This week Sam LaGrone and Gidget Fuentes brought what many of us have been waiting for – more information on the fire on the USS BONHOMME RICHARD (LHD 6) that led ultimately to its scrapping – a multi-billion dollar loss of a high demand/low density asset.
There is a lot in their report including very interesting details on the accused arsonist, failure ashore, lack of attention to the lessons of the USS MIAMI (SSN 755) fire, the missteps up the chain – and I recommend you read it all in addition to the Command Investigation (CI) they posted today. Yes, VADM Conn, USN identifies 36 leaders for their failure to prevent the accident – but for today’s post I’d like to focus on what ultimately caused the loss of the warship; it’s leadership.
There was a little more than an hour where the ship could have been saved if … the crew and its leadership had properly trained, prepared, and led their crew. Why did this failure take place?
Let’s look at the second bullet in the Executive Summary of the CI;
Training and Readiness. The training and readiness of Ship’s Force was marked by a pattern of failed drills, minimal crew participation, an absence of basic knowledge on firefighting in an industrial environment, and unfamiliarity on how to integrate supporting civilian firefighters. To illustrate this point, the crew had failed to meet the time standard for applying firefighting agent on the seat of the fire on 14 consecutive occasions leading up to 12 July 2020.
That’s the center mass. Back to Sam and Gidget’s 19OCT21 article, let’s pull out some of those details;
“The training and readiness of the ship’s crew were deficient. They were unprepared to respond. Integration between the ship and supporting shore-based firefighting organizations was inadequate,” wrote Pacific Fleet commander Adm. Samuel Paparo in his Aug. 3 endorsement of the investigation.
“There was an absence of effective oversight that should have identified the accumulated risk, and taken independent action to ensure readiness to fight a fire. Common to the failures evident in each of these broad categories was a lack of familiarity with requirements and procedural noncompliance at all levels of command.”
“Procedural non-compliance.” That can be due to one of two things – or perhaps both; 1) leadership knew but didn’t bother; 2) it was unknown and uninspected for.
Conn highlighted the lack of adherence to the Navy’s special procedures for fire safety, which the service put in place after a 2012 arsonist fire resulted in the loss of attack submarine USS Miami (SSN-755), as a major cause of the fire.
“The considerable similarities between the fire on USS Bonhomme Richard (LHD-6) and the USS Miami (SSN-755) fire of eight years prior are not the result of the wrong lessons being identified in 2012, it is the result of failing to rigorously implement the policy changes designed to preclude recurrence,” Conn wrote in his report.
This cannot be emphasized enough; this was a multi-billion dollar warfighting asset. If training, drilling, and preparing for the greatest danger in a shipyard – fire – was not a training priority, then what was? Of the time invested in training in the last, let’s say 90-days, what were the topics? How much time? How many drills were run?
The first hint of trouble on July 12, 2020, came just after morning colors. Just after 8:00 a.m., a junior sailor walked through the upper vehicle deck as she headed out to a vending machine after her watch. She noticed a “hazy, white fog” in the lower vehicle deck around 8:10 a.m. But she didn’t report it, the investigation found, noting that “because she did not smell smoke, (the sailor) continued to her berthing.”
How long was this Sailor in the Navy? When was the last time she was involved in DC/firefighting training?
Around that time, another sailor who stopped at a sideport door in the Upper V to chat with a sentry “observed white smoke rising from the Lower V ramp into Upper V,” according to the report. One of them ran up the ramp and through the hangar to reach the quarterdeck, telling the officer-of-the-deck about the smoke.
OK, we’re batting .500 here.
At about 8:15 a.m. the engineering duty officer ran into a civilian contractor who told him of smoke near the mess decks. The EDO went to investigate and met another crew member who was also investigating a report of smoke.
5-minutes in. A fire can do a lot in 5-min.
“Numerous sources agree to having heard a rapid ringing of a bell but disagree on whether the casualty was announced as ‘white smoke’ ‘black smoke,’ or ‘fire,’ as well as the location of the casualty: ‘Lower V,’ ‘Upper V,’ or ‘Hangar bay,’” the investigation found. “At 0820, the Petty Officer of the Watch (POOW) noted in his log: ‘Fire reported in Lower V.’”
Confusion is expected … and trained for.
10-minutes in.
“The OOD stated that the [Damage Control] Central watchstander informed him that they already made a 1MC announcement. Having not heard any announcement, at 0820, the OOD called away the casualty over the 1MC,” the report found. The officer told investigators “he delayed calling away the casualty due to the possibility of a benign reason for the smoke (such as starting an Emergency Diesel Generator).”
Had this happened before? If so, was a casualty called away? What was the response by the chain of command in? Was this a conditioned response, or just a miasma of carelessness?
That 1MC call was the first time the ship’s command duty officer, who was in his stateroom, learned of the fire. He reached the hangar, where the crew was organizing an initial suppression effort, at 8:24 a.m. The CDO had texted the ship’s commander and executive officer, who were both at their residences, about the reports of smoke. Bonhomme Richard’s commander, Capt. Gregory Thoroman, received the text about the black smoke at 8:32 a.m., shortly before the senior enlisted sailor – the command master chief – called to tell him “that a few sailors suffered smoke inhalation.” Thoroman drove to the base, as did the XO, who was told of the fire by the CMC.
A text? Just a text to the CO that is ship was on fire? Why only a text?
At 8:22 a.m. the sound of the ship’s bell could be heard from a nearby parking lot.
Minutes later, crews aboard destroyers USS Russell (DDG-59) and USS Fitzgerald (DDG-62), which were also berthed on Pier 1, reported black smoke coming from Bonhomme Richard. Both destroyers “assembled their duty sections and began equipping Rescue and Assistance (R&A) teams,”
…and off we go. The magic hour lost, and so was the ship.
“In those early minutes, the sailors had no radios so they used their own cellphones to communicate,” the lead investigator found. And the 1MC “did not work in many areas of the ship to include DC Central; and there was a lack of urgency. When initial responders from Ship’s Force descended into Lower V, no one shared the same understanding of what firefighting capability was online, contributing to their failure to apply agent to the fire or set fire boundaries, which enabled smoke and heat to intensify.”
When was the last drill for his crew?
Attack teams had trouble finding serviceable fire stations. In fact, 187 of the ship’s 216 fire stations – 87.5 percent…Was this known? Again, when was the last drill?
Despite thick, choking smoke spreading through the ship – and amid dangers from searing heat and possible fire flashes – some sailors, including several chief petty officers, didn’t don the required firefighting equipment. They mistakenly believed they couldn’t do so while wearing the Type III Navy working uniform, rather than their coveralls.
The stupid Type III … again. They do not belong on a ship while on duty. No. So stupid. Again, when were drills run and who was running them?
“The DC Central Watch Supervisor stated that neither he nor EDO had an idea of how bad the fire was until later events forced them to evacuate DC Central. At no point did either the DC Central Watch Supervisor or EDO attempt to start any additional equipment or activate Aqueous Film Forming Foam (AFFF) firefighting systems,” investigators wrote.
“Despite the lack of reports that any of announcements were received or acted upon, neither the EDO nor DC Central Watch Supervisor sought confirmation that their announcements were broadcast,” investigators found. “Though the senior EDO in the duty section (name redacted) did not hear any 1MC announcements from DC Central, he did not proceed to DC Central to determine whether the EDO was attempting to execute control of the firefighting effort.”
Worse, the ship’s installed AFFF systems weren’t put into action “in part because maintenance was not properly performed to keep it ready and in part because the crew lacked familiarity with capability and availability,”
I’m without words. Who, if anyone, from outside the skin of the ship, inspects for these things? Are they not identified in … drills?
Investigators found that none of the crew evacuating the ship used an emergency egress breathing device (EEBD), which is a metal bottle of compressed air. “There are conflicting accounts as to whether all berthings had EEBDs in place,” they wrote. One sailor they interviewed looked for an EEBD, but could not find one and most of the sailors “did not try to find an EEBD or were concerned that returning to find an EEBD might have led to them becoming trapped by the fire.”
No, I don’t think they did effective drills … and yes, I’ve been stringing you along. Starting on page 124 of the CI, here are a few nuggets strung to together;
507. Between 26 March 2019 and 24 March 2020, BONHOMME RICHARD conducted 25 training evolutions for DCTT. , BONHOMME RICHARD DCTT Coordinator, participated in 9 of 25 training events. Records do not show CHENG participating in any of these 25 evolutions. Records show the BONHOMME RICHARD XO was designated as the DCTT Leader; but he did not participate in any of the 7 DCTT training events occurring after he reported aboard 12 November 2019. … 518. Use of AFFF in response to a fire had not been drilled for over a year and were neither drilled nor simulated after AFFF stations 3 and 4 were brought to an increased state of readiness in April 2020 to support fuel onload. … 520. BONHOMME RICHARD IETs failed 11 consecutive RE-03 fire drills from 28 December 2019 – 22 February 2020, with no indication of additional remediation drills being scheduled or executed. … 524. The BONHOMME RICHARD CHENG stated that he did not receive any reports on training effectiveness nor did he receive any training critiques. Training critiques were routed from duty sections straight to the XO and CO. [Encl 219] 525. The BONHOMME RICHARD CO and XO were not aware of any specific issues with IET drills nor that BONHOMME RICHARD IETs failed 11 consecutive RE-03 fire drills between 28 December 2019 and 22 February 2020. … 535. Several BONHOMME RICHARD Sailors reported they had not participated in egress or EBD training since they had checked onboard, with some asserting they had never received EEBD training.
There is more there, give it a read.
Finally, we have this sad scene;
“Although the CO, XO, CMC, [Chief Engineer], and DCA were all present on the pier prior to the explosion,” the investigator continued, “they failed to establish command and control of the situation and did not lead action to integrate fire response efforts.
“Instead, Commander, Expeditionary Strike Group THREE (ESG-3), the ship’s operational commander who has no assigned role or responsibility in response to a shipboard fire during a maintenance availability, stepped into a command and control vacuum to align the various ship, installation, and external organizations by employing a make-shift emergency response organizational structure.”
Well … at least here, BZ to COMESG3.
While I lean to the “ultimate responsibility of command” here … there is something about pointing to a systemic failure of our Navy … as outlined in the reports.
We should not simply focus on the senior leadership of the ship, even though at least 51% of the blame is there.
However, our Navy selected these leaders. They did not rise to their position for no reason. They had a proven track record. In theory, there is no reason this looks to be such a shambolic mess, but it is. Yes, it is there, but … to use the most important word in the English language … why?
Is this just is another example of our leadership – and goodness knows we have plenty of senior leadership and staffs – being focused on a lot of things, but perhaps not the important things. It can’t be we simply don’t have good, professional leaders. Nothing in the records I can see points towards that.
What series of incentives and disincentives – and the priorities they produce – brought this ship, its crew, and the brave firefighting crews ashore and from other ships and even helo squadrons together the summer of 2020
What were they investing their time in, and why?
