Proper application and value of “lessons learned”

Preliminary opinions, mostly “armchair quarterbacking”, of the horrific fire aboard the almost-completed refurbishment of the USS BON HOMME RICHARD, (ed. note: abbreviated here as BHR) have started. Murmuring that “lessons learned” regarding the ship’s material condition, monitoring of contractors, and security and safety duties by the crew may reveal inadequate measures taken in one or all areas. Or that an electrical malfunction or overheated equipment started the fire. Reduced to “duty section” personnel aboard ship during weekends in-port in the United States, as the fire was initially called away on Sunday morning, is a long-standing practice of balancing the safety needs for the ship, reduced operations, and liberty for crew who may be at-sea and away from home for nine months a year. This reduced manning may have prevented casualties. Published reports indicate that construction materials were stored in a large interior area where the fire is suspected of igniting. Equipment, furnishings and materials used aboard Navy ships are specifically designed to be fire-resistant and low emitters of toxics. However, during the transition from the yard to an operational state, material may have still been staged in containers called “tri-walls”, These rugged, large-volume, cardboard cartons and their contents might have fed the blaze. For anyone familiar with shipboard life, cleaning is an around-the-clock process aboard a vessel. A maintenance period makes the effort more difficult as well as more important. Dust removal which is omnipresent on ship, salt corrosion due the maritime environment, any trash left by the contract workforce, and improper stowage of cleaning rags and agents all contribute to ship safety issues. Work performed in the vicinity preceding the fire may be suspect. Investigation will likely include any activity in the twelve hours prior to the fire being reported.

Existing practices

Standards in place over several decades, incorporating “lessons learned” from reports of incidents around the Fleet, are managed by several departments within the Department of the Navy. Guidance is distributed by directives from the Chief of Naval Operations (OPNAV), from Naval Safety Center’s investigations, and from Naval Sea Systems Command (NAVSEA) which oversees all afloat construction, maintenance and repair, including shipyards and at other facilities. In past, established practices to monitoring work being performed at any hour, scheduled inspections and audits, and well-practiced safety operations would likely be sufficient to mitigate risk. As with any work or potential hazard, human error, negligence or malicious conduct is not always preventable.

Fire is an ever-present danger

Fire is an ever-present threat at sea. On a ship or submarine, crews are thoroughly trained to fight several emergencies from flooding, collision, munitions, toxic gases, electrical and different classes of fire. Identified by the combustible materials, those that burn leaving an ash such as paper, bedding, clothing, or stores can be extinguished with one agent. Fuels and oil require an oxygen disrupting agent. And Class C fires, are electrical in origin, and take different methods to extinguish. On the latter two, “starving” the fire of oxygen knocks the fire down. Besides corrosion to metals and equipment, the danger of electrical shock to firefighters or arcing is present with water, while its use against fuel fires disperses flaming fuel instead of extinguishing it. On three different classes of ships during my eight years at sea, we practiced incessantly for emergencies at-sea and in-port. And practiced security drills. With millions of dollars of valuable equipment aboard and in a time when espionage and terrorism are real concerns, members of the ships’ crew are assigned to accompany contractors, not otherwise cleared for unrestricted access, while aboard. For all “hot work”, that is, welding or grinding, a Sailor and/or a civilian performed as a “fire watch” for the welder. Sometimes, shipboard personnel charged with the vessel and crew’s safety would monitor both the welder and the fire watch. Why such a fuss? The danger from welding or grinding is due to heat or random sparks being generated which could cause combustible material to smolder (sometimes for hours) or set material ablaze in adjacent compartments through convection or radiated heat.

Systems and thorough practice

Aboard ship, the Engineering Department is the primary team responsible for damage control and management of the fire safety systems. These systems consist of pressurized fire mains, firefighting chemical (Aqueous Firefighting Foam or AFFF) and Halon gas (fire suppression) systems. The corrosive properties of seawater on metals and electrical components is well-known, so the Damage Control team evaluates available resources to fight a fire. However, the danger (the BHR fire was reported to be as hot as 1000 F) of water flashing into steam adds to the hazards for firefighters. As has been reported, the Halon system was undergoing maintenance and unavailable to flood a compartment that was on fire. Seawater therefore was apparently the primary means to fight the fire and attempt to cool the hull and compartments to contain its severity. According to one report, the team using AFFF were evacuated due to an explosion in one of the machinery compartments, and it is unclear whether they were able to resume its use. (According to another source, some non-Navy firefighter personnel abandoned their stations when a pump exploded requiring the Navy personnel to be withdrawn.)

Danger during Maintenance periods

The conditions during a maintenance period can contribute to safety hazards. Combustible materials may be used during maintenance contributing to conflagration. Sometimes a heavy paper is affixed to bulkheads (walls) and decks to minimize abrasion from equipment being moved. Terrazzo, a chemically-bonded interior decking material, sometimes has plywood overlaid by shipyard workers to prevent marring by heavy equipment and foot traffic during a maintenance period. Sometimes hatches are not dogged properly, which might either be due to inattention, protruding temporary cabling or poor placement. An improperly closed hatch or scuttle might then allow flammable material or gases to receive sufficient air to burn, or fire to penetrate other compartments. Or improper placement or shifting of material used during the maintenance period might cause running equipment to overheat. Or an electrical problem may cause arcing (sparking) to occur.

The human factor of safety practices

During my time in the U S Navy (nearly three decades), willful damage (in the case of USS MIAMI or USS COMPTE DE GRASSE) was not often suspected, and particularly not suspected to be caused by members of the crew. However, in 2012, a Navy contractor aboard the former, at Portsmouth Naval Shipyard in Maine deliberately started a fire which resulted in the sub being scrapped. In the latter case, in 1994 a Navy crewman on the SPRUANCE-class destroyer, purposely damaged reduction gears causing extensive damage to propulsion and prevented the ship from deploying.

The investigation of the submarine fire revealed that the perpetrator was not being monitored continuously by a member of the submarine’s crew for a specific period of time. The civilian deliberately set a “small” fire expecting to get off work early. Having too few members of a “duty section”, assigning additional tasks for the crewman assigned to monitor that contractor, or improper vetting of civilian workers may have contributed to the incident. Once the reports have been issued by the investigation aboard the BHR, and the repair costs evaluated. the Navy may return the same verdict as in the MIAMI.

While Navy veterans and those currently in uniform, hope that the destructive fire aboard her was the result of accident, lapses in judgement, or an “act of GOD”, the Navy should not rule out sabotage. Evidence will reveal one or all of these factors. If sabotage, justice will be meted out. In the case of the civilian in the USS MIAMI case, the perpetrator was given a 17-year prison sentence. The sailor in the USS COMPTE DE GRASSE incident also received a lengthy sentence.

Lessons to be learned and then applied

However, the most important lessons to be gathered from this recent fire are to find where the shortcomings were, what worked well, and to implement change with practices, systems or personnel. Others have commented that implementation of lessons from prior incidents and casualties may have been slow to promulgate due to the bureaucracies responsible, or the incident the practice inspired receding into history. The practices that need to be changed will be studied, but the immediate operational effects are more troubling. The loss of the ship’s ability to deploy will cause more problems for the Navy meeting its commitments. With the recent quarter-billion dollar overhaul making it one of four similar ships to provide amphibious F-35 fighter support, the loss is substantial. Billions of dollars and years of construction and validation may be required to replace the USS BON HOMME RICHARD. The void left in the interim will likely result in longer deployments for other ship crews in order to balance the increasing militarization by Russia, China, and other actors in the world.

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