Yesterday, The Navy Times obtained a portion of the JAGMAN investigation report on the accident, and posted some of the findings. Excerpts:
Assigned to a small boat handling team, the three were trying to transfer a British harbor pilot off the submarine near a breakwater on the way out of port. At the time of the accident, the team was on the deck and the pilot was in the hatch of the Forward Escape Trunk. Although bad weather approached — in fact prompting their departure from England — it was deemed manageable at the time, according to the JAG Manual Investigation report.The article goes on to say why the CO and ship's leadership were found to be at fault:
But while the three sailors stood exposed on deck, a strong wave hit the sub hard enough to slam the outer trunk hatch down on the pilot, causing him to bite through his upper lip. The pilot re-opened the hatch but the sub captain, Cmdr. Edwin Ruff, ordered Higgins, Holtz and Sowa below decks. Before they could get through the hatch, a second wave hit, knocking the three sailors into the sea.
The pilot got safely inside the submarine. The three sailors remained outside. They were rocked by heavy swells and struggled to get back aboard, but remained tethered to the submarine by lanyards fastened to a safety rail, according to the report. A shipmate went up to the deck but was also washed overboard before he could clip his lanyard to the rail. A nearby escort boat picked him up.
The sailors were being tossed back and forth across the deck. Sowa survived when a wave washed him onto the deck allowing him to pull himself toward the open hatch. A swimmer tender, Storekeeper Seaman Garrett Degler, grabbed him, cut him free and hoisted him inside, according to the report. Another sailor went out after Higgins and Holtz but he too was washed overboard. He tried to swim back to the ship but was quickly rescued by an escort boat.
With Higgins and Holtz still tethered to the submarine, water from 10 to 15 foot waves was pouring into the submarine, leaving “several inches of standing water” in the mess deck and filling bilges. It took a crew member several tries to shut the hatch, which had been fouled by the Jacob’s ladder. The submarine was maneuvered in heavy seas to keep it clear of the nearby breakwater and provide a lee for the trapped sailors. Higgins and Holtz were eventually recovered by the escorts. They were later pronounced dead at a nearby hospital.
Overall, fault is assigned in the report to leadership for not correctly analyzing available information or anticipating sea conditions in their location. The harbor master, a British civilian with 15 years’ experience guiding ships and submarines in and out of Plymouth, is faulted for giving the crew “poor advice” and not sharing information about “potentially dangerous sea states past the breakwater.”[Emphasis mine] There's no doubt that this was a tragedy, and hopefully lessons were learned Force-wide that will prevent similar accidents. Still, I'd like to see the Submarine Force sometime do a spot check on other submarines when they cite training as a problem, just to see if the boat that had the problem did less significantly less training than the average boat on the cited subject(s). If the results were to come out as I suspect they would, maybe the Sub Force blame-apportioners might decide that "ability to predict all potential hazards as accurately as post-accident investigators with 20/20 hindsight" shouldn't be a requirement to remain as the CO of a submarine.
A lack of crew training in risk management and man-overboard procedures is also cited. After the accident the submarine had to continue on a 14-hour transit to its dive point further out to sea. It could not return to port because of changing tide conditions.
