View Full Version : Final Report on USS San Francisco Grounding

08 May 05,, 21:51
Specifically, an investigating officer and three admirals who reviewed the report concluded that then-San Francisco commanding officer Cmdr. Kevin Mooney and his navigation team failed to develop and execute a safe voyage plan, then failed to exercise enough caution while transiting through a region dotted with steep undersea volcanoes.

The Navy’s Pacific Fleet released the 124-page report at 6:30 p.m. EDT Saturday to organizations it said had requested a copy through the Freedom of Information Act. The initial report was completed Feb. 3 but release was delayed for official review and the deletion of material deemed sensitive. The report will be made available to the general public May 9.

While the admirals were unanimous in blaming Mooney and his navigation team, they also equivocated slightly. In his endorsement of the report, Vice Adm. Jonathan W. Greenert, commander of 7th Fleet, noted that the sea mount struck by the sub was not on the primary chart being used at the time of the mishap and that “opportunities exist for systemic improvement in functional (formal and on-the-job training) and administrative (directives and inspections) areas.”

But he also found that the sub had other charts onboard that did indicate a sea mount within 2.87 miles of the sub’s “intended track” but that the charts were not properly reviewed during the planning process.

“I find it difficult to conclude absolutely that grounding could have been avoided,” Greenert wrote. “It is absolutely clear to me, however, that if command leadership and the navigation team followed basic specified procedures and exercised prudent navigation practices, they would have been aware of imminent navigation hazards and therefore [been] compelled to operate the ship more prudently.

“At a minimum, the grounding would not have been as severe.”

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

Those cautionary measures, Greenert said, could have included stationing additional navigation watchstanders, establishing limits on speed and depth and reducing the navigational sounding interval to more frequently check on variations in depth.

Mooney declined to comment on the report, other than to provide a written statement to Navy Times that read: “I accept responsibility for the grounding as the ship’s CO.” Mooney was relieved of his command by Greenert Feb. 12 and is now assigned to an unspecified position in Washington state.

Greenert also criticized the executive officer and navigation team, saying their “failure to adequately and critically review applicable publications and available charts led to submission of an ill-advised voyage plan and hindered the commanding officer’s ability to make fully informed safety-of-ship decisions.”

The navigation team consisted of Mooney and several officers and enlisted sailors whose names were deleted from the report. They included the sub’s executive officer and navigator, and three enlisted electronics technicians: the assistant navigator, a senior chief petty officer; the navigation supervisor, a first class petty officer; and the quartermaster of the watch, a second class petty officer.

The entire navigation team and one other enlisted sailor received nonjudicial punishment March 22, with punishments ranging from reductions in rate to punitive letters of reprimand.

The crew’s voyage planning process began Jan. 4 when, according to the report, the 7th Fleet Submarine Operating Authority, or SubOpAuth, issued a basic track or “moving haven” for the sub to follow on a voyage from Guam to Brisbane, Australia.

The track also includes a rough timeline the sub is expected to follow. The information, contained in what submariners call a “subnote,” allows the SubOpAuth to roughly track the submarine while underway and to ensure no other submarines are operating within its moving haven in order to reduce the risk of collision.

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

The San Francisco was due to deploy three days later, and Mooney and the sub’s navigation team wanted the subnote much sooner. The assistant navigator complained to the SubOpAuth that they needed to get subnotes out more quickly “because the review process will fall down because we don’t have enough time to get everything done. … ”

Yet the assistant navigator felt confident about the basic track, saying an official contact at the SubOpAuth told him that “other submarines had used this track previously.” Mooney wasn’t as confident initially, saying of his initial review of the track, “I was concerned about the path. … I was familiar with the Caroline Islands as being a region that was going to be a concern to drive through.”

But later, Mooney felt better about the route, considering that he’d be in the middle of a 40-mile-wide moving haven “that didn’t have any navigation hazards on it.”

The navigation team was relying on a bottom contour chart labeled E2202 that includes historical sounding data for the region. To the team, the area where the sub ultimately grounded was a flat spot. The team, including Mooney, did not look at a 1989 chart, DMA 81023, that contains a dotted-line circle labeled “discolored water” that was on the sub’s track — and which actually is about three miles south of where the mishap occurred. The discolored water indicates a potential hazard.

Mooney told the investigator that he expected his navigator to examine every available chart on a given route, and that he wasn’t shown DMA 81023 and didn’t ask if another chart for that area existed. According to the report, Mooney also said he considered charts containing sounding data to be significantly better. But he also said that, in retrospect, he thought his navigation team “should have laid our track down on the 81023 chart … they should have looked around for navigation hazards, and then transferred them over to the chart.”

At one point during the planning process, the navigation supervisor pulled DMA 81023 out of a drawer on the sub, looked at it but decided its detail was inferior to E2202. He put it back. Later, the assistant navigator looked at E2202 for 15 minutes but apparently did not notice the area of discolored water — the result of an incorrectly charted 1963 sighting.

The sea mount’s exact location was known, however, but not to the National Geospatial-Intelligence Agency, the government group that produces all U.S. military charts and maps. It was indicated on a 1999 Landsat 7 satellite image indicating a likely undersea mountain rising to within 100 feet of the surface, according to the U.S. Geological Survey’s National Center for Earth Resource Observation and Science.

In addition, a shallow danger spot correlating to the incorrectly charted discolored water spot was loaded on a digital nautical chart loaded in the sub’s digital navigation system. According to the report, “no watchstander noticed it.”

Once in the Carolines on the night of Jan. 7-8, Mooney’s night orders called for depth soundings and a positional fix to be taken every 15 minutes. Deviations between actual and charted soundings would be cause for alarm, officials say. On Jan. 8, the 0645 sounding showed a depth beneath the keel of 832 fathoms, or 4,992 feet. According to the chart, it should have read between 7,200-7,800 feet. The discrepancy was not noted.

The last recorded sounding in the sub’s fathometer log, taken at 1130, was 6,192 feet beneath the keel. Soundings in the preceding hour had been “trending shallower” but were consistent with E2202.

Details regarding indications of depth and speed at the time of the grounding — 1138 — are blacked out in the report.

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

The study included a “thorough review of navigation voyage planning procedures,” he said.

The report holds NGA blameless, noting only that, in the future, all critical navigational hazards should be included on soundings charts such as E2202. The investigator’s opinions regarding the performance of the 7th Fleet SubOpAuth are largely blacked out of the report.

Mooney and his navigation team were held wholly responsible for the mishap.

“The investigation reveals a series of bad judgments, faulty assumptions, poor attention to detail, and complacency among the navigation department, watch standers, and command leadership,” wrote Adm. Walter Doran, Pacific Fleet commander, in his endorsement of the report. “But for outstanding damage control efforts and post-grounding leadership, this event could have had far more disastrous consequences.”

Greenert agreed with the latter, offering praise not only for the crew’s successful efforts to save the sub and return safely to Guam, but also for Mooney’s prior record and performance.

“Although the grounding incident compelled me to punish (Mooney) and remove him from command, in my opinion it does not negate 19 years of exemplary service,” the admiral wrote. “Prior to the grounding incident, USS San Francisco demonstrated a trend of continuing improvement and compiled an impressive record of achievement under (Mooney’s) leadership.”

William H. McMichael is the Hampton Roads bureau chief for Navy Times.

09 May 05,, 04:01
*sigh* A sailor dead, many severely, several valuable careers ruined, one billion-dollar SSN FUBAR'ed. :frown:
Not a good day at all.
Rick, other than the obvious "close the barn door" knee-jerk reaction, how would you say the various submarine commands in the USN, and indeed throughout the world, have reacted to this tragedy?
Oh hell, share the barn door reaction as well, I'm no submariner :redface:

09 May 05,, 04:39
Navigation procedures will certainly come to the forefront of all submariners conciousness. Their will be more focus, questioning and double-checking of future voyage planning and of course actual navigational execution.

There were many failures here by alot of people. If only one person would have paid a little more attention and acted on their instincts and misgivings it would never have happened.

This didnt happen unfortunately.

Some of course are more culpable than others and were held accountable accordingly but others held to a lesser standard could have taken simple actions that may well have averted this tragedy both higher and lower in the chain of command.

Its water under the bridge now. It will be up to individuals to heed the "lessons learned" to see that a similar incident doesnt happen on their watch.

As time passes of course complacency, over-familiarity, not heeding the little warning bells that go off in a pesons head ie instincts, arrogance, time pressures could(will?) increase the risk of further incidents.

Submarining is inherently dangerous but it is also tedious with routine and repetition. Long periods of relative boredom are punctuated by acute and brief periods of frenzied activity.

Hopefully those acute periods arent the result of failures during the boring periods.

Time tells all things.

Heres what the person who was the Engineering Officer on the submarine I served on said during the Kursk tragedy:

The Russian Submarine Situation: A Statement by Vice Adm. Grossenbacher

(Navy Office of Information)

The following is a statement attributed to Vice Adm. John J. Grossenbacher, commander, Submarine Force Atlantic, on behalf of the men and women of the U.S. Navy:

The situation with the Russian submarine is most unfortunate. Our thoughts and prayers are with those submariners and their families in this difficult time.

Submarining is inherently dangerous. The undersea environment is very unforgiving. Conquering these elements and actually operating submarines submerged at sea is a tremendous accomplishment of man and machine.

Like all Navies that operate in this extreme environment, the U.S. Navy takes every precaution with its submarine force. From the design and construction of its submarines, with redundant systems and back-ups, to the extensive training of its crews, in fire fighting, damage control and emergency egress procedures, safety is paramount in the U.S. Navy submarine force.

We hope this situation resolves itself quickly, and without loss of life.

Vice Adm. John J. Grossenbacher,

Commander, Submarine Force Atlantic

09 May 05,, 17:10
This whole thing reminds me a little bit of my ex-roomate's story about the 637-class he was on that got caught in a fishing trawler's net and nearly went to the bottom due to lack of propulsion (the net had wrapped around the shaft).

09 May 05,, 22:12
This whole thing reminds me a little bit of my ex-roomate's story about the 637-class he was on that got caught in a fishing trawler's net and nearly went to the bottom due to lack of propulsion (the net had wrapped around the shaft).

Holy Crap!!!!!!!!!!!!!!!!!!!!!

Glad I missed that one. LOL

I have stories of my own which you may have seen.

And most submariners I know have equally hair-raising tales to tell.

But if I had the chance Id do it again. Im getting pretty old now though. LOL

Its a brutal life for those who take it the most serious(ie 24/7 for prolonged periods) but if you want to find out who you really are its one of the few pursuits that can show you in a very short period of time.

And when it isnt taken serious enough by ALL involved you have incidents like the USS San Francisco.

The rewards are few but the consequences of even minor failures much less disaster haunt you a lifetime.

I know because I still wake-up in a cold sweat occasionally some 25-30 years later after a vivid bout with the past of times that werent particualrly pleasant.

Scares the hell out of my wife. LOL

09 May 05,, 22:34
Yeah, from what he said, it was hair-raising. I checked out the date, August of 1992 in the Irish Sea.
Once they got the surface, they had guys out on deck with knives cutting away the net and passing pieces of it down the ladder (covertly?)
His best friend (now a CPO) tied his share around his ankle and I believe keeps it there to this day.

09 May 05,, 22:47
Yeah, from what he said, it was hair-raising. I checked out the date, August of 1992 in the Irish Sea.
Once they got the surface, they had guys out on deck with knifes cutting away the net and passing pieces of it down the ladder (covertly?)
His best friend (now a CPO) tied his share around his ankle and I believe keeps it there to this day.

Not surprised!!! LOL

Heres a snippet from Admiral Doran that pretty much sums up the points I have been trying to make:

"“The investigation reveals a series of bad judgments, faulty assumptions, poor attention to detail, and complacency among the navigation department, watch standers, and command leadership,” wrote Adm. Walter Doran, Pacific Fleet commander, in his endorsement of the report. "

And of such things are tragedies made. If anyone would have interceded at any point in any of the the four issues mentioned odds are this would never have occured.

Coulda, shoulda, woulda three simple words easier said than done. As I unfortunately know all to well.

10 May 05,, 21:08
Changes Under Way In U.S. Submarine Force
Navy looks at training and chart-making in wake of USS San Francisco crash

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Day Staff Writer, Navy/Defense/Electric Boat
Published on 5/10/2005

A series of mistakes that began days before the USS San Francisco went to sea in January led to its crashing into an underwater mountain, a new Navy report concludes.

The command investigation report reached many of the same conclusions contained in a preliminary investigative report that was finished weeks after the January accident, including that the crew relied on an inaccurate chart and ignored warning signs before the accident.

With the investigation now closed, the Navy's top submarine officer said the undersea force will continue to draw lessons from the accident, and has started to make changes to training, chart-making and operations to prevent a reoccurrence.

“It continues to be a reminder to us of the demanding profession we live in, (and that) there are parts of what we do that are uncertain,” said Vice Adm. Charles Munns, commander of Naval Submarine Forces. “We need to move forward from this, learn from this and make sure it does not happen again.

“This part of our business is more art than science. The science part of our business we do exquisitely, and I think the rest of the world recognizes that. The art side is a whole lot more difficult.”

Adms. Walter F. Doran, commander of the Pacific Fleet, and J.W. Greenert, commander of the Seventh Fleet, both said in letters accompanying the 124-page report that they could not state absolutely that the grounding could have been prevented.

But Doran wrote, “I am convinced that the ship would have most likely avoided grounding had prudent measures been taken based on an assessment of the risks. ... If not wholly avoided, the grounding would have been far less severe.”

Greenert wrote that while the actions of the captain, Cmdr. Kevin Mooney, immediately before the grounding “fell below Navy standards commensurate with command,” he could not recommend that Mooney be forced to resign.

“Although the grounding incident compelled me to punish (Mooney) and remove him from command, in my opinion it does not negate 19 years of exemplary service,” Greenert wrote.

“Prior to the grounding incident, USS San Francisco demonstrated a trend of continuing improvement and compiled an impressive record of achievement under (Mooney's) leadership,” Greenert wrote. “Moreover, the crew's post-ground response under his direct leadership was commendable and enabled USS San Francisco's recovery and safe return to port.”


The San Francisco left Guam on Jan. 7 headed for Brisbane, Australia. Early in the morning of Jan. 8, in an area where charts said the water depth was 1,200 to 1,300 fathoms, the sub recorded a depth of 935 fathoms, still far more water than it needed for safe operation, but 22 to 25 percent less than charted.

The captain's standing orders required that in the event of a discrepancy of more than 20 percent from the chart, the navigator should be called to the control room and the captain, executive officer, assistant navigator and officer of the deck should be notified immediately. But the discrepancy was not reported.

Soundings in the hour before the grounding had been trending shallower, but were consistent with the chart, and the last recorded sounding, taken just minutes before the grounding, still showed 1,032 fathoms beneath the keel.

But while traveling near top speed at 525 feet below the surface, San Francisco slammed into an underwater mountain near the Carolina Islands.

One crewman was killed, and 97 others were injured to some extent. A preliminary estimate put repair costs at $88 million, and repairs are expected to take more than a year to complete.

The investigation showed that the navigation team relied too heavily on one chart that did not show the seamount over others that showed areas of muddy water in the vicinity of the accident, an indication of shallow water.

“The simple way to say it is, the mountain was on some of the charts that they had, (but) it was not on the chart they chose to navigate with,” Munns said. “At a minimum, the planning process should have recognized that the mountain was there, and they should have taken more prudent measures to manage that risk.”

But the report also notes that while there were some deficiencies noted in navigation practices on the ship in 2004, in January the San Francisco won its squadron's top awards for navigation, seamanship, damage control, supply and medical services.

Munns said the submarine force will launch an external review of the accident, drawing navigation experts from the Coast Guard, the Merchant Marine, and possibly other countries, to gauge its navigation strengths and weaknesses.

“There are a lot of schools out there that teach navigation skills to masters, mates and pilots,” he said. “We think we're the gold standard here, but we're going to benchmark ourselves against some of these other organizations.”


The force has changed the curriculum in its Submarine Learning Center, based in Groton, so that every new officer and navigation technician learns how the San Francisco accident happened, and how to prevent such an incident.

Munns said the Navy also will work closely with the National Geodetic Agency to get information into all charts more quickly — though there were signs of an undersea mountain in the area for more than 40 years, it was not on the chart that the San Francisco was using at the time of the crash.

And the written procedures that navigation teams must follow on a submarine have been rewritten to make perfectly clear the risks of navigation in open ocean.

In addition, Munns said, the submarine force will speed up plans to get the Voyage Management System, a computerized charting program, into the undersea fleet. Many submarines, including San Francisco, have the VMS, but it is not certified as a primary navigation tool on most.

The VMS display on the San Francisco was showing a warning that the submarine might be headed into shallow water at the time of the accident, but because the crew had been warned not to rely on it for navigation they did not pick up on it.

“It will still take us several years to get to every submarine, but we put enough money into the program to accelerate a several-year program by one year,” Munns said.

There are a host of other areas being reviewed as well, Munns said. For instance, dozens of men were seriously injured, and the crew's mess, or dining area, was converted to a hospital while the San Francisco was underway. But the ship's communications system did not support the hospital corpsman struggling to care for the injured and stay in contact with doctors on land or on other ships who were trying to help him.

Munns said perhaps the most important change will be encouraging submariners to take extraordinary precautions in planning a voyage and question anything that seems even slightly out of order.

“It's not like there was a bright red shining light that said, ‘caution, caution, caution,' ” Munns said. “They were subtle judgments that, because they were not being skeptical, they missed.

“They were not skeptical enough about driving in this uncertain water,” he said. “They should have asked more questions.”