conning officer ordered 150 feet in an effort to reduce
cavitation noises. The diving officer acknowledged the depth change
and proceeded to carry it out. When at about 145 feet indicated depth
the conning officer decided to go deeper and ordered a depth of 200 feet.
Again the diving officer acknowledged the order depth and proceeded toward
200 feet. At almost the same time the submarine touched bottom.
OPINIONS AND FDIDINGS
1. The conning officer erred in ordering a depth that was greater
than the depth of water and was responsible for the unintentional
grounding. The error is attributed to the conning officer's failure
to keep in mind the actual depth of water in which he was operating
while conducting the approach.
2. The diving officer was responsible to a lesser extent for
failure to associate the ordered depth with the insufficient depth
of water.
D-45
COMMENTS
It is of paramount importance that the Conning Officer of a sub-
marine always keep in mind the actual depth of water in which he is con-
ducting submerged operations. This becomes increasingly more important
when the depth of water is such that it restricts the submerged operations
to less than the operational capability of the ship.
The Diving Officer must always be acutely aware of the depth of
water in which submerged operations are being conducted and most
particularly when the dBpth, of water is restrictive. The diving offi-
cer has a further responsibility to inform the conning officer promptly
when 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 submerged
drills, particularly in shallow water.
2. Drills that could easily result in loss of depth control must be
either carefully supervised by competent personnel or modified to an
extent that resultant loss of control in shallow water will be pre-
cluded.
NARRATIVE
A submarine conducting drills prior to change of command lost
depth ctmtrol and struck the bottom. After completing a "hand dive"
in water of generally 130 feet, sloping to 168 feet, a "collision in
the conning tower" drill was conducted. Upon executing the drill
the Commanding Officer ordered speed increased to full to add a de-
gree of realism, since the depth of water prohibited the flooding of
negative to simulate added weight. The ship was at 53 feet with an
ordered depth of 56 feet. The bow planesman had some dive on the bow
planes. 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, secured
the conning tower AC isolation switch. This switch cut off AC power
to 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 both
planesmen. The loss of indication had been interrupted by the planes-
men to be loss of power. In their minds the Diving Officer's order
added confirmation and they attempted to shift to energency power.
The bow planesman had difficulty with the pin of the emergency hand-
wheel and was assisted by the Chief of the Watch. The stern planes-
man was assisted by the trim manifold operator. Both planes were at
full dive. During the shifting operation the ship assumed a sharp
angle, estimated at about 25 down, and dropped from 53 feet to the
bottom.
D-47
During this time the Diving Officer took the following addi-
tional 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 circuits
were dead the order was then given on the XJA phone.
The total time elapsed from AC failure to striking the bottom
was about 35 seconds. The resultant damage was estimated at about $17,600.
OPINIONS AND FnIDINGS
The grounding was considered as not resulting from negligence but
rather from the poor state of training of the watch personnel.
The casualty resulted indirectly from the loss of AC power in the
control room while rigging for flooding in the conning tower. The slow
reaction time and lack of supervision by those standing supervisory watches,
plus the failure to test and to verify wiring accomplished pursuant to
a 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 close
supervisiQ!!1,lunan,datory to prevent accidents.
In order for a command to be carried out it must reach its des-
tination. Positive -communication throughout the ship is necessary
to carry out all orders without delay.
The Diving Officer must constantly be aware of the watch per-
sonnel in the control room, their abilities, and their whereabouts.
He must closely supervise his planesmen, particularly under conditions
when they may, by their actions, endanger the ship. When he gives
an order, he must insure that the order is acknowledged correctly
and is carried out as given. If any misunderstanding is encountered,
he shall correct the situation immediately. Proper procedure is a
must.
Whenever a submarine has any equipment that is not functioning
properly,corrective action must be taken immediately. Until such
corrective action is completed all watch personnel must be made aware
of the malfunction, such as the improperly wired conning tower isolation
switch, and act accordingly.
D-48
The Diving Officer must always take into consideration the
bubble angle on the ship, whether for depth control or for damage
control purposes. In this instance the control room depth gage was
reading 130 feet, but with the 25 down bubble the bow was at about
170 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 safety
precautions while in drydock.
NARRATIVE
While in a floating drydock, a submarine had #2 MET painted with
white plastic, the painting being completed about 1600. Welding work
was performed between 1600 and 1900 adjacent to #2 MET, from which the
tank top had been removed. No fire watch was stationed. About 1930
a fire started in #2 MET, rapidly becoming very intense due to the
draft created through the flood holes in the bottom of the tank and the
holes (about 18 inches in diameter) in the top. Additional minor fires
were caused inside the ship and in the well deck of the ARD.
1. Hull section and associated piping inside of #2 MET must be re-
newed at a cost of approximately $900,000.
2. That had adequate fire hoses been available and promptly used the
fire would have been contained and extinguished before serious damage
occurred.
3. That the regulation concerning the stationing of fire watches was
not being enforced.
COMMENT
It is well known that fire is the most serious danger to be feared
while in shipyard overhaul, an ever-present danger that is amplified
when welding and burning is in progress. In this particular case, the
danger was made greater due to the proximity of the white plastic paint
(formula 89), which has a flashpoint of 400
0
F and a ignition point of
4350F, thus constituting a serious hazard.
AlthOUgh burners and welders are supposed to obtain fire watches
before commencing work, ship1s force must be ever on the alert to pre-
vent such violations as occurred in this case. To this end, all hands
E-5
should be indoctrinated concerning the dangers of fire and the neces-
sity for continuous inspections by the Duty Officer, the Duty Chief
Petty Officer, the Below Decks Watch, and the Topside Watch.
In addition, adequate fire-fighting equipment must be on hand ready
for use at all times. This includes CO2 extinguishers and fire hoses,
and personnel must be well trained in their use and location. It is
not enough that the fire watch merely be stationed where they can do
.,little except pass the word if a fire starts--they must be equipped
and trained to fight the fire in order to be effective.'
E-6
CASE
Near collision with moored submarines by Tender parting her
moorings.
PRINCIPLE
Duty Officer and Duty Section must be ready at all times to get the
ship underway.
NARRATIVE
The Tender was moored port side to pier 22 in Norfolk. Submarines
were nested across the slip in 2 pairs of 2 each, one pair astern of
the other. During a northeaster, 50 knots of wind pulled out the pier
bollard that held the Tender's forward lines. The other mooring lines
quickly parted and the ship began to drift downwind to starboard,
endangering the submarines at pier 21, even though both of the Tender's
anchors were let go. By quickly warning. the submarines when the danger
was 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 the
Tender which came to rest against pier 21 astern of the submarine.
COMMENT
This case is a perfect example of why the Duty Officer must stay
aboard and not wander up the dock or go over in some other
boat. It is also a good example of why an alert topside watch is
necessary.
E-7
CASE
Near g r o ~ d i n g due to loss of rudder angle indicator.
PRINCIPLES
1. Emergency rudder angle indicator should always be energized in
confined waters.
2. Speed used in confined waters should be selected so as to provide
a reasonable safety factor in case of a mechanical failure.
NARRATIVE
Submarine was roaring by Southwest Ledge Light enroute New London
Op-area for local operations, attempting to pass a submarine ahead.
Helmsman reported, "Lost steering". The Commanding Officer, who was
on the bridge, ordered "All stop", and "All back emergency" as the
ship began to swing left. Maneuvering room then reported, "Fire in
the maneuvering room". Since the Commanding Officer had not obtained
the backing turns he had ordered, he ordered the anchor let go. By
skillful veering, the ship was stopped to the ~ of Southwest Ledge
Light, heading in the general direction of the Griswold Hotel with a
thoroughly chagrined Commanding Officer and OOD on the bridge.
COMM:ENT
The principal lesson is that "hot-rodding" in confined waters is
folly. The few minutes gained are never worth the risk, and often
the 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 of
losing steering as he reported, the helmsman lost only rudder angle
indication. The emergency rudder angle indicator was not on as it
should have been. The fire in the maneuvering room was the result of
excessive arcing igniting some cork when the "all stop" bell was
answered 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 sudden
large unexplained weight changes are needed or when ship apparently
fails to respond to control.
2. Diving Officer must keep Conning Officer informed when off depth
or 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 of
100 feet was ordered, and upon passing through 150 feet the planesman
was directed to cut in the shallow depth gage. Instead, he mistakenly
secured the sea valve to all depth gages. The gage vent valve leaked,
however, so the gages continued to indicate a slow decrease in depth
as the pressure vented off them, and of course this indication con-
tinued when the Diving Officer attempted to level off at 100 feet. In
an effort to stop the apparent ascent of the boat, the Diving Officer
requested speed, took a down angle, and began to flood water into
auxiliaries, but still the gage indicated decrease in depth. When the
Diving Officer requested full speed with a six degree down angle, the
Conning Officer, who had heretofore been busy checking sonar informa-
tion on the ASW ships--took note of the depth on the conning tower
depth gage and the boat was leveled off about 100 feet below its test
depth. More than 30,000 pounds of water had been flooded into the
variable tanks during the attempt to stop the "ascent".
COMMENT
The Diving Officer made no checks of other depth gages or-of pres-
sure gages when the ship apparently insisted on rising despite large
speed with good-sized down angles and the intake of many thousands of
pounds of additional water. The ship had been operating properly in
reasonable trim minutes before, and any such radical change in variable
ballast or measures to maintain depth should have given rise to checks
to see if the depth indication was in fact valid. Had the Diving
Officer reported his difficulty with depth to the Conning Officer, it
E-ll
is likely that the Conning Officer would have immediately taken more
interest in his own depth gage and thus would have detected the trouble
earlier. It is also significant that the near casualty would not have
occurred in the first place had the planesman been properly checked
out 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, depth
should be checked with other gages to insure proper depth keeping.
NARRATIVE
Submarine tlA": While running at 90 feet rendering services to
DDs, the submarine was rigged for depth charge. The sea valves to
depth gages at the depth control stand were shut. On securing from
depth charge the sea valves to the gages were not opened and the
boat was thought to be still at 90 feet in good trim. The auxilia-
ryman noticed abnormal sea pressure on the air manifold sea pressure
gage, upon which it was found that the boat was well below test depth.
Submarine "Btl: While running at 150 feet, depth was ordered
changed to 175 feet. Bow planesman secured shallow gage stop and
stern planesman secured deep depth gage stop thinking he was securing
his shallow gage stop. Depth was then 175 feet. Later, after
venting deep depth gage, the stop was discovered shut. On opening
the deep gage stop the boat was found to be below test depth.
COMMENTS
1. During "Rig for Depth Charge" the depth gages that are not
secured should be checked against each other often and personnel in
compartments with sea gages should be required to keep check on sea
pressure.
2. When shifting to deep depth gage it should be checked against
another gage to insure its proper operation.
3. The ease with which this type casualty can occur is primarily
due to the piping nightmare that connects the depth gages at the con-
trol stpnd to the sea chest(s). Piping should be modified to locate
the stop for each gage immediately below the gage itself rather than
hidden 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 for
DDs. AC power was lost, thus baw and stern plane angle indicators
were lost. The Emergency Plane Angle Indicators failed to work, with
the result that control of the boat was lost and it broached in the
center of the DD group.
COMMENTS
1. Emergency plane angle indicators are provided for just such oc-
casions as this, and must be maintained in proper operating condition.
2. The torpedo room watches should be trained to report when the
planes are jammed (as is undoubtedly what happened in this case), as
well as the position of the planes when requested by control due to
failure of the indicators in the Control Room.
3. Ina similar case of stern plane angle indicator failure, all
indicators indicated planes on full rise. The boat, however, re-
acted as if they were on full dive. Investigation revealed that
they were actually on full dive and that the mechanical linkage to
the normal and emergency plane angle indicator transmitter had car-
ried away, putting both normal and emergency indication out.
4. Loss of plane angle indicators should not prevent operation of
the planes if the false reading of the indicator is ignored and the
planes operated in the manner indicated by the action of the boat
itself. The hydraulic gages provided at the baw and stern planes
handwheels will indicate when the planes are in the stops and in
which direction.
E-15
CASE
Broaching from loss of control when backing submerged.
PRINCIPLE
Evasive maneuvers should be selected with due regard to the exer-
cise depth and the experience of the ship control team.
NARRATIVE
Submarine was operating at 125 feet with DDs conducting coor-
dinated attacks. Boat was using "all ahead full", then "back full
l
'
when speed had built up to 12 knots. Control was lost and the boat
broached with a 32
0
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 125
feet .
2. 125 feet is not sufficient depth to exercise at this type evasion
without skilled planesmen and Diving Officer.
3. The difficulty of removing an unwanted up
perative that special attention be given to prevent
engaged in this type exercise.
E-17
makes it im-
up angles when
CASE
Uncontrollable up-angle on first dive of the day.
PRINCIPLE
Trim changes from compensation should be entered as changes from
previous trim to specified new trim.
NARRATIVE
Submarine made first dive of the day for an ORI approach.
Boat took a 15
0
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 of
25,000 pounds to appear as 35,000 pounds. Compensation was effected
by giving auxiliaryman a new set of tank readings. The change in
after trim was negligible, resulting in the auxiliaryman flooding
in approximately 10,000 pounds to agree with the desired trim
readings.
COMMENT
The best practice is to effect compensation from the
diving book which shows the former trim, amount of change, and the
trim. Such a system provides a double check on getting the
proper trim. Compensation should always be accomplished through
the Chief of the Watch, never by the Diving Officer's handing the
auxiliaryman a slip with some figures on it.
E-19
CASE
Excessive angle.
PRINCIPLE
Knowledge of the boat by all hands is essential to its safe
operation.
NARRATIVE
During a wartime patrol, a submarine lIlost the bubble
lf
while
diving to such an extent that all hands in the control room lost
their footing and slid to the forward end of the compartment, from
where the air manifold operator was unable to climb back to his
station. A crewman in the after battery was able to climb lIdown-
hill" to the air manifold, which he immediately manned, and blew the
forward group.
COMMENT
This incident indicates the necessity for well-trained person-
nel who know the boat and each other I s jobs. Had this man been less
familiar with the air manifold the boat could easily have been lost
while 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 morning
darkness. As the conning tower upper hatch was shut, "You left me
on the bridge" was heard over the lMC. All vents were shut, sur-
facing alarm sounded, and "All stop" was rung up. On surfacing a dim
light was seen well astern. The man !.was recovered in approximately
9 minutes. Since it was standard practice for all lookouts to
wear life jackets the man was well supported in the water althOUgh
only half of the jacket inflated and he was dressed in foul weather
clothing. The man had just relieved the starboard lookout and did
not hear the word "Clear the bridge" from the OOD, probably due to the
rain parka pulled tight around his head.
OPINION
Although the man should not have been left on the bridge, the
important lesson is that with proper training, cool thinking, and
careful checking of equipment, such a casualty can be successfully
handled with no major injury or harm.
COMMENTS
1. It is the responsibility of the ODD to keep track of the number
of personnel on the bridge and to insure that all get below before
shutting the hatch. This can be a problem on dark, rough nights
with 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 the
hatch.
E-23
2. The casualty points up the need to have lookouts repeat loudly the
word ltClear the bridget! when they hear it passed, and the need to have
lookouts trained in the procedure to follow if they are left topsid.e
on 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 until
the bridge is under.
E-24
CASE
Man overboard.
PRINCIPLE
Heavy weather precautions are required for personnel going on the
main deck.
NARRATIVE
During LANTSUBEX a submarine put one man on deck to repair a badly
leaking main engine exhaust valve. A heavy sea parted the fastening ring
on his safety belt and washed him overboard. He Was wearing a life
jacket and was recovered in 6 minutes.
OPINION
This could easily have been a tragedy but for the precautions taken
and the skill exercised in maneuvering and recovering the man.
COMMENTS
1. Risking a man's life for a repair ttat is not essential is never
warranted.
2. When necessary to put men on deck the following precautions are in
order:
a. Life jackets should be worn and inflated. At night the jacket
light should be turned on.
b. Safety lines and equipment should be adequate and checked in
good condition.
c. Men should be tended from the bridge in addition to their
safety line to the safety track. Such a tending line in this case
would 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 on
the main deck an to repair the overtaking light. A wave washed both
men overboard, parting their safety lines. The EMC was recovered, the
officer perished.
OPINION
Not available.
COMMENTS
1. The repair of the overtaking light was of little importance com-
pared to the risk involved.
2. It is probably safe to assume that the safety lines used were
wholly inadequate for the use to which they were subjected. It is
unknown whether life i jackets with lights were worn.
3. See previous Man Overboard case for precautions to be taken when
sending 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 any
purpose except as a diving
NARRATIVE
A new submarine enroute to war zone was exercising at Battle Stations
Gun Action. The Commanding Officer sounded one blast on the diving
alarm 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 the
surface--as a signal to dive the boat. It is most doubtful if it even
could have been heard well enough topside to accomplish the desired
result in this particular case. The ship's whistle or the QM's whistle
can be used effectively.
Under conditions of wartime crulslng it is not uncommon for the
vents to get opened on the first blast--it can be expected to happen
again.
E-29
CASE
Accidental submergence while flooding down.
PRINCIPLES
/
L Flooding down of a submarine must be done in a orderly manner with
positive control of the flooding at all times to prevent inadvertent
submergence.
2. Flooding down should be done only when the boat is either positively
rigged to prevent accidental submergence, or is in all respects ready
to submerge if control is lost.
NARRATIVE
A submarine at sea flooded down to recover torpedo. With main
ballast tanks flooded, and negative flooded, torpedo recovery party
topside, the order was given to, "Vent safetyll, which was dry. When
safety was vented the boat submerged to 48 feet leaving all personnel
topside swimming. Luckily the bridge hatch was shut before it went
under and fortunately no main deck hatches were open. The boat was
quickly surfaced and all personnel recovered.
COMMENTS
L Evidently bridge personnel in ordering, llVent safety" thought that
the floods w ~ r e shut.
2. ,Flooding down should not be attempted except in accordance with
Principles stated above. This requires the Diving Officer in Control
to 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 keep
the bridge hatch clear for shutting.
2. The upper conning tower hatch must be checked clear for shutting
immediately after surfacing, after passage of personnel through the hatch,
and after dumping garbage.
NARRATIVE
After dumping garbage, the Commanding Officer ordered a dive im-
mediately. When the OOD pulled on the hatch lanyard it was found to
be wrapped around the hatch handwheel. The Quartermaster, in freeing
the lanyard., jammed the hatch dogs in the "Dogged" position, prevent-
ing the hatch from closing. Luckily the dive was stopped before the
hatch went under. The mess cooks, in dumping garbage, had eVidently
wrapped the lanyard around the handwheel to keep it out of the way
while bringing up garbage through the hatch.
COMMENTS
1. Since the lives of all on board may depend on the upper conning
tower hatch being shut on diving, all personnel should be indoctri-
nated 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 is
jammed, and this should be the first effort, for if the hatch can be
shut, it does not have to be dogged to prevent entry of water. It can
be held tight until it is firmly seated by water pressure as the boat
submerges. As shown in this case, too often efforts to clear the
lanyard result in preventing the hatch from being seated. Quarter-
masters should be thoroughly drilled in the proper procedure and
made aware of the primary need to first seat the hatch, then dog it.
Realistic drills of this nature can be held safely by shutting emer-
gency vents before sounding the diving alarm.
3. In a similar case a submarine anchored for the night in a rigged
for dive condition. On the first dive on the following day: the hatch
could 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 hand-
wheel when the hatch is open) was inoperative. Good practice requires
that the hatch be checked often by the OOD, lookouts, and Quarter-
master, not only to insure that the hatch itself is free for shutting,
but to insure that no foreign material has been caught on the seating
surface 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 salvage
inspections should be done by Ship's Force.
2. After being gagged for salvage inspection or drill, hydraulic oper-
ated equipment should be operated in power to insure proper operation.
NARRATIVE
The submarine completed a two week upkeep period during which a
salvage inspection was conducted. Prior to getting underway the boat
was sealed and a pressure in the boat attempted. Main Induction showed
"Green
ll
but the pressure could not be built up. Visual check of the
main induction valve revealed that it was about ~ inch open.
COMMENT
Many casualties have occurred due to failure to reposition properly
the gagging gear on exhaust valves and other power operated valves after
a salvage inspection., In every case the inspection team from the ASR
is blamed. Since the submarine personnel are more familiar (or should
be) and of necessity more interested in the mechanical equipment in-
volved, they should accomplish all gagging and ungagging of valves for
the inspecting party.
As shown in this case, it is always good practice to Rig for Dive
and check out all equipment at the end of an upkeep period prior to
getting underway. This should always include, as was done on this
submarine, 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 northern
patrol area in the midst of some of the worst weather ever experienced
in the North Atlantic. Winds of 70 knots and waves of forty to fifty
feet in height were prevalent for weeks. The ship was experiencing
rolls up to 57 degrees on the su.rface and 12 degrees at depths of 200
feet. It had been two days since the ship had submerged and the diving
alarm 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 ship
broke 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 ob-
tained at a depth of fI:) feet, but continued to increasetci 15 degrees
on passing 70 feet, in spite of blowing negative and ordering rise on
both planes. The Conning Officer ordered right full rudder and all back
:full to help catch the bubble which was now passing 20 degrees. The
forward group and bow buoyancy tank were also blown and immediately ven-
ted to catch the angle. The ship leveled off at 180 feet. A maximum
angle of 26 degrees was experienced. An immediate check of the compen-
sation was made to include readings on all trim tanks, WRrs and status
of torpedo tubes. All these checks indicated that conditions were nor-
mal and the llloss of bubble
ll
was attributed to the sea lifting the
stern on the dive and the planes not catching it in time.
The Conning Of.ficer then ordered the ship to be brought to the
original ordered depth of 120 feet with a 3 degree up buble. The ship
took a 7 degree up bubble and came up to. 35 feet. No combination of
speeds or plane positions could prevent this from happening. Two
additional diving attempts were made to reach and maintain the ordered
depth with the same happenings occurring. The following items were
investigated 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 nor-
mal 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 readings
at trim manifold.
f. All main ballast tank vents operated in hand power to insure
their 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 full
rise position without much effort on the part of the planesman regard-
less of the stroke setting. It was believed that the stern plane opera-
ting linkage must have broken. If this were the case though, the planes
would have been sucked into the propellers when the backing bell was
used during the initial dive. That the trouble was with the stern
planes was fairly well determined, but the exact extent of the casualty
to the planes could not be determined from any examination from within
the ship.
The ship did not attempt another dive enroute to New London. On
arriVal, divers from E & E DePartment f':ound that the ste;rn planes and
its connecting shaft had completely fallen off the ship and no evidence
of any of their parts was visible. Subsequent drydocking substantiated
this finding. Bronze from the stern planes bushing was wiped into the
pores of the foundation steel casting and hydraulic jacks plus heating
and cooling failed to remove these bushings. These facts indicate that
the stern plane shaft had probably been snapped by the force of the
fully 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 submitted
to CNO under .ATULE serial 001 of 18 December 1956 via COMStJBI..ANT.
CO:MM.F.m
This was the- first time that this casualty had been witnessed by
anyone on board .ATULE and discussions with personnel from COMSUBLANl'
Staff, Development Group, and the Base E & R Department could reveal
no one who recalled a similar casualty. It might be added that these
planes had received a careful inspection for unusual wear in the
drydock at Portsmouth Naval Shipyard just four months prior to this
casualty.
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 essential
operations are completed.
N.A.RRATIVE
The submarine was conducting a post-overhaul shakedown. Upon
diving, an inexperienced EMFN tripped the forward auxiliary distribution
board disconnect switch instead of the air compressor strip switch. The
vents were opened, planes rigged out, and a periscope raised, leaving
no hydraulic power to shut the :Qlain induction. The lMC and 7MC, motor
order telegraphs, and bow plane tilting motor were lost, and the phones
were not manned. 1I.All Back Dnergencyll was ordered by telephone, the
vents 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 never
be rigged out until the vents are opened and the main induction shut.
2. Had the phones been manned, this casualty could have been
more easily handled.
E-39
Injury of a diver with submarine propeller.
PRINCIPLE
In-port evolutions must be coordinated by the Duty Offlcer
through the proper channels.
Divers at the Submarine Base" New London, were directed to change
a screw on a submarine. The leading diver requested the ship to secure
the stern ylanes" rudder, and screws. The OOD supervised the pulling
of fuses to the stern plane tilting motors, the steering motor and the
engaging of the jacking gear on the propeller shafts. It is not known
whether or not the below decks watch, the duty controllermen, or the
duty chief participated in these actions or were informed of the
reasons for them.
With two divers waiting in the water near the screws, the leading
diver requested the starboard screw to be jacked over thirty degrees
by hand. This request was received by the Duty Chief, who ordered the
junior Duty Electrician to perform the task, but neglected to inform
the D.1ty Officer. The junior electrician decided that hand-jacking
was too much work" however" and decided t<, turn the shafts with the
use of main power from the battery -- II just touching the shafts a
little" so they would turn the desired amount. With this in mind,
he disengaged the jacking gear" and energized the motors" upon which
the shaft started to turn at about 30 rpm. By the time he could move
the starter lever to the 1I 0 ff
ll
position the shaft had made two com-
plete revolutions. One of the divers was immediately sucked into the
screw" whipped around" and thrown unconscious to the bottom when the
screw stopped. Fortunately, the screw also cut off his weight belt
and face mask" so that he immediately popped to the surface where he
regained consciousness from contact with the icy water. He had
slashes and bruises in ten places on his body. The other diver was
swept clear of the screw by the screw current and was uninjured.
1. The Duty Chief erred in not informing the OOD of the request to
have the shaft jacked over by hand.
2. The D.1ty Chief erred in not supervising the evolution" which
should have been considered potentially dangerous" as it indeed
proved itself to be.
3. The junior electrician erred in not carrying out his orders to
jack the shaft over by hand.
E-41
4. The leading diver erred in having divers in the water while a
shaft was being turned, in direct violation of the U.S. Navy Safety
Precautions Manual.
COMMENT
This is an example of what can result from allowing operations
to get out of the proper channels. Had this been properly coordina-
ted by the OOD, with the necessary personnel being informed of what
was going on, and with the required operations conducted by properly
experienced personnel, the accident would not have happened.
E-42
Personnel injury, electrical burns.
PRINCIPLE
Electrical circuits should be de-energized before any main-
tenance is performed.
NARRATIVE
Submarine had a ground in the main propulsion system. In
isolating the ground it was found to be in the cables from the bat-
tery to the cubicle. Permission was obtained to work on the ground
and an officer was supervising the OPeration. After completing one
of the tests, the electrician in charge neglected to OPen the for-
ward battery circuit breaker. He then entered the cubicle to replace
the disconnect links and was burned when arcing occurred.
The main propulsion electrician1s mate, who was the injured
man, although a well qualified and experienced submariner, displayed
carelessness in Violating a posted
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 proven
but there remain individuals who feel that the rule does not apply
to them by reason of their experience and knowledge. Current canI t
tell the difference between an FN and a CPO and couldnI t care less
which is the path to ground. It is impossible to devise an inter-
lock for the human brain. The only answer is to use the brain, and
in work such as this, two brains are better than one. There should
be a double check that the power is off before anyone is allowed to
enter the cubicle. Proper training and eternal Vigilance will pay
dividends .-- 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 bottomed
in about fI) feet of water found that it was impossible to shut th,e
escape trunk door after the first group of escapees had left the
trunk.
Subsequent inspection revealed that the outer handle on the
escape trunk door was installed 90
0
out of position so that the
closing arm operated from the forward torpedo room rotated the handle
enough to extend the dogs about a quarter of an inch, thus preventing
seating 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 a
submarine is of such importance that special salvage inspections are
required to .be made by personnel of the rescue vessels. These in-
spections should be meticulous and should be attended by shipls
personnel. Too often, as in this, instance, shipls force fail to
plake any inspections of their own to insure that everything is in
readiness 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 before
attempting any work therein.
2. Two persons should be required to check the cubicle safe before
permitting any work therein.
NARRATIVE
A submarine duty chief, an EMC,_ attempted to clear the starboard
cubicle (split CUbicle) to permit welding in it. All starboard levers
were placed to the uOffll position, the starboard motors excitation switch
was opened, and the disconnect to numbers 1 &2 batteries (Guppy II)
were opened. Workers using a portable light with a wire guard inad-
vertently fouled the guard between the battery bUs, causing an arc which
burned a worker. No other damage occurred.
1. The port battery lever was in the "an" position, thus causing the
forward part of the starboard cubicle to be energized.
2. Use of a vo.ltmeter to check on the cubicle would probably have
prevented this casualty.
COMMENTS
1. No cubicl-e work should be attempted until the entire cubicle has
been disconnected and checked. "dead" with all battery d.isconnects open.
2. Any work involving danger to personnel such as this should not be
permitted until the conditions for safety are finally checked by two
separate checks by two separate people, i.e., in this case the EMC
and 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 Tower
set the bucket on the edge of the hatch, steadying it with his left
hand as he attempted to pull himself through the hatch. Ue took hold
of the hatch I s lower handle and as he did the hatch shut, knocking over
the water and inflicting second degree burns as it spilled on the man.
COMMENTS
1. Safe practice requires that doors and hatches he properly latched
when opened so that the handles placed thereon may be safely used.
2. The springs on hatches should be kept adjusted so that when a hatch
is undogged, it will fly open with sufficient force to latch open
securely. '
3. All hatches and doors should be checked after being opened to insure
that they are in fact securely latched open.
4. In the case of WT doors on submarines, the latch should be adjusted
so that the door is held tightly against the compressed rubber buffer by the
latch in such a manner that the door will be moved sufficiently by the
buffer 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 in
to 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 goggles
and was subsequently injured when one of the wires flew off the brush and
lodged in his left eye.
The seaman had been instructed to wear his goggles while using the
power wire brush. They were not the standard ventilated type and thus
fogged up. This is presumably the reason they were removed.
COMMENT
Submarines should always have standard protective goggles on hand
and should insure that all personnel understand the necessity of wear-
ing them at all times when using power brushes, grinding wheels, etc.
Of equal importance is the necessity for personnel to wear goggles when
working adjacent to a power wire brush. In one such case a man 15 feet
from the wire brush was injured and lost his vision in one eye when
struck by a wire fram the brush.
E-51
CASE
Personnel injury resulting from operating handle of engine induction
valve.
PRINCIPLE
Sloppy practices result in trouble sooner or later.
NARRATIVE
During an ORI conducted by a SubRon Staff, a drill IICollision in the
forward engine room
ll
was instituted, with the ship surfaced. During the
drill the main induction was shut, the hull induction and the two engine
air inductions were shut, but the handle for the after engine room air
induction was hanging down loose. A pressure was put in the forward
engine room as part of the simulated casualty control. Subsequently
a pressure was put in the after engine room also, in order to permit
the door between the engine rooms'to be opened. Before the door was
actually opened, however, the drill was secured and the main induction
was opened. Pressure which had evidently built up in the induction
piping was immediately vented off thrOUgh the main induction. This
action lifted the after engine room air flapper valve, swinging the loose
handle. The handle struck the Engineer Officer a glancing blow on the
head, knocking.him unconscious for about ten minutes.
COMMENT
Had the handle been in its proper place this incident would not
have occurred. Lax practices such as this can be expected to lead to
trouble.
I - - ~ -
CASE
Personnel injury, fractured arm while locking the main induction.
PRINCIPLE
Hand operation of hydraulic operated equipment requires that the
hydraulic power first be secured.
NARRATIVE
In attempting to lock the main induction valve operating gear shut
during a dive the mess cook disengaged the locking pin before the valve
had been shut hydraulically. The handwheel spun rapidly, breaking the
mess cook's arm.
COMMENT
The first concern for the main induction operating gear is to insure
that it is SHUT. Once it is seen to be shut, then the action to lock
it shut should be commenced.
The power exhibited by thehandwheel of a piece of hydraulic gear
when hydraulic power is cut in with the mechanism in the "hand" position
is almost unbelievable. Positive safeguards must be used to prevent
hydraulic power from energizing hydraulic eqUipment in the "hand" position
when 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 connectors
between cells #2 and #3 in the after battery well. The well temperature
was 100
0
to 110
0
with the air conditioning out of commission. The man
was perspiring profusely and had stripped to the waist. Ground readings
taken the previous night on completion of the charge were minus 25 volts
and plus 30 volts. EVidently no readings were taken just prior to com-
mencing the work. There was a known intermittent full voltage ground
that resulted from insulation damage to the cell voltmeter leads during
the battery renewal of the previous overhaul. Bakelite sheeting was
used on the outboard row of cells with nothing between. The man acciden-
tally completed the circuit from a terminal of cell #3 under his arm
through his opposite shoulder blade to a buss on the battery disconnect
switch. The circuit was completed to cell #123 by a full voltage
round. on the voltmeter lead. The c u r r ~ n t flow was not enough to blow
the cell voltmeter lead fuses.
COMMENT
This casualty emphasizes the point that extreme caution is required
when working with any electrical circuit, and especially when working in
submarine battery wells. It also emphasizes the extreme importance of
locating 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 check
for proper operation.
NARRATIVE
Submarine was on surface conducting drills. One of the drills re-
quired that the after battery be isolated. Excitation was shifted for-
ward and after battery main circuit breakers tripped. When excitation
was shifted, the holding coil on the battery paralleling lever properly
tripped open. Following this drill, another drill was held that neces-
sitated the isolation of the forward battery, so excitation, was shifted
aft and the forward battery isolated. On the completion of the drills,
and when all casualties were reported restored, a dive from four engines
was made. Since there had been no bells answered on the battery during
the surface drills and the battery paralleling lever had not been moved,
there was no power from the battery on diving because the holding coil
on the paralleling contactors was still tripped out. As can be imagined,
this lack of battery power on a four engine dive caused great consterna-
tion.
COMMENT
Restoration of casualties following any drill in which the normal
cruising conditions are disrupted should include a check for proper
operation to insure a return to normal cruising conditions. In parti-
cular, disruptions to the cubicle as were required in this case neces-
sitate a good propulsion check-out similar to that required on getting
underway. Also, anytime the excitation switch is thrown for any reason,
it should be automatic to throw the battery paralleling lever to the
II OFF" 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 to
survival at sea.
2. In a heavy sea, main ballast tanks must beblown frequently to
insure maximum surface stability.
NARRATIVE
The submarine was cruJ.sJ.ng in a sea five and upwards, with
wind velocity about 55 knots. and visibility varying to & minimum of
about 100 yards. The upper conning tower hatch' and induction were
shut, air induction being taken through the snorkel,mast. The low
pressure blower was being run about once each watch as a. ql8.tter of
routine. The Commanding Officer's night orders required the OOD and
lookouts to be tied to the bridge with safety belts. The ship was
rolling heavily in this sea and wind qonditiqn and on one occasion took
an extremely large roll of about 80 degrees to starboard. On this roll
the bridge and fairwater were completely submerged for a considerable
period,.the Ship showing a tendency to hang in this position. The star-
board lookout was washed overboard but held by the safety line he was
wearing and was later pulled back ontq the bridge. The port lookout
was not wearing a safety line but wedged himself into a position such
that he was not washed overboard. The OOD had a safety line
but was not wearing it and was washed overboara. A search of several
hours duration failed to locate the OOD and was finally abandoned after
the time had elapsed beyond which a human could not survive due to ex-
posure.
1. That the OOD was washed overboard when the bridge of the sub-
marine 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 ser-
vice 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 were
aggravated by the filling of the interior of the fai:ryater with 'Water.
COMMENTS
The failure of the OOD to comply with instructions of the Command-
ing Officer to utilize available safety equipment resulted in the tragic
loss of his life. This laxity also caused one of the lookouts to fol-
low the OOD's example and only goodforturne prevented him from also
being lost. Safety lines should always be used in heavy weather. Their
usefulness in saving lives is strongly illustrated in this case by the
fact that the starboard lookout was washed overboard, held completely
submerged for a prolonged period, but was held fast to the ship by his
safety line and later pulled back onto the bridge.
With safety and negative tanks flooded, in diving trim and blowing
up about once a watch, the submarine was in a normal cruising condition.
An inclining experiment conducted prior to this casualty showed a meta-
centric height well above the minimum of the average submarine. However,
approximately six hours had elapsed since the last time the tanks had
been blown dry and this probably had an adverse effect on the submarine's
stability. In high winds and with wave heights of 25-30 feet, the aver-
age angle of roll was 25 degrees. With this amount of rolling and the
long time since blowing main ballast tanks, considerable air could have
been spilled from the tanks, resulting in reduced buoyancy and stability.
This may have contributed to the excessive angle and consequent loss of
lips. Main ballast tanks must be kept blown substa:t;ltially dry in heavy
seas to insure maximum sta1?ility. The frequency of blowing tanks is a
matter of judgement depending upon the amount of roll and other condi..
tions. However, in heavy weather, a good procedure would be to blow up
at least twice a watch; it would not be excessive to blOw up once an
hour in very heavy seas. If in doubt - run the blower. It may do some
good, and it certainly will do no harm.
Of interest in connection with the OOD not having his.safety belt
secured is the fact that the Commanding Officer had verbally directed
him to secure it just minutes before the accident.
E-62
CASE
Personnel injury, fractured skull, as a result of being struck by a
hand 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 ~ h i p .
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 in
the motor position. Valve grinding compound was placed in the clutch in an
attempt to free the shafting. The hand crank was affixed to the operating
shaft and held there. With.the clutch in the motor position, the motor
was turned on. The binding in the clutch assembly was aggravated by
the presence of the grinding compound and as a result the crank was
thrown, lacerating the head of the man who was holding it and fractur-
ing the skull of another who was sitting on the deck nearby. Fortun-
ately the ship was in the channel enroute to port with a doctor on
board. First aid was administered on board and an ambulance was await-
ing on a r r i ~ a l .
Similar type accidents may be prevented in the future by never
engaging the hand crank unless the clutch is in the position for hand
operation and the motor is off.
COMMENTS
Work on' an auxiliary means of steering normally should not be at-
tempted while the ship is maneuvering in a channel. Positive safe-
guards must be employed to prevent equipment from being operated in
other than the designed positions. Personnel should keep clear of the
rotating gear while testing the effectiveness of any repair.
E-63
CASE
Electrical fire as a result of improper "set_up" on cubicle in con-
junction with failure of safety device.
PRINCIPLES
1. It is mandatory that Duty Officers and Duty Chiefs make inspections
as required by Ship's orders.
2. Duty Officers, Duty Chiefs and cognizant department representatives
must be kept informed of all ship's work in progress and be aware of
any abnormal conditions.
3. Leading Petty Officers of departments should not leave the ship until
informing responsiole on-board personnel of the status or condition of
machinery and equipment undergoing repair or maintenance.
NARRATIVE
At 0830 on Monday, after proceeding from drydock, an attack class
submarine moored outbOard of two submarines in a tender nest. Work on
the ship
1
s electrical equipment, interrupted by the undocking, resumed:
At approximately 1100, as a measure to facilitate removal of arc chutes
in the cubicle, the main motor field rheostat 'Was operated the flfull
on" position, the starboard propulsion set-up cam shaft 'WaS placed in the
flparallel" position, and the starboard main motor propulsion contactors
were closed. This set-up on the cubicle, made by a person or persons
unknown, resulted in a starboard main motors parallel combination with
cables and armature resistance equal to about .0112 ohms. The forward
and after main battery circuit breakers, opened on securing the maneu-
vering watch, were designed for instantaneous trip at 20,000 amperes.
The application on mail battery voltage (500 volts) to the resist-load
resulting from the fiset-up" on the cubicle could result in an instan-
taneous current in excess of 40,000 ampers.
Shortly after 1100, the leading petty officer supervising the work
in the cubicle departed without furnishing the duty chief, who happened
to be the chief in charge of main propulsion, the status.and condition
of the cubicle. At 1600 the duty officer was relieved. The on-coming
duty officer did not inspect the ship with the off-going duty officer,
nor did he inspect the ship with the duty chief. Both inspections were
required by ship's regulations. He did however, conduct a complete in-
spection of the ship at 1700.
E-65
l
At about 2330, incident to lining up for a battery charge, the
charging electrician attempted, unsuccessfully, to close the forward and
after circuit breakers remotely from the maneuvering room. It should
be noted that this electrician had just qualified as a charging control-
lerman that day and had stood only seven battery charging watches under
instruction. Of these seven, two were in-port charges. The electrician
assumed that the remote mechanisms were faulty and ordered the breakers
closed manually by the assistant charging electrician. The breakers, in
actuality, were prevented from closing by an electrical interlock. When
the assistant manually closed the forward breaker the electrical interlock
was overridden; however, the instantaneous overload current trip operated
properly and tripped the breaker out again. When the forward breaker
was initally closed, the electrician in the maneuvering room was alerted
by the whirring sound of rotating machinery and meter deflections on
board, noticed the "set-up" on the board, and attempted to call his
assistant and prevent him from closing the after breaker. During the
interim, the assistant, believing he had shut the forward breaker, pro-
ceeded to the after battery and attempted to close the after battery
circuit breaker manually. This time the instantaneous oVerload trip
failed to function and an excessive current passed through the after
battery circuit breaker contacts, fusing them together and negating the
protection provided for overloads.
The intense heat generated by the overload current set fire to com-
bustible material. Simultaneously, full after battery voltage was ap-
plied to the starboard main motors and the ship was propelled forward.
The fire continued until the metallic points of the electrical contact
in the circuit breaker were consumed and current ceased to flow. Insula-
tion and cork in the area continued to burn for about 10 minutes there-
after. Damage was as follows:
1. After battery circuit breaker: Beyond repair.
2. Main power cables from main breaker to battery disconnect link
in 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-up
breaker supply.
c. From back-up breaker outlet to second set of disconnect links.
E-66
Additionally both sets of auxiliary power disconnect links, the anti-
pump relay assembly for main battery breaker remote operating circuit,
the anti-pump relay assembly for auxiliary power back up breaker operat-
ing c i r c u i ~ , and the automatic individual cell voltage scanner for the
after battery, were all damaged beyond repair. Various other electrical
equipment in the vicinity required extensive cleaning and repair.
The relative lack of experience of this submarine's electrical gang
must be considered as a contributing factor. The following table illu-
strates by rate the relative inexperience of this ship's four leading
electricians:
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 in
its possession an engineering report from the bUilding contractor dated
six years prior to the casualty reporting the failure of the after bat-
tery breaker to operate properly, and recommending a remedy. No known
effective action had been taken by any activity on the basis of this
report.
COMMENTS
An almost unbelievable chain of events and circumstances coupled to
overcome the installed safety features and permit this casualty. The
"set-up" on the cubicle was not unauthorized and had been used in the
past to assist removal of arc chutes. However, on this occasion, none
of the duty personnel were aware of the set-up. Although the duty officer
inspected the ship alone at 1700, be might have noted the "set-up" had
be made the required inspections in company with the off-going duty
officer and the day's duty chief. Similarly, had the duty chief, who was
also in charge of main propulsion, kept himself informed of the status
of 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 charging
electrician must be considered. The fact that there had been a history
of difficulty with the involving remote closing of the battery
breakers 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 whirring
sound. Instead precious seconds were lost while attempting to contact
the assistant electrician.
In conclusion, it must be realized that there is a definite. short-
age of experienced personnel on board many of our submarines tod13.y.
There is no substitute for experience. The solution to this problem
lies in close supervision, extreme. thoroughness, and increased
to duty on the part of the officers and leading petty officers who do
have 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 i n s i g ~
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 motors
and 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. An
unusual clicking noise was heard coming from #1 main motor. Investiga-
tion revealed the noise to be caused by a 9/16 X1-3/4 bolt lying be-
tween a main field pole and the armature of the motor. Further inspec-
tion revealed no damage to the motor.
Prior to opening the motor all casing bolts were checked and
found to be in place. There was no access to the motor through which
a bolt of this size could have accidently entered. The motor had not
been opened since the previous shipyard overhaul.
COMMENT
This was a close one. The probable disastrous results of heavy
backing vibration
l
thus shaking the bolt into the airgaPI can be readily
imagined.
This case was
out at the shipyard.
ears to spot trouble
casualty.
caused by some officer who failed to get the bolt
It was saved b y ~ s o m e 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 salvage
exercise. Word was passed over the announcing system to II stand easy
on stations
tl
In the Engine Room the snorkel exhaust line drain was
opened and water was noted by the watch to be draining continuously
from this line into the bilge in a stream about the diameter of a
pencil. At 1100 this bilge was pumped.
No inspection of this bilge was made at the relieving of the
watch at 1145. The next bilge inspection was made at 1345 by the
auxiliary electrician during his routine tour through the boat. At
this time no water showed above the lower deck plates in that bilge.
At 1400 the Engineer Officer noted a very low ground reading
on #2 generator, which was located in this boat down deep in this
same bilge. In:o:nediate inspection revealed that water in the bilge
was over the lower deck plates and had entered the casing of #2
generator.
Subsequent in-port tests revealed a leak in the snorkel exhaust
piping in the superstructure.
FINDINGS .AND OPINIONS
1. The rate of leakage into the bilge concerned from the snorkel
exhaust line drain increased some time after the 1100 pumping of that
bilge, such that the water level in that bilge at the 1345 inspection
was just barely below the lower deck plates in the bilge.
2. A continuous monitoring of the leakage would have detected the
increased rate of leakage, resulting in timely pumping of the bilge
and 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 the
boat's greatest friend by hiding the boat, but that the sea can also
be the boat's greatest enemy by flooding the boat, and that HULL
OPENINGS MAKE THE DIFFERENCE.
F-5
The status of all hull openings, whether by intent or by mater-
ial failure, must be known by all compartment watchstanders and super-
visory personnel. KNOWN LEAKS deserve meticulous attention!!!
"Stand easy on stations
tl
should never mean to any submariner that he
no longer'needbe concerned with leaks into the boat.
F-6
CASE
Main engine damage from blank flange in engine lube oil supply
line.
PRINCIPLES
1 Enploy extremely thorough and careful procedures when starting
a main engine after extensive maintenance periods.
2. Believe gages, meters, and indicators when these instruments
show that abnormal conditions exist.
NARRATIVE
A submarine was conducting initial test running of an engine
following it's overhaul by ship's force during yard overhaul. For
reasons l.inknown to the Engineer Officer and operating enginemen at
the time, the eng;i..ne lube oil low pressurealB.rn1 was "inoperative.
The E r i g i n e ~ r decided to conduct the test runs without it. The en-
gine was started and idled for five minutes. The. lube oil pressure
gage showed abnormally high lube oil pressure, but since the genera-
tor bearing was draining oil normally, the Engineer Officer decided
to continue the idling for the five minute period.
The next day the engine was again idled, sti11without the
benefit of the lube oil low pressure alarm. The +ube oil pressure
gage showed abnormally high lube oil pressure again, and again the
Engineer Officer decided to continue the idling, since the genera-
tor bearing again indi.cated a normal oil drain from it. This time,
however, the fittings on the line to the lube oil pressure gage
ruptured. 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, that
several main bearings had seized, and that several bearing support
webs had warped from overheating. This inspection also revealed a
blank 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 had
caused the abnormally high lube oil gage pressure.
4. The only thing wrong with the lube oil low pressure alarm was
the 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 should
have been immediately shut down and examined to discover the cause.
The engine should not have been restarted until the trouble had been
corrected.
COMMENTS
This case is an example of an advapced degree of negligence
and incompetence.
During a shipyard overhaul period, operating procedures tend
to get out of channels. During an engine overhaul period, the engine
undergoes disassembly and reassembly. Both of :these periods
call for very careful resumption, of upon completion. When
both of these occur simultaneously, then maximum care must be
cised in restoring machinery to operation.
Even under regular operating periods thr.ottlemen are trained
to shut down their engines whenever conditions become abnormal, and
never to start their unless all the protective alarms are
operative. In this case the conditions were as far, as possiQle from
regular operating conditions. Not only did the lube oil pressure
gage show abnormality to its limit, but it even exceeded its limit
and 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 exhaust
gasses to prevent premature opening of "All valve on next snorkel start.
NARRATIVE
A submarine attempted to snorkel start #1 engine. The II All valve
would not open. After re-checking for proper rigging for snorkel, a
second snorkel start was attempted on #1 engine. The "A" valve opened
prematurely 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 bulged
liners, 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 pres-
sure trapped in the line between the "B
II
and "All valves from the
first aborted snorkel start.
4. This trapped pressure resulted in premature automatic opening
of 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 became
inevitable that hydraulic compression damage would result in that
engine, regardless of any action taken by personnel.
COMMENTS
The failure of the cook on watch to place the lIA" valve in
power while preparing to snorkel is a serious one. The question
of reliability of personnel in performing submarine is
so 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 from
any reason, shows lack of understanding of the snorkel system and
what happens to various parts of the system while snorkel starting,
F-9
If the personnel involved in the operation of #1 engine during these
attempted snorkel starts had known their plant, then they would never
have tried to restart that engine as long as they lacked positive
indication that exhaust-gas back-pressure no longer existed in the
snorkel exhaust system.
The means by which the II All valve is opened during snorkeling
.has been changing through the years, but the newest procedure uses
the already-existent snorkel safety circuit as an aid, essentially
as follows:
a. The engine builds up a 17 psi back pressure in the exhaust
line.
b. A bellows type switch completes the circuit to the llA
ll
valve.
solenoid.
c. The llA
Il
valve spool valve itself is positioned by the sole-
noid action above.
The change in operation of the "N' valve has been a source of
potential danger to those submarines whose personnel have came from
submarines with different snorkel systems. This case emphasises the
need for individuB.11y tailored re-qualification programs for person-
nel 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, and
other 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 the
pressure of the oxygen therein. A few minutes after one of the flasks
had been gaged for pressure and secured, it exploded. No personnel
were in the vicinity of the explosion and negligible material damage
was incurred, except for the damage to the flask itself'.
COMMENTS
Oxygen flasks contain oxygen. Oxygen plus fuel plus heat produce
burning. Rapid burning become an explosion. The greater the concentra-
tion of oxygen present the more certain the burning under given fuel
and heat conditions.
Submarine training should include these simple facts, as well as
the two following thumb rules for oxygen flasks:
a. Never use any fuel material, such as oil or grease, in an
attempt to free up oxygen flask fittings.
b. Always test oxygen flasks for leaks by means of a pure
neutral soap solution, using 'a solution kept on board specifically
for the purpose.
F-ll
CASE
Flooding a main engine during an airless start after an airless
surface.
PRINCIPLES
1. Do not leave an outboard exhaust valve open unless. certain that
the 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 lI a irless surface, airless start,
2 engines". The seniorthrottleman decided to start both engines
simultaneously, a practice that the ship had employed several times
in the recent past. Only three enginemen were stationed in the Engine
Room at the time, two throttlemen and 1 oiler.
One of thethrottlemen prepared one engine, the other prepared
the other engine. One rang up IlReadyll to Maneuvering Room:.and manned
both throttles sinrultaneously. As one engine commenced to rotate
due to its generator being motorized, this throttleman momentarily
let go of the other engine's throttle to shut the exhaust drain valve
on the rotating engine. As the other engine commenced to roll, this
throttleman momentarily let go of the first engine's throttle to shut
the 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 he
opened that engine's outboard exhaust valve. He then noted that the
other engine's exhaust back pressUre had built. up so he opened that
engine's outboard exhaust valve.
Both enginemen then heard what sounded to them like cylinder
relief valves opening, and noted water spraying out of one of the
engines . They shut down both engines immediately, However, no
engine order telegraph signal was transmitted to the controllermen
nor were the generator trip switches opened immediately.
The controllermen did not realize that anything had gone wrong
in the Engine Room aside from failure of the engines to fire. Thus
they attempted to restart the engines. This time the enginemen
opened the generator tri;p switches immediately.
F-13
Investigation revealed one engine flooded with the following
resultant 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 extensively
requiring rebuilding and reboring of that liner bore.
FINDlliGS AND OPlliIONS
1. The first engine had not fully fired off at the moment the
engineman let go the first engine's throttle to shut the
exhaust valve for the second:. This resulted in the first engine
dying before it had blown the muffler and tail pipe clear of -water
and while the tail pipe was still below the waterline after .the
airless surfacing.
2. Most of the engine damage occurred on the attempt to restart
this first engine whic4 was now full of water. This damaging attempt
to restart was due solely to the Engine Room's failure to signal
"stop" to the Maneuvering Room and their failure to OPe.n the gen-
erator trip switches .
3. Although the desire to perform an airlesssurfac-e with an air-
less start on two engines in a minimum of time is appreciated, atten-
dant risks are not outbalanced by the rewseconds saved by starting
two engines at one time.
COMMENT
The great difficulty of coordinating this two-headed evolution
should 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 was
damaged by the engineman in charge of the Engine Room. This was re-
ported to the electricians for repair but was not r e p o r t e ~ to the Chief
Engineman nor to the Engineer Officer. Repairs were attempted bui{
were not successful. The engine continued to be operated as needed
despite 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 gage
showed zero lube oil pressure. The engine was stopped and examination
revealed that the' shaft driving the attached lube oil pump had broken.
Further eXamination revealed that all main bearings and four connecting
rod bearings has been wiped, and that two cylinder liners were cracked.
FINDllfGS .AND OPINIONS
1. The engineman in charge of the Engine Room violated shipf s
,orders and good engineering practice in that:
a. having knowledge that the low pressure lube oil alarm was
not 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 the
CSMP nor any notation of necessary work to correct this condition in
the "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 person-
nel before extensive damage was.done.
COMMENT
This case is an illustration of personnel failing to employ
established procedures. Loss of proper lubrication and overheating
F-15
are the two most common causes of engine damage. For this reason, alarms
to indicate impending damage from these failures are installed to warn
the operator. Lack of these alarms places the operator in a precarious
position of having to note the gages continuously in order to be able
to obtain the same information. Had the engineman in charge of the
Engine Room fully realized that one reason for requiring reports of all
material failures is that otherwise unreported failures might result in
inadequate emphasis on repair, and inevitably much greater damage, then
certainly he would have reported the damaged alarm without delay to his
seniors. Trying to aviod blame in this case resulted in the additional
cost of thousands of dollars, hundreds of man-hours of additional work-
load, 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 the
propulsion plant alongside.
NARRATIVE
A submarine connnenced a regular 6-hour battery test discharge along-
side the pier at 0700. The evolution was being conducted by an EMl con-
trollerman and the Engineer Officer as Officer of the Deck on the bridge.
other personnel" both officer and enlisted" were available on board" but
were not called upon to assist.
In starting the discharge" the controllerman made several ser-
ious mistakes. He failed to start the main motor lube oil pumps" he
failed to energize and test the low lube oil pressure alarm" he failed
to commence taking bearing temperatures" and he' failed to employ a
routine electrical log sheet.
At 0745 the controllerman was relieved. The new controllerman
did not correct any of the mistakes of his predecessor.
At 0805 this controllerman was relieved. Th.e third controller-
man commenced using an electrical log sheet and taking bearing tem-
peratures as a result. At 0814 he noted the forward starboard bearings
reading was so high as to be off the scale. Noting then that the lube
oil pumps were not running" he started them. He also stopped the
propeller shafts" and reported this to the Officer of the Deck.
Subsequently the shafts were turned slowly to prevent shaft
seizure until the bearings cooled to 140
0
F. Examination revealed
all 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 had
the electrical log been properly employed. This in turn would have
resulted in proper lubrication of the main motor bearings before
serious damage could result.
3. The electrical log would have been employed and the low lube
oil pressure alarm energized had routine maneuvering watch procedures
been employed" with adequate personnel stationed in the Maneuvering
Room.
F-17
4. Conducting a battery test discharge alongside should require
stationing line handlers, an OOD, a bridge talker, a helmsman, two
controllermen, a Maneuvering Room talker, an electrician in each
battery compartment, with the Engineer Officer and his leading
electrician's mate free to supervise the plant.
5. Routine procedures for relieving the watch, no matter what
watch, should include proper methods of relaying the information
needed to intelligently assume the watch.
COMMENTS
The real fault here was that no established procedure was em-
ployed. The use of non-standard procedures gets minds out of channels,
and watch personnel will fail to do things which regularly they would
never fail to do.
Regular getting-underway procedure should be employed at any time
that the propulsion plant is operated alongside. This includes battery
test discharge, breasting out, and shipyard overhaul dock trials, as
well as the regular or emergency getting of the ship underway
F-18
CASE
Damage to normal fuel oil tanks from excessive pressure of fire
main.
PRINCIPLE
Enploy established procedures during all evolutions affecting the
fuel system to prevent excessive pressures being placed inside fuel tanks.
NARRATIVE
A submarine was filling its fuel oil ~ k s with compensating water
alongside following the drydock period during shipyard overhaul. Water
was being taken from the shipyard fire main into the topside compensating
water connection. Tanks being filled were being vented through their fuel
filling connection. Shipyard fire main pressure was 75 psi. The fuel
king 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 the
pressure was. No one was assisting the fuel king in the filling operation.
As soon as the first tank became full, water commenced passing
out the fuel filling connections from that tank. Shortly thereafter
the tank ruptured.
1. In. order for the water to leave the filled tank as fast as it is
coming in, it is necessary that the internal tank pressure equal the
line pressure forcing the water in. This pressure (75 psi) was ex-
cessive, and the tank ruptured.
2. The immediate cause of the casualty is attributed to failure
of personnel concerned to observe rudimentary precautions preparatory
to subjecting a compensating water system to an outside and unknown
dock pressure.
COMMENTS.
The fuel tanks in the conventional submarine are built to with-
stand an internal pressure differential of 45 psi, are tested during
shipyard overhaul to 37 psi, and should regularly be fueled and de-
fueled using 15-20 psi.
The established procedure for fueling ship requires a man at
the tank being filled, at the next tank to be filled, at the top-
side filling connections, and at the expanSion and collecting tank
liquidometer location, with the fuel king and Engineer Officer super-
vising the entire evolution, free to observe and direct from any and
all locations. The procedure requires that all personnel stationed
F-19
for fueling keep aware of pressure in the tanks and lines at their loca-
tion by use of pressure gages placed at these locations specifically for
the purpose. The procedure requires that personnel stationed :for fueling
be in continuous communication with each other directly by sound-powered
phones. Positive control of the incoming fueling pressure by means of
hull and topside stop valves is mandatory. The plan of fueling and the
complete understanding of the system should be included in the pre-
fueling conference with each of the fueling
During shipyard overhaul periods, procedures tend to get out of
channels. This in turn tends to cause people to try to use shortcut
methods and bypass established procedures. This lesson of e:xperience
again 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 water
leaks into bilges, despite other diverting influences.
NARRATIVE
A submarine was conducting an overside sound survey incident to
entering shipyard overhaul. At the request of shipyard survey personnel,
the ship's force was operating individual auxiliary machinery on a
called-for basis. The particular person who was operating this machinery
was the below deck watchstander. He was doing this at the direction of
the ship's Duty Officer. No one else was below decks inside the sub-
marine.
Being involved in the sound survey, the below decks watchstander
failed 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 occurred
to a depth of three feet, and that the main motors were flooded through
missing bolts and faulty end bell seals.
FINDINGS MilD OPINIONS
1. Although the stern tube was leaking at this time more than was
usual, no flooding of the main motors would have occurred had the
motor room bilges been pumped on each hourly inspection.
2. The ship's Duty Officer was violating the shipI s orders when
he diverted the below decks watchstander from his hourly inspections
of all conrpa.rtments.
COMMENT
This is another illustration of personnel not adequately under-
standing the need for following established procedure. The Duty Officer
should have assigned an additional man from the duty section to operate
machinery for the sound survey, and under no circumstances should he
have employed the below decks watch in such a manner as to divert his
attention from his primary responsibility: Integrity and security
of 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 to
close the after hatch and 25 men were trapped in the torpedo room.
She was a very small submarine and floating cranes were able to lift
the bow and the men were released.
AMERICAN SUBMARINE 0 - 5
The 0-5 sank in Coco Solo, Canal Zone in shallow water, and
here again floating cranes were able to raise the forward end and
two men were rescued after 36 hours.
DANISH SUBMARINE DYKKEREN
The Dykkeren was a small submarine of 150 tons and was rammed
by a steamer and sank in 28 feet of water off in November,
1916. The bulkhead abaft the conning tower was shut leaving nine men
alive Only six had Draeger breathing available.
The Commanding Officer decided to go into the Conning Tower with three
men and help them escape by Conning Tower hatch. These three men
used their Draeger gear and escaped successfully. The Commanding
Officer, however, was not successful in shutting the hatch and per-
ished. It is probable that he failed to work his oxygen valve prop-
erly and became unconscious, as iater when his body was recovered,
his oxygen was full. The remaining five men went into the torpedo
room while this escape was going on. Water gradually entered the
torpedo room and the storage battery, forming chlorine gas. By using
the spare potash regenerators of the Draeger gear they did not suffer
much from the chlorine.
Salvage vessels arrived and a diver made contact by acousti y
< <
Morse signals. After conferring with the three men who had escaped
successfully, the amount of damage could be assessed and it was de-
cided to hoist the bow to the surface by means of salvage craft.
Approximately four hours after the accident, air connections were
made and air at atmospheric pressure was passed to the man imprison-
ed 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 was rammed by the E-4 on 8 August, 1916 off Harwich
in water 45 feet deep. When the E-41 was hit, an attempt was made
to shut the forward bulkhead door, but the water was rising rapidly
and everyone was ordered on deck. While the men were still going
up, the boat sank by the bow. The rising air pressure blew open the
upper conning tower hatch and carried two sub-lieutenants to the
surface. The FIREDRAKE, hurrying to the spot, was able to pick up
only 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 e s c a p ~ is a tale of indomitable courage in the face
of difficulty.
As the boat was sinking he tried to shut the lower conning
tower hatch, but water was coming through it, and he had to retire
aft. He could find no one else alive, and found himself alone in
the engine room of the sunken submarine, which was dimly lit by a
single pilot lamp. His only hope of escape was by the torpedo hatch,
arid, with water rising round him, he started to disconnect its gear-
ing and unship its strongback. Twice or thrice he had to dive under
water to work the wheel of the gearing, and received several severe
shocks from the switchboard. The water rose steadily, and the air
pressure increased, but his most strenous efforts only succeeded i ~
opening the hatch half-way. For close to an hour he wrestled with
it 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 give
up hope, and, as a last resource, he decided to flood the boat as
quickly as possible. Opening a deadl1ght in the bulkhead, he allowed
the engine room to flood completely. With the water right up to
the coaming of the hatch,. he 'knocked out his pin. "I then raised
the hatch, and escaped", he wrote. He rose 4 feet to the surface,
and was picked up by the FlREDRAKE after a desperate, but never-
despairing 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 10
to 15 seconds. The torpedo hit between the central compartment and
the engine room. All the men in these compartments, and on the
bridge, were killed by the explosion.
As dinner was being served, a large number of the crew were
gathered in the crews' space. Water entered the living quarters
immediately, and the men retreated into the bow compartment. Among
them was the Commanding Officer. Emergency lamps were taken. 18
men 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 not
to make any attempt to get out. (It is thought that both he and the
Chief Engineer, who was also forward, had been dazed by the actual
explosion of the torpedo).
After about 4 hours, the air began to get very foul and the
Draeger gear was used to breathe from. Before long, however, this
gave out and the conditions became very bad indeed. When nearly
G-4
GERMAN SUBMARINE U-51 (Cont'd)
all the men were dying, two made their escape, but it must
be presumed that they equalized the pressure either by flooding or
releasing lIP air, or a combination of both. Both got out and reached
the surface, but one was already dead. This was approximately 10
hours after the boat sank.
When the submarine sank, 3 men were also left alive in the
after compartment. The after hatch had been slightly bent by the
force of the explosion, and they were unable to make an immediate
escape. One of these 3 men was very dazed, and in a weakened con-
dition. Finally, 50 hours after the accident, these three men
escaped, presumably by flooding the compartment. All wore their
Draeger gear; two arrived on the surface, not only alive, but in
apparently good condition; the third man was assisted towards the
surface, but apparently died on the way up, as they had to let him
go during the ascent, and he was never seen again.
The K-13 sank in the Garelock in 60 feet of water, in January
1917, due to the engine room ventilators being left open. Thirty-two
men in the after part of the submarine were instantly drowned.
Forty-eight others were alive in the fore part. The Captain of the
submarine, Commander G. HERBERT, went into the Conning Tower with
Commander F .H.M. GOODHART, who was afterwards killed during the ascent
by hitting his head on the chart house roof. GOODHART, was the
Captain of another K-boat, anq was taking a trip with K-13.They
intended 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 left. Compressed
air was used to equalize the pressure. Commander HERBERT
the escape as follows:--
"During the night we heard sounds as if someone was trying to
locate the ship with a grapnel, and about 6 or 8 a.m. we reported
to the divers, tapping, but could get no sense with the Morse Code.
During the forenoon I asked Commander GOODHART if he would try and
get out at low water, 12:30 p.m., with the necessary instructions
to those on top for giving us air and food.
Accordingly, after thinking things out, Commander GOODHART
decided to try for it, and I agree.d that I should try and close the
door after him. I arranged a code of signals to LT SINGER in order
that he could drain down the Conning Tower after Commander GOODHART
had gone clear.
Commander GOODHART and I worked all forenoon taking away the
projector 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 bottom
door 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 with
instructions 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 the
water rose to our waists, I turned .on the H.P. air. Commander GOOD-
HART knocked off the clips of the Conning Tower hatch. The Conning
Tower lid began to let water in and was soon wide open. Commander
GOODHART stood up in the dome, took a deep breath, and then made his
escape. We were both exceedingly out of breath at the time. Almost
immediately I put my hands up to feel for the lid, and without know-
ing, found myself carried through the opening into the shelter, the
roof of which must have struck my head, from the bruises, and a cut
I 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 any-
thing; I fdund myself shooting through the square hatch in the top
of the wheel house. I breathed hard all the way to the surface and
fortunately arrived up between two craft, one of which hauled me
aboard"
HERBERT came up 23 hours after the submarine sank. From HER-
BERT's report and knowledge of the boat, the divers were enabled to
connect up,H.P. air (another submarine (E":'50) supplied the air), and
by this means the survivors in the boat blew out some tanks. This
extra buoyancy, plus large wires which were passed under the bows,
allowed salvage craft to get the bow to the surface; a hole was cut
in the hull, and the survivors escaped 54 hours after the disaster.
Foul air might have killed them before this, had not the divers
connected a 4 inch flexible pipe to the ammunication hand up. This
was approximately 40 hours after the accident. A divers air pipe was
passed down this 4 inch pipe for refreshing the air inside.
There are two particular points of interestj one is that the
survivors were saved by air being passed them, and that HERBERT
describes in two different erports written shortly after his escape
that "I breathed hard all the way to the surface", and again "swim-
ming vigorously for the surface, I was compelled to place my hands
over my face and take a deep breath which to my surprise was air and
not water. Shortly after this, I broke surface." It is probable
that HERBERT's e x p e r i ~ n c e was the excess pressure in his lungs exhaust-
itself on the way up. Nothing of course was known of excess pressure
in those days. It is possible that there was so much H.P. air exhaust-
ing from the Conning Tower that he was actually coming up in a large
air bubble or air stream.
G-6
liB-57
The liB-57 struck a mine off Dover in the 1914-18 war, and sank
in 128 feet of water. The boat flooded rapidly aft, filling up to
the forward Control Room bulkhead. The forward bulkhead leaked
badly. Twenty men were alive in the forward compartments. It was
decided to distribute eight of these men in the Conning Tower, and
the remainder under the fore hatch. Only four-Draeger breathing
apparatus were available.
They first attempted to equalize the pressure in the boat by
using H.P. air from the bottles and torpedoes, but this proved in-
sufficient, and they had to flood the boat in addition.
It was not until approximately 1-1/2 hours after the accident
that they succeeded in equalizing the pressure and opening the
hatches.
The flooding-up period was terrible; chlorine gas caused bad
coughing, and the constantly increasing difficulty in breathing with
aching pain in the ears made conditions well nigh unbearable. Two
men could not stand it any longer and shot themselves. The Officer
in Charge contemplated taking morphine, and the following is this
officer's story of his escape:--
trThe water was in the boat at a height of about one foot above
the floor plates, when I 'once more tried to. open the hatchway.
Suddenly, against my expectation, by the increasing inside pressure
the hatchway cover was torn out of my hands and flung open. I just
could shout "hold on", and then was lifted, without any effort on my
part, and remained for just a short moment up to the lips out
of the hatchway cover without getting wet. I stood in front of a
dark black greenish wall, through which the outlines of the Conning
Tower were perceptible. Then the water broke all over me and I com-
menced to rise. To previously inhale deeply was impossible for me,
due to the difficulty of breathing and the exertion while trying
to open the hatchway cover. For that reason I had not inflated the
life-belt and only closed its valve; so that no water might get into
it. While rising I had the senstation to constantly increase in
size. I was curious to see how long I would be able to hold my
breath, 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 of
my cheeks. (Looking upon what had happened an easily understandable
case, because I had air at 3.5 atm overpressure in my lungs which,
while rising, expanded gradually). I therefore commenced to stop
my trip to the surface by energetically moving my hands. How long
it took until I came to the surface I do not know, and it has been
impossible for me to even guess at that length of time. No two of
the queue leaving the Conning Tower at any event had arrived at the
surface 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 from
the fore compartment appeared. Of these, some, after a terrible
scream, went down again. This I explain by the fact that their
bodies were internally bursted (by holding their breath). My sur-
prise was great when at the surface my swimming vest was filled
with air to the point of bursting. (Reasoning out what had hap-
pened, a very simple case, exactly the same conditions influencing
my lungs). From one of the men saved I heard that the crew in the
fore compartment had seen in the rising of the manometer an indica-
tion of the boat rising to the surface, and had commenced to hastily
pack their clothing. When the manometer showed 6 meters they thought
that the boat had come to the surface and opened the hatchway cover
through which - very much to their suprise - the water heavily rushed
in. 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 the
boat 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 swell
running, it'was impossible to see the other men. We tried to keep
together by shouting at each other. My watch officer, who against
my advice had undressed entirely, after some time did not reply any
more and no doubt was benumbed (heart failure). The water had a
temperature of about 4 degrees Celsius. I myself left in the boat
only my sea boots, cap and gloves, so that I did wear what during
cold weather one has of clothing aboard a submarine. After some
time the masts and fmmel of a guard ship came in sight. By jumping
out of the water and clapping the hands I indicated to her our
location. I was picked up by her already unconscious with six others,
amongst them the Chief Engineer. How it came about that I 'became
unconscious I do not know. I only remember without any struggle or
fear of death. I only know that with my clothing thoroughly soaked,
I had to swim hard notWithstanding the life-belt in order to remain
floating.
My Chief Engineer was lifted on board by the guard ship as the
first man. She lowered a boat and made a search for about an hour
and twice picked up each time three men. During their second trip
they 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 at
1212 on 9 June 1931 in 130 feet of water. 18 men were trapped in the
after part and perished. Of the remainder, 27 left the submarine by
the Conning Tower before she sank and 8 were trapped in the fore ends.
Of these, five made successful escapes, 1 died making his escape and
2 never came up.
G-8
POSEIDON (Cont'd)
The tube space and stowage compartment were flooded by means
of number 3 bowcap, draining to the main line and into the compartment
by the W.R.T. suction. Pressure was equalized after 2-1/2 hours when
two men escaped through the fore hatch, whereupon it shut again. Of
these two, one came up with his mouthpiece cock Shut, and was dead on
reaching the surface. Death was diagnosed as a burst lung although no
autopsy 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 serious
loss of oxygen. In addition, his nose clip was knocked off on leaving
the submarine. This man suffered no ill effects although he lost
consciousness whilst supporting the dead man on the surface. On the
way up he states that he kicked and swam in order to speed up the
ascent at the beginning (presumably he started with negative buoy'-
ancy) and exhaled through his nose during the later part of the as-
cent.
The compartment was flooded up again by the remaining 6 men
and 3-1/4 hours after the disaster, the pressure equalized again and
4 men managed to escape.
The first came up using his D.S.E.A. solely as a buoyancy
bag, full of air, with the mouthcock shut and the exhaust clip on,
his oxygen having run out. This P.O. (WILLIS) gave the following
account of his escape:
"The hatch then flew open and the compartment was immediately
filled. I seemed to hang around the hatch for a few seconds and then
seemed to shoot up, having very violent pains in my chest at the same
time. A short time after getting out I opened by mouth; I could not
stick 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 no
ill effects.
The next two men (one a Chinese boy) came up without removing
the exhaust clip at all, resulting in slight caisson disease in the
case of the Chinese boy and no ill effects in the case of the other
man. Nose clips were in place and there was no escape gas at the
mouthpiece.
The fourth man came up having used all his oxygen. Just be-
fore leaving he broke the small emergency outlet. He came up with
the mouthpiece in and the exhaust clip off, but suffered from severe
caisson disease. He felt no symptoms until he reached the surface
and boarded a boat. He then "went paralysed and had shooting pains
in all his joints".
Of the two who never came up (one a Chinese boy), one had a
set but no oxygen and is presumed to have drowned on leaving the
hatch. The Chinese boy had no set and is presumed to have drowned
in the compartment.
G-9
U.S.S. SQUALUS
The U.S.S. SQUAWS sank at about 0840 on 23 May 1939 in 220
feet of water. The water temperature was 29
0
F.
At 1040, 23 May, it was noted that the SQUALUS' expected sur-
facing report was orie hour overdue. The submarine SCULPIN was or-
dered to try to contact SQUALUS. The Submarine Salvage Ship FALCON
was also warned at this time to be ready to stand by.
At 1241 SCULPIN reported having sighted a red smoke bomb from
SQUALUS. later SCULPIN reported locating the marker buoy from
SQUALUS at latitude 42
0
53'N., longitude 70
0
37'W. This position
was 3 3/4 miles westward from the reported diving position of the
SQUALUS. This fact is pointed out in order to emphasize the extreme
value of the alert lookout kept by SCULPIN" and undoubtedly saved
a tremendous amount of time which otherwise would have been spent
searching for the SQUAWS.
The Commanding Officer of the SCULPIN reported that he had
picked up the marker buoy" which was the forward one of the SQUAWS
and had held two minutes conversation over the buoy telephone with
LT J.C. NICKOLS and LT O.F. NAQUIN, Commanding Officer of SQUALUS
which was in substance as follows:--
WILKIN "What is your trouble?"
NICHOLS "High induction open" crew's compartment" forward
and after engine rooms flooded. Not sure about after
torpedo room but could not establish communications
wi th that compartment. Hold phone and I will put you
on to the Captain."
WILKIN "How are things'l"
NAQUIN "Consider best method to employ is to send diver down
as soon as possible to close high induction and hook
on salvage lines to flooded compartments and free
them of water in attempt to bring her up; for the
present consider that preferable to sending person-
nel up with lung."
At this point the marker buoy cable parted. ~ t e r investiga-
tion showed that a bight of the buoy cable had been caught on some
sharp 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 the
Experimental 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 the
night. It had been ascertained that the personnel in the forward
compartments of the SQUALUS were in no immediate danger. Satisfac-
tory communications had been established with the SQUALUS since 1345
by tapping in Morse code on the hull of the SCULPIN and hearing simi-
lar messages from the SQUALUS. Early messages indicated 33 men alive
forward. Conditions were reported satisfactory but cold.
On 24 May at 0415 Commander Allan R. MC CANN, USN and 12 divers
on the Experimental Diving Unit arrived at the scene of operations.
At 0425 the U.S.S. FALCON arrived. Divers from FALCON were
sent to SCULPIN to familarize themselves with the layout and eCluip-
ment to be found on the SQUALUS, which was a sister ship.
FALCON, owing to wind and sea conditions, had some difficulty
in getting to the right position but at 1014 the first diver went
down and reached the SQUALUS at 1017. The descending line used was
the buoy line which had been attached to the drag anchor by PENACOOK
and this line was discovered by the diver to be only six feet aft of
the forward torpedo room hatch.
At 1028 the rescue chamber downhaul wire was shackled to the
descending line and lowered to the diver who shackled it to the hatch
at 1039.
The extr.emely skillful work of this first diver resulted in
marked expedition of the whole rescue operation and contributed
greatly to its ultimate success. In addition to shackling on the
downhaul wire, it was necessary for him to clear the bight of the
marker buoy line, which lay across the hatch, and was still fouled
somewhere over the side. Had this buoy lirte been allowed to remain,
it would have endangered the rescue chamber operations by possibly
fouling or preventing a tight seal on the hatch. The rescue cham-
ber was hoisted over the side for the first trip at 1130 and re-
ported on the submarine at 1212. The operators reported the SQUAWS
to have a 7 degree list and to be down by the stern.
At 1240 the chamber had been secured to the submarine and the
upper hatch opened. The lower hatch was opened and contact estab-
lished with the submarine crew at 1247.
Provisions and dehydrating materialswere delivered to the
crew, the submarine was ventilated through the chamber for several
minutes, and several passengers taken aboard.
At 1256 the submarine hatch was shut.
At 1342 the rescue chamber reached the surface and survivors
evacuated.
G-12
U.S.S. SQUALUS (Cont'd)
The first three rescue trips were made expeditiously, and
equipment functioned as designed throughout these trips. This was
the first occasion in which the rescue chamber had been used for
other than training purposes, and the results achieved have fully
justified the vision, faith and hard work of those involved in the
development of the equipment.
The fourth trip of the rescue chamber proceeded apparently
according to schedule up to 2022 when, during the ascent with the
last survivors on board, the air motor which dri'les the downhaul
equipment stalled and could not be restarted. An attempt was made
to continue the ascent by controlling with the brake instead of the
motor, but at 155 feet, the reel again jammed and no further down-
haul wire could be let out, even with the brake released. The
equipment could not be moved either up or down, therefore
the decision was made to lower the chamber to the bottom and send
a diver down to unshackle or cut the downhaul wire to free the
chamber.
At 2122 the downhaul cable was cut by a diver. An attempt
was immediately made to heave up the chamber with the winch but the
strain on the retriever wire was abnonnally heavy and at 2125, the
retriever cable stranded. The strain was quickly taken off and the
chamber lowered to the bottom. After a conference it was decided
that the best method of getting tpe chamber up to adjust
the buoyancy of the chamber as nearly as possible to neutral on
the negative side and the haul in the frayed retrieving wire care-
fully by hand in order not to part the remaining strand. In using
this method, the danger of acquiring positi.ve buoyancy of the cham-
ber with resulting swift ascent to the surface, and the possibility
of its coming up under the FAICON had to be accepted. This method
was entirely successful and the chamber surfaced and the last known
survivors were evacuated at 0025 on 25 May.
It was now decided to make a trip in the chamber to the hatch
communicating with the after torpedo room in order to be absolutely
certain that there were no survivors remaining in the SQUALUS.
FALCON therefore changed mooring and after a new downhaul cable had
been fitted the chamber commenced its last descent at 1719. It was
necessary in this operation to equalize the pressure in the rescue
chamber with that of sea pressure in order to enable the submarine
hatch to be opened, without flooding the chamber. At 1815 the res-
cue chamber reached the submarine. When the after torpedo room
hatch was cracked, water commenced to flood into the chamber from
the after torpedo room, proving that this room was flooded. The
hatch was secured and the rescue chamber started to ascend, and,
at 2107, was landed on the deck of the FALCON. It should be noted
that, in the final operation, the two men in charge of the rescue
chamber 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, when
the downhaul cable became jammed, each trip of the chamber to the
submarine and back to the surface took approximately 2 hours and 15
minutes.
The'last survivors reached the surface at 0025 on 25 May. The
SQUALUS sank at 0840 on 23 May, so that these survivors were submerg-
ed for a total of 39 hours and 45 minutes.
All survivors complained bitterly of the cold in the submarine
while waiting to escape. The water temperature was 31G:F. and the
compartment air temperature was only 36
0
F. The air in the compart-
ment was foul with CO
2
, but thi s could never have reached a very high
level as this air was refreshed with each trip of the chamber.
Chlorine was just beginning to make its presence felt when the last
survivors were taken aboard the rescue chamber.
H.M.S. THETIS
The THETIS sank off Liverpool on trials in June 1939, in a depth
of 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 bulk-
head had clips and butterfly nuts instead of being quick closing,
they were unable to close it quickly enough to prevent further
flooding. Had this door been quickly and securely shut the subma-
rine could have been brought to the surface by the crew's own efforts.
Both fore end and torpedo stowage compartment flooded, i.e. all
compartments forward of No. 40 bulkhead.
With the crew and trials party, there were no less than 103
people left alive in the remaining parts 'of the submarine.
It was first decided to pass into the flooded part of the
submarine for purposes of shutting the tube and so pumping 'out, using
the escape chamber as an air lock. An officer first went in alone
with a D.S.E.A. set, but was unable to stand the pressure. A second
attempt was made by a different officer and P.O. They practically
reached the full sea pressure (120 feet), but as the P.O. complained
about his ear hurting the attempt was abandoned. This same officer
went in again with another P.O., but the second P.O. showed signs of
distress as the pressure was built up, and the attempt was again
abandoned. The officer at no time suffered unduly except from the
cold water.
G-14
H.M.S. THETIS (Cont'd)
There is no doubt that this incident was most unfortunate, as
it must have had an adverse effect on the survivors, making them
lose confidence in a normal escape from the chamber at this depth.
A great deal of work was done in the subma;rine during the
night with the subsequent building up of C02 with the large numbers
in the confined space remaining and breathing fast was already
noticed 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 suf-
ficient1y to get the stern up, but by that time most people had
headaches 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. This
extra strain on men already distressed by the C02 can be appreciated.
For example, one officer stated at this time that, by the time he
got aft) he had to rest for 10 to 15 minutes before having enough
energy to don a D.S.E.A. set. 18-1/2 hours after the accident, breath-
ing was becoming increasingly difficult, and the older men were in a
bad way.
Two officers went into the after escape chamber and made their
escape without any real difficulty. The after chamber was about
10 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 the
main 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 they
made 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 that
decided them to make the fatal mistake of putting four people in
at once in a chamber designed for two. They were flooded up, but
either they got jammed or panicked) for after a quarter of an hour
they were still in the flooded chamberj the hatch was shut, and the
men pulled out.. Three were dead, and the fourth nearly so. (All
four had D.S.E.A. sets).
Two were sent in after this, one of whom was a civilian who
had never used D.S.E.A. before. These two men made their escape
with D.S.E.A. sets in the normal manner without any great difficultyj
the 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 remain-
ing were in too bad a state, due to the foul air, to be any longer capa-
ble of making the physical effort of the escape.
After the boat had been salvaged and the submarine under water
for nearly three months, the escape chamber mechanism was still in
perfect working order.
There is every reason to suppose that, had the normal routine
escape been made early enough before the air became foul, a large
majority would have reached the surface successfully.
The lack of a ready means of supplying air at atmospheric pres-
sure was also a disaster. Had the crew removed the manhole to Z tank
which was secured by bolts to the after compartment bulkhead and run
the compressor once the stern was on the surface, they could them-
selves have obtained air through Z vent which was above water, but by
this time approximately 18 hours after the disaster, they were too
overcome by the C02 to think or reason clearly.
u-40
The u-40 hit a mine off Dover in mid-October 1939 and sank in
115 feet of water. The two forward compartments were immediately
flooded and everyone in them drowned. Nine men were left alive in
the 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 hour
after she sank. One survivor stated the air was getting foul, but
the others did not confirm this. Some ate biscuits while waiting,
some nothing. Some put on a lot of clothes, some had only a suit
of underclothes. There was no panic, a certain amount of good humor,
and no tendency to blame anyone for the disaster. Valves were opened
and the compartment took 10-15 minutes to flood. The men took pre-
cautions not to be knocked over by the inrush of waterwhen the hatch
spring was released. The 9 men escaped in between 3 and 4 minutes.
They did not use their pressure release stopcocks, but allowed the
surplus oxygen to escape out of their mouths as they ascended. The 9
men reached the surface, but one was missed fairly soon, and no reason
could be given for his disappearance. The remainder complained bitter-
ly of the cold. All of them had lifebelts, which they inflated by
blOWing them up when they were in the water. Four men huddled to-
gether in the water for warmth, 'but after a few hours exposure, one
after the other died until only WEBER was left. Five men lost their
lives through exposure. The three survivors think that this was due
to cold, but it was probably accelerated by the inhalation of water as
the three survivors were intensely thirsty in the hospital. One states
that, just at dawn, a small boat passed near him, but his cries were
not heard. He lost his courage and the cold was so unbearable that
he deflated his lifebelt with a veiw to drowning. He found the sen-
sation 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 about
mid-day after being in the water between 9 and 10 hours.
Two of them lost consciousness before being picked up. They
were in the hospital 4 to 5 days, and at the end of this time, they
were fit to travel, and a month later were in excellent health.
Only one in the water vomited after about two hours. He was
the one who had eaten biscuits.
The hatch by which they escaped is closed against a heavy
spring. The clips were undone, and when the pressure equalized the
hatch 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 the
oxygen until the last possible moment. This was' not because of .any
instruction they received, but because they regarded the apparatus
as rather an uncomfortable thing which one had to put on at the
last moment, only as a means of escape. When they got to the sur-
face they disconnected their mouthpieces and relied entirely for
support 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 attach
from the aircraft in 131 :feet, in April 1940. There were eight men
left alive in the submarine, and it is believed that they flooded
the whole boat, and escaped via the Conning Tower hatch, opening
every possible valve and means of letting in water. All eight
men survived, and came up without any apparatus.
The II-49 sunk in November ,194o, off the Dutch coast, inapproxi-
mately 70 feet of water. The only details known are from a conversa-
tion held ina P.O.W. camp in Germany as the sole survivor was sub-
sequently 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 is-
sue D.S.E.A. sets to all in the Motor Room. He did this and found
he had left himself without a set. The next thing that he remem-
bered was regaining consciousness on board a German trawler and
finding that he was the sole survivor.
UMPIRE
The UMPIRE was sunk by a collision off Sheringham 0030 on 19
July 1941, in a depth of 60-65 feet. The submarine was listed heavily
to 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 30
0
She was also bow down approximately 10

0
She was holed forward.
Four men collected in the Control Room and 17 in the Engine
Room. Those in the Control Room decided to make their escape via
the Conning Tower. Water was pouring through the Forward Control
Room bulkhead; probably through the ship's ventilation trunk. These
four men (two officers amonst them) allowed the pressure to built
up in the Conning Tower by venting through the lower hatch and allow-
ing the pressure from Control Room to enter Conning Tower.
There was some chlorine present in the Control Room, but it was
not bad in the Conning Tower. Pressure was equalized, and the Con-
ning Tower hatch opened after approximately 40 minutes. The men in
the Conning Tower had neither D.S.E.A. sets nor lifebelts. Owing to
the shallow depth the pressure equalized before the water level
reached the Conning Tower. Of the four in the Conning Tower, the
first to leave reached the surface and was alive and talked with one
of the survivors, but he was not picked up. Two others left and
survived; the remaining man, anE.R.A., was in a very bad way before
the escape was made, and it is the opinion of the survivor inter-
viewed that he never left the Conning Tower, and was drowned in it.
One of the survivors (the last to leave) said he held his breath
all the time. The two survivors suffered no ill effects.
Meanwhile, in the Engine Room, preparations to escape by the
twill trunk were made immediately after the forward bulkhead door
was 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 experi-
enced opening the D.S.E.A. lockers, due to the strong pins.and wires
used to secure the lids.
Owing to the list, it was difficult to shut the forward bulk-
head door, and tackles had to be used to do this in the dark. Flood-
ing was normally carried out through the flooding valve provided,
and the hatch was opened, when the pressure equalized, by the first
pair to escape. There was a small air lock left in the trunk prior
to opening the hatch.
Unfortunately, it is not known how long the flooding took, but
the Engine Room survivors had surfaced less than 1-1/2 hours after the
collision.
As there were three men without sets, it was decided to send
them up with men who had )sets. Of the first two to escape in this
way, both reached the surface alive, hanging on to their opposite
numbers with sets, but they were not picked up and clearly drowned
.afte.r reaching the surface. The third man without aset started with
G-18
UMPIRE (Cont'd)
hi s opposite number wi th a set, but although he was alive when he
entered 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 sur-
vived, but some of those who came up successfully only used their
sets as buoyancy bags. How many is not known. One definitely lost
his mouthpiece by fouling the hatch as he went out; others lost
their mouthpieces when they struck the wiT mast during the ascent.
One man on the way up became entangled with this mast, and had some
difficulty getting clear. The one man with a D.S.E.A. who failed
to 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 hinderance
than anything else.
The escape from the Engine Room was an excellent example of
good leadership, cool thinking, and the correct working of the
twill trunk method. For example, the Chief E.R.A., after some had
escaped, went up into the trunk, right to the hatch, to see that all
was clear and then returned back into the submarine to tell the
others. It is difficult to give 'an exact analysis, but of the 7
men who attempted to escape with neither D ~ S . E . A . nor buoyancy bag,
five reached the surface alive. The others undoubtedly drowned by
lack of some sort of buoyancy on the surface. Of the 14 attempting
escape with D . S . E . A ~ , 13 were successful, but some of these used
D.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 to
the bottom. When they reached the bottom the forward bulkhead door
to the Control Room was already shut and jammed by the force of the
explosion. Some ratings were still alive forward, but the door was
jammed and could not be opened. Shortly afterwards these men were
heard screaming, and then silence, so it, was presumed the compart-
ment flooded forward fairly quickly. The remainder of the crew was
still alive; 24 in all. They went into the Engine Room, but owing
to the congestion, three (1 officer, and 2 men) went to the Conning
Tower to make their escape from there.
The D.S.E.A. sets were all broken out, and after the forward
Engine Room bulkhead door was shut, the men in the Control Room
heard those in the Engine Room start flooding up; but none survived
from the Engine Room.
It is fairly certain that the reason for this failure to es-
cape 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 to
clip down these hatches to prevent the hatches leaking due to IIjump"
when depth charges exploded very close.
The submarine was listed about 20
0
The officer, P.O., and E.R.A. climbed into the Conning Tower.
P;ressure was equalized by flooding. As soon as the pressure equal-
ized, the hatch was opened and they escaped. The E.R.A. escaped
first, 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 attempts
were made to remove his mouthpiece, blood came out.
None of the three had any trouble or experienced any real dis-
tress when flooding up.
The P.O. (KIRK) was a tall, rather timid man, with average
physique. 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 Tower
had equalized outside I filled my bag up by taking air in through
my nose and closing the mouth cock. The E.R.A. then -went up and I
took in a breath of air, put my clip on and followed him straight
away. I had to hold my breath, but I had to open my mouth and took
in 2 or 3 mouthfuls of water. However, the next mOment I broke sur-
face. I did not breathe oxygen in the Conning Tower at all".
KIRK had his mouthpiece cock shut before he started the ascent
durin,g the ascent and on his arrival at the surface.
The officer worked his D.S.E.A. set correctly and used the
apron for the ascent.
The P.O. was in the water for 1-1/2 to 2 hours before being
p i c ~ e d 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 approxi-
mately 170 feet of water.
There was one survivor. The story of the survivor is as fol-
lows:--
G-20
PERSEUS (Cont'd)
"Exactly at 10 0' clock there was a very considerable explosion
and the ,boat went over to about 25
0
to starboard and in a matter of
about 3 seconds was vertical, bow down. I was in the after bulkhead
going 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 further
over to about 30
0
You could not stand on the deck at all; you had
to hang on overhead. Before she reached the bottom all the lights
had failed and the battery was out. I was in complete darkness.
The bulkhead door shut itself. '
For ~ b o u t ten minutes I was feeling my way about trying to
find a D.S.E.A. torch or the secondary lighting. Eventually, in the
starboard bilge I found a D.S.E.A. torch. Water was seeping in 1;l.11
around I went into the stokers' mess and found three fellows
under the lockers. All the overhead woodwork had collapsed. The
men were slightly injured but fairly sensible. I went through the
mess bulkhead to the Motor Room; t4ere all the switches had come
down and one L.T.O. was completely burned. I then went through the
bulkhead to the Engine Room and by the time I got there it must have
been anything up to 20 mInutes.
In the Engine Room water was over the tops of the engines and
just seeping back into the Motor Room. There was no one alive above
the water. The boat was slightly down aft. The Engine Room bulk-
head door itself was shut and tight, but it had no clips.
I proceeded back aft and shut the Engine Room door and put
the dogs on it. I examined the L.T.O. but he was definitely dead
and I left him; I didn't both to find out who he was. I shut the
Motor Room door and in the mess the three young stokers had extri-
cated themselves and were sitting on the deck which was at a big
angle. I told them to get back aft which they did and we shut the
compartment door and clipped it.
At this time I thought we had better consider flooding. It
took half an hour to ,clear all the stores and boxes, etc., that had
fallen from the space under the D.S.E.A. trunk. The pressure then
was still very slight, almost normal. There was no smoke, I attemp-
ted to use the flooding up valves, but they were useless. On the
starboard side of the PERSEUS was the underwater gun which was in a
favourable position for flooding by opening the breech. The water
came 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 she
was flooded half way up I shut off and we got the trunk dow, and
secured it. I flooded up again and by this time breathing was pain-
ful. I continued flooding until no more water would come in. It was
then 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 help
of a spanner I undid No. 4 H.P. air group to the underwater gun and
let air come into the compartment, as I was afraid that, with the
hull leaking, we would be flooded before we could get out. I suc-
ceeded 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 not
put it on. I dived down and got inside the trunk and found there
was about two feet of air inside. I undid the four dogs and water
began to seep in through the rim of the hatch. I gave the hatch a
heave and nearly went out in the bubble. The other three fellows
had their sets on and I saw their exhaust cocks were open and they
went out. They had to be pushed out and they had to help themselves
because of the angle. I then put on my set and adjusted the nose
clip and dived down. Immediately I got inside the trunk there was
such a blast of air that I knocked the set off. I returned to the
compartment and put the mouthpiece and nose clip on again, and put
a little gas itl the lung, because I had lost it all. I had the ex-
haust cock open and everything was working properly, although there
was one disadvantage" a drum of enamel had burst open and it was all
on the surface of the water inside" so that immediately you dived
down you were covered in it. However this time I held the set on
wi th one hand and in the other held the torch. I eased myself out,
feeling for the jumping wire" and steadying myself by putting my
feet in the rim of the hatch. I let myself go, holding the apron
out most of thetirrie. It took about two minutes to come up.
I felt no ill effects at all. It was a bright moonlight night
and there was nobody in sight at all. The other three could not
have 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 re-
serve, as there are various incidents difficult to account for.
Three different authorities who all saw this man separately are
doubtful of the whole story. There is no other means of checking
the facts and it is possible that this man, who was only taking pas-
sage in PERSEUS, may have been on the bridge or in the Control Room
and got out before she sank. At the same time there is no direct
evidence that his story is not in substance correct.)
The X-3 sank on 4 November 1942 at 1350 in Loch Striven in a
depth of water of 114 feet, due to a leaking engine valve. The whole
crew, consisting of three officers, all made successful escapes after
the submarine bottomed.
G-22
X-3 (Cont'd)
Immediately after the submarine dived, it was realized that
water was coming into the boat and she was brought to the surface at
a very steep angle of about 80
0
, but only stayed on the surface about
five minutes before sinking rapidly by the stern. All possible meth-
ods of surfacing after sinking failed. The motors continued to run
until the boat bottomed. Very shortly after hitting the bottom,
chlorine appeared and all three donned their D.S.E.A. sets. LT LATES
was the first to enter the W&D hatch and the flooding of the W&D was
done by opening the equalizing cock in the top hatch. The forward
hatch 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 not
working. LATES was exposed to a shower bath and he felt cold, miser-
able and frightened. He was breathing from his set very fast and his
oxygen ran out in about 20 minutes, he thinks. He was nearly uncon-
scious, but he opened the forward door of the W&D and went back into
the Control Room, where he lost consciousness.
GAY, the second survivor, stated that when LATES came back into
the boat, he looked very frightened, was almost hysterical, was shak-
ing allover and complained of being unable to get any oxygen to
breathe. Immediately after that, LATES lost consciousness. The other
two officers placed another set over the one that LATES was wearing
and stuck the mouthpiece in his mouth. He was only breathing the
atmosphere from the boat for about half a minute. GAY now entered
the W&D but flooded it up this time with the forward door open. The
boat itself was flooding more rapidly now. It had been flooded on
its own from the momeni of the accident. LORIMORE and GAY had
opened an induction valve and this apparently did increase the rate
of flooding. They also tried to break the glass of some scuttles to
increase the rate of flooding but this was unsuccessful. GAY pushed
open the hatch of the W&D as soon as the pressure was equalized
which took approximately 20 - 25 minutes from the time they bot-
tomed. (Note: From the account of surface vessel the first sur-
vivors appeared approximately 30 minutes after the submarine sank).
GAY breathed from his set the whole time, Le. from the time
the ship bottomed until he made his escape. He carried out the
drill completely; he drained his lung and the bag before he put
oxygen into it. He was therefore breathing pure. oxygen for about
25 minutes before opening the hatch. All this time the water was
gradually filling up until it was level with his face and he was in
a continual shower of water the whole time. He experienced a slight
feeling of breathlessness before he actually made his escape, but
attributes it to his exertions whilst trying to open the hatch.
After opening the hatch he climbed out of the W&D and intended to
remain there in order to pull LATES out, as he was unconscious, but
unfortunately, he did not hold on to anything and immediately started
to float up. He pulled his apron out and came up at the standard
45
0
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 not
after that. He had a nose clip on and his mouthpiece in all the
time. He stated "It was lovely going up". He had no pains in his
chest at all. At the surface he carried out the routine drill and
felt no ill effects except soreness of his shoulder muscles. These
remained sore for about three days and he attributes this to muscle
soreness following his exertions to open the hatch and crawl out of
the 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.LATES
recovered consciousness at this point. He came to with the sensa-
tions of terrific pressure on his ears and stinging of his eyes due
to chlorine. He was wearing two D.S.E.A. sets and as he was thrust
through the forward door of the W&D, the mouthpiece of the set he
was breathing from was knocked out of this mouth. Somehow he passed
through the upper hatch of W&D and he then opened his eyes and strug-
gled, swimming to the surface. On the way up he held his breath as
long as he could and then released the air from his lungs through
his mouth. He thinks he released too much as, just before he reached
the surface, he wanted to breathe in and did in fact get some water
in his mouth, but almost simultaneously broke surface. It is con-
sidered by the physiologists that LATES' condition was one of syncope
produced by overbreathing and this view is supported by the fact that
both his sets were found to contain oxygen after he had been rescued.
It should be noted that none of the three survivors suffered from
any marked or permanent ill effects.
UNTAMED
The UNTAMED sank about 1400 on 30 May 1943 in 160 feet of water
off Campbeltown. There were no survivors. The UNTAMED was subse-
quently salvaged and examined.
Disaster was due to faulty operation of the "Ottway" log, caus-
ing extensive flooding forward. Two men were trapped in the crews
space which had been flooded in an attempt to escape.
For about four hours attempts were made to surface the subma-
rine which were entirely inadequate and, in many cases, incorrect.
Preparations to escape were not made until this period had elapsed
and it is presumed thatthis was due to the fact that at this time
there was access only to a limited number of D.S.E.A. sets, and be-
cause the D.S.E.A. flooding valve, which was especially fitted for
flooding 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. Also
a drain into the after ends was left open resulting in that compart-
ment having to flood up as well.
G-24
UNTAMED (Contrd)
It is estimated that flooding must have taken at least an hour
by which time the danger of C02 poisoning must have been acute.
Evidence has shown that escape by the Conning Tower was con-
sidered 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 men
in the Engine Room were without sets.
From a tabular statement showing the state of D.S.E.A. sets
after salvage, half the sets were full and half empty, or nearly
empty, and in most cases the mouthpiece cocks, and exhaust valves
were shut. From this it would appear that the effects of CO2 were
not appreciated until it was too late and most of the crew succumbed
without attempting to use their sets as a breathing apparatus in the
foul atmosphere.
WELIMAN X
As the result of an accident the WELLMAN craft sank in 186
feet of water with one man aboard - a Norwegian named PEDERSON.
The boat sank with a steep angle down by the stern. After vainly
attempting to surface the craft, this officer set about escaping.
The boat was flooding rapidly. He started up the direction indica-
tor which kept air circulating and put on the Momsen Lung, charging
the lung up with oxygen by 'means of the flexible connection pro-
vided. He smelled chlorine so started to breathe from the lung,
but as the water rose he floated up with it thereby breaking the
connection to the main oxygen supply. He then broke the oxylet an-d
tried to open the hatch but the pressure had not yet completely
equalized. He dipped under water and connected the flexible con-
nection and so got more oxygen into the lung. But the supply soon
ran out and a few minutes later there was nothing left to breathe
from. Again hetried to open the hatch and this time he succeeded.
He states theiate of ascent was slow and began to feel himself
passing out through lack of oxYgen, at what he thought was about
30 feet. (He states "It had grown quite light".) He' lost conscious-
ness.
Loss of consciousness was almost certainly due to a lack of
oxygen, plus asphysixation due to almost drowning. He was under
water a considerable time before escaping and when he lost conscious-
ness his mouthpiece fell out of his mouth.
The officer surfaced approximately 20-25 minutes after the
boat sank. When picked up (there was a boat immediately on the spot
which picked him up the moment he surfaced) he was floating face
downwards and unconscious. Approximately 30 seconds after surfacing,
G-25
WELLMAN X (Cont'd)
he was breathing, although poorly. He had his Momsen lung on, but
the mouthpiece was out of place.
Artificial respiration, combined with the
soon restored normal rhythm, which was only disturbed by frequent
vomiting. This may have been due to chlorine, but most probably
was due to the salt water swallowed. There was no smell of chlorine,
either on the patients breath, or in his vornit. The vomiting con-
tinued for half an hour after PEDERSON was in bed, and by this time
he was only bringing up a little blood-stained mocous, probably due
to rupture of small blood vessels caused by strain of retching. He
was of course from cold and shock, but his recovery was
rapid and apparently complete. Thanks to his magnificent physique,
and the fact that he was able to receive immediate skilled atten-
tion, he was, two days later, back at work' entirely confident and
treating the whole matter as part of the days work.
U-533
The U-533 was sunk by alc in the Persian Gulf on 17 October
1943. The submarine dived as soon as she sighted the ale, and the
first depth charge exploded when she was at approximately 75 feet.
All the went out. At 180 feet, approximately, another depth
charge exploded near the hull apd she sank. This holed the subma-
rine arid she flooded throughout very quickly.
One officer and one man got out. They were in the Conning
Tower at the time, and they suddenly found themselves up to their
necks 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 reached
the surface, but the officer was unconscious. The rating supported
him on the surface for nearly an hour, but he did not con-
sciousness. The rating himself states he lost consciousness for
a short period, but came to on the sur:face.
This rating then swam to the coast and. was swimming for 28
hours (prisoner's word only for this).
The depth from which they came up is uncertain, but it was
certainly 180 feet or deeper. Both men were under pressure for a
verY short time indeed, before they ascending.
U-741
The submarine was diving at 150 feet, approximately, off the
Isle 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 but
leaked badly. The pressure aft in the boat had already increased
considerably before the survivors started to flood up. There was a
certain amount of chlorine present.
The method of flooding was via the diesel exhaust valve and
then through the inboard drain, approximately a 4 inch diameter
pipe.
There were 12 men in the after part after the accident; all
had Draeger breathing apparatus.
There was possibly 310 C02 present before the accident as the
subma:r:ine bad been submerged from 12 to 15 hours previous to the
accident and for some unknown reason bad not been using the puri-
fiers. (This is only the survivorts statement and cannot be relied
on implicitly; they may have been running some of that time without
hi s knowledge).
The order to don their Draeger gear was not given until there
was considerable pressure in the boat, and it was not until some of
the men passed out (obviously with C02 poisoning from the high par-
tial pressure) that the remainder donned their equipment and started
breathing oxygen. All were panting for breath before donning their
apparatus.
The submarine was listing approximately 40
0

About 10 minutes after the disaster they started flooding.
(Note: there was some pressure already in the compartment before
flooding started). Flooding lasted approximately ~ minutes, un-
til the hatch could be opened. Approximately 15 minutes after the
flooding started several men started to shout and scream and said
they had no air and became unconscious. (It is not certain whether
they were getting oxygen poisoning or had run out of oxygen--it is
more likely oxygen poisoning).
At this time there must have been a very high concentration
of C02 as the survivor stated he tried taking his mouthpiece out to
breathe from the air pocket to save oxygen, but he felt his throat
contracting and it was impossible to breathe after taking only a
very few breaths. The water in the compartment was waist high by
this time.
A stoker P.O. ftrst started to try to open the hatch, but as
soon as he commenced making the extra exertion he could not get
enough air and fell back into the water.
G-27
U-741 (Cont'd)
At this time, when the pressure was practically at its maxi-
mum, anyone who started doing work passed out. (It must be remem-
bered that all were wearing Draeger gear--capacity approximately
30 minutes).
As the pressure started to reach its maximum, several men
complained of ear trouble and became very excited about it. The
survivor cleared his ears by blowing, with his fingers holding his
nose.
Towards the end the men became very quiet and only four or
five could talk at all; one after the other they passed out. (Did
they go out with oxygen poisoning or lack of oxygen due to the
bottle being expended? It is probable it was oxygen poisoning, as
had it been lack of air, it is more likely they would have dragged
their mouthpieces out of their mouths to breathe in from the air
pocket. From one survivor's report, they did not do this, but
passed out with their mouthpieces still in their mouths).
The survivor, realizing that the men were passing out possibly
because their oxygen was running out, managed to get hold of a sec-
ond unused set which he donned. He managed to get the hatch open.
There was no twill trunk in this hatch and therefore there was a
large air bubble that was released as the hatch opened. He shot
out in this bubble and ascended very fast indeed; in fact, when he
reached the surface he bounced out of the water to waist level.
Before leaving he noticed his oxygen was nearly finished (this may
have been that the bag was merely collapsed due to the pressure and
he had not put enough in). As soon as he left the hatch and started
to ascent he felt the oxygen bag expanding and he at once started to
breathe more freely. He felt that he could breathe more freely as
soon as he was oi:lly a few meters away from the boat. He had his
mouthpiece in his mouth all the way up. When he reached the surface
he was a+m0st unconscious and had great difficulty in keeping him-
self afloat. He later had pains in his ears. He was sick in the
boat which picked him up, but he himself attributes this to the fuel
oil he swallowed, as there was a lot of this in the compartment dur-
ing flooding up.
One other survivor reached the surface alive and shouted, but
sank just before the Corvette's boat reached him. He was also wear-
ing 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 in
November 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 sub-
merged for about 6 hours. The following is the account of an officer
who escaped:--
"Almost immediately a depth charge exploded somewhere extreme-
ly close under us, lifting the stern and causing us to hit bottom
hard. This charge extinguished the greater part of the lighting,
although one or two of the emergency lights held. About five sec-
onds 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 the
door at the after end of the torpedo stowage compartment. Immedi-
ately, I gave the order "Shut water tight doors" and turned to make
sure that the three ratings in the tube space were brought out of
that compartment before the door was shut. By the time this door
was shut, the water was flooding very much faster and had risen
above the deck boards in the stowage compartment. It now was above
our knees. It was flooding through the door so fast that the ratings
were unable to shut this door. The position of the stop (retaining
door in open position) on this water tight door was such that to
remove it one had to stand in the doorway as the port side of the
door was blocked by stores. Hence, due to the furious rate of flood-
ing, this could not be removed. "In what appeared to be an incredi-
bly short time, I was keeping above water by clinging onto a hammock
which was slung from the deck-head. The crew in my compartment be-
gan to sing, but I ordered this to stop and told the crew to get out
and put on their D.S.E.A. sets. The first I managed to reach had a
defe'ctive valve on the oxygen bottle and I could not move it. The
second was in working order and I put this over the head of one of
older ratings who was panicking and in tears due to the pressure
effect on his ears. The pressure in the boat at the time was immense
and the chlorine content in the air considerable. The water all
round 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 heard
to be escaping through the hull forward and the water was still
rising fast. At this time Leading Seaman GIBBS was in the escape
hatch trying to slack back the clips. He shouted to me that he
could not move the third clip. Speaking was nearly impossible due
to the pressure. I swung up into the trunk alongside GIBBS and
tried to remove the clip. After what seemed like an hour, and what
I suppose was really a minute, I managed to move the clip by ham-
mering it with my fist . By this time there was no hope of using
the escape trunk as the water was already up to the metal combing
which houses the twill trunking. I took off the last clip and as I
did so the hatch commenced to open. Immediately this clip was free,
the hatch was blown open and Leading Seaman GIBBS was shot out so
suddenly that I cannot remember him going. The hatch slammed shut
again and hit me on the top of the head, but immediately blew open
again 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 at
the time, are known to have left the submarine alive, although only
eight were picked up. The Ship's Cook was later seen to be floating,
face downwards, on the surface, but was obviously drowned; it is not
known whether or not he wore a D.S.E.A. During the flooding up and
prior 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 cer-
tain he had the mouthpiece cock shut. He was in a very bad way on
the surface and would have drowned had not one of the other sur-
vivors on the surface blown up his D.S.E.A. bag by opening the
oxygen bottle. Another who wore a D.S.E.A. set is believed to have
left the submarine with it, but was never seen on the surface, this
was probable the man, aged 55, who was in a very bad way before the
escape and could not have been expected to survive in any case.
Three others were seen to be handling sets before the hatch was
opened but it is not known whether any of these survived or if they
did, whether they had time to don their sets or not.
The Japenese destroyer dropped two more charges after the
submarine was hit, but these were not so close and did not do any
more damage although they p ~ o b a b l y acceleraten the flooding.
"Throughout the above experiences the behaviour of the crew
in my compartment was magnificent".
H.P. air was escaping all the time during the accident and it
is known that they had an excess pressure in the submarine over the
sea pressure. The effect of pressure was described by the officer
as follows (the pressure at this time must have corresponded to a
depth of 160 feet):--
"Speech was practically impossible; one could make movements
wi th one's mouth but no noise came. One's head was swimming and
you could not think quickly. You could not hear anything except a
ringing sound, and it felt as if one had been holding one's breath
for a long time".
The time between sinking and escape was probably 15 min-
utes.
Of the 14 men in the compartment only
seriously from the suddenly rising pressure.
well under the increasing pressure.
one apparently suffered
The men behaved very
The officer stated his ascent seemed very fast and he felt the
air being forced out of his lungs as he ascended. Apart from a pain
in his chest some 48 hours later and fairly severe bends, which
lasted for 3 days, he was none the worse. Once the hatch opened
the men escaped very quickly.
G-30
STRATAGEM (Cont'd)
A sailor who survived also felt the air being forced out of
his lungs as he ascended.
Both the officer and man interviewed considered that, while
they were under high pressure, they would not have carried out simple
orders or worked valves, etc.
U-1199
This submarine, which had been Schnorkel-cruising for 3 to 4
days, was badly damaged by depth charges and bottomed at 73 metres
(240 feet), with a list of 35
0
to 40
0
She sank off the Wolf Rock.
At this time the whole crew of 47 were alive and orders were given
to abandon ship and stand by with life-saving equipment. CLAUSSEN
was in the Control Room together with the Commanding Officer, the
Engineer; and Control Room personnel, all of whom, with the excep-
tion of the First Lieutenant, had Draeger gear, but no swimsuits.
It was a standing order that anybody on watch carried his Draeger
gear even if he only went from one compartment to another.
No bulkhead doors were shut and flooding was rapid through
the damaged hull and through the outboard vents of the trimming
tanks which were opened for the purpose. There was no chlorine.
CLAUSSEN was first in the Conning Tower followed by others
crawling up the ladder and the time between his entering the Conning
Tower and opening the hatch was a matter of seconds rather than
minutes. He was unable to give any estimate of the time between
commencement of flooding and his escape, but it must have been sev-
eral minutes.
During the flooding he had been breathing oxygen from his set
and was totally submerged before being able to open the hatch; there
being no air-bubble in the Conning Tower.
At this time he was wearing his Draeger gear with mouthpiece
cock open. He had opened the oxygen valve slightly when first don-
ning the gear, opening it further as pressure increased, but had
forgotten to close it again later. It is probable that he also for-
got to open the exhaust valve. Before leaving the craft, he experi-
enced a senstation of great pressure which caused a ringing or hum-
ming in his ears and, after having lifted the hatch, felt very weak
and quite incapable of further physical effort. This weakness per-
sisted for the first few feet of his ascent which was rapid, but
feeling his chest to be intolerably expanded he held his nose and
twisted the mouthpiece to allow gas to escape from the corner of
his mouth, which relieved both discomfort and weakness. This was
a spontaneous action and not the result of training. He continued
to 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 and
he subsequently blew it up by mouth to give himself buoyancy. He
was on the surface for about 10 minutes before being picked up.
He experienced pains in his chest and in his knees for 2-3
days, 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 depth
of 18 feet.
Of the 46 men alive and provided with sets when the boat bot-
tomed, only one man escaped successfully, although flooding was
rapid, and some were actually on the ladder of the Conning Tower
just behind the sole survivor.
The most probable explanation of this fact is that all col-
lapsed with oxygen poisoning, having been breathing from their sets
for some minutes under pressure. CLAUSSEN's loss of strength and
difficulty in muscular movement seem likely to be advance symptoms
of collapse fram oxygen poisoning; a view which is strengthened by
his rapid recovery on releasing pressure by the mouthpiece.
He, in fact, escaped only just in time. It may be that CLAUSSEN's
suggestion is correct (that the man following him got stuck and
prevented others from emerging), but again the effects of breath-
ing oxygen under pressure would so weaken the crew that the addi-
tional 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 al-
though he stated that he felt a desire to inspire he was unable to
do so. It is, however, a fact that buoyancy was lost during ascent
by escape of gas through the twisted mouthpiece and this would help
to avoid the risk of burst lungs and of vascular embolism in the
last of the ascent.
This submarine was sunk on 26 March 1945 at 0520 by depth char-
ges. She was submerged at the time at a depth of 50 meters, i.e. 160
feet, 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 air
was still quite good in the boat at the time of the attack. It is
presumed that the C02 absorption unit had been working, but the re-
port does not state so definitely.
PFLOCK was on watch in the Control Room and was beside the
depth gauge. They were at 50 meters depth when attacked and the
Engineer 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 and
water commenced to pour in. The crew did not all have their life
saving equipment with them and PFLOCK himself had none. He made his
way into the Conning Tower where there were two others, also with-
out breathing sets. The water rose very rapidly and he told one of
the others to open the hatch. While he was opening the hatch the
water was up to their shoulders. They were" all three very nervous
and scared stiff. Just before the hatch opened the water was almost
to the top. PFLOCK took one deep breath and shot out. The other
two men never left the boat as far as he knew. He thinks they just
held on to the rail and never made an escape.
On the way up to the surface he did exactly what he had been
told. He held his arms out wide to slow down his rate of ascent
and allowed the air from his lungs to escape through his mouth. All
the way up he had no desire to breathe in. He had no sensations
during the ascent probably because he was so scared. He does not
think he was in the Conning Tower more than two minutes before he
mad.e hi s e seape
After reaching the surface he was in the water about 3/4 of
an hour before being picked up. It was March and the water was very
cold. Coldness was the only sensation he had. He swam to the Cor-
vette, but had to be hauled on board from the lifeboat, he was so
weak. After getting on board he began to feel pain in his chest
and was taken to the Sick Bay where they gave him artificial res-
piration, after which he began to feel better. He couldntt lie down
properly because of the pains in his back. Breathing also remained
painful for some time. He suffered no eye trouble or visual dis-
turbances.
Just before he escaped and when under high pressure he states
that 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 him
to ascent to the surface, but it seemed a very long time.
Note: There is little doubt there must have been at least
two per cent of CO
2
in the boat before it flooded, and yet PFLOCK
took a deep breath of highly compressed air just before leaving the
boat. He was scared and stupid and would have been expected to do
all the things conducive to drowning. This is a typical example of
a man who is terrified making his escape and yet he knew he had to
breathe 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 neither
of 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 was
submerged at the time of the accident and had been submerged about 20
minutes with no air purification working during that 20 minutes. She
was hit forward and listed temporarily to about 40
0
then the trawl-
er's propeller hit and holed the submarine aft. The Commanding
Officer ordered the W&D top hatch to be opened, this was unclipped,
but naturally could not be opened owing to water pressure. She sank
to the bottom stern down nearly vertical (survivor's estimate) water
pouring in aft all the time.
When she hit the bottom she straightned out and settled with-
out any appreciable list. E.R.A. SWA'ITON at time of accident was in
the Control Room. The First Lieutenant was in W&D when she hit bot-
tom and SWATTON was halfway intoW&D.The two W&Dhatches leading
forward and aft were open all the time. By the time the pressure
had equalized BWA'ITON and the First Lieutenant were both in ~ h e W&D
wi th their heads in the air lock. The top hatch was already un-
clipped. Owing to the very large hole aft,' the pressure eqUalized
in a few minutes, possibly not more than 3 minutes. A shower came
in round the lip of the top hatch when the pressure was practically
equal, but this shower did not prevent the women breathing in the
air pocket right up to the mtch' being opened. There was still an
air pocket when hatch was opened, which at the end, was approxi-
mately 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 a
deep breath before coming out. Neither had any l i ~ e b e l t . SWATTON
never felt any pain in his ears at any time, neither did the First
Lieutenant 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 had
ever 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 way
up because of the big pressure at which he had been. He did so
well all the way up by puffing through his lips, about half way up
he felt he would like to breathe in but decided definitely to hold
his breath until he surfaced. In actual fact he refrained from
breathing in and thinks he'never stopped breathing out all the way
up, at no time did he feel a desperate urge to breathe in. He
didn't notice that he was breathless on breaking surface.
It must be remembered that this man had done a course of div-
ing. The interesting point is that suddenly, on the way up, it
dawned on him that he must breathe out, this was probably an uncon-
scious 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 water
entered his mouth or nose on the way up, neither does he remember
any air going out of his nose. SWATTON, on surfacing, felt no
effeGts at all, nor did he feel any later. He was picked up almost
immediately after surfacing.
The First Lieutenant left the submarine immediately after
STtlA'ITON, in fact practically simultaneously, they arrived on the
surface together.
This manls evidence bears out that confidence inspired by know-
ledge 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, I
had given up all hope of getting out and resigned myself to keep
calm until the end. Pressure was becoming acute and I kept clear-
ing my ears. Suddenly water poured into the W&D. I was not fully
conscious because,I cannot remember clearly what did happen, but I
imagine we had bottomed and levelled off. I thought the hatch had
opened 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 the
water and I imagined I was coming up to the surface
ll
SWATTON stated that the Who reached the sur-

face almost simultaneously with himself, was unconscious and he
grabbed him as he was sinking. He was still unconscious when he was
brought on board the trawler but was brought round. by artificial
respiration and later in the afternoon he was alright and was none.
the worse afterward.
U-1195
This was sunk in April 1945 in the Channel off the
Nab. She VTas submerged at approximately 75 feet when she was holed
by depth charge forward. She rested on the bottom in 96 feet.
Nearly all the crew was alive--approximately 50 in all.. These split
into two parties, one lot of 33 went into the after part, the re-
maining 17 went into the Control Room.
Taking first the escapes from aft. There was an officer in
charge. All the clips were taken off the escape hatch and the
hatch secured by a piece of rope. This could then be cut when the
pressure equalized and the hatch would open itself. (Iri German
submarines the hatches are shut against a spring). This hatch had
a twill trunk which they rigged.
G-35
The submarine was listed to approximately 40
0
All the men
had Draeger gear except 4 or 5. The officer in charge had a Draeger
set, but the oxygen bottle was not working. Those without Draeger
sets were given life jackets and one man dinghies and were to make
their escape first. As soon as these preparations were complete they
started to flood the after part of the boat i.e. from the after Control
Room door to right aft. They flooded the boat through the Diesel
exhaust drain by opening main exhaust valve and then the drain to this
exhaust--approximately a 4 inch diameter pipe. Fortunately the officer
had a watch and he states quite clearly that from the time of flooding
to the escape it was 20 minutes. He stated the flooding seemed very
slow and was bad for their morale.
During the flooding the batteries in this part of the sub-
marine started giving off chlorine so that they shut the door to
this compartment which helped to isolate the chlorine.
At first, apart from the coughing due to the chlorine, all
went well, but as the water and pressure rose the situation started
to deteriorate.
The men with Draeger sets stared breathing from them as soon
as flooding up started - the men's eyes were running. They were
breathless and "snapping for air like fishes".
The officer was very worried as to how to get the men into the
bottom of the twill trunk owing to the excessive angle of the sub-
marine. When this officer recknoned the pressure was equalized he
sent a Stoker P.O. to open the hatch. This man was wearing a life
jacket, but no Draeger gear. The P.O. succeeded in opening the
hatch, but was drowned in the process and was left gripping the
coaming or rail and it took three men to finally pull him back into
the compartment.
The escape then started. Those without escape gear, but with
life jackets went first. The officer stationed himself at the bottom
of the trunk and literally thrust each man down and under the twill
as they had difficulty in getting d o ~ n and under due to the buoyancy
of their life jackets. He was under water each time he did this
bobbing up to breathe from the air pocket between each escape. Ex-
cept for the Stoker P.O., the four who went out thus, without
Draeger, reached the surface successfully and survived. One with
Draeger gear then went up.
The officer went up next. As his oxygen bottle was hot work-
ing he blew up his Draeger bag with his mouth while his head was in
air at the top of the compartment. He then took a deep breath and
tried 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 and
again 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 he
had his Draeger blown up as a lifebelt, the mouthpiece in his mouth
with the mouthpiece cock shut. He states he put the mouthpiece in
his mouth as the mouthpiece cock was leaking and he did not want the
air to go from his Draeger bag.
He swallowed a little water during his struggles to get under
and through the trunk. He reckons he must have been a minute strug-
gling under water before he got clear. He held his breath after
getting out for what he guesses was about half the way up; but all
the 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 escape
finally made him want to breathe in before he reached the surface.
Although he wanted to breathe in very badly he managed to keep his
mouth firmly shut. Some water came in through his nose which final-
ly stopped him trying to breathe in. He distinctly felt the expand-
ing pressure in his lungs on the way up. Ite was in the water about
10 to 15 minutes before he was picked up. His eyes and lower part
of his chest hurt him after rescue. The pains in his chest made him
feel that he could not get enough air, but these pains wore off after
about 20 minutes. His nose was permanently running for about 3
hours. He had no other pains and no visual disturbances; although
his eyes still hurt him when it is cold.
When this officer reached the surface there was another sur-
vivor, in a dinghy, in a very weak condition who was suffering with
his chest. This man had been breathing from a Draeger set before
he made his escape and as far as is known he had the mouthpiece in
when making the ascent. This man, before the escape, had lost all
hope and was very demoralized and had to be shouted at before he
would do anything.
After SCHICK had made his escape, the Ship's Cook, wearing
only a schwimmveste, became jammed at the bottom of the twill trunk.
FRUHWALD was sitting on top of the starboard diesel. The re-
mainder in the compartment surged forward in a panic around the twill
trunk. He heard the Chief E.R.A. shout that the only means of
escape now was through the after torpedo hatch. He then made his
way 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 over-
come by the surge forward of the remainder (these were .all inexperi-
enced and rather panic striken young stokers).
He noticed during the flooding up that a powerfully built man
who was sitting right forward and not wearing a breathing apparatus
suddenly collapsed.
On leaving the hatch he shut his exhaust valve and ascended
very rapidly in spite of the fact that he held his arms and legs out
to 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 as-
cent. On reaching the surface the mouthpiece came out of his mouth
and the bag deflated, so he blew it up as a buoyancy bag.
He considered that NEIDERHAUSEN, who assisted him in flooding
the compartment and w.ho remained aft the whole time during the
flooding up, made his way to the after torpedo hatch as soon as the
pressure equalized, opened the hatch, which was submerged due to
the list, and escaped, as he was already in the Corvette when FRUH-
WALD was picked up. (Note: Due to the list the air pocket in the
compartment would remain when the after hatch was opened).
A wiT operator who escaped out of the twill trunk with SCHICK
did not put on his set until the moment of escape and was very ill
after being picked up. FRUHWALD suffered no ill effects.
Seventeen men, including the Captain and First Lieutenant
went into the Control Room and started to make their escape from
there. Three of the seventeen had no Draeger gear, but these three
had lifebelts.
They flooded up through Q tank (presumably by kingston and
inboard vent) also via the ballast pump. The three without sets
were sent up into the Conning Tower to escape first. The remainder
with their Draeger were collected in the Control Room. The lower
hatch leading from Control Room to Conning Tower was open. There
was a certain amount of confusion. During the flooding up a lot of
oil fuel came in withthe water and bothered the men' s eyes.
The flooding was upset by rivets overhead in the pressure
hull leaking. The escape of air due to leaking rivets overhead
meant that there was no air pocket left in the Control Room when
the pressure had equalized and the only air pocket left was about
4 to 6 inches at the top of the Conning Tower. Thus everyone in
the Control Roomwas completely submerged.
The three without se:ts were left with their heads in this
tiny air pocket in the Conning Tower. They opened the hatch and
went up. (The survivor whom the Committee examined, GMOEHLING an
Engineer, was most intelligent and lucid. He had also taken con-
siderable interest in escape during his Draeger training).
One of these three described in detail how he and the others
were breathing very rapidly in this tiny air pocket immediately
prior to opening the hatch. He also stated he was unable to take a
deep breath before leaving as there was so little air left (and that
little contained-C02 at a high partial pressure). In this high con-
centration 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 soon
as he started ascending he no longer WANTED TO BREATHE IN.
As he ascended he let air escape out of his mouth as he had
been taught to do. He states "he just opened his mouth and away
it went." He let out air all the way up.
After leaving the boat at first he felt he was going too slow-
ly, he therefore let more air into his lifejacket (not the Draeger
set which he was not wearing). He. then went up faster and at no time
did he attempt to check his ascent. He felt no ill effects after
reaching the surface. He stated quite clearly that he had no desire
to breathe in on the way up; on the contrary he had too much air and
wanted to get rid of it.
Fortunately the survivor interviewed was responsible for the
air purification and had taken this just before the accident occur-
red. It was then 2'/0. They had been submerged from 2 to 3 hours be-
fore the accident.and the air purification plant had been switched'
off (to avoid noise during the attack).
From ~ h e ~ i m e the flooding started untilthe hatch was opened
was about 10 minutes. No one, as far as thi s man remembers, com-
plained of the rapidly increasing pressure.
Out of the Conning Tower and Control Room 6 reached the sur-
face and survived. Three without Draeger gear, three with it. It
is of considerable interest that these three with Draeger gear were
submerged completely for what must have been several minutes before
they could coine out of the Conning Tower. Of the original 50 sur-
vivors alive in the submarine after she sank, 14 survived. Of these
7 came up with no Draeger gear, 1 came up using the Draeger only as
a lifebelt, with mouthpiece cock shut .and the remaining 6 had Drae-
ger gear. Six had survived from the Control Room and the Conning
Tower, 6 from the twill trunk hatch aft and two from the after
hatch with no twill trunk at all.
Note: This survivor stated that the Draeger school has appre-
ciated mixtures must be breathed at big depths (nitrogen and oxygen).
The deeper the more accurate must be the mixture. He was asked if he
felt he could come up from 306 feex (if necessary) with no apparatus
and replied Yes, provided he was only under pressure first for a
very short time prior to the ascent.
U.S.S. TANG
The submarine sank after being hit by one of its own torpedoes
circling 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 stick-
ing out of water. The upper'Conning Tower hatch was open as she
sank; those in the Control Room managed to shut the lower Conning
Tower hatch, but it was strained by the explosion and leaked. The
confusion at this stage with men and gear falling around, due to the
acute angle, was great.
All but two of these in the Conning Tower were probably drowned
almost at once. One of these, found himself breathing in a ring air
pocket. He struggled out of this, and reached a larger pocket at
the fore end of the Conning Tower. These pockets were, of course,
due to the acute angle. Very shortly after his accident, this offi-
cer ducked out from his air pocket and made a free ascent through
the Conning Tower hatch without breathing apparatus or lifebelt.
This officer had been taught to exhale during a free ascent at the
Submarine School. He came up from 50-60 feet,and described his
ascent as follows: "I began to swim up using both hands as hard as
I 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 letting
the 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 would
have to swallow some salt water I burst ov.t on the surface and began
sWimming
ll
He was none the worse, had no pain in his chest, and
swam around for about 8 hours, before being picked up. The second
man alive in the Conning Tower was dazed and frightened. He was
to 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 Control
Room and compartments forward, and in the Engine Room and after
Battery Room. The compartments abaft the Control Room fiooded
fairly rapidly, and the men opened the door and got forward with
the water already half up the door. Approximatelyl5-30minutes
after the accident, a rating in the Control Room opened a.tank vent
by hand, and the submarine sank to the bottom and levelled off with-
out any very serious angle. The depth was now 180 feet. The men
made their way forward tinti145of them (at least 2 with broken
limbs and many others injured) were collected in the Forward Tor-
pedo Room. One of them, a Negro, had had his face smashed in when
the door into the Forward Torpedo Room was opened. The emergency
lights were working.
Not long after this an officer and some men tried to pass
through the door aft, but as they cracked the door" dense smoke and
fumes poured in through the door. This smoke was serious for some
time. Men complained of irritation of throat and lungs and eyes, and
tt some seemed actually choking to death in it"; one survivor stated
t1this 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 conditions
improved. There is little doubt that there was a bad battery fire
in the Forward Battery Room which continued right up to the end as
the lower part of the bulkhead at the after end of the Torpedo Room
got hotter and hotter until the paint began to peel. There had pre-
viously been another fire forward when the forward plane rigging and
tilting motor burned out completely, lasting about 10 minutes.
There was probably a continuously build-up of pressure from
the flooded portion aft, as the escape proceeded, through some drains
in the battery compartment via a sanitary tank and from this through
drains into the Torpedo Room. This must have been assisted by the
increase in pressure when men were admitted from the flooded part;
by the fact that the explosion had fractured the air lines; and by
the draining of the chamber into the compartment during the escape.
Some survivors are said to have noticed the heightened pressure, but
there 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 is
probable 5 attempts to escape were made. In the first attempt to
escape four entered the escaPe compartment taking a rubber boat with
them. There was a difference of opinion among them as to the drill,
rigging and' trunk, life line, etc.; there was also some difficulty
in getting this l;ine out.'" One man didn't wait for the line and went
out, this man had already been injured about the head in the first
crash and is reported to have used his lung and taken two pistols
and a bayonet with him. lie was not seen again and whether he reached
the surface or not is unknown. Some 40 minutes later as there was
no signal from the trunk those inside drained it down. The three
remaining must therefore have been under pressure equal to 180 feet
for 40 minutes. The failure of these three men to escape after 40
minutes in the trunk must have discouraged those in the compartment
especially as one of them stated he didn't care to attempt to es-
cape again.
At the next attempt 5 went in, very much crowding the escape
compartment, but the lifeboat was omitted. After another 40 minutes
and no signal, those in the Torpedo Room drained the compartment and
found 3 had gone up; one of these men had already been 40 minutes
under pressure during the first escape. But 2 men remained: one was
in a stupor, the other was very exhausted and had got forward of the
life line which had pinned him to the trunk; the line was cut adrift
and he was brought bac;k into the submarine. Of the three who did es-
cape, one survived, one was seen at the surface drifting away, and
the third was never seen again.
The failure of these 2 and their exhausted condition together
with 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 to
try an escape although they knew what was going to happen to them
below" - another states - "after 2 hours over half of the men did
not care to attempt it". The rising partial pressure of CO2 and
the smoke added naturally to their discouragement. For example a
survivor states - "the constantly increasing pressure, smoke and
heat seemed to effect everyone's thinking, after the difficulties
of the first escape and the smoke all formed enthusiasm died down
and many didn't care whether they escaped or not". (Apparently
there was no panting, or difficulty in getting breath). To add to
these terrible conditions the Japanese were dropping depth charges
from time to timeII
A third party of one officer and three men then attempted the
escape. Some difficulty was found in opening the door but this was
soon overcome and the pressure was equalized by flooding, when the
first man went to charge his lung from the oxygen manifold there
was no oxygen, thi s greatly di scouraged the other three. For about
15 minutes under the full pressure they attempted to rig a new life-
line, but the first man (the officer) who had blown up his lung from
his 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 lungs
I 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 life
line as a buoy. I would have let the ring go up to the surface and
then gone up the line but I was so near passing out I went up with
it. The other men could have escaped if they had only stepped out
of the hatch, but they didn't want to try without oxygen although
I explained how they could".
After this man got out he lost the mouthpiece of his lung
about 20 feet from the submarine due to the men below jerking the
line, he then made a free ascent, he states as follows:--"After 20
feet - I lost my lung, so I blew the air out all the way to the
surface trying to equalize the escaping air the way the lung would
have done, on reaching the surface I was exhausted and sick
ll
He
got t9 a life buoy, which another survivor had with him and 'Was
picked up about 3-4 hours l a t e r ~
The fourth attempt was made by4 men. One of these had al-
ready been in the trunk for 40 minutes under pressure and caught
in the life line, another had also made a previous attempt. All
these four escaped and probably reached the surface alive some 45
minutes after the. previous men surfaced, although one of them dis-
appeared soon and it isn't known what happened to him.
The last escape is very confused, and there may be more than
one 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 after
the wounded manj he was nearly unconscious and had to be supported
as his lung didn't give him enough buoyancy. The survivor who held
him up stated:--"He kept gasping as if he couldn't breathe and
wouldn't understand anything. His condition grew worse until he
stopped breathing.
The second man (a Negro, possibly the man who has his face
smashed) had no lung, and probably no lifebelt. His arms were seen
flailing the water for a few seconds, and he was then seen floating
away drowned.
The third man had a lung, and probably used it. He seemed
very weak at first, but recovered after holding on to the buoy for
some time. He talked to another survivor, and did not complain that
anything was wrong with him. He was picked up by the Japanese, 1-1/2
hours later, and thrown into a boat. He now began to froth at the
mouth, and became blue, although he continued breathing for 10 min-
utes at least. He was then separated from the other survivors and
never seen again.
SUMMARIZING THESE ESCAPES: In the Conning Tower, there were
2 survivors, of whom one made a free ascent from 60 feet, and the
other probably never attempted to escape. In the Forward Torpedo
Room there were 45 survivors, of whom probably 13 tried to escape 8
or 9 reached the surface, and 5 survived. One of the survivors made
a free ascent without difficulty. Of these who died on the surface,
one was probably already injured, one had been exposed to the pres-
sure of 180 feet of water for a long time twice, and all had been
subjected to rising pressure and smoke inside the submarine for
several hours.
COMMENTS
It is evident from analyzing the few known facts of attempted
and successful submarine escape that strong leadership and a will
to survive is essential. Equally important is a detailed knowledge
of escape equipment, procedures) and the physiological phenomenon
encountered at increased pressures and during changing pressures.
Understanding the effects of gasses particularly under increased
partial pressures, and a means of combating them may well mean the
difference between success and failure.
Analysis of survivors' reports combined with experience gained
through experimentation, training and continued searching for better
methods of escape have brought about many changes in the Submarine
Escape Field. Probably the major improvements are better equipped
and more efficient Submarine Rescue Vessels and the adoption of
BUOYANT 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 on
board ship.
PRINCIPLES
L The requirements for the security of safes on board ship must be
complied with at all times.
2. The cognizant Bureau requirements regarding the administration of
a ships depsrtment must be complied with at all times.
On this occasion, a submarine was making a partial commissary
return covering two months and seven days of an operating quarter.
Money for Cash Sales of Meals to Officers "had already been collected
for the first two months and was in the custody of the Commissary
Officer. This money was kept in a cigar box in the Duty Officers
safe in the yeomans office. The combination to this safe was known
by all Duty Officers.
On Monday afternoon, while the ship was in port, the Com-
missary Officer removed the box from the safe preparatory to col-
lecting mess bills for the last seven days of the period. The
money, about $289.00, was missing.
The last time that the Commissary Officer had seen the money
was about 1400, the preceeding Friday, while the ship was returning
to port. At that time, he took the money, clipped it together and
placed it in the bottom of the cigar box with the records of meals
sold on top. The box was then returned to the safe.
That night the Duty Officer entered the safe to obtain an en-
velope, containing money for a member of the crew, which has been put
there for safe keeping. The envelope was not found. Next morning,
Saturday, the Commissary Officer entered the safe and found the en-
velope, and returned it to the proper man. Over the weekend, other
Duty Officers may, or may not, have had occasion to enter the safe.
Investigation revealed that the Duty Officers had, on n u m e r ~
ous occasions, left the safe open and unattended. It was also cus-
tomary to keep money belonging to the crew in the safe for safe
keeping. This information was common knowledge among the officers
and many members of the crew. In addition, although the Bu8anda
requirements that the Commissary Officer have a combination sat'e
for his exclusive use were known to the Commissary Officer, they
had 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 safe
just a short time prior to this incident. This loss was attributed
to 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 undetermined
officer without being constantly attended while open.
2. Requirements of BuSanda Manual, Volume VIII, Par. 82131.4b in re-
gard to having a combination safe for the exclusive use of stowage of
funds collected for the sale of meals from the general mess were not
complied with by the ship.
3. The Commissary Officer used poor judgment in keeping such a large
sum 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 the
loss, no routine procedure exi sted for checking safes shut l3.nd several
witnesses stated that the safe in question had been left open and un-
attended on" numerous occasions.
COMMENTS
This case illustrates how accepting an administrative discrep-
ancy because it has "always been that way" leads to trouble. The
Commissary Officer used the Duty Officers Safe to stow public funds
because 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 safe
because it had also been done in the past. The Duty Officers were
lax in locking the safe because they had done thi sin the past with
no untoward incidents. The Commissary Officer kept large sums in the
safe, despite a recent loss, because it was 'easier than trying to turn
it in monthly to a disbursing officer. The above open safe with money
in it and a thief on board combined at last to result in trouble that
did not need to happen had routine administration procedures been ob-
served.
H-4

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The Commanding Officer of the submarine commenced his approach and

6. The information concerning the current in

She was also bow down approximately 10

SWATTON stated that the Who reached the sur-

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