What Happened On The GW

At 6 a.m. May 22, an ensign standing aft of Elevator No. 3 aboard the aircraft carrier George Washington smelled smoke. The officer told a chief boatswain’s mate. Both suspected the ship’s incinerator was the source, but a check of the machine revealed no problem.

The crew continued to prepare for an underway replenishment as the ship sailed off the west coast of South America, not knowing that a discarded cigarette butt had somehow ignited cans of refrigerant compressor oil, papers and clothing, starting what would be-come a raging fire in the lower aft decks of the nuclear-powered ship.

At 7:45 a.m.—almost two hours after the ensign smelled smoke—a machinist’s mate second class in the Air Conditioning and Refrigerant Division office on the sixth deck saw smoke wafting from a manhole cover leading to an ad-joining auxiliary boiler exhaust and supply space. The sailor called Damage Control Central, but the line was busy. The sailor left the space to notify the at-sea fire party but never told DC Central.

By then, the fire had spread through ventilation trunks and cableways, alerting other crew members of the danger in their midst. It would be 12 hours before the fire was contained and the ship secured from general quarters; 37 crew members were treated for minor burns and smoke-related injuries.

Despite the fact that the fire damaged 80 spaces and cost $70 million to repair, it could have been far worse. A command investigation into the incident showed the GW was a disaster waiting to happen. The high-level investigation — released Oct. 3 — found a weak damage control program, unconcerned leadership, lax inspections and poor oversight by the chain of command.

The crew made a spirited effort to fight the fire, but the incident revealed major flaws in the ship’s most basic mission next to war fighting at sea: preventing and fighting fires. It became the biggest carrier fire since the 1967 blaze aboard the carrier Forrestal, which killed 134 crew members. And it didn’t have to happen.

“The start of the fire and its magnitude was the result of a series of human acts that could have been prevented by George Washington personnel,” Rear Adm. Frank Drennan, who commands Naval Mine and Anti-Submarine Warfare Command in San Diego,wrote in the report.

The following is based on that investigation.

Oil cans ignored

Sometime in April, a month before the fire, the chief engineer, a commander, found 346 gallons of refrigerant oil stored below the deck plates in the auxiliary boiler room on the seventh deck. They weren’t supposed to be there.

He told the auxiliary division officer, a lieutenant junior grade, that he had found the oil. The auxiliary division officer ordered a chief machinist’s mate and a machinist’s mate second class to turn the oil in to the hazardous material division.

The chief engineer mentioned his finding at that evening’s department meeting, reminding others to clear out any hazardous materials from their spaces. Other department heads got his reminder at their meeting the following day.

But the supply officer, a commander, didn’t tell his HazMat division officer about the chief engineer’s finding of the refrigerant oil, and no one else investigated the re-port. And the sailors in the EA-03 shop didn’t turn in all of the oil.

The investigation found that 90 gallons never made it to HazMat but instead were kept “on hand” in an access space beneath a manhole cover, a space where, since 2005, the sailors had stored technical manuals and foul weather jackets. The reason appears to be convenience: A machinist’s mate second class told investigators, “It is hard to get things from HazMat.”

Investigators suspect that at least one smoldering cigarette butt, found in an exhaust fan near the space where sailors hid the 90 gallons of refrigerant, sparked or fanned the fire.

Investigators surmised that regular inspections would have forced the sailors to report or re-move the illegally stored oil and flammables. But the George Washington had no program to conduct routine zone inspections, contrary to the ship’s own rules.

Problems fighting the fire

Around the time the MM2 called DC Central on May 22 and got a busy signal, the ship’s executive officer, Capt. David Dober, spotted white smoke aft of the is-land while he stood in the auxiliary communications station on the 07 level.

Then two more reports arrived: Squadron Ready Room No. 5, on the 03 level at frame 185, told the engineering officer of the watch of white smoke. Sailors saw heavy smoke and a glow in a corner of the dry provisions storeroom on the fifth deck at frame 180 — seven decks below the squadron ready room.

Within two minutes, the engineering officer of the watch reported over the 1MC smoke near the ready room and called the at-sea fire party to the scene. In came more reports of smoke sightings, reaching from the sixth deck to the flight deck near frame 180. Sailors reported bubbling paint on bulkheads and passageways.

The fire was spreading. The engineering officer of the watch told the reactor officer, a captain, that he suspected a fire in the ventilation system.

About 8:20 a.m., four sailors re-ported they were trapped in the Pump Room No. 3 control room, on the seventh deck. Intense heat and smoke blocked their only exit through an access trunk. About that same time, commanding officer Capt. Dave Dykhoff ordered the ship to general quarters.

For several hours, firefighting teams fanned across more than a half-dozen decks and multiple, smoke-choked compartments to stage a massive, multiple-front at-tack on the fires. They sweated under their heavy equipment and breathing apparatus as bulky hoses bulged with water. Sailors reported seeing water boiling on the decks. The massive effort eventually brought the four sailors to safety after 5% hours trapped in the ship’s belly.

The ship was safe, but another kind of heat was just beginning. The George Washington—destined for its new overseas home port and role as the first U.S. nuclear aircraft carrier in Japan—was about to fall under an unforgiving spotlight. When it was over, the commanding officer and executive officer were sacked, and six others received administrative punishments.

Scathing criticism

After identifying the fire’s source, investigators then turned to how the crew fought it. The top investigator found a weak DC training program that didn’t run enough drills, had too few experienced personnel and too few sailors on its DC training teams. On top of all that were senior shipboard leaders unconcerned with those problems.

In his critical endorsement of the report, Pacific Fleet commander Adm. Robert Willard blamed the fire’s extensive damage on systemic discrepancies and a lax command, and he criticized the lack of damage control training and oversight to ensure the ship resolved its problems. He also noted that it took nearly eight hours before Damage Control Central discovered the fire’s starting point.

Investigators identified other problems that made a bad situation worse:

•Too few drills. The George Washington conducted three general quarters drills in the first six weeks after leaving Norfolk, Va., on its way to its new home port. Drennan said the three drills were “insufficient to address the major concern to in-crease basic DC training and knowledge throughout the ship’s crew.”

•Missing or malfunctioning DC equipment. The majority of Repair Locker 1-B’s firefighting ensembles lacked liners, which help protect skin from heat. The liners were being laundered at the time. One sailor tried a shortcut, putting on two sets of the ensembles that lacked the liners, but he got slight burns on his legs and arms.

•Multiple repair lockers had faulty batteries for their thermal imagers, which are hand-held cameras that allow firefighters to see through smoke, revealing hot spots and heat or fire temperatures on walls, hatches or inside spaces and rooms. On May 22, on-scene leaders had no portable radios, and teams didn’t have enough helmet lights.

•Poor DC command. On the day of the fire, Repair Locker No. 5 deployed fire teams and managed the larger firefighting effort, a co-ordinating role usually done by DC Central. DC Central personnel couldn’t properly sort through all the incoming reports to determine the fire’s location and coordinate the rescue of the four sailors, and it took them 50 minutes after they learned of the fire’s source to report it over the 1MC.

•A fractured DC oration. The fire marshal, a lieutenant, lacked the experience typical for the job aboard a carrier. The chief engineer didn’t recognize that special damage control training for sailors in each division hadn’t been done until a month before the fire. That was when the skipper received a plan to improve and strengthen the program. And the ship’s smoking policy wasn’t covered in the ship’s own “school of the ship” indoctrination training, which usually teaches new crew members about the ship’s regulations and standards and covers issues ranging from safety to physical training and conduct. Enforcement was poor, too. Two crew members told investigators they’d found butts outside of authorized smoking areas, including near a vent duct in Pump Room No.

Investigators also found that external evaluations by Naval Air Force Atlantic, Carrier Strike Group 8, Afloat Training Group and the Board of Inspection and Survey had raised concernsabout damage control and hazardous material handling during the ship’s unit-level training. Drennan said a “lack of common focus” by Dykhoff and Dober and their inability to resolve the issues allowed problems with fundamental “weaknesses” in damage control capabilities to fester.

“Neither the CO nor the XO were adequately involved in assessing and improving the DC readiness of the command,” he wrote in an addendum.

The ship’s XO “believed that the DCTT and his crew were undergoing the standard learning curve for a carrier undergoing that phase of training,” he added.

Blame goes higher

The George Washington spent nine months doing unit-level training, longer than the usual six months for Nimitz-class carriers. The ship’s ISIC, or immediate superior in charge, who oversees most external evaluations, was Naval Air Force Atlantic. The role transferred in December to Carrier Strike Group 8 during the transit to San Diego.

Drennan noted that from June 2007 to March 18, 2008, external evaluations of the ship’s training and readiness “consistently pointed to weaknesses” in the DCTT’s ability to train the crew and “significant weaknesses” in the DC Petty Officer program. The problems were validated by an InSurv report and material inspection, he wrote.

Willard, in his endorsement, went a step further. The Pacific Fleet commander pointed some blame toward GW’s superiors, questioning the decision to over-haul the ship’s manning and training processes during the work-up period, along with the criteria used to give ships a passing grade when major deficiencies were found. Willard also found “possible shortcomings” in the oversight roles by ISICs and type commanders.

The Carrier Strike Group 8 commander had no plan of action to address the deficiencies, Willard wrote, and ISIC and TyCom’s actions “did little to assist USS George Washington to be better prepared to deal with a fire of this magnitude.”

Both Fleet Forces Command and Pacific Fleet “must demand more complete oversight and hands-on engagement in corrective actions by TyCom and ISIC commanders and their staffs,” he added.