URCLASSIFED RENT The court, after inquiring into all the facty and cireusstences connected with the incident which occasioned the inquiry, and having considered the evidence, finds as follows: FINDINGS OF FACT 1. That the 0.8.8. Thresher (S5(K)393) was butlt at Portsmouth Naval Ship- yard, Portanouth, New Hampshire, the first of anew class of nuclear Uv Powered attack submarines, capable of diving toa depth of ] feet, and feexey— with significant advences in sonar equipment, abiiity to resist shock, and to operate with reduced noise radiation, 2, That THRESHER, under che coumand of Lieutenant Coumander U.S. Navy, B(p _, departed Portswouth Naval Shipyard, on the aorning of 9 Apeii 1963, to conduct scheduled sea trials following a post chake- dow availability vhich extended from 16 July 1962 to 11 April 1963, 3. That THRESHER was a unit of Subsarine Development Group TWO, and was operating under the orders of Commander Submarine Force, U.S. Atlantic Fleet (Acninistratiea) Fortencuth, for the sea trials, 4, Thet the folloving persons, in the status indicated, were on board THRESHER vhen she departed Portsmouth, New Hampshire, and were on board rev ota wee tats SARVEL, JohnH, vo tow 055 Tinssie ‘Garvin, Fat i, Tope Tex USS THRESaE ‘DI NOLA, Michael J, LCDR USM ‘USS THRESHER Dinan, Jota Ses JF, Pa tow USS TenesiE Sun, ohn (Sy De. it st 068 TRESUER TARSOHS, Gry C.. Jes tise tox 065 TRasER fay, janes go Jes bra Tox 058 minesren ascodx, Roneid’c, ae Ost USS THRESH Sue, dotn 2. tise (oD 08S Sumas PALIGEE, Feank J. uve ee Usd Uss THRASHER CocLIER, weretit #. i sn USS HieseR Gearten, Soha 6. ie tn USS SmesMER WAG, nobere oon vow szArr, Derury communneR SUmALINE FORCE, U.S. amano Fuser ARSENAULT, Tilmoa J, ‘ENCA(SS)-P2 Ust USS THRESHER Ban, Tonita & mates)? Uow 055 TeRBSER BELL, Jona 8, faee Tey 05s Tanase dessin, bégie 5. ma(ss)-P2 oy Use Tamasen SOSTER, cocsta 6. Bo(s8)-P1 ten ss THRESHER BRACEY, George (n) sp3(SS) USN ‘USS: THRESHER Bai, Biches mva(s5)-F2 Gen ss TRGSTER CARKOSKI, Richard J. ‘EN2(SS) USN ‘USS THRESKER cam, seven c. mass) ey USS TORESIR GamasitansE, Edvard (a) SHS) bey uss FmESHER Sanh, eetey ESGa-72 tor uss Hansen Cts, Thongs 5. Ens) Sor se TRESHER sescuefmiGs, Prencta M. CARMODY, Patrick W. DABRUZZE, Samuel J. DAY, Donald C. DENNY, Roy 0., Jr, DIBELLA, Peter J, DUNDAS, ‘Don R. DYER, Troy BE. DAVISON, Clyde Z,, IIT FORNT, Ellwood FOTI, ‘Raymond P. PREBMAN, Larry ¥, PUSCO, Gregory J. GALLANT, Andrew J, Se. GARCIA, Napoleon T, GARNER, John E. GAYNOR, Robert W. GOSNELL, Robert GRAHAM, Willian B. GUNTER, Aaron J. BALL, Richard C. HAYES, Norman T. HEISE, Laird C. HELSTUS, Marvin T. HEWITT, Leonard 3. HOAGUE, Joseph H. HODGE, Janes P. HUDSON, John F. INGLIS, John P. JOENSOR, Bravner G. JOHNSON, Edvard A. JOHNSON, Richard L. SJOMISGH, Robert. JONSON, Thonas 3. JONES, Richard W. KAUUZA, Bémund JL, Jr. KANTZ, "Thomas C. KEARNEY, Robert D. HETER, ‘Ronald D. RIESECKER, George J. KL, Billy M. KRONER, George R. LANOUETTE, Norman 6. TAVOTE, Wayne W. MABRY, "Templemas 8.» JF MANN, “Richard H., Jr. MARULLO, Julius 7., Jr. MCCLELLAND, Douglas B. MC CORD, Donald J. MC Donobcx, Karl P. MIDDLETON, ‘Sidney L. MUISE, Ronald A. MUSSELWHITE, James A. '3082(83) SK2 BTN2 (6S) EN3(SS)_ wql(ss)-P2 Sw BIN2(SS) En1(SS)-P2 ETR3-P1 $0CA(SS)-P1 r1(S8)_ Frz(S8) EN2(S8)~P2 CSS) sp1(68) YNSN(SS) EN2(68) sa(S8) 800 (S8)-PL qui (ss). ETR2(SS)-P2 uP? vw-P2 2 Eyca(ss) mass) Na N2(8S) N ¥IG1(SS)-22 ENCA(SS) BMS ‘TMc(ss)-PL 2r1(S8)-P2 By2(ss) 3052($8)-P2 ETR2(88) 3 102(S8)-F2 ma2($8)-P2 EN1(SS)-P2 33 qui (ss) ywi(ss) mN2(68)-P2 302(88) uicss) 32(S5) (Ss) -P2 ™3(ss) wan ($s)-P2 sz, TN2($S)-P2 1680 USN vss uss uss: uss uss USS vss uss, uss uss uss uss uss uss. 35, 38, USS, USS uss uss USS uss uss uss uss USS USS, USS uss vss USS. ‘TRRESHER ‘TRRESHER ‘THRESHER ‘THRESEER THRESHER, ‘THRESHER THRESHER ‘THRESHER ‘TERESEER ‘TERESHER ‘TURESHER ‘TERBSHER ‘THRESHER THRESHER ‘THRESHER ‘THRESHER ‘THRESHER ‘THRESHER ‘THRESEER ‘THRESHER. THRESERR ‘THRESEER ‘THRESHER THRESHER THRESIER THRESHER ‘TRRESHER ‘THRESHER ‘THRESHER ‘THRESUER ‘THRESHER THRESHER THRESHER TERESHER THRESHER ‘THRESHER THRESHER ‘THRESHER ‘TRESHER ‘THRESHER ‘THRESHER ‘TERESHER ‘THRES HER ‘THRESHER THRESHER ‘THRESHER ‘THRESHER ‘THRESHER ‘THRESHER ‘THRESHER ‘THRESHER sae NCLASSIFED $2 ated(RCLASSHED AULT, Donald B. es1(ss) USN USS TRRESHER NoowIs, Walter 3, Byes) VSN USS THRESHER NORRIS, John D. Briss) -P2 VSN USS THRESHER GETTING, Chesley c. EMP? YsN USS THRESHER PENNINGTON, Roscoe C. BMcA(SS)-P2 USN USS THRESHER FETERS, Janes G. Eycs-P2 USN USS THRESKER PEULLIFPL, James F. '5052(88) USN USS THRESHER PETLPUT, Ban A. 2y2(S5)~P2 UsN USS THRESHER PODWELL, Richard (n) m2-P2 USK USS THRESHER REGAN, John S. ya (S5)~P2 Us USS THRESHER RITCKIE, Janes P, ma USN USS THRESHER ROBISON, Pervis (a), Jt. SN USN USS THRESHER OUNTRES, Glenn A. quacss) UsN USS TERESHER RUSHETSKI, Anthony A, Ena UsN USS THRESHER SCHIEWE, James M. EuL(SS)-P2 Ng Use uss THRESHER SHAFER, Benjanin N. EMcm(SS) -P2 ‘, UsN USS THRESHER SHAFER, John D. Excs(ss)-P2 (YD USN USS THRESHER SUNK, Joseph T. ye-2 UsN USS THRESIER SHOTWELL, Burnett 4. EIRSW USN USS TERESHER SINNETT, Alan D. ¥F7G2 (SS) USN USS THRESHER SMITH, Willian #., Je, Bnl-P2 USN USS THRESHER SOLOMON, Ronald 8 2-72 USN USS THRESHER STEINEL, Robert E, 301(5S)-P2 USN USS THRESHER SNIDER, James L. 1 USN “Uss. TERESHER VAN PELT, Rodger B. 1C1(S5)-P2 USK USS THRESHER WASEL, David A. MSN USN USS THRESHER WALSKI, Joseph A. wash (SS)-PL USN USS TERESHER WICGINS, Charles L. FTG1-P2 USN USS THRESHER WIS2, Donald £, yoica (SS)-P2 USN USS THRESHER WOLFE, Ronald E. Qusu(ss) USN USS THRESHER ZWEIFEL, Jay H, + EMPL USN USS TARESHER ALLEL, Philip H rene USN PORTSMOUTH NAVAL SHIPYARD BILLDNGS, John it. Lope. USN PORTSMOUTH NAVAL SHIPYARD BIEDERMAN, Robert D. ur USK PORTSHOUTH NAVAL SHIPYARD ERESCOTT, Robert D. Civilian Employee, Design Division, . Poreeuouth Naval Shipyard CHARRON, Robert 2. Civittan Employee, Design Division, Portsmouth Navai Shipyard GUERETTE. Paul A, Civilian Employee, Design Division, Portsmouth Naval Shipyard FISHER, Richard K. Civilian Employee, Design Division, Portomouth Raval Shipyard WHITTEN, Laurence E. Civilian Employee,Combat Systems Division, Portsmouth Naval Shipyard imac rain micecans, aes 4INCL ASSIFED(NCLASSIED “SUES DES JARDINS, Richard R. Civittan Employee, Combet Systems Division, Portenowch Naval Shipyard CRITCHLEY, Kenneth J. Civiltes Employee, Production Department, Portsmouch Naval Shipyard CURRIER, Paul C. Civilian Employee, Production Department, Portsmouth Naval Shipyard ABRAMS, Fred P. Civiltan Employee, Production Department, Portsmouth Naval Shipyard PARGR, Franklin J. Civilian Employee, Production Deparcuent, Portsaouch Naval Shipyard DINEEN, George J. Civilian Eapleyee, Production Department, Portsaouth Naval Shipyard MOREAU, Henry C. Civilian Employee, Production Department, Foresmouth Naval Shipyard CORCORAN, Kenneth R. Contractor's Representative, Sperry Corporation JAQUAY, Yaurice F, Contractor's Representative Raytheon Corporation KeusTER, Donald W. Contractor's Representative Specry Corporation STADEMLIZR, Donald T. Contractor's Rapresentative, 4 Sperry Corporation 5. That the pereons {fated as being on board vere military menhers of the naval service on active duty, civilian employees of the Portsmouth Naval Shipyard or civilian employees of activities under Government contreet, ae indicated. . 6. That all persons on beard THRESHER were on board for the puryose of - executing official duries. 7, That U.$.8, Skylark (A5R20), under command of Lieutenant Commander U.S. Navy, was designated to act af escort fo TORESHER during sea criais, perguant to orders of Conmsnder Submarine Flocilla TWO. Commanding Officer, THRESHER, vaa Officer in Tactical Coenind. 8, That THRESHER's movement orders were CONFIDENTIAL; SKYTARK's were A Wiclassitied. Sea cial agenda, igeved by Comanding Officer, TRESHER, (GIMP) ware unclassified and were not held by SKYLARK. 9. ‘That THRESHER effected a rendezvous with SKYLARK at abour 0949R on 9 April 1963 in che vicinity of Lacteude 42-56 North, Longitude 70-26 wesc. are(RCLASSIRED sere 10. ‘That on completion of @ scheduled shallow dive, the two sbips pro- ceeded independently during the aight to @ second rendezvous in the vicin- ity of Latitude 61-46 North, Longitude 65-03 West. During the transit, THRESHER proceeded surfaced and submerged and conducted various test, evolutions, including full power propulsion, 11, That at O745R, 10 April 1963, SKYLARK was in the vicintcy of Leti- cade 41-45 North, Longitude 65-03 West, and TARESHER reported to her chat SKYLARK bore 1479 True, 3400 yards from TRESHER, ogee zeae ll ge lb A eR nciometey See eae eee ir aerate aa Rhee etna toh eee ieee ee 13. That SKYLARK carried a rescue chamber with a maximum depth capability of 850 feet. 1s, That the sea van calm, with 2 slight evell, at 0900R on 10 april. Wind wae from O15° True at seven knots. Depth of water io this ares ie about 8500 feet, Visibility wae about ten miles, No other ships are kmowa to have been in the vicinity. 15, That at O747R, THRESHER reported by underwater telephone that she vas starting a deep dive, Depth for chis dive hed been set at GN feet. SEWARK then saintained her spproxinate Position. THRESHER repocted {COE » but SKYLARK did not plot THRESSHIR’s equrse changes and depth change position. 16. Thet the deep dive appeared to SKZLARK personnel to proceed satis factorily until about O915R, when TURES’ reported to SKYLARK ¢o the tifect, "Experteacing winor diffteuities. lave positive up angle. At Sccempting to Sloe, Wil} keep you inforned, yf 12. hat at shout OP16L, SKUARK hescd « gacbled ecaneatesion which vas (oOHh) delieved to contaia the words ",., test depth”, An addtctonel garbled Ecenmeianlon wes received about O317R, reported as containing the vords : NUhnine huodeed North, 18, Thac Commander Oceanographic Systens Atlantic obtained information thie gN and that affifgh energy, low frequencyJnotee dtetur= UV! bance of the type which could have been made by an inploaon enenaced . Advised THRESHER of SKYLARK's course and requested range and bearing from TKRESHER. cy Asked THRESHER at about 09158, "Are you in control?" and repeated this query, 8. Established LORAN position (logged at 0921R as 41-45N 64-59H) fe. Attempted to establish communication by undarvater telephone, sonar and radio, £. At 1060R commenced Groping series of hand grenades indi- cating to THRESHER that she should surface. 23, That at about 1045R, SKYLARK begen preparation of 2 aessage reporting rhe loss of contact with THRESHER. 2, AE about 0940R, when the Operations Officer had asked the Comanding Officer 1f he should send such a messsge, the reply was te the effect chat, “Et 18 too early," b. At about 1045R, che Commanding Officer, SKYLARK directed the Operations Officer to initiate the message. c. Although SKYLARK had conducted radio communication checks with NBL (Radio New London) sarlier on the morning of 10 April, diffleulty waa reported at the tine of transmission of the message. SKYLARK shifred co an alternate frequency. d, NBL receipted for che message ac 1245R. 24, That SEYLARK's message, 1016062, stated, “UNABLE 10 COMMUNICATE Ii ZERESHER SINCE 0917. "WAVE. BEEN CALLING BY UQC VOICE AND CW QRS CW EVERY MINUTE EXPLOSIVE SIGNALS EVERY 10 MINS WITH NO SUCCESS. LAST ‘TRANSMISSION RECD WAS GARBLED. INDICATED THRESHER WAS APPROACHING TEST DEPTH. MY PRESENT POSITION 41-43N 64-57H CONDUCTING EXPANDTNG STARCH.” 25. SKYLARK message 101604Z did not convey to operational commanders the full extent of the information available. Although imelueion of additional information such as the O913% UQC transmission "Experiencing ainot difficulty...” etc., vas suggested by the Operations Officer, the Commanding Officer Ber aor tolats veal teers (INCLASSIEi (CLASSI Bi b. SKYLARK did not toclude such additional information in any subeaquenc reports. 26. ‘That on 10 April 1963, Comnander Submarine Force, U, . Atlantic Fleece (Vice Adwirel pf Wai) waste Anmapslis, Maryland, ina duty status, delivering a submarine presentation. fis adminis- erative headquarters remained ip Norfolk, Virginia, Vice adafral = returned t0 Norfolk at abour 14208, At 1435R he was advised of THRESHER's statue, 27. That on 10 April 1963, Deputy Commander Subsarine Force, U, S. atlantic Pleet (Rear Adniral __ USK) was en route to New Yondon, Connecticut from Key West, Florida, He had been conducting an inspection of units at Key West. He arrived at Trumbull Atzport, Groton, Connecticut, at sbout 1830R. He proceeded by helicopter co Newport, Rhode Island and enbarked in the U.S.S, Blandy to proceed to the seene of the search. 28. That on 12 April 1963, the Court of Inquiry requested that SKYLARK witnesses and records be made available as goon as possible co acquaint + the coure with the decals of the last transmission from THRESHER and the best knowledge of her Last known movenents. a, Deputy Conmander Submarine Force, U, $. Atlantic Fleet, waa relieved as search force commander (CTS 89.7) by Commander Submarine Developmen Group TWO at about 16308 on 12 April. Lieutenant (jg) (7 USN, Navigator of SKYLARK, cwo enlisted mea, “and necessary SKYLARK Logs were transferred to SLANDY for return to Newport to permit appearance before the Court of Inquiry. b. Shortly after the transfer to BLANDY, Rear Adntral interviewed Lieucenant (Jz) (Gy and exanined che Uoc (onderwater telephone) tog, Upon seeing the UIC log, ear Admiral G\p | becane knoviedgeable for the #1752 time of the 1aSt'comuntcations from TARESHER, This inforsacion had not previously been coomuntcated to him or te anyone outeide SKYLARK. ce Rear Admiral Qiy advised Comander Submarine Force, U, S. Aclancic'Fleet by meseage of the eubstance of the Last Ugc transuissions, 4, This information from SKYLARK was made known to che Court of Taguiry in testimony on 13 Aptil 1963. - eH 29, that shortly afcer 0917, when efforts to communicate vith THRESHER URCLASS: ib had been unsuccessful, SKYLARK conmenced an expanding search pattern. The QUR-A sonar was the principal means of underwater detection avatiadle to SKYLARK.UNCLASSIFIED AEE 30, ‘Thst SKYLARK was joined in the search area by patrol etreraft and by the U,8,8, Recovery (ARS-43) during the afternoon, 31, ‘That at about 17308, RECOVERY sighted an ofl slick about seven miles to the Southeast of SKYLARK's 0917R position. 32, That samples were collected and articles of debris vere recovered. These itens and debris subsequently recovered were examined by Labora- tory personnel of the Portsmouth Naval Shipyard and were determined to be matertais which could have coe from TARESHER. 33. That radiation measurements vere taken in the search area by surface ships and subserged submarines. Water samples and the recovered debris were examined by laboratory personnel. No radio- activity beyond normal background level vas found to exist in the search area or in any of the material examined. 34, That additional ships and aircraft were employed in the search etfort. Command of the search force passed from Comanding Officer, SKYLARK, to Coomander Subsarine Development Croup THO at about 0530 on 11 April 1963, and was subsequently exercised, for varying and consecutive periods, by Deputy Comnander Submarine Force, U, 8, Atlantic Fleet, Comander Submarine Development Group TWO and Conander Submarine Squadron BIGHT. "35, that whtZe operating as a unit of the search force, the U.5.3. u © 5 ‘wolf (SSNS75) recorded possible electronic eulasions and underwater notsea. None of the signals which SEAWOLF received equated vith anything that could have been originated by human beings. 36. ‘Tac Naval units and personnel were assisted by civilian Scientists and research ships. The search for TERESHER is continuing. es Bs URCLASSIAEDVv ASBEDENTE 37. Thac TARESHER was designed by che Bureau of Ships, aspieted by Portssouth Naval Shipyard in concract design phase (1937-1958) 5 working plans were developed by Portsmouth Navel Shipyard (1958-1959). 38. That Porcemouch Navel Shipyard bullt THESHER, starting in 2958+ Ieitini sea trials vere bela on 30 Apri? 1961 to 2'May 1961, bot vere eborced at B\ feet by instrumentation deficiencies. Severe water hanner Was experienced, resulting in an extensive propria of byéraviic shock and {mpulee teats on tris «nd drain Gnd sucliary sea wirer systens, Speci#l operating procedures Gere prescribed for the trim and drain system. The next sea teil, felly instrumented, comenced on 22 Hay 1961, vas fully succesefut, and the hull atreases measured confirmed stresses ¥ predicted by cartier model teace. eon 39. That there were several design reviews of THRESHEA Class during che builéing period, The Chief of Naval Operations review in March, 1959, was one such Tevtew. 40, That TIRESHER vas commissioned snd detivered on 3 August 19615 the condition of che sbip vas defined by the certificates of condi Hon fienished by the Comander, Portsmouth Naval Shipyard and che report of the Soard of Inspection and Survey. In general, che ship was boile in accordance vith spectéieations and was in geaerslly good sacerial condition. 41, That EY-80 steel has been used to the construction of al} suclear subsarines, ineiuding THRESHER, since the streamlined single serew hull was adopted, Nuclear submrrines make many more excursions to tese depth than battery submarines have made ia che pasts This Increased number of cycles and che paucity of knoviedge —(/ in the facigue atreagth of HY-80 require periodic survetllance of subgarine hulls, cope) 42. ‘Ther THRESIZR's sutn propulsion plant consisted of a model Vv SSH puclear pover plant. io 43, Thar ativer braze joints and flexible hose conmecttons were extensively ased {n vital piping systens throughout the ship in sccordance vith usual eubsarine building practice and che spect fteattonn. 44, Trac che factors of safety relative to test depth of the conpertnents {n TERESHER vere as follows: Bagine ROW. ys ee J Auxillery Machinery Space J sve ee et Contrel Space and Reactor Goopartment . 45, Tae a bigh pressure hydraulic speten sintlar to tho preceding streamlined, single screw submarines, ves instal y THRESHER vo provide the forces required under high speed amveuvering hi congitions,46. That as compared to the SKIPJACK, the iunediately preceding clas of attack subsarine, THRESHER had: sn dnerease in case depth frow Bl yfeet co Bi \feee. bs AbouE the same reserve buoyancy. és AOWE Ene aah igh pressure aie bank capectey. + age at cone depths Q) & reduction In the asoane gf ballase ubich could be diow frow By per cent to ®l per cent. (2) & reduction in the race gf blowing ballast frow uv [BN cons per ainste to Ol tons per inate, (corey 47, That the increasing operating deptha of oubsarines has coupressed the time avetlable in whteh co take effective damage control action with respect co flooding. The shortness of time available to control flooding {s not well recognized. The table below indicates, Zor THRESHER, in tons per Minute, the rates at which water can enter chrough 4 leak, the maximum rate at which it can be discharged by drain pump or by bloving tanks, and the tatio of waximm rates of taking in water co getting rid of it, Flooding Rate inert ats Size tole Flooding co Depth tn Inches Drain Punp / Air Blow Discharge ia Fata, —_— — isle. Ke ast — v All rates in tons per uinute. eee 48. That the Bureau of Ships design criterta for aly aysten ballast tank blow capacity is that there should be capability to blow 12 sain ballast canke’ Bi a There is no modifteation to thie criteria for depth of blowing or for cost depth of che ship involved, There are no requirements relative to the mechanical design of systems which would prevent the formation of Blockages due to ice which may form during an extended blow. There wes v0 ptovision for emergency debsllasting by means other chan air. Debydrators were not installed. oe 49, Thar che Bi pet reducing valves tn che aela dallase tank blow system of THRESHER were fitted with conical mesh ctrain y + Ce s,s iwi ean neo arte eee IAL RCIFLEL shore tine.Bj _, Thie requires « sustained period of blowing. ccore— There is no requirement in the specificattons for butlding ships to completely blow down the air hanks rhrough the sain ballast tank blowing system, There have not been promlgated any test results which show as a result of such a full blow down: a, The temperature of various components vf the air blowing syste, b, The workability of components at these teuperatures wich frozen mofeture from the air cyetem complicating Ehe situation, es The low temperature effects on che blow system piping and component oatertals, 4. The required air dryness ro prevent Leing. Under a test required by the court, strainers in the reducers of Vi the TINOSA vere blocked and ruptured by the formation of ice in ap about thirey seconds. ri Sl. That the high pressure air system of THRESIER Class subuarines was so designed thar in event of loss of electrical pover to the balleee control panel, air banks 2, 3 and 4 would automatically be “shut off and air bank #1 would be opened up slowly, It takes thirty seconds to get valves fully open again; this 4s because of che 200 pei/sec, allowable pressure rise co prevent dieselization; thus yf after lose of electrical power ot significant voltage drop, there Siz Blowing copebtiley for vows period tatennn 10°30 secoadss (Gre) 52, That @l1 sea water ayatem bull and scop valves in THRESHER y Eiiajens el aes oipraoeecog ae en ncpattceeplecieal treap tyerscitc operetta, aod tere web o specifica Feuttenne for vais cepeoteye, cy 53. That the muxiIfary sea water tyeren in THRESUER was a high pressure syaten, consteting of two sixeinch supply headers and two four-inch i Glscharge headers so arrehged ta the ehlp co provide for # Loop y operation, (cox) Se she Aryl elle ava ieee etre eet a ee eect eee el 55, That the constune vent syscem in THRESHER was directly connected to'the susiliary see werer aystan and atilized paptag, Cletibie tones 5 tad fusible covplingy fees the visiour coupucett ee juis ther to ee (||M NCIC] ‘uxiliery sea vaer piping systen. This crose-cotnected the auxiliary jpy {| 0 u sea water systen, d heBi _ This requires « sustained period of bloving, ter There is no requirement tn che spectficatfons for buflding ships co completely blow down the alr banks through the main ballast tack blowing syste, Tuere have not been promlgared any test reavlts which show as « result of such a full blow down: &, The temperature of various components of the air Blowing system, b. The workability of components at these teaperatures with frozen moisture from the air system complicating the situation, ce The Low temperature effeccs on the blow system piping and component materials. d. The requtred air dryness to prevent icing. Under a teet required by the court, strsiners tn the reducers of che THOSA were blocked and captured by the foraation of ice tn uy about thirty seconds, cop) Sl. That the high pressure ate system of THRESHER Clase subsarines ‘ead go designed that in event of loss of electrical power to the ballast control panel, air banks 2, 3 and 4 would automacteaLly be ‘abut off and ete bank’ # would be opened up slowly, It takes thirty seconds to get valves fully open egein; this {2 because of che 200 patJane. stloveble pressure rise to prevent dieselizartons shus | after lose of electrical pover or significant voltage drop, chera Ls 29 air blowing capability for sone period between 10=50 seconds, cole 52. That all sea water system hull and stop valves in THRESHER could not be renctely operated at tuo seperate stations vsing hydraulic \) operators, and there vas no specified cequirenent for this capability. ops 53. That the auxiliary sea water ayetea in THRESHER was a high pressure syiten, consiatiog of two eix-inch wupply headers and two four-inch 5 Giecharge headers so arranged tm the sbip co provide for a Loop y, Siac oh est) Ho iy ABS ec gp ele craks nell nsy ata face usateasestt toe eet GoteetO or cae direct epee eerie cbf 55, That the constant vent system in THRESHER was directly comected ro the auxiliary eea Water systen and utilized piping, flexible hoses wad flexible couplings from the various components to join them to the This crosn-connected the auxiliary Sen untae epecene ne 7 ARELASSIFLE56, That the normal operating sode of constant vents ae set forth in the Ship Information Book and plans for THRESHER is for them to Vv be opens eget) 57, That the spectfications for building submerines do not require Uy, a low pressure auxtilery sea water system. (oxy 58, That the normal operating modes of the auxtliary sea vater, gain sen vatecy tir coutitioning aod erin and drain valvea in ) THRESHER called for them to be fully open to reduce friction losses ts wd toisa. th Eht dyacand. of) 59, That vital electrical svitehboards installed in THRESHER vere J protected from vacer dripping, but ot fully from spray fron below Er frou machanical Gerengeonst fea 8 titer’ otra oh 60, shat certain atvrntte and upplaaeningHdentict sgutporse sere locced tn clove procimiy {e'bach othe, For eample the two lube ofl pumps for each ehip's service turbogenerator set Sersimabuin clas artoct tu lover "Ievl pocket unt to pore Sia"fesctoecd of hn ethtrdion sete Plane Bly contol oft" fr sbipte service crhopenesttor chretfies I supplied by thee Tube Stifpuaper” fhe abocejele ear preeretoraecrace tocates To close \) peovlnity ta the engine Tome git) 61. That the Bl KW ship's service motor generator sete and thetr clactrical switching end otber connections are located in the tuxiliary machinery space in close proxiaity, They provide for Conversion of Bi volt A, C, £0 Bi volt D.C. wader normal condietons of the Ship's Service turbogenecavor sete providing pover, or, shen pover in provided by the battery of She éissel generttor, ‘coavert Bl volt B.c. to Ql volt A.C. Much of the ship's vital electrical tnd Indieating eqitpment {# supplted from B\ volt A.C, sources (or transformed therefrom). 62, that a ceavaley to BARBEL during the lacter stages of ‘courrrodtion,” focused sttantton bu exe igeteqoaty of worance methods txployed in fabrication of sliver braze ad Joints ba ubonrine’ couwtracttor by Dorthaioth evel Bulverde peor cope to 1961. 63. That subsequent to az investigation of the BARBEL casualty, Silver braze foacs in THRESHER"s vital systems vere subjected to visual examinations, mallet tests, chemical sater{al re~identificacion tests, hydrostatic teats and hydraulte preseure cyeling teste. 64. That chere vas no extensive retrofit of silver braze Joints in THRESHER, likROLASSIFED ‘SOUEDENEEAE 65, That quality assurance procedures employed at Portsmouth Naval Shipyard durdag THRESHER's construction period, consisted im general of aachants and Line supervision, vich some syatsa reste being conducsed by inspectors, 66, That hull production processes during THREGHER's building period did not include the use of #11 the techniques and safe- guards for hull surveillance which now exist. 67, That the ultrasonic method of resting silver braze joints vas not available for use during THRESHER's construction period. 6B. That during THRESHER's construction, x-ray techniques vere used extensively for non-destructive ceeting of welds, forgings and castings. Some ultrasonic testing vas used to detect internal flaws in steel plates. To supplement these techniques, and wherever possible, hydrostatic pressures were applied to pressure vessels and piping systema. These test pressures were, im general, one hundred and fifty per cent of the designed working pressures, In the case of those piping systems exposed £0 sea pressure, chi rect pressure was also equal to that sea pressure expected to cause collapse of the hull, lydro~ static pressure testing 18 a standard engineering technique and was the best mn-destructive method of cesting s{iver braze piping Joints available at the tine of THRESHER construction. 69, Thar the Ship Tiformation Books (81,8) for THRESHER vere prepared by an outetde firm under subcontract from the Portsmouth Naval Shipyard; the subcontractor used an SS(N) 588 Class Ship Information Book as a guide and virtually copted large portions of {t, although many systens on TERESHER vere quite different. The TERESHER Ship Information Book was, accordingly, not approved by the Bureau of Ships; @ temporary book was provided, The y finally approved version was not available to THRESHER even ac the end of the post shakedown availability. (coy) URELASSIFEDYO. That following commissioning, THRRSHER conducted operations in the Bastern Atlantic area, for the purposes of shakedown, training and evaluation. TL. That chis vas a much longer operating period than ts normal before 4 poke shakedown availability, and was provided because of the need to _ test che many new developments and equipnencs incorporated into THRESHER, 72. That THRESHER conducted about 40 dives to test depth ‘%\ feet) u auring this period. we 73. That frog 16 April 1961 to 21 May 1962 TERESHBR viaiced che Eléctric Bost Division of General pystuics Corporation, Groton, Connecti~ cut, for instrumentation and shock hardening in preparation for scheduled shock tescs. 74. That during chis availability, 115 s{lver brazed Jointe in her a hydraulic systens were teaced by ultrasonic means, Of these, eight did not weet 211 requirements of thea extseing bonding standards. Two of (oon) these joints vere replaced. The rensining aix were accepted after decision by the Bureay of Ships thar the existing deficiencies ware not such ao to warrant replecesent. / 75; PME ehaae six Joints all aatisfectortiy wichatood the shock seats (opi) tien followed. / 76. Thet during a visit to Cape Canaveral in early June, TURESHER vas struck by a tug and suffered damage to the exterior plating of one of che main ballast canke, 77. That THRESHER returned to the Blectric Bost Division, vhere all casage vas repaired. 7B. That # thorough tnepaction revested no danage to the prassure hull nor any damage vhich affected the eafety of the ship. y = 15. That shock tests of THRESHER were conducted in the Key West area (cone) during the pariod 17 - 29 July 1962. vy 80. That the shock tests involved detonation off i (ereter— 81. That the gaxioum shock factor wes” Ty uv esterery— % 82, That similar shock tests have deen conducted against other sub= (cose) sarines, including nuclear submarines. 83. That the shock factor (relationship becveen the veight of the uv nae URE ASSiEED84, That during THRESHER's ehock teats, there was no lose of wain power, ‘and no bull rupture wes suffered. fierings, bolt: 85, That a nusber of derangements occurred to Joint: rivets, straps and some michinery foundation elenents. 86. That alchough an inspection was wade and danaged ttens were scheduled For repair during the post shakedown availability, additional tress con~ tinyad to become evident, even in the late stages of the availability. eS ee or er er is Liga cet Secuud Ate oligos ean tas eldtaeatisranresdyvd rr Sc 38. That depth was Iimteed to less than 200 feet unt che post shakedown avallability when the nature of the damage could be determined. 89. Thee full power trials were conducted en route to Portamouth, New Haspehire, for post shakedown availability. 90. That THRESHER arrived at Portemouth 11 July 1962. 9. That che commanding officer's evaluation of the firet year of opera~ thons {a contained in his letter, serial 086 of 26 November 1962.(Ex- 111). 41, He called THRESHER "the best ASW submarine afloat today.” Be pointed out THRESHER's defictenctes, highlighting the following: (2) overly complex in many areas. (2) Difficult co handte on surface or near surface. (3) Vulnerability of auxiliary sea water aysten. c. He stated, "In my opinion the most dangerous condition that extets is THRESHER ts the danger of salt water flooding while at or near test depth." 92. That post shakedown availability commenced on 26 July 1962, wich an estimate of approxinately 35,000 nan-days and 2 scheduled duration of six sonthe. 93, That major Jobs originally scheduled for post shakedom availability included bard tank stiffening, comverston of hydraulic systems from cel- lulube to petroleum based ofl, items based on findings of the Board of Inspection and Survey, and repair found necessary as a result of inspec- tions to be made for shock trial damage. 94. That the post shekedown availability grew by addition of new work, including a large job tnvolving the PUFFS (Passive ranging sonar) equipment, extensive items pertaining to additional noise reduction, and other modifications u (ooteyURCLASSIFIED —SoNEIDENEEAE 95. That THRESHER's post shakedown availability completion date was successively extended from 18 Jaauary to 15 February, to 28 Februaty, to 30 March, to 2 April, and finally to 11 April, because of work added end the under-estination of the effects of new and old work. The total of man-days expended was over 100,000. 96. That damage to THRESHER caused by shock tests was intensively investigated by ship's force, Bureau of Ships, and Shipyard personnel after the cesta, during sound trials and transics, snd on retura to uJ Portsmouth Naval Shipyard, Despite such efforts, shock denige con- Hinued to be Found during the entize post shekedown availabiiicy. (coke) Of significance was the discovery of loose condenser foundation bolts in January, 1963, and 2 misaligned torpedo ejection pump in March, 1963. This pattern of continuing discovery of shock damage during post shakedown availability parellele rhat found in SKIPJACK and SKATE in similar extended availabilities after shock trials. 97. That at THRESHER's arrive) conference, a visual and ultrasonic sutveillance of s4l-braze joints 2 inches and larger in sea water syaceas which vere unlagged and accessible wes placed on a not-to- delay vessel baste. 98. That by letter to the Comander, Fortamouth Naval Shipyard dared 28 August 1962, the Bureau of Shipn:CExbibic 115): J = a. Galled attention co the fact that gross failures of (oon) sil-brazed jointe ia vital subearine eystens made i a matter of urgency £0 develop an inapecties proses for then. b. Directed Portemouth Naval Shipyard co “employ @ ainiaim of at least one ultrasonic test team throughout the entire assigned post shakedown availabilicy to exanine, insofar as possible, the maximum number of sil-braze Joints." €- Requested Portsmouth Naval Shipyard co forward comments, suggestions and recommendations based on rasults of the tests. for use of one ultrasonic rest team, co test first those joints not « lageing, Tagged, and provided that if tine permitted thereafter, 99. that job order tnaved for tbe survaitlonee inspection celina v, wotia be senoved to perme testa of SAGiAional Jeunte. o 100. That the job orders called for periodic reports of resulte of one tests to the Planning and Sscimating and Design Divisions. UNCLASSIFED eas(RCLASSINED CONEEDENT Aa 101. That the periodic reports of sil-braze inspections were not uy, Phe peeontay earth last salwanraane ooh Eeeeias 102. That by 29 November 1962, 145 old joints had been ultrasonically ys tested in the surveillance program, with 4 rejection rate of 13.8 (contr) 103, Thée the standard prescribed by the Bureau of Ships for acceptance \// of 4 sil-braze Joint by ultrasonic teat was 40 per cent bond, 25 per (coy) ceat ainimm, either lend. 104. Thee on 29 November 1962, the Quality Assurance Division reported uy, Ie Tater ation aiiapaee panne messmo Fe eee ee eap dtteal ote ceaedaialnecipenitor abcde rnuion tor conti 105. That decielon wae made on 4 December 1962 not to unlag and ultra- sonically test additional old Joints in THRESHER. This decision vas known to the management personnel of the Shipyard, including the (ops) Production Officer and the Commander, who were apprised of the resulcs of the survey. «106, Thae a copy of this decision was furnished the Coumanding Officer of THRESHER. 107. That no further ultrasonic testing of old sil-braze Joinzs war conducted pursuant to this program after 29 Novenber 1962. 208, That neither the results of the surveillance not the dectston not to proceed further with ultrasonic tests of old joints vas made known to the Bureau of Ships or co anyone in the operational comand Line higher than the Consanding Officer of THRESHER. 109, That Portsmouth Naval Shipyard manegenent end workera exhibited 2 high degree of confidence in all-braze Joints in THRESHER's piping ayotens. (CLASSIFIED110. ‘That the results of ultrasonic teats on sil-braze Joints in SCULPIN and SRIPJACK during shipyerd availabilities were as follows: Bik GA Appemtorss, gst tesected or oe SCULPR Mare Inland pest 1962 387 U Seine Metal’ MESES oo Al, That prior to THRESHER's post shakedown availability, there had eer eneney uel lh v LL2. That che approxinate number of sil-braze joints in an SSW reactor “{eoxry equipped ship ts) Be __ jad above in hazardous systens. M13. That results of the ultrasonic teats of eil-braze joints in sxresack were not reported by Zortemouth Naval Shipyard to the Bureau of ships, (Ci Deputy Coamender Submarine Pocce, U. 8, Atlantic Plest, or higher authority. 114, That flexible hoses vere replaced ducing THRESHER's evailabilicy ta accordance with process instructions existing in the Shipyard, 115, That the process instructions did not fully define specifications fpr allowable ovist. 116, That a crataing program existed for making up flexible hoses. 117. That no formal training program extsted for installing flexible hoses. LIB, That some flexible hoses were twisted in initial installation, but were corrected, 119, That an inspection progras for flexible hose installations existed a end 'vas carried ou. 220, That a comprehensive flexible hose Listing was prepared for THRESHER. This wae used for quality assurance planning and inepection, 121, That some valves in THRESHER's hydraulic, auxttiacy sea water and other systems were installed backwards during the post shakedown availe~ bility to permit testing of systems, come due to inadvertence and one due to an error in the ship's plans; hovever, all were corrected and properly installed prior co departure of the ship for sea trials. 122, That the Ship Information Book and working plans for THRESHER's auciliary sea water ayetem coll for cross-connection of the system as Che pora¢l operating mode, [nstallation of new check valves in the constant vent portion of this system during the post shakedown availa~ ley'nade’possibie’ couplet Sepatacion of the Siniitery aca wares 4 HRCLASSIFI ‘SenPieTTAL.LASSIE 123. That high pressure air and hydraulic systems require « high order cf emall particulate matter rejection during fabrteation, installation and repair, es & = 124. That disficulties were experienced in operating the high pressure aLr syetes, snd in leakage from the reducing Valves, These difficulties, whteh began early in the life of che ship and. extended throughout the post shakedown availability, appeared to ste from the presence of tinute particles in the system, 125. That the difficulcies vith the high pressure air valves, particularly leakage and eating, were teported as having been corrected prior to sea trials 126. ‘That the hull repair, access patches and hull stiffening work was done in accordance with existing Bureau of Ships instructions and vas checked by nonedestructive test means as being satisfactory. 127, That the bull surveillance tnepectton scheduled during the post shaka- dove avallebility wae compleced. 128. That after the final system test of the auxiliary sea vater systen (cons) aft Reserve Peed Tank io. 2 wes over-presnurized on 8 March 1963. "129, That the Reserve Feed Tank top was displaced one to two inches by over-pressurizarion and the chip's | galloa-per-dey distiller vas {608E)~ also displaced, oa 130, That the drain Line end other Lines mounted oa the reserve feed oye) tank top were affected by the displacenent of the top. 131. That the distiller wee restored to ite proper position and checked eat by visual, hydrostatic and short operational fest, Lio. Muse Cibisebins2ibd tank oad epttcod-all evil by pRAsonts und. (OH) Schad agacdestnuseive cath, 133, That based on a dectaton that no overstrees problen was involved, ee ttevth:nd bei fees gar Eon beck Cop wera ROE EGLEeE “aoe Oare SeEST falccintions sade prior ro san flair 134, That stresses calculated after the lose of THRESHER by tve separate activities indicated thet stress levels on the drain and other lines «cory mounted on the tank top vere not excessive, eed fottoving . «ebrr) 135. That the ouxtliary sea water system aft was not ret the casualty to the reserve feed tank, 136. That documancation of ship's aystens, components and Aorual operat= ing modes was not delivered to THRESHER by che end of her construction period. It wax never wade complete and accurate in all respects.Af). Ther detatton damage mst spnitne sé floating tsiwetties, ome Uf seapeuechy ait sctemaegaed sevice ave Woe aipitoe Ny ine movie” psy tpeciicationa for TERESHES. 138, That the ELret dockside simulated operational cruise for purposes of crew training (fast cruiee) vas held 23-26 March 1963, and was Cera~ Anated because of che large number of material deficiencies noted; the second and last “fast cruise" was hegun on 31 March and satisfactorily completed on I April 1963, 139, _that Atlante Pinet subgerinn Torco Tavtructions did fot raqulte tnd TMBSHER's sea trlel agenda for deep dives on 10 Apel] 1963 aid sot (COM) provide tery opevazton ef san vaiven it vatlign Geptn’ peipr£o proosad= {ng eo cest depth for the firet Cine after her post ahakedown svailability, 140. In the second “fast cruise’) during one of the drills involving « simalated flooding casualty in the after auxiliary sea water systen, it required twenty minutes to igolate a leak. This vas one of the early drills. Changes had been wade in the system involved during the post shakedown availability, va. 3 . vy There vas no evidence to indfeate chat THRESHER planned ore to test che“Gperation of sea valves at various inrermediate depths en route to test depth on her first deep dive. There is evidence that it was planaed to do thie on a second scheduled dive to deep depth. 142, That THRESHER was at the Sound Pler for sound trials during the period 1 April to 4 April, and in drydock from 4 April to 8 April 1963, £0 make repairs to torpedo door shuttere and main circulating water valve WSW5, During this period liberty was granted to the ere. 143. That testing of syetens was in accordance with Portsmouth Naval, Shipyard Instruction 4855.2 and the substance of Portsmouth Naval Ship= yard Instruction 4730.8 (of March 1963), and other applicable {nstruc= tions, A couprehenaive test program was conducted, Luh, That the number of people in the quality assurance progran in the Portsmouth Naval Shipyard haa increased from 152 co 243, and the direct expenditures for the program from approximately $1,200,000 to approxi~ nately $2,800,000 in the past two years. AGS. That a11 work undertaken by the Shipyard ducing TIRESHER's post shakedown availability wes reported as having been completed satisfac torily, and the Comanding Officer expressed bis concurrence that the work wae complete. 146, That Portamouth Navel Shipyard hse had an extensive training program over the past two year, expending about $1,300,000 in the shipyard, of which the Pépe Shop (55) portion was about $400,000, ov pacer eerie ketene cttoce pertorsed at Porewnouth Navel Skipyacd lay included construction AULADO!!108. That starting in 1962 there was a Jofat identification plant prepered by shipyards for new construction submarine! a3] be akiaks Wrrtenrn Seyullilcjack! aes 1p we Sbonderd om tariduailleg tn Sp ile et ectie ahraipia dersauem werent? ship's eyetens as regards operational etatue, caoponents renoved, eo J ponents unusable, reatrictions, etc; such a procedure is often called a Eipeot ants foie ciartessce. el rts aay tor pies ee cables ooeeeoerear unipssiee Se ompmoeae coeneNOUALTT= 150, Thar Portsmouth Naval Shipyard has authority to deviate from buslding specifications in certain aveas, and is using the specifica tions as goals rather than requirenents in certain cases, ASL, uae workers. and managenet at Portinouth Maval Shipyard are not U. Jnvattlcaner adhering so the provers and procedure decmence so tanere (9H) the benesite which desive foe euch doonmenta, 182, That Portanouch Naval Shipyard considers the state of cleanliness of Shop 56 (Piping Shop) not adequate to permit work of requisize ry) quality. This vas confirmed by 4 view of the preaises taken by the Court, ‘the Shipyard is constructing "clean room" facilities for ceo) sanfacture and asseably of air and hydraulic piping systens. 153, Thac during the course of proceedings, a test demonstration for the Court of Inquiry was held in Drydock No, 2 at che Portsmouth Waval Shipyard. A stream of water vas released to atmoaphare ar THRESHER's teat depth pressure against a piece of electronic equipaent. The Stream produced trenendous force, spray, fog and noise.. Be. By ) Bi 8155, Thar the complexity of nodern suboarines has increased at & tapid rate, The advent of nuclear propulsion, ballistic missiles, and gresely increased speeds and operating depths has made tt essen~ clal chat all Snformation affecting their safe operation be analyzed and promptly dissentnated. ie jal ementer sameaee ieral tite: Grate (FAs b dui be Giameseis Abt tae tite tcPltes Wesseiat cperectzi ite. Shs 7 jaan ie pepe ae GY eee wes UE Geeyoviny ents Sie carpeaituctucy SY booker bays 158, That submarine diving trainer equipment does not have the capa- » op bility to simulate the attendant effects of large flooding and ‘asso~ elated damage control sitvations far craining. 139. That all oubmarines are now restricted to a maximum depth of v. ‘Bl fect. som 160, That during che past four years, the Nawy"e sanual shipbutiding . program hae ncreased fros approximately $2,500, 000,000 to $4,500,000, 000, 161, That during the past four years, the civilian personnel ceiling of the gureau of Ships in Washington, D. C, has been reduced froa 3800 to 3100, 462, That during the pertod from 1959 to 1963, the nusber of naval officers designated for Engineering Duty (ED) has ¢aclined from 1057 £9 abour 860. 163. That the number of naval officers serving ap technics? sad sapagenent officers in the Portsmouth Naval Shipyard has been reduced over the past fev years. This i# particularly serious in the Design Tlylaten ante, da/iss6, dive Asslutant Desige Gapertatandeuea ere’ cage secugnes ” none {4,40 thatpned today; and in tne Shipbutlaing and a) ASSIEE coals Divteton, where thevloss of ron qualified O€fteers,(asinly BVT ANSEL rt _ HOLAQOG LU in 1961 and 1962 has reduced eapabilscine.URCLASSIFIED “oe 164. That during recent years, the advent of the nuclear submarine has resulted in a major increase in the complexity and difficulty of subsarine design, construction and maintenance, 165. That the increase in complexity of auclear submarines has resulted ip an appreciable increase in che responsibilities imposed upon their comanding officers during the construction and post shakedown avail pality periods, 166, That the following changes of key personnel were effected during, THRESHER's poet shakedown availability: a, There was a change of THRESHER’s Commanding Officer in January, 1963. b, There was a change of TERESHER's Executive Officer in January, 1963. c. ‘There was a change of THRESHER’s Ship Superintendent in Decenber, 1962, @, There was a change of THRESHER's Assistant Ship Super~ intendent in Novenber, 1962. UNCLASSIFIEDoP INI0Ns, . That the lose of the U.S.S. THRESHER was in all probability due to: conjecture may be stretched too far and become accepted narrowing the field of search for possible cat ‘That the fact chat the court has singled out certain c 4, Aq initial flooding casualty from an orifice between 2" and 3" tm size in the engine room, which continued, compounded by D. Lose of reactor power due to an electricel2y-induced autouatic shutdown, J €. Inadequate opatating procedures with respect to minimizing (cory the effects of a flooding casualty and the loss of reactor 9 power, and 4, A defictent air system, susceptible to freeze-up, with low capacity and low blow tate. snd conjecture, fact, thus 8 of the casualty. ‘That there is a danger that, in melding together fa 2 for study should not deter others, particularly meubere of the crews of simtiar ships, from continuing to study the many questions raised by the THRESHER's loss. readiness has been reasse: ‘That ic would be prudent to retain the current interim depth lintta- Vv, tion now imposed upon all submarines until cach individual subnarine «cont xd im regard to the factors listed in Opinion 1 5, That a flooding casuilty in THRESE®Z .uld have resulted from: ‘That loss of re: A faulty stl-braze Joint. RU Undiscovered shock danage. cS) c. A flexible hoee failure. A casting or piping failure. e. Awinor bil failure, Uaimowas, including component failure. stor power in THRESHER could have resulted froa: a, Inadequate protection of electrical evitchboatds from salt 3 water, particularly from below. b. Location of vital equipments and back-up equipments where a = lieCOMBIDENTIA- —— 7. That submarine operating procedures at the time of che loss of u ‘THRESHER were inadequate, in that: won a, Cross-connecting of sea water aystens was excessively used, particularly at deep submergence. b. The concept of securing salt water systems on 2 flooding ‘cagualty and the cesulting operating limirecions and capa bilities had not been appropriately investigated, ts the ctpemnod” BY Jeten the attendant sivancages vey not gendratly apprectattd and Mas not folloved on the deep dive sf THESIER. a. B ¢. Fre-planned denage control actions and system isolations in brder to reduce flooding control reaction time had not been fully explored. £, Submarine Force, Atlantic Fleet Insteuctions did not require and THRESMER agenda for deep dives on 10 April 1963, did not provide for operation of sea valves at various depths to Ageure proper operation prior to proceeding to test depth . for the first tlee after a protracted ovetheul, a, An inadequate blow rate. b, An inadequate capacity, cy A tendency to freeze up at Line restriction points; for example, at the conical strainers in the reducing valves, and E 8, A designed closing of the co-line afr bank valves when electric pover was lost, followed by a 10-50 second air equalizing delay time before the reserve bank te avatiable on the line. 9. That to provide aaximm sefery ac deep deptha Bj feet and greater), — U/ ait Large son water ayarem hvll and stop valves should be hydraulically | CeO operable, To provide saximun aaavtance of operabiiity, sex velvee should be operated from a primary station in or near a normally eaaced area, while hull valves should be operated froma different station, so located that a Leak would aot prevent access to at least one station. 10. Thar a lov pressure auxiliary sea water system (low pressure fresh or aait water) would greatly reduce the pousibility of Elooding st deep depths nd should be provided in new construction at an early date, (The great Neduction in the length of piping and hoses exposed ro sta pressure would —— —_TAGLASSFEDeliminate the need for considering wany of the solutions proposed here= after for the currently inetalled aystema. Their consideration is Sesireble for submarines already built and under construction. A heat exchanger installation is probably the quickest way to provide « low pressure auxiliary sea water system, but other aethods should be ta- vestigated, ) LL, That the basic auxiliary sea water loop system concept and design for the THRESHER Class 19 good, and 4s an improvement over the single header "Christoas trae" systeas installed in orher nuclear submarines. 12, That, operstion of the cursent auxiliary sea water system in che Ay with tenoce control from © single operating atetion, prefela che wancuvering ates, vould inprove overs}1 aysten reliability and particularly fron # system igelation viewpoint; therefore, the Ship's Tnstruction Book and yorking plans for che TURESHER Class auxiliary sea water system which call, i shocld be podified at the earliest co requize splte plant operation as nomasl Bode. 13. That the constant vent system in che THRESHER Class is a safecy bazerd, 1. That conacant vente in subsarine auxiliary sea water aystens need ko be closed at deep aubsergence to increase the safety of the ship; design of components must take this into account. 15. That chere were wany teasons for the Bureau of Ships and Portsmouth Naval Shipyard continuing the use of sil-braze Jointe in piping systens of submarines, These included: years of shipbuilding practice and service, extensive ~rz., improvement in processes and non-destructive test techniques, the lack of veldable fittings, and the bigh welded= Joist rejection rates in all shipyards, 16. That prior to THRESHER’s povt shakedown availability, there had been 4 sufficient mumber of serious failures of sil-braze piping joints in aubaarines Co require thorough invescigetion by 412 responsible for THRESHER's safety (Pact 111) 17. Thae there vare indications of high rejection rates of sil-braze Joints sade in the period 1958-1961 in shipyards other than the Portsmouch Naval Shipyard (Pact 220) 18. Thar Portsmoueh Naval Shipyard did not aggressively pursue the ultrasonic ingpection of eil-braze joints in THRESHER ae required by the Bureau of Ships letter of 28 August 1962 (Exhibic 115) Comsander Subwarine Force, U.S. Atlantic Fleet did not agave pursue the ultrasonic inspection, nor did the Commanding Officer, THRESHER, 29. That the rejection rate of 13.9% on original sil-braze joints in THRESHER was a clear indicator chat addicional action vas required. o coal v coos ANCLASSIFL20. That the confidence of the Portsmouth Naval Shipyard personnel in sil-braze Joints was not fully warranted in the case of the auxiliary sea water, trim and drain, or air conditioning systems in THRESHER be- 4. Several submarines had auffered casualties which nearly re~ sulted {a cheir lose, Of these, the oost pertinent was the {C8NF}— U.S.S. Barbel, hich suffered « failure of a 5-inch sil: joint on 30 Novesber 1960 at an approxisate depth of Bi b. BARREL investigation shoved inadequate quality assurance in Portsmouth Naval Shipyard efl-brazing process prior to 1961. c. There had been no extensive retrofit of high quality s{l-braze joints under che improved quality developed by Portemouch Naval Shipyard after THRSSHER's initial criticality. 4. Portsmouth Naval Shipyard had conducted ultrasonic tests on s{lsbeazed systens in SKIPJACK, finding about 22.5 per cent of J Joints not meeting the Bureau of Ships prescribed scandards. oe In thie case the Shipyard did not report che results to the Bureau of Ships or to Deputy Comander Submarine Force, U.S. Atlantic Fleet. ¢. Mo ultrasonic tests of original sil-braze Joints in the auxillary sea water or trim and drain systems in THRESHRR had been conducted prior to the post shakedown availabiiity, 21. That the managesent of the Portasouth Naval Shipyard dtd not exer~ Vv, cise geou Judgment in deteratning uot to wnlag pipes in order co concinue (Oxf) the directed ultrasonic teat survetilence of original sil-braze Jointe in THRESHER after Novenber 1962. 22, That che Bureau of Ships improvement and corrective actions regard- fag the sil-braze problem ware not applied at the Bureay level, or in (cont) - the field, wich sufficient vigor in that: 4. The continuing flow of information from the operating forces indicated that poor workeunship or design fad resulted in inferior and unsatisfactory applications of the silver braze process; chie should bave resulted in nore detailed ‘avestiga: tion of che adequacy of sil-braze in hazardous systems; b, There wae ingufficient inspection and eudit by, the, Bureau of che shipbuilding and repair activities to insure that specifications were being met; and €. The best tool for determining adequacy of sil-braze, i.e., jonie inspection, was nor auffictently exploited from UNCLASSIFIED23. That it appears that insofar as aubmarine shock © 8. The instrumentation and inspection cechnigues and levels of effort utilized ca date have not insured that all danage is found in the early intensive investigations of damage. b. That nore effore aod instrumentation ie required to dasure that all dazage bas been Found. Rl 4, That until che matters mentioned briefly in a, b. and ec, above are wore fully explored and necessary acciona are taken, 12 vould be prudent to: (1) Limit the shock Eactors used in shock tests co or less. (2) Increase considerably che level of action {a arranging shock teats co provide intensive planning, calculation of effects, instrumentation and {ngpection before and after such teats. 247 That in view of the many potential sources of cesualties and their Serious consequences in high performance subuarines, ouch ae THRESHER, there is a need to re-emphasize and improve, where indicated, the quality sgaurance program {a shipbuilding end repair yards 25. That the quality assurance program of the Portsmouth Naval Shipyard ould be iuproved by appropriate consideration of the following: 2. Quality Assurance Division should report directly to the Shipyard Commander. Bb. Quality assurance should be engineered and planned, utilizing he stariscical approach and should de-enphasize the Anepector™ approach. c. Quality assurance audits should be forvarded to managenent on a regular basis. 4. Quality assurance should record all dafecte, not just re- aining defects (for exanple, brazers and tnepactore reject jotate and do not ceport defects found witch are readily correctable. This aethod does not reveal to sanagenent all process deficiencies). 2. Quality assurance ulerasonic test and welding radiographic Hest cequirenents should not depend on initiation of inspec- tion requests by pipefittere and welders, but should be separately initieted by che Job order preparing authority to facilitare croag=checking.UHCLASSIFED sopra £. A quality assurance program should be developed for flexible hose installation and checkout. g- The Quality Assurance Division does not currently have power to disqualify workers observed to be violating procedures, process controls and normal operating instructions, but must s0 recomend to the shop ‘supervision involved. It might be advisable co permit quality assurance personsel to temporarily remove qualifications (brazers’ cards, ete.) under guch circumstances to insure that defective work 11 not built into submarines during the nomal adainiestrative handling time for disquelification action. hh. Welding quality ts under the Welding Engineer and 4s not Completely integrated vith the quality assurance progran in the same manner as other processes are, It is believed desirable to integrate this effort. 4, Condition sheets (for defects discovered) should be reviewed, analyzed and summarized by tha Quality Assurance Division for presentation to management to insure that process de~ ficiencies are brought to management's attention. 26, That che Portenouth Naval Shipyard atcttode tovarde, and facilities for, ainite particulate matter Fejection, in general, are not conducive) to delivery of high perforasnce aystens of the requisite tuper-cleanliness. Frocesaee sf fabrication, installation and repair of euch piping systems Fequire engineering revision and facilicy preperation and, ore teportantly, personnel training to provide an adequate basis for super-clesalinces, Gate ie nose tapertent for high pressure tix and hydraulic eyetens, Sut fe applicable for other aystens.) ) 27. ‘That éwmy valves used a8 spacers and valves installed backwards for teats should be so marked (tagged) end should be designared in the ship's eystem stacus or "rip out” procedure. 28. That the quality of work performed by Shop 56 (Pipe Shop) at Ports~ mouth Naval Shipyard has improved since the BAREEL incident, particularly im the eil-braze area and in material identification and control, vork- qvonhip ani quailty ansctenee- A 29. ‘That cfpe vemaplars shout ba proviiled with the capabtiity to svalunes bill surveilleace piureetion for sik individu) sitanvine. cop wssc UNCLASSIFIED30. That an identification and Misting program for flexible hoses, as provided by Portenouth Naval Shipyard for THRESHER, vas excellent and should be provided for 212 subsacines. 31.’ That the pipe Joint identification program developed in 1962 by submarine new construction shipyards should be applied to earlier sub= sarines to provide a sound basis for checking Joint quality verification 32. That thone regponsible for Submarine Ship Information Books should insure that they are compleced and delivered with the ship. 33. Thee there is a need at Portemoth Naval Shipyard for additional Getatied uricten repair procedures, inspection routines and guality assurance audit programs, to: 4, Insure that repairs to submarines ate, in fact, accomplished im accordance with the sound engineering jedguent available. b. Insure that management's policy is fully carried out. c. Remait planned audit procedures for quality assurance co provide the high assurance of quality and safety necessary, 4, Provide the baeis for management information for problea~ solving. 3h. That a “ship's System Status" o. "rip out" procedure is needed to maintain information op the status of the complicated systens of nuclear subsarines and the division of responsibility between the submarine and the Portssouth Naval Shipyard. 35. That conerace designs of subuarines datermine the basic operational and safety procedures; therefore, tt is important that the Bureau of Ships shoul a. Ingure chat design personnel are fauiliar with operational procedures, By b. Ineure that there 1a adequate feedback of information on earlier syetens fron shipbuilding yards and submarine operating personel. e, Insure chat damage control under various casualty conditions te thoroughly considered before the final system parameters are rigidly defined, aad B\ Ingure that design personnel become familiar with each other's problens and goals; in effect, break dovn tha walls which apparently compartment such personnel into sual areas of expertise, =, (opty S) (ooKr) a RCLASSIFED36, That the basic design of THRESHER Class submarines is good, and Ate impleaentation resulted in the development of a high performnce suboarine. There are certain improvements desirable to increase the safety margin, as set forth in the recommendations. 37, That since high performance submarines require full quality assurance and a high degree of uniformity, the Buread of Ships should require adherence to spect fLeattong, J 38. ‘That all cubserine ar nysten deoign criteria need to be reviews for adequacy and safety, Of particular importance are the following: (Op) 4, Air blow rate for mata ballast tanks, b. Air bank capacity, ce, Eéfect of depth, 4, Ate condition as regards! (1) Pareteulate matter rejection (2) Moisture e. Aix system zechanteal design for inclusion of and positioning filcers, strainers and denydratore, Bnergency blow capability. B+ Number of allowed pressure reductions in air system. h, Allovable xechanteal pressure reduction devices in main ballast tank normal aed energency blows, 4, Provision of internal drainage of water from air banks into the pressure bull. J. Euergency de-ballasting by chemical gas generation or other k, The fail-clowed concept for the three air banks now normally carried on the Line {n the THRESHER Class {8 not desirable for fety of the ship at teat depth and should be modified to provide fail-on-the-line; t.e., air beak valves open. 29, That the high pressure blov of subeacine sain ballast tanks ceeds (Gi) fo be coated wnder conditions wimolatiag a fll Dlov at test cepth, 40, That equipment locations in the THRESWER Class subsarines are not ao selected as to maximize resistance to damage and to facilitate control after danage; for example: oa UNCLASSIFIEDB, ‘That procection ffda vater streams and spray of che Ol im Shipls, sarvige ogcar punerance tes nod cust wiaceEitl Ceabectious ia chs serillery aisiaery ieee inchs TUGSHER Class suboerices needs inprovenent. ceases GL. That electrical evitchboards In the auxtlfary machinery space and engine room of subaarines are not sufficteatly protected “w from water streans or spray, especially fron below. coon) 42, That the deficiencies which probably caused THRESHER's loss (Opinion 1) could have been reduced by thorough and imaginative analysis and timely dissemination of all inforsstion to be had from v the BARBEL and other casualties. (gpk so ett cere ently coeetaca viceeeticmearescernerey Se Reh eet rat tame en Berrie aletaptoeaieeioral sea ea pean patent abate eee o entero oye 4h, That there Le a lack of information regarding operating proceuces J for submarines under varying casualty situations. coo) 4S, That the following is a reasonsble rationalization of probable events in TERASHER berween 0909-0918,1R on 10 April 196: Ie 4a recognized that che specific nature of the ZHRESHER loss cannot be determined by assumptions and computer solutions based on those assump~ tions, The following analysis is made in an effort to determine the parazeters .of the unknown factors, such as size of leak, by utilizing known factors "and the wost probable variants of their interpreration ag the inputs for computer solutions, it is fmpossible, with the inforuation nov available, te obtain 2 more precise determination of whac actually happened. Analysts of ail of the facts avaliable led co che conclusion chat the location of @ flooding csovalty which might have initiated the loss of THRESHER vas in the engine room, From the sany computer solutions there energe three which bracket =U. the probable accual situation, wseener It is known with reasonable certainty that at 0909R che THRESHER wi ac test depth, At about 09108 « message from THRESHER announced a course change to 090°T from 000°F and gave oo indication of say difficulty. Te ie known, without uch doubt, that at O9LIR the main coolant pumps of THRASHER, which had bean running Bi bince che start of the dive, either stopped or were slowed! Gy A dhesonta octienr pang -Atoppads. chavs Spud here Vien di sucnanté reactor snotdomn (SOMO, This could have paue 0 aorael nate propal tien pouer evatlable wncit atcer che /el ainstes Datvenn OVLIN and Tima of collapse depth There is an Eacrgency Propulsion Yeter vatch could be fun frow the beteccy, ue Le qust Ge mclorthes. Prog watn curblan drive (ILD Sot-ibe pover avallcile toa ehis source in oaly eutficiene'aer abevt's IB eel! WULAOUITILE knocs.IE, ingtead of stopping, the main coolant punps hadi Ti nove been Fier for about pi knots, In cas i a5 The showed te would have cransmitee ‘and main propulsion therefore kept available;there could se I of the three computer solutions the essuaptions vere: At test depth. On ain propulsion at about 8 knots, TS) Power float at O911R when pumps atop. Exergency propulsion motor placed on propulsion at 09138. Blow of main ballast tanks From 0913,6 to 0914.18. Collapse et 0918.1R, ship trajectory curve developed by couputer solution of this cese to be not highly probable, mainly due to the fact chat the ship decreased depth only about 100 feet by the time rhe message was .§ saying, "Experiencing minor difficulties , , ." etc. In this case, assuaing @ seasonably good trim, the size of orifice through whlch Flooding could have occurred (with .B coefficient of discharge) would have been Tp Ga greater than 2" and nearer 2" then 3", sse II che assumptions ar AE test depth, On main propulsion at about 8 Inots,/ Bi om @ curn with 20° right rudder and 50 dovn angle on the boat. At 0910.58 flooding occurs and pumps Bi > Full speed and 15° up angle ordered at 0911, Main propuleion power remained available at least until 0912.52, at which time a speed of about %\ knots vould have been reached. Main ballast tank blow initiated ae 09098R and ceruinated at O911.3R. Second main ballast blow began at 0913.68 and ceased at O914.1R. ar 0918.1.UhULavui ily 4od the main turbines remained on propultion auch longer thin 0912.58 side i oes mechan reps Bh ‘unsia could have surfaced with a fIéoding casualty due to any vipe ripture in, the Seip except) BH The next smaller pipe size in THRESHER is 2 Even # Q\ size line rupture would produce excessive trim angle pote to che tinker the wersage Sfuich indicated “ainor diffiesity.” duin elreviociag water Lint rupture, oF Mul supture axe diemisted an remote possibilities, lace she sctoal hell Callapes accetred st OMG.1N ond woeld ova nevarted auch ecrLier hed slike GE these fo carualtien occucred, canning the change in pover at OSTIR. In Case IIT the assuaptions are: ‘The save as in Case TZ, except that both flooding and full speed with a 15° up angle occur 1,5 minutes earlier. ‘This {s the aost probable approximation of the sequence of events. The ship trajectory curve developed from a computer run with these assumptions indicates that, Just prior to the sending of the "Minor difficulties ..." message at O913R, depth would have been reduced to about Bt feet, and a0 trouble would yet have developed in maintaining the ordered 15° up angle. The air blows postulated in both this case and in Case II are predi- cated on indications on (| and on the demonstrated tendency for the gtraisere in the air reducing valves to ice up and fail in approximately the times indicated in the aseumption, Furthermore, the phrase "Am atteapt- fog te blow .,." dn the O9L3R message would not be inconsistent wich a 90 second blow which had been interrupted by a frozen reducer at 0911.3R or ao electrical failure which would have imposed a denial of main ballai tank blow capability for at least ten to fifty seconds. Cave ILI indicates a hole of @ Little more than TV From all of these studies, it vould appear that the flooding which occurred vas through a hull orifice (vith coefficient of discharge of .8) a bee not much larger than Gi The corresponding pipe sizes a in THRESHER'# piping syatens would have been between’ Q\ 46, That manpower loading by the Shipyard in the last two weeks of THRESHER's post shakedown availability was not excessive. 47. ‘That TERESHER's crew had adequate time for rest immediately prior co departure for sea trials. 48, That the Commanding Officer, SKYLARK, failed fully to inform higher authority of all the ‘nformation available to him pertinent to the circun- stances attending che last cransmission received by SKYLARK from THRESHER on 10 April 1963, a ¢ was his duty co do, for an vareasonable length of time; but that this could not conceivably have contributed in any way to the lose of THRESHER and vas not matertaily connected therewith. i J =e a oo fone of meaUCLASSIFED 49, That although we may never learn the exact cause of the tragic loss y of TERESHER, we do know enough to make it necessary for us to explore in Vv depth the miny possible causes, to the end that their correction may re- y duce the probability of a future submarine loss from the same cause. (copay Some of the possible causes are in the material and operetional {elds and have been separately treated. Less tangible and more dif- Elewlt are the possible causes that fall in the personnel field. TRESWER was vell manned by experienced officers and men. They enjoyed the reapect of their contemporaries and had earned ir. Portsmouth Naval Sbipyard Management and vorkers looked upon THRESHER so their finest creation. They were proud of her. Yer, in conscience, the court must report that there are causes ia the personnel field which may well have contributed to the loss of THRESHER, and vhich deserve earliest attention at the highest level. During a period of expanding volune of work and greatly increasing techaicel complication in submarine construction and repair, the court Hinds that the oumbers of specially trained, technically competent offi- cers, in both the Bureau of Ships and in the Porcomouth Naval Shipyard, have been serfously reduced. Some of these have been replaced by civilian engineers, but the workload on the officers remaining continues to in- Treas, This situation is seriously impairing the submarine building aad repair programs. At the Portsmouth Naval Shipyard it is resulting in a reduced level of attention to vital subsarine desiga and operational maths which could affect safety, If the situation continues, Portomouth Naval Ship- yard could well become an unreliable and uneafe activity just at the tine when the overhaul of Polaris Fleet Ballistic Missile submarines must begin. 50, That the nuclear submarine program is placing upon the Navy and the nation denends for highly qualified and trained mmpower in great numbers. ‘The Navy has established training prograns to provide the officers and wen to man and operate our highly complex and advanced new subsarines but urgent stepe axe required to attract {nto the subarine program and fo hold the high callber young asa necessary for safe operation of our submarine force. 51. That during the overhaul and post shakedown availabilicy periods, yy the responsibilities of the commanding officars of these ‘acressingly coon couplex submarines have become a0 extensive ax to require a bigh order of fechnical backup from the operationsl chain of comand. This backup {0 Presently limited by the lack of adeqoate noabers of officere exper fenced in the operation of high speed submarines. [HAE ROpIricn Hipp Book er z=52. That the evidence does vot establish that the deaths of those am barked tn THRESHER vere caused by the intent, fault, negligence or inefficiency of any person or persona in the naval service or connected therewith. 53. That the cuberantially contemporaneous transfer of THRESHER', Comunding Officer, Rrecutive Officer, Ship's Superintendent snd Assistant Ship's Superintendent in tha final portion of her post shakedown availability was pot conduciva to optim completion of the vork undertaken. Sh. That the lessons learned from the inquiry into the loss of THEESEER are of such manent az to require wide dissemination within the Navy. y 55. That the findings and opinions of this court point out numerous Yy practices, conditions and atandarda which were short of those required (coe) to insure’ the thorough overhaul and safe operation of the U.8.3. Thresher. / These emae shortcomings ailitate against tha safe construction and ovar= haul of all subsarinea at the Portsmouth Naval Shipyerd and are, in varying degrees, applicable to other subaarine construction and rapalt yards. Vigorous atepa abould ba taken to correct them. ‘These shortcomings bave daveloped incident to the rapid changes In materiala, workmanship and operating conditions of submarines during the last decada and to the accelerated paca of the submarine prograa. ‘hay can ba blened on no individual or individuals, and many vould not have coma to notice had THRESHER not been lost. The responsibility for the loas of THRESHRR cannot be charged to neglect or dereliction on the part of any individual or group of individuale. Bh : UNCLASSIFIEDRECOMMENDATIONS, 1, Thae the interin depth restrictions now imposed upon all subaarines should reosin effective util carefal consideration, for each individual Subuarine, is given co the probable factors contributing to the loss of THRESHER, as Listed in Opinion 1. (sepher) gfe hn iia af mcilincia wen woe phen [Le evinpeh- dada construction be modified av follovss a. Provide a low pressure systen for auxiliary sea water service. Provide remote hydraulic operation for all nea water syste jea and hull valves, with the sea valves operated from = primary etetion in or near a normally manned area and the hol] valves operated from a different station so located that a leak will not prevent access to at leest one of the = tuo stations, coop) 2:ae vse eo ea pone eres pelbeript | @. That the constant vent sub-system be eliminated. 3. That for THRESHBR Class subsarines the following be provided: a, Elimination of che constant vent sub-systea, with subseicu- tion of fnternal venting by oanval means. b. Rydraulic remote operation for bull and stop valves. . Modifications to the auxiliary sea water system plane and Ship's Information Bock to show split loop operation as the norsal mode. 4, Instructions in the Ship's Information Book for eafe operation of the trim and drain system at deep depths, with information on valve opening and closure tines, 4. That additions} inepection, repair and certification of sil-braze joints for operating submarines be performed to attain an acceptable Tevel of relimbility. «carte 5. That in new submarine construction all s{l-brace joints in hazardous systeas above one doch ia ineide diameter be ultrasonically tested, coon certified and docunented. 6. That én baeerdous piping systems of subuarinas designed to opsrate Below B\ feet, sfl-braze Joints of wore than tvo inches in inside diameter, be replaced by welded jotns when replecenent is required. SCLASSIFE7. That for atv construction submarines, welded piping Jotate ba ) tpecifted for jotnte of nore than two inches in inside dlaneter ‘ in hazardous syatens. (oor) 8 That shock tests of nuclear submarines be deferred until such oe, cine as the Bureau of Ships has reassessed the following: 2, The adequacy of inatrumentation coverage and capabiliry to insure that all danage ts found shortly after the shock tests. The shock resistance and mass interaction of systea components and their associated piping and foundations as compared to hull resistance, = 9. That shock factors not exceed approximately &| vhen coats are resumed unless the action taken pursuant to Recoumendation 8 above v indicates it is safe to proceed further. CesERET 10. That the quality assurance program at Portsmouth Naval Shipyard be further eaphasized and improved in scope along the lines indicated in this court's opintona. LL. Thac the Bureae of Ships require cubmarine shipbuilding activities to: a. Adhere to specifications, and . >. Obtain approval of the Bureau of Ships for all waivers where this is not practicable. 12, Thet the Bureau of Ships increase its audit activity to insure acherence Co specifications for submarine building, overtaul and repair. 13, That subuatine air aystem design criteria be reviewed for a adequacy and safety and, subsequent to such review, chat the air systems be podified. (See Opinion 38) (oy 1s, That dn THRESHER Class submarines, the air system modifications ~{2eN=}— and teste include: a. Plmination of the conical strainers in the Marotca reducing valves, b. Tese of the atx systems for full air bank blow through the miin ballast tanks to imgura full blowing. c. Teste of the main ballast tank structure to determine ite adequacy on a direct 4500 psi blow. 4, Elimination of the Aj pal reducore ns coon as the air syste and ballast “anki have been proven or eltered jy = to be capable of accepting 4500 pei. UnGL Agel EH WULAUUH ¢. Provision of 4500 pai plow of sain ballast canks.15. That {ncreased enphasis be given to damage control considerations in the selection of locacions for vital submarine equipment, and chat peinery and. secondary sources not be located in close proximity to each other. 16. That efectrical ovitchboards of subsarines be better protected froa salt water. 17, That submarine diving trainers be provided the capability of simlating ship reaction to flooding caaualties at deep depth. 18, That studies be undertaken on a high priority basta to develop subsirine operating procedures which will maximize recovery posat- bilities under various damage control situations. The following are nertly a few examples of the many cfrcumstances vhich aight obtain and viich should be explored: di 19, That separate and distinct submarine operating procedures be eatablished to govern operations under various situations of depth and speed, to include the following: Bi © uw KK D- WNCUSSIFED 3 April 1963. The court opened at 1347 hours ALL persons connected with che coure who were Bresenc when the court recessed were again sresenc in court at be rei ee Bho es resortel at this point Lieutenant (Jundor grade), U.S. Navy, ow ata sitsicdas. Cpe” Me daieri, ede dyly! tenures Sap marred at aie rights under érticle Uniform Code of Military Justice, was informed of .rhe subject msceer of che inquiry and examined as follows DIRECT EXAMINATION Questions by counsel for the court Q. State your asme, grace, organization and present duty station? AL he » ligucenant (Junior grade), Navigator and First Lieutenant on che USS SKYLARK, che 88-20. @. Lieutenant (Junior grave), niced Seates Savy 2) Uniced Stetes Savy. Q, Directing your attention co the morning of 10 then seationed on the SKYZARX? 4, Yas, sir. ril 1963, you were LARK vas, proceeding in company with another And on that morsing che Yes, sir. Q., Please state che circunscances A. We were proceeding fron an area where the USS THRESHER completed her shallow dives to an area where she vas going to make her test dive, deep test, and on arrival on station we established comunication and she proceeded. 2 @. By 0800 on the morning of the 10th, where was your initial position? I A, We vere locates at che initial rest posizion at 41.47 Norch and 65.01 West. Q. And where was THRESMER with relation to you A, The last cocmwnication we had, 2 range test that she had with us bearing [47 ac 3409 yer: @. and your base Lieutenant A. Base course and sree? cr that Cime was I believe, 270. Q. This was around C200 in the aorning, loca! rine? A. At 0801 our base course wes 270, Q. And speed? AL Ae two and 2 half knote, We vere using RPM's co maintain steeragevay Q. Now was this the course and speed of SKYLARK only, ot of THRESHER als , AL This was only SKYLARK's course and speed. Q. And what do you know of THRESHER's course and speed at about hac tim A. We were given fo indication as to her actual speed. We/ean only jy eas to vhat ic might be, f a A. Ber course was in 4 southerly Se Declassified by cNO ity 5511 RPS/smap Ser 09N2/9U52I064 of 16 Feb 89Declassified by CNO 1tr 5511.2/ 5 g RPS/cmap Sex 09N2/9U527064 of 18 @. Where were you in SKYLARK ac chat time? A. Iwas in the pilot house ac the chart desk Q. And at 0800 who was oper. ment? A, Boatswain's Mece Third Class gay sir ing the UQC, the underwater relephone eq Q. and who wes recording che Crananissions and che messages received | the ugc? Ay Radlomen third clees ‘py Q. Now had there Deen good cosmunications between SKYLARK and THRESH! by way of the UCC prior to chis cine? A. Yes, sir. Q. Was THRESHER on che surface at 0306? A. No, sir, she was st periscope depth @. You could see her? A. Yes, we held her on radar for several -- well, for 2 considerable period of time before she submerged. Q. She remained at periscope depth, thea, unctl her dive? AL Yes, sir Q. Until she commenced performsnce of her deep dive? A. Yes, sir. Q. Do you have che officis! tRC Log of che SKYLARK in your possession’ A. Yes, sir, I have ic in front of me, Q.. Produce it, Is this ict A. Yes, sir. che court for che purpose of introducing it iy COUNSEL: I offer the log evidence REPORTER: This will be Exhibit 16. 6) wag submicted to the courc and was offered in The log (Exhibit che court, for the purpese of intreducing it inca evidence by counsel evidence din evidence was rece There being no obj ries for the 9ch and 1Gch of . Does this log, Exit ril of this ye: A. Yes, sir. 5 contain Q. Mow, before referring to the toy, you have told us of your positio at chat time -- of the ship's yosicion et that time. Do you have the of- ficial navigatione) chare end Crack of SKYLARK? A. No, sir, I don't, e's being prepared and submitted from the ship at a later date. Q@. Directing your attention, thea, to the morning of 10 April, et 2 ¢ about eight o'clock, was there 2 clock located on the bridge -of ¢! A. Yes, sirs-it Waste the left and above the chart desi eee a7 WHCLASSIFED aS (WELASSFED 2 @. Can you tell us whecher that clock had been reser recently to the correct time -- recently with relation co that motning I mean? A. Yes, eit, it had bean, This is a daily morning routine performed by the Quartermaster. He gues into che radio shack with s comparing watch that has @ proven race and gets a cine fix, comes up and compares it, Tesets the clock, and shortly afterwards he will give che motor room end engineering spaces the Cime-cat@ so thet they can reset their clocks in accordance with what he has in hand. sat the tine of reset of the clock Q, Do you recall whet the error « fon the morning of 10 april? A, No, sir. Was it a goad clock; did you have trouble with ic? Never have had any trouble with ic. . You're satisfied, then, as to its accuracy on che morning in questio Yes, sir. Q Ns Q. Now, if you will refer to fxhibit 16 and to the entries for the Loch af April, starting at roughly about 2 quarcer Of eight or eight o'clock, wha ever the firet entry in that scope is there -- 1 note that the log contains @ “Time of Entries"; how vere tines logged for the entries im that log? A. In wost cases they are logged as ro the nearest minute. a aone quses there are multiple enrries nade on the minute or within @ few seconds sfter the minuce . Now referring ro the log at the tine of about 0745, quarter of eight in che morning om the 10th of April, what was the last carefully fixed position of THRESHER which is recorded there? &, In relation to SEYLSK, st 0755 che TRABSHER held us Searing 147 at 3400 yards. Q. Do you know her course and speed ec chat tine? A. No, sir, we had no indication ae to her course at that particular ti We did get the course information from her after this time. Q. It was generally southerly, you have already testified; is that correct? A. Yes, sir. Q. Then at 0800 does the log reflect that she notified you of her cours A. Yes, at 1800 che informed us that her course was 180. Q. What was che pervose of your being in company with her ae about chis ime in the morning’ A. We were standing by ker while she was conducting her rest dive. Q. Now I éirect your attention to an entry for O77 on thet day. Bid + receive # message from her over the underwater telephone which vas logged? A. Yes, sir. Q. What was the message? A. AC O74? she informed us she wes starting her deep dive.3 WOUSSID sc And at the time of receipt of this message che was at periscope dept! 4S. Yes, sir. &. How often did you conmmicate with ker while she waz doing her deep dive? Or let me put the question another way if that's difficult. Did you request GERTRUDE checks? A. Yes, sir, we requested CRRTRUDE checks every figteen minutes. @. Now that GERTRUDE is spelled Like the giri's name GERTRUDE? A. Yes, sir. Q. Whee does tc mean? 4. It's an underwater telephone. Q. And a GERTRUDE check means that she vas to communicate with you ever} fifteen minutes; is thet right? A, This is correct, Q, Or more Erequentiy. AL Yes, sir. Q, How what was the next communication between THRESHER and SKVIARK which followed chat? 4, After the GERTRUDE check? Q, After she notified you at 0747 that she was comencing her deep dive! AL The next communication we had from THRESHER vas at 0749, when she inforted us that it was 0, {. to maneuver as long as we remained in present position. Q. And the communication after that? A. This conmmication was passed at 0750, The communication was we re- suested a GERTRUDE check every fifteen minutes. 5 Q. And following that, a 0752 entry? A, Yes, sir, she informed us that she was at 400 feet checking for leaks Q, What time? A, 0752, sir. ORESTDENT: Counsel, you should caution the witness that ££ one of your estions requires an answer that would be classified, he should so inform us rather than ansver it giving classified information, We are gerting into depths now. G. [have already given you thet warning, have T not? @. Wokaileaee Q. And you have it firmly in mind? AL Yes, sir. You were evperiencing no trouble with communications between her and Mo, sir. Now the next entry is at 0734, ts it not? “ RPS/ewap Sex 09N2/ eo a peeDeclassified by CNO tr 5511.2/ WWCUSSIR og Q. And the next transmission, please? A, The next transmission THRESHER informed us that her course was 180 @. And the time for that? 3. at 0800. Q. Now you made a reply to her on the UGC, did you not? A. Yes, sir, we gave them a ROGER, which means we acknowledged her tre mission. Q. And then at 0801? A, This was the time that we had given them the ROGER, We also told t at the same time that our course was 270. Q. Wow courses which are logged in degrees are logged in degrees True, are they not? A. Yes, sir. ch other the Q. What was the relative position of the two vessels to if you know? Were you to the north and vest of then? A. We assumed that this was our relative position, that we were to the north and they were to the south. Q. And you would have them then on: A. Probably on the starboard quarter. Q. Now what was the next message received from then? A, The next message received was at 0809. THRESHER informed us that she was proceeding to one-half test depth. Q. To one-half...7 4, Proceeding-- oh, I'm sorry, proceeding one-half test depth. Q. Now I believe that--~ PRESIDENT; The court at this time reminds both the counsel and the witness that we mist avoid disclosing classified infermation. COUNSEL: May I request the court be cleared, sir. PRESIDENT: Clear the court, ‘The witness was watned not to discuss his testimony with anyone during the time the court was closed. ‘The court closed at 1405 hours, 13 April 1963. The court opened at 1413 hours, 13 April 1963, All persons connected with the court who were present when the court closed were again present in court. ‘The witness was reminded that the oath he had previously teken was stil binding. Questions by counsel for the court: 40 RPS/cmap Ser 09N2/9U527064 of Be eee 16 Feb 89 = WHCLASSIFED; Sus’ sche . Q. The reason we called for a clearing of the court was your reply ro the last question, reading from the book, did not seem comprehensible to the court. I£ you will look at the 0809 entry and read it just as it is written there, I believe you will correct the impression made by a misreading. A. 0809 = THRESHER informed us "Am proceeding one-half set distance." Questions by the president: Q. Set distance? AL Yes, sir. Q. Not one-half test depth? AL No, sir. Q. Look carefully, nov, vhat we want is what's in the log, not an approximation of it? A. Yes, sir. Well this is exactly what's in the log, “one-half set distance." PRESIDENT: All right, that's a different story. Questions by counsel for the court: 1 Q. Now the 0835 entry can be read exactly as it is in the log. Please | read it to us? A, 0835 - THRESHER informed us, “Proceeding to test depth minus three hundred feet." Q. And at 08537 A, 08532 THRESHER informed us, "Proceeding to test depth. Q. Now you communicated with THRESHER at 09027 A, Yas, ix. Q. What was that coummication and hig response to it? A, At 0902 we communicated with the THRESHER and we informed her that our course vas 090. Q. And his response? A, And he asked us to repeat the course, or, "Say again," were his exact words, Q. But communications between you were still -- Al Were still good. Q. Then there isan 0912 entry, is there? A, Yes, sir. Q. Please read that? A, She asked us for a GERTRUDE check at this time. Q. And you gave it? AL We came back with a KILO, which means, "Go ahead and transmit," and she came back with « KILO to us. a Q. KILO, K-I-L-07 A. Yes. Q. Did you have a bathychermograph reading to establish the gradient of the water? A. No, siz, we have no bathythermograph aboard, Declassified by CNO ler 5511.2/ RPS/eaap Ser. 09N3/90527064 of BLASS 16 Feb 9 !— 2 Tee eee oe g Q, Had THRESHER told you whet the thermal conditions were? A. No, sir. Q. Hell can you describe what the weather conditions were between then and the time your narrative commenced, at 0745? A. Well the wind was from the northwest about 300 degrees at approxis Jy fifteen knots. The sea state, a little over one, And the eky was ove: T believe that sums it up. Q. Now at 0912 when THRESHER asked SKYLARK for a GERTRUDE check and SKYIARK transmitted ir, did THRESHER "ROGER" for 2 receipt of that? A, At the 09127 Q. Yes A, Wo, sir. Questions by the President: Q, I thought that you gave a KIZO and that THRESHER responded? A, She responded with a KILO, yes, sir. PRESIDENT: Please be accurate in what you tell us, Don't say one thing 4 you mean another. WITNESS: Yes, sir. I thought he wes looking for a specific “ROGER” for the message, PRESIDENT: Please be more concise in your questions, counsel. Questions by the counsel for the court: Q. Well she acknowledged receipt of your transmission? A. Yes, sir. Q. And the time of her acknovledgaent of the receipt was vhat? A. 0912 plus about ten seconds. Q. Now we are coming to a very critical point timewise, AL Yes, sir. @. First, what happened after you received acknowledgement of your transmission? A, We received @ transmission from THRESHER stating: “Have positive up angle, Attempting to blow up." Q. There is no time entry for that particular entry, is there? A. No, sir, Q. But you heard those words yourself, did you? A. Yes, sir. @. And your best estimate of how soon after 0912, when the word KILO was heard, was how long? A. Well due to the ensuing communications between 0912 and this comm ication, I would bave to estimate it approximately one minute, Questions by the. President;© WOUSSFED 2 Q. So your best estimate of the time when the THRESHER advised thet shi had positive up angle vas 9:137 A. Yes, sir. q. That's your best estimate, but it's only an estimate? A. Yes, sir. PRESIDENT: Proceed, Counsel. Questions by counsel for the court; Q. The phrase, “attempting to blow up," Will you explain what chat means in normal naval parlance? A, Well it means that the submarine would close its vents and throligh the air manifold syscem would blow air into the tanks which would clear them of water and normally bring them to the surface, Q. Following your hearing of that me over the UQC equipment? = A. Yes, sir. We could hear what sounded like definite air being blown, or air under pressure. age, did you hear any other soun¢ Q. You said, "We could hear;" who could heer that at that time? A, There was the commanding officer myself, and the two enlisted men. Q, And what happened at that point? A. At 0914 we told the THRESHER, "Wo contacts in ares," and otherwise that it was clear for her to surface, Q. What happened next after you sent chat message? A. At 0915 we requested her course and range and bearing from us. ‘The exact statement is: "My course ts 276, Interrogatory range and bearing from you." Q. You told him your course? A, Yes, sir. Q. Row had you received any reply to your transmission of 09147 A. No, sir. Q. Did the commanding officer, take some action upon the receipt of that message? ‘A. On the receipt of the message that she was attempting to blow up, hi took the microphone and started communicating himself with the THRESHER. Q. Then the 0915 transmission to him was made by the Coumanding Office: of SKKIARK direct on the UQC equipment? A, Yes. Q. Was there an answer to that received from THRESHER? 4. No, six. When he received no answer he coumenced calling the THRES asking, "Are you in control?" And he repeated this question at least four times to ny knowledge and received no answer. Q. Now at this time, 0915, did the SKYZARK hold her course and speed? AL Yes, air. Q: AeQNCLAS Sed You had been on that speed for some tine? Yes, sir. G. ‘While you had been proceeding at that speed, had THRESHER stayed within GERTRUDE range at all Cines previously? &. Yes, sir. Q. What does that indicate with respect to her speed? A, It would indicate that her speed was alow but that she was opening to the south fron us. Q. Now at 0915 you said the comanding officer himself manned the UGC equipment and sent inquiries to THRESHER? A. Yes, sir. Q. While he was transmitting at that time could he hear any sounds coni from THRESHER, or could you? , A. No, sir. Q. Why 4s that? Do you have an explanation for that during the trans- mission? A. Well normaily during the tranemission phase of UQC it blanks out all other sounds, and there's a short period after the cramamission has gone out that this sound will still be blanked out due to the time it takes the signal to get dom and get back. 9, You said you heard "blowing" sounds? A. Yes, sir. @. For how long a duration did those soends continue within your hearin A, Loulé say not over three to four seconds that we could hear. Q. But part of the interim period was taken up with transmissions out- bound from SKYLARK? AL Yes, sir, Q. What was the next thing you heard? A, At 0917 we received a garbled’ message and we can only assune that it was at the tail end of one of our outgoing transmissions, Most of the uesse was blotted out but the two words that the commanding officer and myself cav that were cleatiy understood wera, "test depth. There was sonething pre- ceding it but we couldn't tell what it was, Q. Something preceding it and then the two vords, “test depth"? AL Yes, sir. G. You heard that yourself: A. Yes, sir, Q. And there is no question in your mind about those tuo words? AL No six, @. How much of a garble preceded those two words in time span -- short, Long? A, Well 4t was rather short.* cusses ° "rest depth" clearly? Q, Now you say you heard the words Al Yes, sic. G, Did the commanding officer, who was on the equipment, say that he heard them too? A, Yes, sir. Q. Did he hear any more than thie? Al Bath of us, shortly after that, heard a sound that registered with me as being familiar because of the fact that I had hedré a lot of ships breaking up ducing World War II after having been torpedoed at depths. It sounded as though there was compartment collapsing or something similar to that nature, Q. Did you hear anything in addition to the sound which you identified as similar to a compartuent breaking? A. No, six, Q, Can you describe that sound to the court? A, It is @ rather mited, dull thud. Q, Did the commanding officer indicate that he heard that? A, Yes, sir. Q, Was he able to form an opinion as ro the source of the sound? 4, Both of us discussed it very shortly after and we agreed that it sounded similar to a breaking up noise. Q. Now who was doing the recording in the UQC log of the times and entries during the critical period that you have covered in your testimony? A, A Radioman Third Class named Q. Is he known to you to be a reliable man? A, Yes, sir. Q, Would your previous knowledge of him lead you to have confidence in the accuracy of the times which he recorded? AL Yes, six, Q. After hearing the sounds which followed che last transmission from THRESHER, what did SKYLARK do next? &, Asked for a radio check with the possibility that he might have gone outside of GERTRUDE range and possibly put hie periscope up or his radio antenne Q, But did you keep steaming? AL Yes, sir. Q, Did you change your speed? AL We stopped eventually and secured our fathometer and our sonar equipmen so that we could hear better, and continued to try to communicate with che THRESSER. @, You made every effort to Listen on the UQC? A, Yes, sir, Q. What was the setting on the volume control of the receiver on the UQC?& > WNCLASSIFED © > q, What did you hear? A, Nothing. Q. Now at 0931 did you take some further action? 4. At 0931 the commanding officer directed, and we conformed to his direction by requesting from THRESHER a radio check every sixty seconds. Q, What was the purpose of that? A. If she had gone out of GERTRUDE range and had put her antenna up, we would have been able to communicate vith her. Q, And did you continue with your GERTRUDE checks? A. Yes, sir. GERTRUDE checks were made also every minute thereafter. Q. What was your next action? A. The next action that we took was at 1006, ve asked THRESHER on GERTRUDE -+ I'm sory -- by radio: "QUEBEC, QUEBEC, QUEBEC." Q. That's QUEBEC - Q-U-E~B-E-¢ A. That's it, yes, sir. Q, What is the meaning of sending 2 QUEBEC? A, Well we asked her Co indicate her position by any means possibl Q. And was there any indication of her position subsequent to that nade by her? A. No sir. Q. Were there any other significant noises heard by you on the UQC equip- ment? A. No sir, just normal background noises. Q. Then at 1058 you took your next action, did you not? A, At 1058 we commenced dropping patterns of thiee hand grenades at intervals of about ten to fifteen minutes. Q. What was the purpose of this? A, The purpose of this was to alert the THRESIER that we vere trying to communicate with her and that she should surface if possible, Q. And was there any response fron THRESHER? A. None, Q. Following that, what action did you take? At about 1100? A, At 1100 ve sent @ conmmnication on the radio telephone, the underwater telephone I should say, directing THRESHER to “Indicate your position or prepare to surface. Acknowledge vithin fen minutes or I will initiate sUmCSS." Q. And that was at 11297 A, At 1129 ve sent @ communication on the undervater telephone that: "We have initiated SUBMISS, Indicate your position." Q. At 1100 you said you would, is that it? A. Yes, siz, “RPS[cmap Sex 09N2/ 16 Eeb 89> wweusseen © Q. Now at any time during the operations with THRESHER prior to chee, prtor co chis incident, did you hear machinery noises on your UQC or on your Sonar, omanating from her? A, Nothing that could be identified as machinery noises. Q. Now you testified that your duties on board the SKYZARK included your office as Navigator, right? A. Yes, sir. q. What was your position reference for the’ operation on which you based your reports? A. The THRESHER's position in relation to ue? The last position we had was her bearing and range of 147, 3400 yards from us. Q. And how did you establish your position? A. We established our position by LORAN. @. Can you go into some greater detail? A. Well we have @ LORAN DAS-4 Model, and we have two well establishec LORAN Lines in the area and were getting excellent fixes from the LARAN. Q. You would estimate then that your position was known with adcuracy? AL Yes, sir. Q. Did the position of the of1 slick sighted by RECOVERY, to which you have alluded, correspond with @ reasonably postulated positfon for THRESHER? A, Yes, sir. . Where was the position of that oil slick? A, It was about 7,090 yards to the southeast of the original position. Q What do you mean by the original position? A. Well the position at which it commenced the test dive. G. And, paying particular attention to that time and the time when the oi} slick was reported, ghat was the direction of wind and current? &. The current, normally, according to pilot cherts and books was in- dicated by our Erack was to the scuthvest at about four-cenths of a knot. The wind was blowing from about 500 at about 15 knots, And tha ofl slick tended in the dovnwind éirection of the wind. Q. Again this 300 is true? A, Was, six, Q. Now at 1129 you sent a message -- you made a transmission at thar A, Yes, sir. @. What was that? A. “ave initiated SUBNISS, Indicate your position."2 (WUSSFED © Q. Describe the operations of the SKYLARK thereafter! A. We continued dropping grenades at intervals, and we continued check- ing with the GERTRUDE, and also with the radio, trying to get some sort of coumunication from her, and this continued on up until quite late in the evening as far as the grenades were concerned. Q. And in the evening did you rendezvous with the USS RECOVERY? A. We cendecvoused with her é¢ about 1728, I belfeve it was, at which time she was sitting in the center of the oil slick, Q. You saw the oil slick yourself? A. Yes, sir, I have pictures of it. Q. How were those pictures taken? A. ‘They vere teken with @ Polaroid camera, and at the time we had bright sunlight, One picture turned out very well. The other is rather bright due to the eunLight showing up off the water. @. If you have those prints, produce them, A. (The witness did so.) Q. These are they? A. These are the pictures, COMNSEL: I offer them to the court for the purpose of introducing thea into evidence, REPORTER: These wili be Exhibits 17 and 18. The photographs (Exhibits 17 and 18) vere submitted to the court and were offered in evidence by counsel for the court for the purpose of introducing them inte evidence. WITNESS: ‘The dark areas on the pictures are the actual clear water that was seen. There being no objection, they were received in evidence. PRESIDENT: I might add, for the benefit of the press in the room, that when we introduce these into the record they are not available. Sut I don't think you're missing a thing because I don’t think they'd reproduce. Q. As an eye witness on the spot, do those reflect a true reflection of what the camera lens viewed? 4. Yes, sir, I might add that this of1 slick was approximstely one-half mile wide by 2 mile and a quarter long, tending downwind. Q. Gould you say from your observation of it that it continued to grow? A. Te would be difficult to tell. You could mot determine any real source. It looked as chough it might nave been one gush of oil and ended at that. Q You noted no increased growth while you observed it? A. No, sir, How long did you observe it? We were in the area of the oil slick for approximately two hours.© |CLSSFED Q, .Did’you take anything else from the ofl slick beside samples? A. We have one small item vhich resembles 2 fishing net float, Q+ Produce it, A. (The witness did so.) COUNSEL: I offer it to the court for the purpose of introducing it into evidence. The float (Exhibit 19) was submitted to the court and was offered in evidence by counsel for the court for the purpose of introducing it into evidence. REPORTER: This will be Exhibit 19, ‘There being no objection, it was rece4ved in evidence. Q. ‘The reporter has marked here arabic numeralg 1 and 9 as an exhibit. I note an additional number two with a sharp sign in front of it? A. Yes, these were our numberings for the things that we picked up. ‘The oil was the first, this was the second, Q. You added it after retrieving it? A. Yes, six, We also retrieved an orange-colored xubber glove shortly after retrieving this spool type thing, and it was forwarded to the USS BLANDY, I believe, and forvarded by other weans, Q. Did the BLANDY deliver into your possession two items found in rhe area? A. Yes, sir, Q. Do you have thea? As Yes, sir, Qs Produce them, A. The Eirec icem was a pair of rubber gloves, I think this 4s BLANDY's marking on that. Q. Would it be better to say that there are two individual rubber gloves, and not necessarily a pair? A. Yes, sit, both of them are meant for the right hand. COUNSEL: 1 offer them for the purpose of introducing them into evidence REPORTER: ‘These will be Exhibiec 20, ‘tuo rubber gloves (Exhibit 20) were submitted to the court and were offered in evidence by counse? for the court for the purpose of introduciag them into evidence. ‘There being no objection, they were received in evidence, WITNESS: and this piece of plastic material.© |NCUISSFED REPORTER: ‘This will be Exhibit 21. The piece of plastic material (Exhibit 21) was submitted to the court and was offered in evidence by counsel for the court for rhe purpose of introducing it into evidence, There being no objection, it was received in evidence, Q. The arabic number “3" preceded by a sharp sign was added after that? A. I believe this was BLANDY's marking. . Q. You have no knowledge of your own as to the actual source or circum- stances of the acquisition? A. No, sir, all I'm sure of is that it was found in the general vicinity of where we assume the THRESHER went down, Q. Thereafter SKYLARK continued her search, did she not? A. Yes, sir. Q. And do you have charts and so forth to show the nature and extent of that search? A. We have # track chart covering the entire period from the beginning of her test dive until -- I believe it is still running, the track chart, and also our navigational chart, and @ chronological log of events which will be forwarded as soon as it is completed, Q. You do not have them in your possession? AL I do not have them, Q. Now on that last item, Lieutenant, you hesrd with your oun ears those significant transmissions around 0912, 14, and thereafter, . Could you tell, either from recognition or from the tone of voice, who was talking on the phone: from THRESHER? A. I can only assume that from the tenor of the voice T would venture to say 4£ would be the Gonmanding Officer because hisivotee was unhurtit and shadno ndte*of hysteriay dnd T/W6dkdlassime it would be the Commanding Officer becatise he is the one most 1ikely to carry on in this manner under difficult circumstances. T have no further questions. ‘couNsE: Declaseigied by CNO 1tr 5511.2/ RPS/emap Ser 09N2/90527064 of© wuss) © Me. pe was introduced as reporter and was duly eworn, relieving GL EXAMINATION BY THE COURT Questions by a court mesber, carr Blo: Q. Mr. » was SKYLARK, during this exercise, tracking TRRESHER with her own sonar? A. We could only track her at limited periods of time, Our sonar is Limited to 1100 yards range. This is about maximm under motion conditions. Q. This is by echo ranging on THRESHER? AL Yes, sir. It is not a very satisfactory sonar thet we had aboard. Q. Now at the time that you heard the noises which you identified as possible break-up noises, this was shortly after 0917? A. Yes, sir. Q: Could you refer to your log, I'd Like to ascertain this time as axagbly, gg ye can, recognizing that there are Limitations here, but T believe at yOW heard the garbled message? A, Yes, sit. Q. And the possible break-up sounds were subsequent to 0917? A. Yes, six. Qs You heard these, Could you estimate that they were two minutes after the iast--after the garbled transmission, or three minutes, or what kind of estimate? A. The only thing I'm really sure of is that {t was over « minute afterwards and we were boch standing there listening for something else and rd this noise. The exact amount of time, I can't be sure because we didn't Look at the clock or anything. a transmission relative to radio commnication? Q. It is my understanding that at 0931 you-~SKYLARK--began trying to call THRESHER at intervals, is that correct? ‘A, Yes, sir, every minutes Q. All right, At 1058 you started dropping grenade signals? A. Yes, sir. Q, You mentioned dropping three charges at ten minutes, T think. A, ‘They were not ali definitely ten cr fifteen minures apart, Q. Right, but three charges? AL Yes, when the commanding officer said they should be dropped generally. Question by a pouKGxMenber, CAPE i, + Those will show up in you ship's log?© yprussren © Q. Would you say that dropping three charges is an established signal which THRESHER could be expected to understand? Let me say this again. If THRESHER heard those signals, would they have an established meaning to ‘THRESHER? A, Yes, sir. Q. And that meaning would be? Ay That wpuld be to curse Questions by a court menber, CAPT GW iz Q. T have one question to start out with respect to the relative bearings involved, with reepect to initial orientation at 0745, was the bearing 147, 3400 yards from the SKYLARK to the THRESHER or from the THRESHER to the SKYLARK? ‘A No, we were 147, 3400 yards from the THRESHER. Q. You ere southeast? A. Yes, sir, and che was heading in a southerly direction. Q. Now let us understand, And you note your courses and speeds, is that correct? ‘Ae Qs Now, you were southeast of the THRESHER? Ae Yes, six. Qs And the ofl slick at the-auhen discovered, was #outheast of you? A. Southeast of the positien we were in at that time, Q. And we haves A, The bearing about 160, 1 believe it was, Qs Of course we will have sufficient track charts with updated Loran positions. Ae Q. To establish these positions? Ay Yes, sir, Qs Relatively accurately? Ae Yes, sir. Q How accurate. would you say, with respect to what your repeatabil~ ities vere with respect to your LORAN position in this particular area? A. I'd say it wae excellent at the tine. Qs What is "excellent"? Ai Oh withine= Q, Half a mile’ A, Yes, six. RADM .: There is some doubt in my mind as to where the relative bearing ia but I think if we wait until we get the written transcript,® @ NCLASSITED REDIRECT EXAMINATION Questions by counsel for the court: Q, Was there some confusion i the logging of those columns as to whether it was “frou THRESHER or to" THRESHER that you know of? A, THRESHER has stated “hold you 147 at 3400 yards. PRESIDENT: There couldn't be a mistake there. That "hold you" from the ship means you bear from me. AL Yes, sir. CAPT GN oz Now I am clear. Questions by the president: Q. Mr. QM, you have said that there were two good lines that you were getting your LORAN fixes from? A. Yes, sir. Q. What was the angle between those Lines? : A. Approximately 65 degrees. Q. 65 degrees? A. Yes, sir, We were substantiating them as nearly as possible with soundings after we activated our fathometer again. Q. And were you in an area where the contours of the bottom gave you fairly good index of position? A. Yes, sir, Within 2 ten mile distance off of the thousand fath- emeter curve, it shoaled down to 1600 fathoms, straight southeast and on either side it--well there actually was @ sort ofa valley effect in there 1600 yards deep in a circle from the thousand fathoneter curve, and where we were initially, we got a sounding of 1280 fathoms, and running back end forth we could spot our sounding line in and get on the came depth again, It seemed to be pretty consistent. Q. Now, going back to the transmission at 0917, which was garbled and which you think consisted of roughly four or five words, was there any Andicating of panic in the voice ae you could hear it at that time? A. No,sir. Q. None whatever. Do you have any theory, based on the garbled sounds that you heard before the two words that you did identify as to what any of those three-two or three preceding words--might have been? . Yes, sir. My commanding officer and myself both feel, although we can't be sure, that we heard the word "exceeding" prior to the "test depth.” Q. So i£ you had to bet-- A. Tf I had to make a direct atatement, I would say this was it. How long had you been the navigator of the SEYLARK?© TARUSSE Neither consel for the court nor the court desired to examine this witnes further. The president of che court informed the witness that he was privileged to make any further statement covering anything related to the subject matter of the inguiry that he thought should be ¢ matter of record in connection therewith, which had not heen fully brought out by the previous questioning, ‘The witness made the following statement: I €an't really think of anything to add to this, except that we continued the search and picked up various articles of debris and so forth which we passed to the other ships da the area. The vitness was duly warned concerning his testimony and withdrew from the courtroom, ‘The court recessed at 1505 hours, 23 april 1963. he court opened at 1515 hours, 13 april 1963, All persons connected with the inquiry who were present when the court » boatswain's mate third class, U.S, Navy, was called as a witness by the Court, was informed of the subject matter of the ingutry was advised of his rights under Article 31 of the Uniform Code of Militar Justice, and examined as follows: DIRECT EXAMTMATION Questions by counsel: Q. ‘This is an open session of the ceurt and for that reason clas ified information should not be spoken here, indicated, or divulged by you, If the anewer to any question that I ask you would include class~ ified information, please so state instead of answering the question. A. Aye, aye, sit, Q. State your name, grade, organization and present duty station. A ge Boatswain's Mate Third, J. 3, Navy, USS SKYLARK, ASR20. Q. That is ee z AL Yes, sir, On Nghe A. Yes, sir. Q. Directing your attention to the morning of 10 April. of this year were you then stationed in SKYLARK? ‘Ae Yes, sit. Q. And at about 0745 in the morning, what was your station inLoss at sea of USS THRESHER SUMMARY OF EVENTS On 10 april 1963 aduirat USN, Commander in chief, U. $. atlantic Fleet, ordered a Court of Inquiry to inquire into the circumstances of the loss at sea of the USS THRESHER (SS(N)-593) on 19 April 1963. ‘The Court tricluded Viee Admiral ust, President and the additional members: Rear Adniral USN; Captain | USN; Captain » USN; and Captain USN. Captain | USN, wes designated to serve a5 counsel for the Court. The Court met for the first time at &:25 p.m. on Thursday, 11 april 1963. Before the Court closed on 5 June 1963, it heard 179 separate appearances of witnesses and had occasion to recall 56 witnesses. The Court developed 1718 pages of testimony and received as exhibits in evidence 255 seperate offers, Among the witnesses who testified were Vice Admiral > USN, Bureau of Ships; Vice admiral . Chief of Naval Personnel; vice Admiral Coumsnder Submarine Force, QU. S, Atlantic Fleet; Rear Admiral Deputy Commander, Submarine Force, U. S. Atlantic Fleet; Rear Admiral a Chief, Bureau of Ships; Rear Admiral , USN, Special Assistant to the Secretary of the Navy; Rear Admiral » Commander, Portsmouth Navs! Shipyard; and Rear Admiral » Chief, Office of Industrial Relations. Cormander USN, the former Cormanding Officer of TARESHER, was questioned by the Court very esrly in its proceedings and provided valuable background information, The Court considered many aspects of the circumstances surrounding TURESHER's loss in light Gf present day complexity of the aodern submarine Information was developed regarding THRESIER's construction, her post countssioning operations, and her post shakedown yard availability, in addition to the operations af sea which resulted in TURESHER's ultimate loss. The following detailed determinations by the Court of Inquiry provide significant information concerning the tragic loss of tite Navy's first of 2 new classof nuclear powered attack submarines with her crew of 12 officers and 96 men and 21 additional passengers on official business, 17 of whom were highly qualified civilian employees. spire aeHLoss at SEA of the USS THRESHER SUMMARY OF EVENTS THRESHER Operations at Sea 9-10 April ‘TURESRER, under the command of Lieutenant Commander J. VW. Harvey, USN departed Portsmouth Naval Shipyard on the morning of 9 April 1963, to conduct scheduled sea trials following 2 post shakedown availability whien extended from 16 July 1962 to 11 april 1963. “we “® THRESHER vas a unit of Submarine Development Group TWO, and was operating under the orders of Commander Submarine Force, U.S. atlantic Fleet (Administration), Portsmouth, for the sea trials. USS SKYLARK (ASR 20), under command of Lieutenant Commander U. Ss Navy, was designated to act as escort co THRESHER during sea trials, pursuant to orders of Comander Submarine Flotilla TWO. Commanding Officer, THRESHER, was Officer in Tactical Coumand of the two vessels. At about 9:49 a.m. on 9 April 1963 in the vicinity of Latitude 42-56 North, Longitude 70-26 West, THRESHER affected a rendezvous with SKYLARK. After THRESHER completed a scheduled shallow dive, the two ships proceeded independently during the night to a second rendezvous in the vicinity of Latitude 41-46 North, Longitude 65-03 West. During transit, THRESRER proceeded surfaced and subuerged and conducted various test evolutions, including full power propulsion.At 7:45 a.m., 10 April 1963, SKYLARK was in the vicinity of Latitude 41-46 North, Longitude 65-03 West, and TURESHER reported to her that SKYLARK bore 147 degrees true, 3400 yards from THRESHER. Shortly thereafter THRESHER began a deep dive which appeared to SKYLARK personnel to proceed satisfactorily until about 9:13 a.m., when THRESHER reported to SKYLARK to the effect, “Experiencing minor difficulties. Have positive up angle ‘Am attempting to blow. W{L1 keep you informed." After this Last clear message, SKYLARK received two further garbled commmicatié At 9:00 a.m. on 10 April, the sea was calm, wich a siight swell. Wind was from O15 degrees True at 7 knots. Depth of water in this area is about 8500 feet. visibility was about 10 miles. No other ships are kaown to have been in the vicinity. THRESHER was lost at sea with all on board at about 9:18 a.m. on 10 April 1963, in the vicinity of Latitude 41-45 North, Longitude 65-00 West. There was to evidence of sabotage or enemy action in connection with the loss of THRESHER. SKYLARK'S ACTIONS DURING OPERATIONS WITH THRESHER Upon receipt of THRESHER's 9:13 a.m. cotmnication ("experiencing minor difficulties. . . ." ete.) SKYLARK initiated certain actions. she advised THRESHER of SKYLARK's course and that the area was clear, and she requested range and bearing from THRESHER. At about 9:15 4.m. SKYLARK, in an attempt to establish communication not only by sonar and radio butalso by underwater telephone, asked and repeated this query, “Are you in control? SKYLARK established its LORAN position (Logged at 9:21 a.m. as 41-45 N 64-59 W), and at 10:40 acm. conmencedéropping a series of hand grenades indicating to THRESHER that she should surface, At sbout 10:45 a.m. the Commanding Officer, SKYLARK directed the Operations Officer to initiate a message reporting the Loss of contact with THRESHER. Difficulty was encountered with transmission of the message to NBL (Radio New London), notwithstanding the fact that SKYLARK had eofiducted radio commumication checks earlier that morning. ‘At 12:45 p.m, New London receipted for SKYLARK’s message which eteced, “UNABLE TO COMMUNICATE WITH THRESHER SINCE.O917R. HAVE BEEN CALLING BY UQC VOICE AND CH QHR CW EVERY MINUTE EXPLOSIVE SIGNALS EVERY 10 MINS WITH NO SUCCESS, LAST TRANSMISSION RECD MAS GARBLED, INDICATED TRRESHER WAS APPROACHING TEST DEPTH, Mf PRESENT POSITION 41-43 N 64-57 W CONDUCTING EXPANDING SEARCH," 7 Therefore, SKYLARK‘s message did tot convey to Operational Commanders t full extent of the information then available, nor did any of SKYLARK's subsequent reports include such additional information, Moreover, THRESHER last messages Were not disclosed to higher authority until 12 april, whea LTIG oe y Ravigator of SKYLARK, boarded the USS BLANDY wich ch underwater telephone log which was examined by Deputy Commander Submarine Force, J, $, Atlantic Fleet, However, the Court of Inquiry formed cheopinion that SKYLABK's Commanding Officer's failure to promptly notify higher authority of all the information evatlable to him pertinent to the circumstances attending the last transmission received by SKYLARK from TURESHER on 10 April, as it was his duty to do, 4ia not contribute in any way to the loss of TRRESHER and was not materially connected therewith, THE SEARCH FOR THRESHER Deputy Coumander Submarine Force, U, S, Atlantic Fleet (Rear Adistral tor» USN) was in route to New London, Connecticut from Key West, Florida and errived at Trumbull Atrport, Groton, Connecticut, at about 6:20 pam, Upon notification cf THRESHER's status, he proceeded by helicopter to Newport, Rhode Island, and embarked in the USS BLANDY to proceed to the scene of the search, Command of the search force passed from Commanding Officer, SKYLARK, to Commander Submarine Development Group TWO at about 5:30 a.m, on 31 April 1963 and was subsequently exercised, for varying and consecutive periods, by Deputy’ Conmander Submarine Force, U, S, Atlantic Fleet, Commander Submarine Development Group TWO, and Comander Submarine Squadron EIGHT, Shortly after 9:17 a.m,, 10 April, when efforts to communicate with ‘THRESHER had been unsuccessful, SKYLARK commenced an expanding search pattern Sonar wes the principle means of underwater detection available to SKYLARKPatrol aircraft and the USS RECOVERY (ARS 43) joined SKYLARK in the search area during the afternoon. At about 5:30 p.m, RECOVERY sighted an ofl slick about seven miles to the southeast of SKYLARK's 9:17 a.m, position. Samples were collected and articles of debris were recovered, These items and debris subsequently recovered were examined by laboratory personnel of the Portsmouth Naval Shipyard and were determined to be materials which could have cone fron THRESHER, Radiation teasurements were taken in the earch area by surface ships and submerged submarines, and the water samples and recovered debris, examtned by Laboratory personnel, were found to contain no radioactivity beyond normat background Ievel. As the search for THRESKER continues naval units and personnel are being assisted by civilian scientists and research ships, GONSTRUCTION OF TUR ‘he construction of THRESIER commenced at the Portsmouth Naval Shipyard in 1958, and she was commissioned and delivered on 3 Auguet 1961, THRESHER had been designed by the Bureau of Ships, assisted by the Portsmouth Naval Shipyard in the contract design phase (1957-1958); working plans were Seveloped. by the Portsmouth Naval Shipyard. The THRESHER Claas underwent several design reviews during the building period, including a review in March, 1959, by the Chief of Naval Operations,‘he condition of the ship wheh delivered was defined by the certificates c£ condition furnished by the Commander, Portsmouth Naval Shipyard, and the report of the Board of Inspection and Survey, In general, the ship was built in atcordance with specifications and was in generally good waterist condition, As part of the general construction of THRESHER, silver braze joints and flexible hose connections were extensively used in vital piping systens throughout the ship in accordance with usual submarine building practice and THRESHER's specifications, Subsequent to the investigation of a casualty Snvolving a submarine of an earlier class, silver braze joints in THRESHER*s vital systems were subjected to visual exaninations, mallet tests, chemical material re~identification.tests, hydrostatic tests dnd hydraulic pressure cycling tests, but there vas no extensive retrofit of silver braze joints in TRRESRER, Quality assurance procedures employed at Portsmouth Neval Shipyard during THRESHER’s construction period, consisted ic general of mechanic and line supervision, with some system tests being conducted by inspectors. Xray techniques were used extensively for non-destructive testing of welds, forgings and castings, Some ultrasonic testing was used to detect internal Flaws in steel plates, To supplement these techniques and wherever possible, hydrostatic pressures were applied to presse vessels and plping systems. These test pressures were, in general, one hundred and fifty per cent of the designed working pressures, In the case of those piping systems exposed tosea pressure, this test pressure was also equal to that sea pressure expected to cause collapse of the hull, Hydrostatic pressure testing is a standard engineering technique and was the best non-destructive method of testing silver braze piping joints available at the time of THRESHER construction, Hull production processes during THRESHER's building period aia not include the use of all the techniques and eafeguards for hul? surveillance ‘ghich now exist, nor @s the ultrasonic uathod of testing silver braze joints available, POST-QOMMISSTONING OPERATIONS AND YARD AVALIABLLITY OF THRESHER Following commissioning, THRESHES conducted operations in the eastern Atlantic area, for the purposes of shakedown, treining and evalustion, much Longer operating period was provided than is normal before a post shakedown availability due to the need to test the many new developments and equipments incorporated into THRESHER, From 16 April 1962 to 21 May 1962 THRESHER received instrumentation and shock hardening at the Electric Boat Division of General Dynamies Corporatic Groton, Connecticut, in preparation For scheduled shock tests. During @ visit to Cape Canaveral in early June, THRESHER was struck by a tug and suctered damage to the exterior plating of one of the main balles tanks, Upon return to the Electric Boat Division all damage was repaired, t=and a thorough inspection revealed ho damage to the pressure hull nor any damage vhich affected the safety of the ship, On 11 July 1962 THRESHER arrived at Portsmouth, New Hampshire, for post shakedown availability efter conducting full power trials enroute, Post shakedown availability commenced on 16 July 1962 with an estimate of approximately 35,000 manadays and a scheduled duration of six month: however, becausa of work added and the underestimation of the effects of new and old vork, 11 Mbrit"t963 became the Final completion date, The total of man-days expended wes over 100,000, During THRESHER's avatlabiltty flexible hoses were replaced in accordance with process instructions existing in the Shipyard, These instructions did not fully define specificattons for allowable twist, and some flexible hoses were twisted in initial installation but were corrected. Although no formal training program existed for installing flexible hoses, att inspection program for flexible hose installetions did exist and was carried out, Also, a comprehensive flexible hose listing which was used for quality assurance planning and inspection was prepared for TURESHER, Some valves in THRESHER's hydraulic, auxiliary sea water system, and other systens were installed backwarés during the post shakedown availability te permit testing of systems, sone due to inadvertence and one due to an error im the ship's plans; however, all were corrected and properly installed prior to departure of the ship for sea triais,‘The Ship Information Book and working plans for THRESHER’s auxiliary aea water systen called for cross-comnection of the eystem as the normal ‘operating mode, However, installation of new check valves in the constant vent portion of this system during the post shakedown availability mada Possible the complete separation of the auxiliary sea water system into two loops. Difficulties were experienced in operating the high pressure air system, “and in leakage from the reducing valves, These difficulties, which began early in the life of the ship and existed throughout the post shakedoun availability appeared to stem from the presence of minute particles in the system, High pressure air and hydraulic systems require a nigh order of small particulate matter rejection during fabrication, installation and repair, However, the difficulties with the high pressure eir valves, particularly leakage and venting, were reported as having been corrected prior to sea trials, ‘The hull repairs, access hatches and nuli stiffening work were completed in accordance with existing Bureau of Ships Instructions and were checked by non-destructive teste means as being satisfactory, and the hull surveillance inspection scheduled during the post shakedown availability was completed, The first dockside simulated cruise for purpose of craw training (fast cruise) was held 23-26 March 1963 and was terminated because of the large number of deficiencies noted, The second and last "fast crutse” aD-was begun on 31 March end satisfactorily completed on 1 April 1963, Tn the second “East crulse”, during one of the drills involving a flooding casualty in the after auciliery sea water system, twenty minutes were required to isolate a leak, This was one of the early drills and changes had been made in the system involved during the post shakedown availability, TTARESHER was at the Sound Pier for sound trials durihg the period 1-4 April, and.in drydock from 4 Apri? to $ April 1963, to make repairs to torpedd door shutters and 2 mein circulating water valve, During this period liberty sas granted to the crew, Testing of systems was in accordance with Portsmouth Naval shipyard and other applicable instructions, A comprehensive test program was conducted, AL] work undertaken by the Shipyard during THRESHER's post shakedown availability was reported as having been completed satisfactorily, and the Commanding Officer expressed Kis concurrence that the work was completed. Portsmouth Naval Shipyard has had an extensive training program over the past two years, expending about $1,300,000,00 in the Shipyard, of vhich the Pipe Shop (56) portion wag about $400,000.00, The number of people in the quality assurance program in the Portsmouth Naval Shipyerd has increased from 152 to 243, and the direct expenditures for the program from approxi- mately $1,200,000,00 to approximately $2,800,000.00 in the past two years. During THRESHER's post shakedown availability, tte total work effect performed at Portsmouth Navel Shipyard also tneJuded construction of five submarines, =th—Other winor ship repair work and some manufacturing work also was accom plished, Portsuouth Naval Shipyard has authority to deviate from pullding specifications in certain areas, and Is using the specifications as goals Father than requirenents in certain cases, COMPLEXITY OF MODRRN SUBMARINES AND REQUIREMENTS FOR SPECIALIZED VANPOWES The complexity of modern submarines has increased at a rapid rate. The advent of nuclear propulsion, ballistic missfles, and greatly increased speeds and operating depths has made it essential that all information affecting their cafe operation be analyzed and promptly disseminated, While there is at present no organisation st any level’ within the Navy with the sole responsibility for submarine safety, Conmahder Submarine Force, U, S, Atlantic Fleet, has @ system of disseminating information which affects submarine operational safety. During the past four years, while the Navy's annial ship buflaing program haa increased from approxinately $2,500,000,000 te $4,500,000,000, the civilian personnel ceiling of the Bureau of Stipe in Washington, D, ©, has been reduced from 3800 to 3100, and the number of naval officers designated for Bnginesring Duties (ED) has declined From 1057 to abovt 840, Hore significant che nunber of naval officers serving as Technical and Manageneat Officers in the Portsmouth Naval Shipyard has been reduced over the past few siteyears, This is pertiovlarly setious in the Design Division where, in 1956, Five Assistant Design Superintendents were assigned ~- none is so assigned today; and in the Ship Building Division, where the loss of ten qualified officers (uainly BD) in 1961 and 1962 has reduced capabilities. During recent years, the advent of the nuclear submarine has resulted in a uajor increase in the complexity and difficulty of submarine design, construction and maintenance, ‘The increase in complexity of nuclear dubmatines has resulted in an appreciable increase in the responsibilities {imposed upon their commanding officers during the construction ané post shakedown availability periods. During THRESHER’s post shakedown availability there wes a change of THRESHER's Ass{stent Ship Superintendent in November, 1962, anda change of TWRESRER's Ship Superintendent in December, 1962, Also, there were changes of THRESHER'S Counanding Officer and Srecutive Officer in January, 1963, OPINIONS OF COURT OF INQUIRY There is a danger that, in melding together fact and conjecture, conjectwy tay be stretched too far and may be accepted as fact, thus narrowing the fiel of search for possible causes of the casualty. The Court’s singling out of certain questions for study should not deter others, particularly mowbers of the crew of similar ships, from continuing to study the many questions raised by the THRESHER's loss, ieThe Court concluded thet a flooding casualty in the engine room is the most probable cause of the sinking of ‘URESHER and that it is most Likely that a piping system failure had occurred in one of the THRESHER galt water systems, probably in the engine room, It was also concluded that in all probability water affected electrical efreuits and caused a loss of pouer, ‘he Court stated the opinion that the basic design of THRESHER class submarines is good, and {ts implementation resulted in the development of a high performance submarine. However, there are certain {mprovenents desirable, as set forth inthe recomendations, to increase the safety margin, ‘The basic auxiliary sea water loop system concept and design for the THRESHER clase is good, and is an improvement over the single header “Christmas tree" systems installed in other nuclear submarines, The dummy valves used as spacers and valves installed beckwards For tests should be 0 tuarked (tagged) and should be designated in the ship's system status or “sip out" procedure, oo3 The quality of work performed by Shop 56 (Pipe Shop) at Portsmouth Naval Shipyard has improved since the construction of earlier class submarine particularly in the sil-brase area and in waterial identification and control workmanship and quality assurance, In view of the many potential sources of casualties and their serious consequences in high performance submarines, assuch as THRESHER, there is a need to re-emphasize and improve, where indicated, the quality assurance program in shipbuilding and repair yards, The Court forme’ the opinion thet the quality assurance progran of the Porteaouth Naval Shipyard would be tmproved by appropriate consideration of the following 1, Quality Assurance Division should report directly to the Shipyard Comuander, 2, Quality assurance should be enginesred and planned, utilizing the statistical approach and should de-emphasize the "inspector" approach, 4, Quality assurance audits should be forwarded to management on a regular basis. Quality assurance should record all defects, not just remaining defects (for example, brazére and inspectors reject joints and 40 not report defects found which are readily correctiblel 5. Quality assurance ultrasonic test and welding radiographic test requirements should not depend on initiation of inspection requests by pipe fitters and welders, but should be separately initiated by the job order preparing authority to facilitate cross-checking. 6. A quality assurance program should be developed for flexible hose installation end cheek out, 7, The Quality Assurance Division does not currently have power to disqualify workers observed to be violating procedures, process controls and normal operating instructions, but must so recommend aeto the shop supervision involved, It might be desirable to permit quality assurance personnel to temporarily remove qualifications (brazers' cards,.etc.) under such circumstances te insure that defective work is not built into submarines during the normal administrative handling time for disqualification action, 8, Welding quality is under the Welding Engineer and is not completely integrated with the quality assurance progcam in the same manner as other procedures ate, Tt is believed desirable to integrate this effort, 9, Condition sheeta (for defects discovered) should be reviewed, analyzed and summarized by the Quality Assurance Division for Presentation to management to insure that process deficiencies are brought to managenent*s attention. Since high performance submarines require full quality assurance and a high degree of uniformity, the Bureau of Ships should require adherence to specifications. ‘here were wany reasons for the Bureau of Ships and Portsmouth Neva? Shipyard continuing the use of sil-braze joints in piping systems of submarines, These included: years of ship building practice and service, extensive tests, improvement in processes and non~destructive test techniques the lack of weldable Eittings and the high welded~jotmt rejection in all shipyards, -15-‘The substantially contemporaneous transfer of THRESHER's Commanding Officer, Executive Officer, Ship’s Superintendent and Aesistant Skip's Superintendent in the final portion of her post shakedown availablity was not conducive to optisum completion of the work undertaken, ‘The evidence does not establish that the deaths of those embarked in THRESHER were caused by the intent, fault, negligence or inetfictency of any person or persons in the naval service or connected therewith, e The Lessons learned fon inqutsy Into the oss of TRRESHER are of such moment as to require wide dissemination within the Navy, Certain actions have already been taken, For example, the Navy's Bureau of Ships is applying a newly develdped inspection teshnique to assure the integrity of high pressure piping eystems on all nival ships, Based upon ultrasonic principles, the new method is being employed initiall on nuclear submarines, Personnel training and ultrasonte inspection eqiip~ went familiarization are necessary and some rescheduling of submarine construction dates and overhaul intervals will be required, RECOMMENDATIONS OF THE COURT OF ENQUERY The bulk of: the Court's recommendations stated the need for careful review of the design, construction and inspection of vital submarine syste such as sea water and air systems, and a review of operating procedures tc improve damage control capability under casualty conditions suck as flood 6=The Court recommended that the quality assurance program at Portsmouth Naval Shipyard be further emphasized and improved in scope along the lines indicated in the Court's opinions, Further, the Bureau of Ships should require submarine ship building activities to adhere to specifications, and to obtain from it approve? for all waivers where this is not practicable. The Bureau of Ships should increase its audit activity to insure adherence to specifications for subearine building, overhaul and repair, ic 4 ¢ = a be or Eerly consideration should be given to the establishment of an organizatior similar to that employed {n Naval Aviation, in the interest of safe submarine operating procedures, Such an organization should be responsible for the analysis of events and developments which pertain to submarine safety and the timely dissemination of such information, =e