oversight

Battleships: Issues Arising from the Explosion Aboard the U.S.S. Iowa

Published by the Government Accountability Office on 1990-05-25.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                    United States General Accounting OBBce
                    Testimony




For Release         BATTLESHIPS:   Issues Arising         from the Explosion
on Delivery         Aboard the U.S.!?. Iowa
Expected at
9:oo  a.m.  EST
May 25, 1990




                    Statement    Of
                    Frank C. Conahan
                    Assistant    Comptroller    General
                    National    Security    and International    Affairs
                       Division
                    Before the
                    Committee on Armed Services
                    U.S. Senate




GAO/T-NSIAD-90-46                                                  OACI Form IKI (X%/87)
Mr.   Chairman        and members of the Committee:


I appear      before        the Committee             today      to discuss           the results              of our
work concerning             several        issues      pertaining            to the April              19,     1989,
explosion        of the center             gun in Turret             II     aboard     the USS Iowa.                   The
explosion        killed       47 sailors.             Since      the Navy's           September           1989
report      on its        investigation          of the explosion,                   concern         has been
expressed         on the adequacy              of the      invest         igat ion    and the          continued
safety      of battleships.


Our work         was based       on requests            received           from     you;     The Honorable
Mary Rose Oakar,              Chairwoman,            Subcommittee            on Economic
Stabilization,             House Committee              on Banking,            Finance         and Urban
Affairs;         and the      Honorable         Howard M. Metzenbaum,                       United       States
Senate.          We were asked            to   (1)    conduct        an independent                  investigation
of the Navy's             technical        analysis        of likely           causes        of the          explosion,
 (2) review        the     safety      aboard        battleships,             (3)    examine          manning        and
training         issues      raised       by the      Iowa's        Commanding             Officer       after       the
explosion,         and (4) review              the battleships'                employment             plans      and
mission.          We engaged          the Department              of Energy's              Sandia      National
Laboratories           to conduct          a technical            analysis          and review           the
adequacy         of the Navy's            technical           investigation.                We addressed             the
other      issues.




                                                          1
RESULTS IN BRIEF


Before       discussing             in detail          our    findings         in each of the areas
reviewed,          let     me briefly           summarize.


Technical          Analysis


Sandia's          analysis         could       not     corroborate           the Navy's              technical
finding       that        an improvised              chemical         device         initiated           the
explosion.               Furthermore,           Sandia        has identified               a potential
hazard       --    the      impact      sensitivity             of the gunpowder                  in combination
with      an overram             at higher       than        normal      speeds         which        could        have
caused       the explosion.                   Sandia     believes           that      further           testing       on this
is needed          to confirm           its     finding.


Safety       and Serviceability


As discussed              in the Navy's              report        on the explosion                  and the
subsequent           Navy Inspector              General's            report         on the gunpowder
experimentation                  that   was taking            place      at the         time,        safety        policies
and procedures                  were not       being       followed         at the       time        of the
explosion.               Both     Navy reports           concluded,            however,           these        violations
did    not    cause         the explosion.               We examined               various        equipment,
ammunition,              and personnel           safety           records      for      the      four     battleships
and did       not        find     anything       to lead           us to believe              that       the
battleships              had experienced               safety       or material            problems            different
than      those      experienced              by other        naval      ships.

                                                              2
Manning       and Training


We found          that,       as a result                 of the        Navy’s       assignment           process,      the
Iowa and the battleships                             were assigned               a disproportionably                  low
percentage              of enlisted               supervisory            personnel,            including        gunners
mates       and fire          controlmen,                 when compared              to a selected            sample         of
other       ships.         Also,           we corroborated                 the     Iowa’s        former      Commanding
Officer’s          perception               that         the quality             of manning        on the battleships
was lower           than        that       for      naval     ships        on average.


We also          identified            some specific                 training         issues.            However,      because
training          records          were destroyed                   in the        explosion,         we could         not
reconcile           the conflicting                      statements          from     the      former      Commanding
Officer          that     his      personnel              were adequately               trained          on the day of
the explosion               and the Navy’s                   accident            investigation            report      that
said      they       were not.


Battleship              Missions


The battleships,                   with          their      combination            of weapons,            provide      an
imposing          array         of firepower.                 They perform              a strike          mission      with
their       cruise        missiles               and their          16-inch        guns are        the best          source
of naval          surface          fire          support      for       an amphibious             assault.           Also,
according            to Navy officials,                      the battleships                can be a strong
deterrent            in a third-world                     scenario.              However,        other     ships      with
cruise       missiles            provide            excellent           strike       warfare       capability          and the
changing          world         security            environment            brings       into      question          the Navy’s

                                                                    3
need to maintain                    the battleships                    to support                 a large     scale
amphibious              assault.



Moreover,           the planned                retirement              of two battleships,                      including            the
%,           raises          questions           about      the usefulness                        and supportability                 of
the     other       two, ships               in the active                 fleet.           A deployed          battleship's
presence           in overseas                theaters          will        be limited              because      of the effect
of peacetime                 operating           and personnel                  tempo restrictions                    on the         two
remaining           battleships.                   Manning         and training                    problems      will     also        be
compounded              by    a    smaller         pool     of experienced                        16-inch      gun-related
personnel.


It     is    inevitable              that       the defense                budget          will     be reduced          over     the
next        several          years.           Given       the     unanswered                safety-related              questions,
the manning               situation,             the mission-related                            questions,       and the
usefulness              and supportability                      concerns,                 the     two remaining
battleships               seem to be top candidates                                 for     decommissioning              as we
look        for    ways to scale                 back U.S.              forces.


SANDIA'S           REVIEW OF NAVY TECHNICAL FINDINGS


When we were asked                      to obtain           technical                assistance              to review         (1)        the
issue        of evidence              of foreign            material                in the         rotating      band of the
projectile              lodged         in the gun barrel                       in which            the explosion
occurred,           which          the Navy interpreted                         as being             from     a detonating
device,           and        (2) the         stability          of the gunpowder,                      we counseled             with
the National                 Science          Foundation               and the            Office      of Technology

                                                                       4
Assessment.            Both       stated       that      the       Department          of Energy's
laboratories,            especially            Sandia          National       Laboratories,               were capable
sources       of conducting               an independent               analysis.


At our request,              Sandia        performed            an analysis            concentrating             on two
areas.        First,       Sandia         explored           whether        the Navy's          finding         of
foreign       material          in the       rotating           band of the projectile                     lodged       in
the     Iowa's       gun and the Navy's                  analysis           of such material               indicated
that      an improvised            chemical           detonator           ignited          the powder          and caused
the explosion.               A major         constraint             to Sandia's             analysis       was that,
after       the Navy's          and the FBI's                analyses,         there        was no longer             any
part      of the       Iowa's      rotating           band that           had not been subjected                      to an
analysis         or examination.                    Furthermore,             the Navy could              no longer
locate       a significant             piece         of evidence--             the     iron     fibers         with
encrusted         material         that       the     Navy said           came from           a detonating
device.          However,         Sandia       was able            to build         upon the       Navy's        analysis
and to obtain             parts      of the band to examine.                           It     is confident            in its
findings,         which       conclude         that      the       foreign      materials          that        the Navy
found       were not       inconsistent               with      the nominal            levels      found
throughout           gun turrets            and were consistent                     with      the maritime
environment.              For example,               calcium        and chlorine--two                  elements        in
the     Navy's       postulated            detonator         --were       readily          detectable          in both
Turrets       I and II          (the       turret       in which          the explosion            occurred)           on
the      Iowa and in turrets                  on the battleships                    New Jersey           and
Wisconsin.             Therefore,           Sandia       could        not     corroborate          the Navy's
finding       that      such foreign                material        was evidence              of a detonator.



                                                               5
Second,         Sandia          explored             whether           the explosion               could      have been
caused      by an accidental                         ignition           of the powder.                    Sandia        agreed
with      the Navy accident                         investigation               report          that      the powder              was
stable      and confirmed                     that         a significant              overram            of the powder
charge      occurred.                  However,              Sandia        has raised             a question             regarding
the Navy's              statement             that          impact      and compression                   of the bag charge
were not          contributing                     factors          to the      Iowa incident.


Sandia      believes                 that     a possible               alternate          scenario           to the        Navy’s

finding         of a deliberate                      act       is that         an unintentional                   high     speed
overram         of the powder                      bags combined               with      the      impact         sensitivity             of
the powder              led      to the explosion.                         Suggestion             of an unintentional
high      speed overram                     comes          from     (1) the        Navy's         accident          investigation
report      which             noted         that      the     rammerman was conducting                            his     first         live
firing      and there                 were reports                  of an unidentified                    problem         with       the
center         gun immediately                      before          the explosion                and (2)         Sandia's
postulation              that         the car              which      brings       the powder             to the gun room
had not         returned,               which         it     normally          could      have during               the time            of a
normal         speed          ram.          Sandia          does not        consider             its     study      complete,            in
the sense              that      a clear            and definite               cause      of the explosion                     has
been identified,                      and it          recommends            areas        of further              investigation
by the         Navy.



The Executive                  Summary of Sandia's                         report        is included              as an appendix
to this         statement               and its             printed        report        will          be available            on
June 4, 1990.                    Mr.        Schwoebel,              who directed                Sandia's         work,      is with
me     today      to discuss                 Sandia's              analysis.

                                                                       6
SAFETY AND SERVICEABILITY


According         to the Navy's           investigation                 report,       approved       procedures
to ensure         the safe      firing         of the        16-inch           guns were not         followed
aboard      the    Iowa on April            19,     1989.             Subsequently,          the Navy
Inspector         General      also      concluded           that       the      experimentation            with
gunpowder         conducted        aboard       the    Iowa was "at                worst     not    safe      and at
best     undetermined          in its       safety."               To further         investigate            the
safety      and serviceability                 of battleships                  we reviewed         reports         of
equipment         problems,        ammunition          mishaps           and malfunctions,                 and
personnel-related              injury       data      for       all     four      battleships         and compared
them to Navy ships              in general.                 This       data      disclosed        no systemic
problems      with       the material           condition              of the guns or the ammunition
components         involved        in the       explosion,              or on the battleships,                     in
general,       that      warrant        any corrective                 action.


Safety      Violations


The Navy's         invest     igation       of the          explos ion           found     that    safety
policies       and procedures             were not           being        followed.          For example,
although       no spark        producing           items        are allowed              in the    turrets,
items      such as cigarette              lighters,             rings         and keys were found                on the
remains      of the deceased              sailors.


The Navy's         investigation            at the          time       of the explosion             also      believed
that     Iowa personnel            had improperly                  approved         and were conducting
gunnery      experiments.               Ship    personnel              were loading           an inappropriate

                                                            7
projectile/powder                 combination              when the explosion                        occurred.               This
involved         5 bags of an authorized                          type     of powder               with       a 2,700-pound
projectile          rather        than       6 bags of the authorized                              type       of powder.
Improperly          authorized              combinations             were fired              on at least               two
other      occasions.              The Navy believed                     that      neither           the presence                 of
spark      producing            devices       nor the            experimental               firing          caused          the
explosion.


The Navy Inspector                   General          subsequently                investigated                the reported
experiments             with     16-inch         projectiles              and propellant                     and concluded
that      the    firings          in question              on the        Iowa were,               in fact,           improperly
authorized          and contrary              to Navy procedures.                           His report               concluded
that      the    safety         hazard       posed         to the        Iowa’s       crew by the experiments
was,      at best,         undetermined.


No Prior Indications     of
Safety or Serviceability                           Problems


We reviewed             reports        of equipment               problems,           ammunition                   mishaps        and
malfunctions,              and personnel-related                         injury       data          for      all     four
battleships             since       their      reactivation.                    For example,                 we examined               the
equipment          failure          reports         that        ships     submit           for      all      equipment
failures         that      affect        their        ability           to perform               their       mission         and
that      cannot        be corrected             within          48 hours.            All         of the           equipment
failure         reports         the battleships                  submitted           for         equipment           failures
affecting          the     16-inch          turrets         since        their      reactivation                    were
categorized             as having           only      a minor           impact       on the              ships’      primary
missions.           We also          noted         no trend          or pattern             in the reported
                                                                 8
equipment       failures         that      indicated           systemic             problems        with     the guns
and other       turret        equipment.


We also       compared        the battleships'                  equipment              failure      experience         to
that    of other         surface        ships      to determine                if      the battleships           present
any undue material               or supply           support           problems.                They do not      appear
to do so.        Between         1984 and 1989,                 for     example,           the battleships
operated       without        any major           equipment            failures           for     a substantially
greater       percentage         of time          than     did        surface          combatants          as a whole.
There      were no distinct               differences             in the percentages                   of the
equipment       failure         reports          submitted            because          the necessary          repair
parts      were not         available        on the ships.


          Previous       Ammunition         Mishaps/Malfunctions


We also       examined        several        data        sources,            including           ammunition       mishap
and malfunction              reports       and investigations.                          We found       no
indications          of preexisting               problems            with       the    type      of propellant
involved       in the explosion.                    However,           ammunition               problems      have been
encountered          with      other      16-inch         ammunition                components        in the past.
For example,          there        were problems               with      split         powder      bags.       A program
is underway          to correct           that      problem.             Other         problems,       which      have
been addressed,              were encountered                  with      earlier          versions         of the
primers       used to ignite              the powder             charges            because       the primers
deteriorated          in storage.




                                                           9
      Susceptibility              to Inadvertent                  Detonation


Concerns        were raised         after           the explosion                over     the ammunition’s
sensitivity           to the     effects           of electromagnetic                     radiation,
frequently        referred          to as HERO.               Communications                   and radar
transmitters            can transmit           radiation              that       can cause ammunition
components        containing             electrical            circuits             to detonate.             The primer
was the only            ammunition          component             involved           on April          19 that
contains        an electrical             circuit           and it         requires           only     moderate
protection        from      electromagnetic                  energy;          it     cannot          be within      56 feet
of a transmitting               AN/WSC-3 antenna                    for      example.            Turret       II   is about
100 feet        from     that     type      of antenna,               so HERO should                  not   have been a
concern.         In their         investigations,                   Sandia          and the Navy ruled                  out

the primer        as the cause              of the          explosion.


While      16-inch        ammunition          components              do not         fully      meet the Navy’s
criteria        for     insensitivity               to unplanned              heat,          shock,      or impact
stimuli,        the current             inventory           ranks         19th      among the          25 munitions           of
greatest        concern         to the      Navy.           The ammunition                   does not meet the
Navy’s        standards         because       it         demonstrates              some susceptibility                  to
sympathetic            detonation        --detonating               in response               to a near-by
detonation            of another         explosive            item.          The requirement                 to meet the
standards        has been waived                   for     the current              inventory,           however,
because        the Navy considers                   that      the     16-inch           inventory           poses a
relatively            low danger         compared           to other          ship       board        munitions         and
because        modifying         other      munitions             has a higher                funding       priority.



                                                             10
         Personnel              Injury        Experience


We    also         reviewed         the       reports           of personal            injuries              and deaths
occurring             on board            the battleships                 and compared                  the results             to
injury            rates     on all           surface       ships         to determine              if        this       would        reveal
any systemic                gun or ammunition                      problems.            They did               not.


Any accident                 resulting           in a fatality,                 a lost         workday,                an
electrical                shock,         a person         overboard,            or a chemical                      or toxic
exposure            must be reported                     to the Navy Safety                    Center.                We found         that
the      injury           rates     for       the battleships                 were lower                than         the     rates     of
other        ship         types     in 1987 and 1988.                        The battleships’                        1989 rate         was
higher            than     that     for       surface           ships       overall,        but         it     would         have been
lower        if      the     Iowa explosion                 was excluded                from      the statistics.
While        the         Iowa had the highest                      injury       rate      of the              four      battleships
in 1989 (again,                    due to the             turret         explosion),              its         injury         rate     was
not      the highest               among the             four      battleships            in 1987 and 1988.


Other        than         the     Iowa’s        turret          explosion,             none of the                 reported
accidents                aboard      the battleships                    involved         firing              the     16-inch         guns.
One sailor,                however,           was injured               in a turret            during              a training
drill,            and another             was injured              in a 16-inch             magazine                 while
conducting                an operational                 test.          Most of the accidents                           involved
injuries             such as toxic               inhalation,                contusions,            and fractures
incurred             during        routine         operations.                 For example,                   sailors         slipped
and fell             on decks            and ladders,              had hatches            closed              on their          hands,
or were            injured         hand1 ing heavy                 equ ipment           or supplies.

                                                                    11
Additionally,             none of the             reported             accidents            involved        electrical
shocks      in the         16-inch          turrets.


MANNING


We found         that      batt lesh ips,              in comparison               to other           surface       ships
were not        assigned           an equal            share         of authorized               enlisted         supervisory
personnel          or personnel               in ratings              associated            with      gun turret
operations.              Additionally,                 the personnel                  assigned        on battleships
rated      lower        by several           measures           than        those       assigned         to other            ships.


Low Manning             Level of
Supervisory             Personnel

We compared             peacetime           authorizations                  to on-board              manning       for       the
battleships             with      the average            of      17 surface              ships       at various           times
in the deployment                   cycle.        We did             not    include         the      battleship
Wisconsin          because          it     had not       deployed              since       its     reactivation.                The
17 surface             ships       included        destroyers,                 cruisers,           and amphibious
assault         type      ships.           We found           that     the      overall          percentage          of
authorized             enlisted           personnel           assigned          to the battleships                   was
comparable             to that           of the sample               ships.           However,        manning        levels        of
all     battleship             enlisted        supervisors,                   including          gunners        mates        and
fire      controlmen            associated             with      the       16-inch         turrets       were generally
lower      than        those      of the other                ships        in our sample.


The battleships                 and the         Iowa deployed                  with      significantly             lower
percentages             of their           authorized            enlisted             supervisors           and    turret-


                                                                12
related         journeymen.          The ships             in the          sample            deployed         with         an
average         of 101 percent            of their              authorization                   for     supervisory
enlisted         personnel        (pay grades                 E-7 through                E-9),        while          the    Iowa and
battleships            deployed         with      92 and 93 percent,                          respectively.                     These
differences            were   more       pronounced               for      gunners            mates      and fire
controlmen,            as table         1 shows.              The situation                   was similar              with
regard      to journeymen               (pay grades               E-5 and E-6)                  in the        gunners             mate

and fire         controlman          ratings.


Conversely,            as the     table         shows,          the battleships                       were assigned                a
higher      percentage           of their            authorized               apprentices               in pay grades                    E-l
through         E-4.

Table      1:     On-board Percentages                        of Gunners Mates and Fire
                  Controlmen Compared                       to Billets  Authorized Levels                                    at
                  Deployment
                                                 Iowa                Battleships                        Ship         Sample
                                                 ----------(percent)-------------

All     Supervisors                                92                               93                           101
Gunners         Mates:
 Supervisors                                       73                               77                           100
 Journeymen                                        88                               82                           135
 Apprentices                                       94                               92                            73
Fire      Controlmen:
  Supervisors                                     92                            88                               120
  Journeymen                                      89                            92                               128
  Apprentices                                    106                           109                                85


The impact             of manning         for      gunners           mates           aboard       the     Iowa was
highlighted             at the    time          of the explosion.                            In Turret         II,         two of the
three      journeymen           level      gun captain                  pos it       ions,       norma lly           E-5s,        were

                                                                13
filled         by E-4 apprentices.                       The center         gun captain            was the             only
journeyman             gun captain.              All      three     of the gun captain                     positions              in
Turret         I were filled             by E-4 apprentices                     and a journeyman                was
filling           the supervisory              turret        captain's           position,         which          is
normally           filled         by an E-6.


Chief       of Naval           Personnel         officials          recently            told     us that          they        had
difficulties                in filling         billets        on battleships.                    The officials                 also
said       that      the     ship     sample       had excess             gunners        mates         and fire
controlmen             at the        journeymen           and supervisory                levels         because          their
personnel            were promoted             at higher           rates.         Also,         personnel           promoted
during         a deployment              are not         reassigned,            even though             on-board
excesses           develop.           Since       the     school       terms      for      those        ratings          on the
sample         ships        are     longer     than       those     for     the     16-inch-related                    schools,
the personne 1 tend                   to be a higher               grade        when reporting               to sh ips            of
the       types      in our sample.


The officials                also     noted       that     personnel            who are assigned                   to the
battleships               and who reenlist                frequently            request         duty     elsewhere               to
enhance           their      promotion         opportunities               by gaining            practical
experience             in the more common gun weapon systems.                                          Similarly,             they
prefer         to attend            schools       for     other     gun weapons                systems       to enhance
their       promotion             opportunities            and,     because         the other            guns have
newer electronic                    technology           to enhance         their        prospects           for       future
civilian           employment.               Sailors       aboard         the    Iowa expressed               similar
views       to us.



                                                              14
Battleship Personnel                    Fare
Worse In Advancement                    Opportunities

As of December             1989,        battleship              officers           had been selected                    at a
lower     rate,       compared          to officers              in the          sample         of other          surface
warfare       ships      for      leadership             positions             such as executive                    officer
and commanding             officer.              Only     23 percent               of the commanders                    serving
on battleships             were considered                   qualified             for       commanding           officer
compared       to 88 percent               of the         commanders               on the sample                 ships.        For
lieutenant           commanders          be considered                  to serve             as executive              officers,
the figures           were      more     comparable              --     53 percent              of battleship
lieutenant           commanders          were considere3                      qualified          compared           to 56
percent       on the sample               ships.          However,             the       Iowa had only              25 percent
considered           qualified.


Dattleship           enlisted          personnel          also         fared       worse        during       the March
1989 promotion             cycle        than      did     personnel              aboard         other       ships         in our
sample.           Battleship           personnel          overall             scored         lower       on the promotion
tests,       a key element              in the promotion                      eligibility            process.              Gunners
mates     and fire         controlmen              failure            rates      for        battleship           and Navy-
wide personnel             were similar.                  However,              the battleship               gunners          mates

and fire          controlmen           failure          rates         of 11 and 6 percent,
respectively,             were significantly                     higher          than        the ship        sample's
failure       rates       of 0 and 1 percent,                         respectively.


Among those           who passed           the      test,         fewer         battleship           personnel             in the
gunners       mate      and fire          controlmen              ratings          were selected                 for
promotion.             For example,              53 percent              of the gunners                  mates         on board

                                                                15
the battleships                 was promoted                  compared        to 65 percent              for     the      ship
sample     and 58 percent                       Navy-wide.              For fire       controlmen,             the      results

were 8 percent                 for      the battleships,                   15 percent            for   the      ship      sample,
and 13 percent                 Navy-wide.

Higher Rate of
Disciplinary Actions

During     fiscal         year          1989,         battleship           personnel            experienced            a higher
rate     of disciplinary                       actions,          including        non-judicial             punishments
(NJ-),         courts-marital,                       and punitive            discharges.               For example,               the
battleships'             NJP rate               per thousand              (195)      was approximately                  25
percent        higher          than       the        ship     sample       rate      (158 per thousand)                   and
185 percent          higher             than         the     Navy-wide        rate        (69 per thousand).
While     the     Iowa had the                    lowest         rate     (173 per thousand)                   among

battleships,             its         NJP rate           was still          150 percent            higher        than      the
Navy-wide         rate.              Similar           results          were noted         for     the battleships'
and the        Iowa's          courts-martial                    and punitive             discharge          rates.


About     70 percent                 of the battleships'                     manning        consists           of personnel
in grades         E-l      through              E-4.         Battleships           also     have a lower               level       of
supervisory             personnel               than        the ships        in our sample.                  Navy officials
agreed      these        factors               may     have contributed               to the higher
disciplinary              rates         aboard             the battleships.


PROBLEMS IN 16-INCH TRAINING


The adequacy              of training                  on the       Iowa became            an    issue       because         the
Navy’s      accident             investigation                   report      on the explosion                  said     that
                                                                   16
unqualified             personnel        were manning                 the     turret.            However,        the        former
Commanding           Officer         of the                 said        the    crew was trained,                   just           that
the    records          were not        up to date.                Since       the      training          records           for
the deceased             crew were destroyed                      in the explosion,                  never       existed,
or have not             been located,             we are unable                to reconcile               this
conflict.            We found,          however,           that       oversight           inspections,             which
should       have assessed              the      Iowa’s       16-inch           Personnel          Qualification
Standard           (PQS) program,              failed        to do so during                 the     18 months
preceding          the     explosion.             Priorities             were placed              on other         areas
during       the     review         or the       review        teams lacked               the expertise                to
evaluate          the     16-inch       PQS program.                  Additionally,                the Navy had not
approved          a training           plan      for      the battleship                 class     and the advanced
training          school       had limited              hands-on          training         aids      for     operation
and maintenance                instruction.


While       the     Iowa had a PQS program                        for       the personnel            assigned           to its
turrets,          insufficient            records          were available                 after      the explosion                   to
provide       an overview              of the          individuals’             qualifications.                  The Navy’s
accident           investigation              report       criticized             the     Iowa for          a lack          of
documentation,               especially           service          record        entries,           for     determining
the qualificat             i ons of assigned                 personnel.                 We found,          however,           that
service       record         entries,          while       preferable,               were not        required           until
personnel           were transferred                   to another             command.           The Iowa and its
type       commander’s             regulations            now require            such entries               upon
completion              of assigned           PQS tasks.                Our review          of service           records
for     selected          turret       positions           in November               1989 found            the new
requirements              had been implemented.

                                                              17
Using     reconstructed                   data,       Iowa officials                   attempted            to evaluate                       the
qualifications                   status      of the personnel                     assigned           turret             positions
on April           19.       Personnel             were considered                 to be *'operationally
qualified"           based         on the number of gun fire                                exercises             and training
drills       in which             they      had participated.                      While          the      information                   they
developed           indicated              that      the personnel                assigned           in the             turret           were
experienced,               we found          weaknesses             in the analysis.                           In our opinion,
the crew's           proficiency                  cannot        be verified             because            the         information
merely       shows that              the      crew members were assigned                                 to a position
within       the      turret         during          the exercises                and drills               but does not
document           that      they        actually          performed            the        responsibilities.                           For
example,           one person              was classified               as operationally                        qualified,                    even
though       he was serving                   in his        assigned            role        for     the        first          time           on
April      19.           In another           case,        the    status          of one individual                           serving               in
Turret       II     was not          included          in the analysis.


The Iowa's               Turret      II     was authorized                 five        personnel               who are              required
to have completed                    training          at the          Navy’s          formal           school          for         16-inch
gunners.            However,              on the day of the explosion,                                  only       two of the
positions           were filled               with     individuals                who had attended                        the
school.


Weaknesses               exist      with      the     Navy’s        formal            training           program              for
16-inch           gun operations                  and maintenance.                     Gunners           mates          aboard               both
the      Iowa and the               New     Jersey         were very            disappointed                   with       the         Navy’s

formal       school          for     16-inch          gunners          because             it     lacked         actual             turret

equipment           and they              believed         it    offered          little           practical

                                                                  18
instruction.                The crews           believed          that      they       learned         their         jobs
through        on-the-job           training.              Likewise,            both       the      school's          internal
evaluations            and the Navy's                  draft      training          plan      for      the battleships
noted     the problems              caused         by the         lack      of training              aids.           Our visits
to the       school         confirmed           that      limited        hands-on           training            was being
provided        due to the           lack        of training             aids.          Training            films       being
used at the            school       were basically                  1940's         vintage.            No improvements
were noted            in the       structure            or available               training          aids       since        the
explosion.             While       the Navy developed                     a draft          training            plan     to
improve        the      16-inch       training            courses         in    September            1989,       the plan
still      awaits          final    approval             and implementation.


BATTLESHIP MISSIONS


In response             to your       request,            we reviewed              the Navy's            concept            of
battleship            employment--              rrhat are the ships'                    wartime         missions             and
how they        are scheduled               for        peacetime          deployment.                My remarks              will
be brief        since         much of the detailed                       information              is classified.


While      the battleships                 are very            capable         weapons           platforms            and have
been included               in deployment                schedules           and operational                   plans,
emerging         circumstances              limit         their      utility.              The battleships                   were
reactivated             to alleviate              existing          force        structure            shortfalls             and to
help    meet         the    600-ship        goal         using      existing           platforms.               The
battleships,               with    their        combination              of 9 16-inch               guns in 3 turrets,
8 5-inch         twin       gun mounts,             16 Harpoon            antiship            cruise         missiles,              and
32 Tomahawk             cruise      missiles,             provide         an imposing               array       of

                                                               19
firepower.               The Tomahawk missiles                           give      them a significant
capability           for     attacking                 land     targets          and other             surface         ships.                The
Harpoon        missiles            also         contribute            to the battleships’                         capability                 to
operate        against           hostile          surface           ships.             The battleships’                     16-inch
guns are          the best              source         of naval          surface            fire      support         for        an
amphibious           assault             and are,             in fact,          the     only        guns larger                 than     5
inches       remaining             on Navy ships.                    When compared                    to air         support            in an
amphibious              operation,              Navy officials                  said        the      16-inch         guns,        within
their       range        limitations,                  can deliver              more firepower                  under           a wider
variety         of weather               conditions.                 Because           of     its     imposing          size           and
configuration,               the Navy believes                        a battleship’s                   presence             can be a
strong       deterrent             in a third-world                      scenario.


While       the     battleships’                 Tomahawk and Harpoon                          missile           capability              is
imposing,           it     is not         unique         within          the     Navy.              Many other           Navy
vessels,          submarines              as well             as surface              ships,         carry       those          same
weapons.            Also,         the     battleships’                contribution                   to future           amphibious
warfare         also       may     be limited.                   The current                maximum          range         of    just

over      23    miles       of the battleships’                          16-inch            guns       (their        only        unique
weapon         system)        impairs             the      ships’        ability            to provide            effective
naval       surface         fire         support           within        the context                 of an “over                the
horizon”          amphibious               assault--           one launched                 from      25 to 50 miles
offshore          and extending                   far      inland.


Furthermore,               with         only      two battleships,                     operating             and personnel
tempo restrictions                       will      limit         future         deployments.                    Cur rent
policies,           for     example,              preclude           a sh ip from deploy ing                         for        an

                                                                    20
additional          12 months           after      it        returns         from a C-month                deployment.
Thus,      with     only      two ships           in the           active       force,       it     is unlikely             one

would      be available               on short          notice         should      a crisis             erupt.       The
battleships           are     also      labor      intensive,                requiring            a crew     of     about

1,500      compared,          for      example,          to       a crew      of   about          360    on an Aegis

cruiser.           Finally,           reducing          the number of battleships                           to two,
especially          with      one homeported                  on each coast,               will         compound         the
manning         and training             problems            discussed          earlier           and further            limit
availability.


There      is current              pressure       to greatly                reduce       the defense              budget,
which      led     to the decision                to retire                two battleships.                 Because         the
battleships           are costly              to maintain              (about        $58 million            to operate
annually          according           to the      Navy),           and difficult             to man, and because
of the unanswered                    safety      and mission-related                      questions,              they    should
be actively           considered              in budget            trade-off          decisions            currently
being      explored           by the Department                    of Defense.




                                                   -     -    -    -   -

Mr.     Chairman,           that      concludes          my       prepared         remarks         and I would            be
happy      to answer           any questions.




                                                                  21
APPENDIX      I                                                                   APPENDIX   I


                                                               Executive Summary




Executive Summary
This report describeswork by Sandia National Laboratories (SNL) relevant to
three aspectsof the explosion that occurred in the center gun room of Turret 2 of
the USS IOWA on April 19, 1989,killing 47 crewmen. Our studies began in
December 1989with initial contacts and information exchangewith the United
States Navy (USN). Technical work began in January 1990and continued to May
 15, 1990.
The essential results of our study are as follows:

   (1) We could neither prove nor disprove the presenceof a chemical ignitor
         proposed by the USN. The interpretation of evidence for a chemical
         ignitor is complicated by the fact that some chemical constituents of such
         an ignitor are found throughout 16 in. gun turrets, not only on the USS
         IOWA, but also the USS WISCONSIN and the USS NEW JERSEY.
         Forms of these constituents are either commonly used in the turrets or are
         a part of the maritime environment. Steel wool was another component of
         the proposed igniter. We found iron fibers in the rotating band that could
         be steel wool, but we were unable to clearly identify a source of fibers of
         their diameter. We believe evidence for the presenceof a chemical ignitor
         is inconclusive.

   (2)   Our analysesindicate that the propellant stabilizer was within acceptable
         limits. We also found only a very remote possibility that this propellant
         could be initiated in the breech by friction, electrostatic discharge,or
         electromagnetic radiation. Similarly, we conclude there is only a very
         remote possibility the black powder could have been initiated in the
         breech by any of these mechanisms. Ether/air combustion cannot be
         achieved becauseminimum necessaryconcentrations are precluded. Even
         if the minimum concentrations are achieved and combustion occurs,our
         analysesshow that the propellant cannot be ignited. These findings are in
         general agreement with those of the USN.
    (3) We confirmed that the powder bagswere overrammed against the
        projectile and determined that the extent of the overram was
        approximately 3 in. greater than that establishedby the USN. Our
        analysesindicate that the bag chargeswere under a compressiveload of at
        least 2800 pounds at the time of the explosion. There may have been even
        higher transient forces due to dynamic loading resulting from a greater
        than normal ram speed. While the rammer is capable of a speed of 13.9
        ft/s, we could only establish that the rammer speedwas at least 2 ft/s.
   (4) The causeof the explosion was not conclusively determined. However, an
       important factor may have been the increase in impact sensitivity of a


                                                                                    1
                                         22
APPENDIX     I                                                                      APPENDIX   I


                                                                  Executive Summary




        powder bag with a reduced number of pellets in its trim layer. (The trim
        layer is an incomplete layer of pellets lying on their sides in the front of the
        bag and just behind the black powder pouch on the next bag.) Our half-
        scale experiments indicate that reducing the number of these pellets lying
        next to the powder pouch increasesimpact sensitivity enough that an
        explosion could have been causedby an overram at a higher than normal
        speed. Our studies indicate that impact initiation depends on two key
        factors: the number of pellets in the trim layer, and the speed of the
        overram. However, these experiments must be extended to actual 16 in.
        gun conditions to establish the validity of this ignition mechanism.
Navy personnel were most helpful in providing information and materials germane
to this study. In particular, we are grateful to Captain Joseph D. Miceli, USN,
Director of the Technical Support Team, Naval Sea SystemsCommand, who
responded without fail to a host of requeststhat grew out of our study. This
included arranging for information gathering visits aboard the USS IOWA and two
other battleships; extensive interactions with personnel at the Naval Surface
Warfare Center (NSWC-Dahlgren), Dahlgren, VA: Naval Weapons Support
Center (NWSC-Crane), Crane, IN; Naval Ordnance Station (NAVORDSTA),
Indian Head, VA; Norfolk Naval Shipyard (NNSY), Norfolk, VA; Naval Ordnance
Station (NAVORDSTA), Louisville, KY; and accessto numerous reports and the
testimony of several crewmen at the Judge Advocate General manual
investigation. We are also indebted to the USN for arranging for us to speak with
Gunner’s Mate (Guns) First Class Dale E. Mortensen, who drew on his extensive
experience to provide us with firsthand information regarding 16 in. gun
operations.
The USN investigation of the accident was extensiveand included a variety of
studies that were conducted in considerable depth. Our studies drew heavily on
that work. It served as a valuable basis on which to extend certain elements of this
investigation, and made our studies more productive than they would otherwise
have been.
Our studies focused on: 1) debris and any foreign materials in the rotating band of
the projectile in the center gun; 2) their possible relation to or consistencywith the
hypothetical igniter described by the USN; and 3) stability and sensitivity of the
propellant and black powder contained in the individual bag chargesused on the
USS IOWA The rotating band is located toward the rear of the projectile and, by
engaging the rifling of the barrel, spins the projectile to ensure stability in flight.
Studies of debris from the rotating band had been performed by the USN and, to a
much more limited extent, by the FBI. Evidence from the rotating band is
considered potentially important becausethe cannelure of the band was exposedto
the initial part of the explosion, and then closed as the projectile was propelled
partway up the barrel of the gun. (The cannelure is a groove in the rotating band


                                                                                       2
                                         23
APPENDIX     I                                                                     APPENDIX   I


                                                                  Executive Summay




 of the projectile.) That is, any foreign material found in the sealed cannelure
 region of the rotating band might contain important evidence regarding the
 initiation process. The stability and sensitivity of propellant is of interest because
 of its age at the time of the explosion (approximately 44 yrs) and the possibility of
 unforeseen effects of storage at elevated temperatures that occurred during part of
 the life of this material.
 SNL personnel had accessto an approximately 10 in. length of the USS IOWA
 rotating band. (The remaining approximately 40 in. of band had been consumed in
 experiments by the USN in its studies.) The 10 in. length of the band forwarded lo
 us had originally been sectioned into several pieces and the cannelure opened and
 examined by the FBI. Accordingly, our studies are based on regions of the
 cannelure that had been opened, examined, and stored some months before.
 The USN reported the presenceof calcium (Ca), chlorine (Cl), polyethylene
 terephthalate (PET) film fragments, certain glycols and iron fibers in the rotating
 band of the projectile. The USN reported that these were foreign materials and
 evidence for the presenceof an ignitor device composed of steel wool, brake fluid,
 and an oxidizing chemical (calcium hypochlorite), placed in a plastic bag.
 We find that Ca and Cl are readily detectable throughout the entire region of both
 Turret 1 and Turret 2 of the USS IOWA, Turret 2 of the USS NEW JERSEY, and
 Turret 2 of the USS WISCONSIN. The presenceof these elements is consistent
 with the maritime environment and the cleaning operations carried out in the
 turrets. We found these elements on two iron fibers that we extracted from the
 rotating band from the USS IOWA. We also observed an additional four small
 iron-fiber fragments that could not be removed from the rotating band for analysis
 without destroying them. The surfacesof three of these iron-fiber fragments had
 concentrations of Ca and Cl that were similar to the two that were extracted. (The
 fourth fiber was retained for another analytical procedure.) The occurrence of
 these elements on the various fibers does not clearly establish the presenceof an
 ignitor device becausethe concentrations of these elements are within the
 statistical variation of Ca and Cl levels on metal fibers found elsewhere in the
 turret.
 The USN had previously removed and analyzed several iron fibers from the USS
 IOWA rotating band. One of these fibers was described in the NWSC-Crane
 repon to have crusted regions containing high concentrations of Ca and Cl. It was
 the analysis of this fiber that was the basisof the USN’s assertion that iron fibers
 with abnormally high concentrations of Ca and Cl were found in the rotating band
 of the projectile of the USS IOWA. When we visited NWSC-Crane to examine
 this fiber, we found that it, along with some others, could not be located. SNL
 personnel worked jointly with NWSC-Crane to examine and analyze several other
 fibers that were retained by NWSC-Crane. AlI of those fibers were free of crusted



                                                                                       3
                                         24
APPENDIX    I                                                                     APPENDIX   I


                                                                 Executive Summar




regions, as were the six fibers we had previously either extracted or observed in the
rotating band at SNL.
The surface concentrations of Ca and Cl on all the fiber samples that we have
analyzed, both at SNL and jointly with USN personnel at NWSC-Crane, were of
nominal levels, not greatly different from levels of these elements on fibers found
in other turret locations. In fact, the concentrations of Ca and Cl observed by both
ourselvesand the USN were very similar, i.e., only small quantities of Ca and Cl
were measured. We could not clearly identify any of the fibers that we extracted as
remnants of steel wool. However, these fibers were found to have low (co.6 at. ‘3)
bulk carbon concentrations consistentwith steel wool, which is commonly made of
iron fibers.
The USN also reported steel wool in the rotating bands of other projectiles stored
aboard the USS IOWA. Those fibers could not be located so we were unable to
analyze their surface composition. We identified some steel fragments in a brush
used to clean the guns in Turret 2, but our analysesindicate that those high-carbon
steel fragments came from bore liners inside the barrels. (A bore liner is the inner
surface of the gun barrel and in direct contact with the projectile.)
The diameters of fibers found in the USS IOWA rotating band by both the USN
and SNL were very similar. The USN statesthat the fibers found on other
projectiles stored aboard the USS IOWA were of smaller diameter. We have not
corroborated that observation becausethose fibers could not be located.
Two glycols in the rotating band of the projectile were identified by the USN as
“significant foreign materials,” possibly constituents of brake fluid used in the
hypothetical igniter device. Our studies show that the first of these glycols is a
constituent of a cleaning and lubricating fluid (Break-Freem) routinely used in the
turrets. Our analysesindicate that the USN identification of the second material
as a glycol is incorrect. The material is actually phenol, which is also a constituent
of Break-Free*M. A third glycol, not considered to be a “significant foreign
material,” was identified by the USN as a constituent of a marker pen. We agree
with that identification, but we find that it is also a constituent of Break-Freem.
The USN found a single fragm#nt of a polymer film in the cannelure and identified
it as a possible residue of PET. The USN proposed that a plastic bag of this
material was used to contain the hypothetical ignitor device. We also identified
fragments of this material in the brush used to clean the guns in Turret 2. PET is
known to be chemically equivalent to Dacronm and Mylarm. Accordingly, such
fragments could have come from several sources,including the bore socksused for
gun cleaning and ordinary clothing. We observed the presenceof many polymeric
speciesin the cannelure of the rotating band, but not PET. Becausepolymeric
fragment can be found in various regions of the turret, their occurrence is not a
unique indication of the presenceof the hypothetical igniter device.
APPENDIX     I                                                                    APPENDIX   I


                                                                 Executive Summary




SNL personnel also examined cannelure debris from a test at NSWC-Dahlgren in
which the bag chargeswere ignited by a chemical igniter similar to the one
proposed by the USN. This ignitor used steel wool, but we found no iron fibers or
fragments of iron fibers in the limited length (-8 in.) of the rotating band that we
examined. The USN found five fibers in the entire band (-50 in.) from another
test of this same kind. Apparently there can be considerable variation in the
quantity and distribution of fibers from such experiments.
The USN provided us with twelve bags of propellant with black powder pads from
the same lot as that aboard the USS IOWA at the time of the explosion. In
addition, the USN provided accessto its extensivestudies and background
information on this propellant and black powder.
The propellant used in the bag chargesfor the 16 in. guns contains a stabilizer
(DPA) that scavengesdecomposition products that are oxides of nitrogen. The
stabilizer helps maintain uniform performance of the propellant over time. The
USN stated that the level of stabilizer in the propellant aboard the USS IOWA was
within specification. We also find that the averagelevel of stabilizer is near the
level reported by the USN. There is a small change in propellant sensitivity over
the range of stabilizer concentration that we measured in pellets from the USS
IOWA bag charges. We have not yet completed our investigation of the
significance, if any, of this change.
The manufacture of propellant involves the dissolution of nitrocellulose in a
mixture of ether and alcohol. Some ether remains in the propellant and
evaporates over an extended period of time, suggestinga potential fire hazard.
Our analysis showsthat the probabiliry of initiating an explosion by ether/air
burning in the breech is so remote as to be practically impossible. Calculations
show that the maximum temperature increase of the propellant that could occur in
the burning of an optimum mixture of ether/air is only 3CkCto 4@C. Initiation of
the propellant requires a temperature increase of at least 17oDC.However, the
thermal ignition of finely crushed black powder by ether/air combustion remains
an unresolved issue requiring additional study. Our studies also indicate that it is
virtually impossible to initiate the propellant or black powder in the breech by
electrostatic discharge,friction, or electromagnetic radiation at levels found within
the turret.
An interior ballistics model was developed for the open-breech explosion. The
model involves the high-speedflow of both hot propellant gasesand pellets from
the open breech. The model was used to calculate the time variation of pressureat
the base of the projectile depending on the point of initiation along the five powder
bags. It predicts with some accuracythe movement of the projectile up the barrel
following the explosion. Our results indicate that the initiation site was most likely
APPENDIX     I                                                                      APPENDIX   I


                                                                  Executive Summary




between the first and secondbag charge,which agreeswith conclusionsreached by
the USN in its field tests.
The USN reports that the propellant bags were overrammed into the breech of the
center gun of Turret 2 by a distance of approximately 21 in. The USN
interpretation was based in part on an analysiswhich assumedthat parts of the
rammerhead gouged the spanning tray. In our analysiswe show that the gouges
were causedby the rammer chain. Using this analysis,we found that the overram
was more nearly 24 in. That is, the rammer moved approximately 24 in. beyond
the point it would normally reach in placing the bag chargesin the breech of the
gun. Therefore, a significant overram and compression of the powder bags
occurred.
The USN reports that “impact and compression (of the bag charges)were not
contributing factors in the IOWA incident.” Our results regarding the impact
sensitivity of the propellant raise the possibility that initiation occurred by impact.
Our one-half-scale (8 in.) experiments indicate that the fracture of propellant
pellets lying transversein the trim layer at the forward end of the bag can lead to
initiation of the powder train. Initiation apparently occurs when the fractured
pellets in the trim layer release burning particles from the fractured surfaces,
igniting the black powder pouch of the adjacent bag. Ignition of the black powder
then rapidly propagates the ignition throughout the rest of the powder train.
Therefore, the ignition processinvolves the trim-layer pellets of one bag and the
adjacent black powder pouch of the next (forward) bag.
We believe the probability of this initiation processdependson two key factors: 1)
the number of trim pellets in the forward-most layer and 2) rammer speed. If
there are a reduced number of trim pellets and the rammer is operated at higher
speeds,the initiation processduring an ovenam becomesmore probable. For
example, if there are twenty pellets in the trim layer, we estimate there is a
probabiliry ranging from approximately one in two to one in three that the
propellant can be initiated at energy levels attainable when the rammer is operated
at 13.9ft/s, its maximum speed. However, propellant initiation by impact is a
complex phenomena and much more work needs to be done to verify this estimate,
particularly in actual 16 in. guns or systemsthat closely duplicate the 16 in. gun.
During a number of inspections in conjunction with USN personnel, we found that
the powder hoist, powder door, rammer, and other mechanismsin the gun room
appeared to be in proper operating condition at the time of the explosion. We
concur with the USN that mechanical operations appear to have been normal and
not associatedwith the explosion.
As established by the USN investigation, the door to the powder hoist was closed
and locked, but the powder car had not been lowered at the time of the explosion.
Immediate lowering of the car on closure of the powder door is the standard


                                         27                                               6
APPENDIX     I                                                                   APPENDIX   I


                                                               Executive Summary




procedure. This suggeststo us that the ramming occurred soon after the closing of
the powder door and took place at high speed. That is, if a slow ram of 1 to 2 ft/s
had occurred followed by 15 or 20 s of sustainedoverram as proposed by the USN,
the upper powder hoist operator would have had approximately 20 to 25 s to begin
lowering the powder car. However, if a high-speed ram occurred, there would
have been little opponunity for the upper powder hoist operator to begin lowering
the powder car. A high-speed overram seemsconsistent with these considerations.

A factor that may have contributed to the overram was an undefined problem in
the loading operation. This undefined problem, reported through the ship’s phone
systemby a member of the gun crew, led to a delay in loading the center gun
relative to both the left and right guns in Turret 2. This undefined problem and
delay could have created confusion during the powder-loading phase.
We conclude that a plausible causeof the explosion aboard the USS IOWA was a
higher-than-normal speed overram of the bag chargesinto the rear of the
projectile, initiating one of the forward bag chargesthat contained a reduced
number of pellets in the trim layer. The fact that the bagswere moved to a
position substantially beyond the normal location is evidence supporting a higher-
than-normal speed overram.
Our experiments of initiation by impact are incomplete and more work needs to be
done on larger assembliesof pellets than we were able to accomplish in the short
time available. Nevertheless,it appears from our present models that the
probability of initiation of an explosion by impact is such that measuresshould be
taken to insure that overrams do not occur at any speed.
These studies of the explosion aboard the USS IOWA represent a brief but
concerted effort by SNL personnel to supplement the USN’s investigation. Our
starting point was the extensivework by the USN, and those studies were helpful in
several phasesof our study.
We do not consider this study to be complete in the sensethat a clear and
definitive causeof this explosion has been identified. There are several open
issuesthat should be further explored, and the Recommendations section of this
report lists areaswe believe warrant further investigation.




                                       28