Navy Cites 'Repeated Failures' in Warship Blaze
By Andrew Dyer
Source The San Diego Union-Tribune
SAN DIEGO — For two hours after smoke was first seen in the lower vehicle storage area of the amphibious assault ship Bonhomme Richard, fire raged before crews began fighting it, according to the Navy’s investigation into the blaze in San Diego last year.
By the time firefighters first sprayed water onto the flames, they were already spreading out of control and any efforts to save the huge ship were doomed to fail, according to the findings, released Wednesday.
Investigators say a junior sailor, Seaman Apprentice Ryan Mays, intentionally ignited the blaze. He is due in court in November for a preliminary hearing. But it was a cascade of failures among Navy leadership and the Naval Base San Diego’s fire crews that sealed the fate of the 844-foot warship, the investigation said. It faults high-ranking Navy officials up the chain of command in San Diego for lax training and oversight.
The ship burned for almost five days at its berth at Naval Base San Diego. Plumes of noxious black smoke blanketed San Diego and National City communities nearest the base. The $1.2 billion warship was a total loss — one of the Navy’s worst peacetime disasters ever — and was sold for scrap.
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Sailors on board the ship were slow to react when they first saw smoke that Sunday morning, July 12, 2020. The officer of the deck hesitated to sound an alarm. The ship’s fire crews were ill-prepared to fight the blaze and, even if they had been ready, almost 90% of the vessel's fire stations were out of commission when the fire started, the investigation says.
These factors, among others, were among the “repeated failures” the Navy cited.
The Navy’s investigator, Vice Adm. Scott Conn, pointed to 36 officials whose action — or inaction — contributed to the loss of the ship. Their cases will be reviewed by the Pacific Fleet admiral for further discipline, said Adm. William Lescher, the vice chief of naval operations, during a conference call with reporters Wednesday.
“No disciplinary actions are off the table,” Lescher said. Currently, none of those 36 is under criminal investigation, he said.
The Navy laid particular blame for the devastating effect of the fire on the lack of training among the ship’s crew for just how to respond, and how urgently to respond, to a sighting of smoke on board.
While crews train extensively for firefighting while ships are at sea, once they return to port, that training becomes less of a priority since sailors are often more focused on the day-to-day maintenance and repair that happens in port. This was compounded in the case of the Bonhomme Richard, the Navy said, because the ship had been in an extensive maintenance period for almost two years receiving upgrades to operate with F-35B fighters.
Its crew, the investigation says, minimally participated in fire drills before the blaze. The crew lacked basic knowledge of industrial firefighting and did not know how to work with civilian fire crews.
“To illustrate this point,” the investigation says, during drills “the crew had failed to meet the time standard for applying firefighting agent on the seat of the fire on 14 consecutive occasions” in drills conducted leading up to the fire.
On the morning of the fire, around 8 a.m., a sailor on her way to the ship’s vending machines passed the ramp to the “Lower V,” the lower vehicle storage area, and saw that it looked “foggy,” she told investigators. However, since she did not smell smoke she continued on to her berthing area.
More than 10 minutes later, another sailor on duty noticed the smoke and reported it to the officer of the deck. However, the officer did not immediately sound the alarm, he told investigators, because of the “possibility of a benign reason” for the smoke, such as starting the ship’s emergency diesel generator.
A ship’s watch stander did not log the report of smoke or fire until 8:20 a.m. At 8:22, witness in an adjacent parking lot heard the ship finally ring its bell, raising the alarm. But precious minutes had been lost. By the time sailors tried to get to the fire to extinguish it, it was too hot and they pulled back, the investigation says.
Sailors on board moved from one shipboard fire station to another to coordinate their attack on the blaze. One had no power. Another had power but no equipment. Hose teams attempted to reach the blaze but could not.
Confusion continued pier-side of the ship when civilian federal fire crews and San Diego Fire-Rescue units arrived on the scene around 8:30 a.m. However, the pier on which Bonhomme Richard was moored did not have a fire main, so firefighters tried using a drinking water supply line.
Federal fire crews stretched a series of hoses down to the lower V but did not initially combat the blaze because one of crews experienced a “low air” alarm, and the team pulled out just after 9 a.m. Another crew detected temperatures of 500 degrees F. That crew had water-pressure issues — the result of an errant valve getting accidentally kicked and closed. They also pulled out without attacking the fire.
Around 9:30, a San Diego Fire-Rescue crew came aboard to fight the fire but federal fire teams told them to leave — there was no coordination between the fire departments during this critical phase of the effort to extinguish the blaze. While the investigation found that the radios each department used were compatible, on that day, firefighters from both agencies believed they were not, so radio communications between the two were nonexistent at the scene.
The confusion spread to Bonhomme Richard sailors as well. They believed federal fire was now in command. Throughout the morning of July 12, no hose teams of Bonhomme Richard sailors attempted to descend toward the fire in the lower V, the investigation found.
Additionally, the hose fittings of the federal firefighters were not compatible with those on the ship, so the ship’s hoses could not connect with those of the federal crews.
Just before 10 a.m., about two hours after the fire started, a San Diego Fire-Rescue finally began hosing down the fire in the upper vehicle storage area, where the blaze had spread. But the fire began heating gas cylinders, causing them to explode and fly across the space.
A San Diego firefighter told an operations chief they’d “lost the space” it was “about to blast,” around 10:35 a.m. Two minutes later, the order came down for fire crews to evacuate the ship.
While the ship’s crew talked about deploying the aqueous film-forming foam fire suppression system on the pier as the blaze raged, the time to do so had passed, the investigation found. Shore power had been cut at 9:44 a.m. and the ship’s fire main had lost pressure. Conditions on the ship were too dangerous and crews never tried to engage the system.
At 10:50 a.m., just seconds after the last firefighters evacuated the ship, there was a “massive” explosion that sent a shock wave and debris across the pier, knocking down personnel. The explosion would have been fatal if not for the evacuation, the report said, and it destroyed key supports on board and led to the collapse of the upper mess decks into the upper V. This created a rush of fresh oxygen to fuel the fire.
Fire crews never again placed firefighting agents on the seat of the fire that first day, and the opportunity to do so was lost once the fire spread beyond the lower V across the entire ship.
San Diego Fire-Rescue crews told Navy and federal teams they would not return to the ship since conditions were too dangerous and the firefighters would not risk their lives since there was no one left on board in need of rescue. Navy officials told them they could leave if they would not go back on board, and they did.
Mónica Muñoz, a spokesperson for San Diego Fire-Rescue, said department crews were following procedures.
“The battalion chiefs at the scene decided it wasn’t safe for the crews to go back inside, so they didn’t,” Muñoz said in an email. She said procedures change as situations evolve but that crews close to shipyards do train with federal fire crews, including about 500 who trained for shipboard fires during an exercise in 2019.
Not only did San Diego Fire-Rescue crews leave the scene, but so did other municipal agencies that had arrived, such as those from Chula Vista, National City and Coronado.
Sailors at the scene were demoralized to see the crews leave, the investigation says.
It notes that although the Bonhomme Richard’s commanding officer, executive officer, command master chief, chief engineer and damage control assistant were all on the pier before the explosion, all failed to establish command and control of firefighting efforts.
It was Rear Adm. Philip Sobeck, the commander of Expeditionary Strike Group 3, who finally took charge that day. Sobeck was an operational commander, in charge of amphibious ships when they go to sea. The investigation notes that although Sobeck had no assigned role or responsibility for fire during ship maintenance, he stepped into a “command and control” vacuum and aligned and organized the various make-shift response teams.
Firefighting boats in the bay sprayed the hull of the ship with water and Navy helicopters dumped water on the ship from above for days. After almost five days, the fire was declared out.
The investigation cites another devastating ship fire that resulted in a total loss — one on the attack submarine Miami in 2012 — that prompted changes to Navy fire policies during maintenance. The report said that officials in San Diego failed to execute those new procedures.
Chief among them, the report says, was the development of a Fire Safety Council to manage risk and drills to coordinate shipboard fire response.
A high level of risk was present among the Navy’s surface fleet ahead of the fire, as fire prevention and response training was lacking. Once the fire started, the response was in the hands of “inadequately trained and drilled personnel from a disparate set of uncoordinated organizations,” the investigation said.
Navy leaders, faced with a pressurized environment and aggressive timelines, the report says, made choices that sacrificed safety in the name of mission accomplishment — a critique reminiscent of the operational attitudes of Pacific Fleet commanders before two fatal ship collisions in 2017.
The investigation cites Naval Sea Systems Command, which oversees maintenance; the Navy Installations command, which is in charge of Navy bases; and Naval Surface Force Pacific Fleet with failing to effectively supervise safety compliance during ship maintenance.
The total loss of a major ship, the Navy’s investigation said, demands “close examination” and accountability regardless of rank or paygrade. The long list of officers and crew mentioned in the report indicate many disciplinary actions may follow.
Among those who bare some responsibility for the failures leading up to and during the fire, the Navy said, is the “command triad” of the Bonhomme Richard: Capt. Gregory Thoroman, the commanding officer, Capt. Michael Ray, the executive officer and Command Master Chief Jose Hernandez.
Other members of the ship’s crew — the chief engineer, damage control assistant, senior medical officer and 12 other damage control sailors and watch standers — are also mentioned though not named, including a duty section in-port emergency team member who failed to report to duty on time that day.
Several senior Navy officials are named, such as the former commander of the Naval Surface Force, Vice Adm. Richard Brown, who is now retired, and the Pacific Fleet maintenance officer, Rear Adm. Scott Brown.
The commanding officer, executive director and other department heads at the Southwest Regional Maintenance Center are also listed, although Capt. David Hart, the commanding officer, is the only named official in the report.
The investigation also cites the commander of Naval Base San Diego, Capt. Mark Nieswiadomy, as having failed to make sure base fire crews were properly trained. The base’s fire chief is also cited, the investigation says, for failing to execute her duties the day of the fire, causing confusion about her authority and responsibility on the scene.
The investigation also cites the former commander of Navy Region Southwest, retired Rear Adm. Bette Bolivar, who was in charge of all of San Diego’s Navy bases until her retirement this year. The region’s federal fire chief is also cited.
The investigation also cites several people for meritorious performance during the fire, including Bonhomme Richard sailors, federal fire crews, helicopter crews and a San Diego firefighter. The report credits the unnamed San Diego firefighter with saving “countless” lives by recognizing the danger of explosion and ordering people off the ship.
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