Monday, May 14, 2007

USS Frank Cable initial accident report in.


From press reports (here, here, here, here) the initial look at the steam incident on the USS Frank Cable is in. About what many expected.

I'll let you read the reports above, and I am not going to dig too deep - Chief Dulay died of his burns 01 MAY - but I will comment on this: we owe it to those who are injured and killed in accidents to look hard at what could be done better, what wasn't done - and why.
Corroded tubing that ruptured during a safety valve check of boilers aboard the submarine tender Frank Cable was the “root cause” of the Dec. 1 steam explosion that seriously burned six sailors, according to a recently completed investigation report.

Two sailors later died of their injuries.

Under what the report termed a “false sense of urgency,” the engineering department sought to “complete some outstanding maintenance, specifically number one boiler safety valve lift checks,” before the day was over.

As the maintenance check began in the early evening, with the visitors off the ship, 14 sailors were in the compartment with the boilers, or the “fireroom.” Early in the test, with steam pressure increasing in the No. 1 boiler, and “no lifting of the safety valve,” a section of the boiler system “split open, emptying the contents of the boiler inside the contents of the fireroom.”

Boiler No. 1’s support tubes failed, releasing steam into the boiler’s firebox and sweeping unburned fuel vapors into the stack, where they ignited.

The stack sent hot steam into the fireroom where 14 sailors were acting as technicians, standing watch or observing the safety check, the report said.

The sailors reacted quickly.

“Watchstanders immediately took action to secure the boiler to prevent further damage and exited the fireroom,” the report states.

All but one sailor who’d been in the fireroom were injured. Six were burned seriously enough to be evacuated to Brooke Army Medical Center in San Antonio.

Machinery Repairman 3rd Class Jack Valentine died of his injuries less than a week later, on Dec. 7.

Chief Machinist’s Mate Delfin Dulay died at Brooke Army Medical Center on May 1.

Among the criticisms leveled in the report are that local ambulances took “47 to 70 minutes” to fully respond to the casualties; that sailors’ coveralls did not offer adequate protection; and that the ship’s stretcher inventory was inadequate for a mass casualty event.

While the reviewing officer holds the opinion that the crew’s response was “satisfactory,” he points out that “most fireroom watchstanders did not don” Emergency Escape Breathing Devices.

In the recommendations submitted by the initial reviewing officer, the commanding officer and the chief engineer committed “errors in judgment” by allowing the safety valve maintenance despite reported deficiencies in the system and both “should be reviewed for administrative or disciplinary action.”

The chief engineer and the executive officer are recommended for similar review for failure to train sailors in evacuating the main space that “may have lead to more serious injuries.”

Four of the 14 sailors had no documented emergency exit training out of the fireroom and no one could recall having a mass training on the subject since 2003, the report said.

The report vindicated the sailors hurt in the tragedy, saying that their injuries were suffered in the line of duty, not through misconduct.
Neither the CO, XO, or CENG were onboard when this took place. Steam incidents like this give me the cold sweats. I am so glad most all steam plants are gone - they give me the willies because I truly fear steam. Respect isn't enough for me - I fear it.
In that light, the following needs to be taken on board by everyone when they get a chance to look at the nuts and bolts of being a Sailor when they get through all the flotsam and jetsam we make people go through on a day to day basis that has nothing to do with making a ship ready to go in harm's way.
sailors’ coveralls did not offer adequate protection; and that the ship’s stretcher inventory was inadequate for a mass casualty event
Ahem. At least Task Force Uniform has us in SA like khaki and black.

Some of the Sailors did not have emergency training. Here are the report's recommendations.
The following are recommendations endorsed by Command Submarine Group, Pacific Fleet for the USS Frank Cable.

1. The commanding officer and the chief engineer errors in judgment allowing the ship to steam No. 1 boiler in order to perform safety valve maintenance before determining the cause of chemistry concentration and abnormal feedwater consumption of the number one boiler should be reviewed for administration or disciplinary action.

2. The executive officer and chief engineer’s failure to conduct proper mainspace (fireroom) and evacuation training may have led to more serious injuries and said failure should be reviewed for administrative or disciplinary action.

3. Several sailors should be commended and recognized for their admirable effort to secure the boiler to prevent further damage to the ship, to assist other sailors with evacuation from the fireroom and to provide first aid to wounded shipmates. A board should be convened to review personnel actions to determine if awards or recognition is warranted.

4. The No. 2 steam drum safety valve should be removed and “hot-tested” prior to reuse.

5. Naval Safety Center evaluate and promulgate best practices for EEBD’s (Emergency Escape Breathing Devices) available to watch standers.

6. That any incomplete actions listed in the preliminary statement be acted upon.

7. BUMED evaluate which stretcher is best suited for medical transport of sailors aboard ship when taking into consideration the possible accompanying on oxygen bottles, and traveling up and down steep ladderwells.

8. BUMED evaluate capability of medical facilities on Guam to respond to a mass casualty.

9. The ship should conduct recurring, meaningful and realistic evacuation drills.

10. The Frank Cable’s engineering department should be evaluated on training, watch standing, maintenance and risk management practice.

11. A training plan should be developed for submarine tenders holding to the same standards of other surface ships with steam plants, but tailored to a submarine tender’s unique parameters.
And we have more units going to Guam - they need to cowboy up, now.
Among the criticisms leveled in the report are that local ambulances took "47 to 70 minutes" to fully respond to the casualties; that sailors' coveralls did not offer adequate protection; and that the ship's stretcher inventory was inadequate for a mass casualty event.
No excuse. If you want better reporting on this, I recommend a visit to Bubblehead's place.

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