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USS STARK Attack Case Study

Navy Damage Control Case Study
by

Tom Peterson

on 25 July 2013

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Transcript of USS STARK Attack Case Study

CDR Tom Peterson
USS STARK Case Study
Terminal Objective
135.1 Understand the importance of the Command Leadership Team in fighting a complex Damage Control scenario.
Enabling Objective
135.1.1 Describe the role of the Command Leadership team in the prevention of shipboard fires.
135.1.2 Discuss the Lessons Learned from various shipboard incidents and their impact on damage control readiness.
USS STARK (FFG 31)
Cases We Will Study
0600 - Preparing for UNREP
0729 - Manned and Ready to bring USS CROMMELIN alongside
0745 - White Smoke aft of the Island
0748 - Emergency Breakaway
0747-0820 - Report of smoke from the 6th Deck to the Flight Deck
0810 - MM2 Reported smoke coming from access cover 6-189-1-Q
0816 - Bubbling Paint on the 01 Level
0818 - 4 Sailors trapped in #3 Pumproom (6th Deck)
0820 - Set GQ
0825 - Loss of Power aft of the Island (Frame 180)
0913 - Loss of HP Air to SCBA Recharging Station - Set up EBACS
0920 - Hot spots in ADP on 4th Deck
1000 - Repair 3 evacuated
1042 - HPAir Restored
1130 - Cableway and Class A Fires on 3rd Deck
1135 - ADCA determined possible source of fire was in Aux Boiler Supply and Exhaust (6-189-1-Q)
1220 - CO ordered access cut to allow egress of personnel trapped in Pump Room #3. Efforts delayed due to low charge on oxygen bottle for first PECU and depleted battery on second PECU.
1227 - DCA Announces source of the fire
1324 - Personnel in proximity suits gained access to Pump Room #3, covered 4 personnel in wool blankets soaked in AFFF and evacuated safely
1345 access cover to Auxiliary Boiler Exhaust and Supply in passageway 1-185-1-L was removed and water sprayed into opening
1545 Access cover in 4-180-1-L was removed and water sprayed into opening.
2016 - Secured from GQ
The fire was in space 6-189-1-Q.
It was being used for unauthorized storage of tech pubs, clothing, lagging, at least 90 gallons of compressor oil and 5 gallons of unknown substance.
Cigarette butts found in plenum of 6-180-0-E AC&R Machinery room which exhausts directly into 6-189-1-Q.
The size of the space led to confusion to as to the actual location of the fire. The space went from 6th deck to 02 Level and about 100 feet wide.
Exact cause of fire is most likely due to unauthorized smoking. Though unlikely, self heating or electrical failure has not been ruled out.
Result: $70 Million worth of damage.
The Cause of the Fire
REFERENCES
Information Gleaned from PowerPoint Presentations on the Student Drive\SOSMRC_Lessons\References\Case Studies
Formal Investigation Into the Circumstances Surrounding the Attack on the USS STARK (FFG 31) on 17 May 1987
AMERICA'S FIRST CLASH WITH IRAN: Tanker War, 1987-88, Lee Allen Zatarain
Conducting training cycle; preparing for Dec 07 INSURV; preparing for Apr 08 3M assessment; and doing homeport shift from Norfolk to Japan.
In Jun 07 XO raised concerns about the need to improve DCTT.
In Jan 08 the XO did not express these concerns to new CHENG when he checked on board. Minimal changes implemented despite his concerns.
12JUN07-18Mar08 DCTT consistently shown as being weak and had trouble training the crew.
14 Aug 07 Completed Crew CERT Phase II. DCTT evaluated as Ineffective and level knowledge was rated as weak.
27 SEP 07 Safety Survey conducted and was rated as average for a CVN.
19 OCT 07 Completed CART II and the reported listed concern of DCTT’s ability to train. Having unqualified members of DCTT was a “major concern for ATG”
OCT07-APR08 Despite multiple hits on DCTT no documented training conducted.
Ship Ops Since Jun 07:
APR08 CHENG found refrigerant oil stored below deck plates in Aux Boiler Room 7-185-0-E and ordered A-Divo to get rid of it. A-Divo told MMC and MM2 to get rid of it but only 256 of the 346 gallons turned. MM2 stated he stored the oil in 6-189-1-Q in order to have it “on hand” for frequent use. MM2 said this space had been used to store foul weather jackets and tech pubs since 2005
CHENG told XO and other department heads about the HAZMAT and told them to check their spaces.
AUXO and A-DIVO walked their spaces and found no oil. MMC reported to A-Divo that all hazmat had been turned in.
11 APR 08 3M inspection conducted received an overall UNSAT and the DCPO program as UNSAT.
22 May 08 Fire
FINDINGS
The fire could have been completely prevented.
If the ship had been better trained it could have fought the fire more efficiently.
This would have prevented millions of dollars of damage and burns to personnel.
The failure of the following contributed to the fire and hampered fire fighting efforts.
Leadership
Lack of Training
Material problems
Sailors not adhering to standards
Multiple hits during training cycle, TSTA/FEP, INSURV and 3M assessment assessed DC as a weak point for the ship.
Little progress was made to correct problems found during assessments.
Getting an “outstanding” for TSTA/FEP may have given a false sense of security.
The ISIC allowed the ship to proceed to the next phase of the training cycle with “no outstanding training deficiencies” despite getting an UNSAT in DC.
The ship was not conducting zone inspections. While the space with unauthorized HAZMAT stored would not have been covered (not on zone inspection list and required unscrewing 28 bolts to access) it could have emphasized to the crew that unauthorized stowage and unauthorized smoking is not acceptable.
The XO saying it was a “normal learning curve” let substandard performance be acceptable. This does not conform with the continuous training policy.
There was a “conspicuous lack of routine reports to department head level and higher” regarding DC Training, Fire Marshall, Zone Inspection, 3M and HAZMAT programs,
Priorities with the home port shift, INSURV, TSTA/FEP, 3M assessment, and COMPTUEX led to DC standards to stay low and put the ship and crew in danger.
Leadership
DCTT continuously stated as being a major problem area. During training cycle “Major concern of ATG of having unqualified people on DCTT.”
The ship had been told on numerous occasions that the ship was sub-standard in the area of DC and needed to conduct more training.
Conducting only 3 GQ’s in a six week period was insufficient in addressing ATG’s concern of the need to increase basic DC training and crew’s DC level of knowledge.
When TRAINO recommend to XO to conduct a GQ once a week TRAINO was told they should put the emphasis on preparing the ship for COMPTUEX instead.
The amount of training conducted would be sub standard for any ship let alone one that had constantly been assessed as “UNSAT”.
Lack of Training Prior to Fire
During fire, multiple reports of SCBA’s being out of air due to not realizing they needed to open the isolation valve to pressure gage. Sailors had trouble adjusting restraining straps with going from 30 min bottles to 45 min bottles or vice versa.
Throughout GQ, Repair 5 managed hose teams and investigators, not DCC.
DCC was not proficient in sorting through multiple reports throughout the ship.
DCC not proficient in simultaneously coordinating fire fighting efforts and rescue efforts.
No one correlated continuing discharge of smoke from ship after setting zebra as indication of a possible ventilation fire.
Took DCC 50 minutes to announce on 1MC location of fire after determining it.
Did not organize a focused, coordinated effort to access fire once location had been determined.
Needed to use handheld flashlights due to shortage of FFE helmet lights.
Misconceptions about halon hampered efforts to rescue the Sailors trapped. Personnel refrained from entering or leaving Pump Room #3 due to reports of halon being dumped in the space.
12 Jun 08 only 50% of required personnel were qualified for their assigned position within repair locker.
If the ship had been better trained, the confusion would have been minimized and the fire could have been extinguished quicker minimizing damage and repair costs.
Lack of Training During the Fire
First two PECU’s did not work properly delaying rescue efforts.
On 3 April 08, 72 of 186 (39%) of line items required in repair lockers were below required allowance. The ship placed an order for SOME of these missing items on 21 Jun 08. The ship did not have everything they needed to effectively combat the fire.
Majority of FFE’s in repair 1B missing liners due to being laundered. This caused 1st and 2nd degree burns to a Sailor.
Multiple issues with NFTI battery life and long recharge times. Also numerous reports of NFTI whiting out.
Material Problems
EA03 knowingly violated the ships HAZMAT policy.
When told to remove unauthorized hazmat Sailors told chain of command it was turned in to hazmat.
When MM2 saw smoke coming from a space he knew hazmat was stored in, he did not make proper efforts to notify chain of command.
Sailors knowingly violating ships smoking policy.
Sailors NOT Adhering to Policy
Train! Train! Train! Train! Push training as much as you can. If operations force you to do it during late hours… do it.
Hold high standards in the spaces. Do not walk past hazmat and not say anything. “If you lower your standards once, you’ve set a new standard” RADM Tom Rowden former CO of SWOS
Know the status of your material. Have senior leadership spot check to help identify anything missing in repair lockers and get it on order
Use your equipment. An actually causality is not the time to find out it does not work.
Do not have all the FFE liners missing from one repair locker at one time. Take a few from each locker and rotate through them. If the FFE liner is removed do not have it out so someone could accidently put it on.
Emphasize Core values among sailors. If they know something is not right bring it up. Set high standards and enforce them.
Get in the spaces
Follow up
Hold to a standard, not a training certification or FRTP timeline
Rotate PMS on DC equipment between repair lockers (FFE)
DCTT LOK directly related to DC Central Performance
Every program has potential to be part of your error chain
Install lagging/insulation on exhaust stacks in uptake spaces onboard all CG-47 Class Ships.
Develop maintenance requirement for periodic top-to-bottom inspection of the exhaust stacks and uptake spaces for heat/structural damage and fire hazards.
Zone inspections are an excellent tool but you need to know what you are looking for.
Non-Battle Recommendations
0434 - Approx Start of Fire – Bridge Watch Team smelled smoke, sparks coming from forward stack
0436 - GQ Ordered by CO – DCA dispatched 4 personnel to investigate
0454 - Fire Out via Firemain/Reflash Watch Set
0619 - Mod Zebra Reset
0657 - Secured from GQ
Mishap Timeline
Ship conducting pre-deployment work-ups.
Estimated cost to repair bulkheads, beams, and deck plating: $1.4M
Root cause was unauthorized storage of combustible material near a heat source.
MISHAP Summary
Improper stowage not identified or corrected (1st LT).
ZIDLs uncorrected (XO/1st LT).
Lack of knowledge of proper stowage procedures/requirements (OPS/CHENG).
Zone Inspection program periodicity UNSAT (XO).
Unsafe Act
Improper stowage of combustible material (Deck Division).
Unsafe Supervision
Faulty/degraded internal insulation in exhaust stack caused a hot spot to exist near the base of the stack.
The hot spot caused improperly stowed combustible material to ignite.
Material Factors
Procedural Factors
MIP does not support inspection of uptakes and exhaust stacks for fire hazards.
MLOC does not require uptake inspection prior to light off.
Lack of lagging/insulation on exhaust stacks exterior surfaces in the uptake spaces presents a burn hazard to personnel & an ignition source to combustible material.
Design Factors
Failure to properly schedule quarterly zone inspections.
Failure to train personnel on proper stowage/combustible material.
Failure to recognize combustible material in uptake spaces.
Failure to follow up on identified zone inspection discrepancies.
Error Chain
2110 Two missiles hit (20 sec interval)
First missile hits port side FR 110
Port side firemain severed
Missile traverse 2nd deck, doesn’t detonate
Punctures STBD hull FR 171 (80’ from entry)
Second missile hits port side FR 100
Detonates 3-5’ inside hull, below main deck
GQ sounded
Blast creates gaping hole in hull port side main and second deck
Instantaneous heat (approx 12 million BTUs - equivalent to 155 gals JP-5)
Space fire totally involved (flashover)
Damage Control
2115 (T+5) Initial actions / effects
Ship slows from 24 kts to 15 kts
Main spaces manned by junior personnel, senior personnel directed to fight fires
Rep 2 degraded due to personnel casualties
HT1 / Air Det try start P-250, ship going too fast to keep suction hose in water
CIC filled with smoke, total loss of power
Repair 2/5 areas filled with smoke
Firemain pressure drops to 60 PSI
XO enroute to bridge orders Stinger missiles & O-3 level .50 cal ammo jettisoned
Five personnel fall OVBD through hole
TAO attempts to rig P-250 on foc’sle
MISSILE #1
MISSILE #2
2120 (T+10)
(T+15) ENC (REP 5) reports Z set, sends out first OBA team
(T+17) CO on bridge, firepumps restarted, only 60 PSI
(T+25) XO directing FF effort from flight deck
(T+34) FM pressure restored aft (STBD side FR 180, Port side FR 232)
(T+33) Repair 2 untenable, aft BLKHD (FR 64) reported glowing red
(T+1:35) S & P lines rigged between bridge, aft steering, CCS; majority of port side amidships and fwd on fire
(T+1:55) CO orders all stop so P-250 on foc’sle can maintain suction; GMG3 uses O-2 level hose to cool missiles
(T+1:55) Foc’sle isolated by heat and flames, paint peeling on inside of missile magazine
FF efforts coordinated from flight deck, initial efforts focus on Wardroom and CPO quarters
(T+2:20) Salvage tug alongside. 4 OS’s remaining in CIC to draft messages, finally leave due to heavy smoke
2210 (T+1 Hour)
0000, Monday 18 May (T+2:50), ship listing 16 degs to port
(T+3:03) Salvage tug directed to cool STBD side and missile mag with water cannon - 2 1/2" hose run from the tug into the magazine
0029 (+3:19) B fire in AMR 1 reported
0058 (+3:48) AMR fire extinguished with Halon
0114 (+4:04) Ship exhausts OBA canister supply, fire regains in wardroom, CPO quarters
0134 (+4:24) DDG-24 motor whaleboat delivers medical and DC supplies
0200 (+4:50) Helo arrives with Dr. and OBA canisters, takes injured personnel. 76MM magazine is flooded
0227 (+5:17) Conyngham 2 nm away, preparing motor whaleboat with DC equip. AC mach room escape trunk discovered filled with boiling water
0230 DC deck too hot to fight fires, foc’sle P-250 burns up
0300 (+5:50) Fatigue and lack of water affects FF effort
0352 (+6:42) Stark does not have enough men to support reflash watches.
0400 List to 17 degrees, dewatering amidships p-way
0500 (+7:50) HT3 is relieved from DCC watch to dewater CPO p-way, but cannot continue due to smoke
First light - R & A teams from DDGs 17 & 24 arrive
0700 (+9:50) Door to RICER is opened and very hot water pours out about 2” above hatch lip
0900 (+11:50) The STBD side fan room becomes a problem when RICER burns through and CO’s cabin deck falls in
0907 (+11:57) Four men recovered by Saudi helo
1000 (+12:50) Fire contained to RICER, CIC and CMAA p-way. Missile mag cooling, less concern about cookoff
1020 Fifth man recovered by Waddell
1100 (+13:50) Men getting very tired. CWO (LaSalle DCA) and DC team arrive, note 18 deg list. Directs dewater missile mag using P-250, recommends cutting holes into CIC
1215 (+15:05) #1 FFP discovered to be flooding fwd spaces through a rupture and is secured.
1240 (+15:30) Fresh FF teams from LaSalle and Reid arrive and are sent to CIC/RICER
1300 Attempts to cut through superstructure into CIC with OXY-ACET torch fails, axes used
1521 (+18:11) 16 bodies recovered, brought topside. 86 men from other ships onboard. List currently 10 degrees
1530 CIC fire under control
1600 Stark made ready for towing by DDG-17
1700 (+19:50) Fire in CIC, most others, extinguished
1800 (+20:50) Stark listing 3-5 deg, under tow by DDG-17
Tuesday, 19 May
0200 (+28:50) More fires and reflashes occur throughout the night
0400 (+30:50) Reflash in IC repair shop; roving patrols are established; warhead is identified
1340 (+40:30) Stark on an even keel. Emergency power rigged, hot spots cooled, 24 bodies identified, 11 bodies unidentified, 2 still missing
2330 Stark moored outboard LaSalle
Weapons effect likely to yield immediate loss of firemain due to damaged sections - must reconfigure, use port pumps
Smoke spread is immediate problem, leading effects of heat and flame - stop it
Deck cooling, venting, indirect attack
During extended FF, water, food and rest periods essential to keep crew going
High FFW substantially decreased stability
Protective clothing essential
Comms lost - practice
Reflash watches were essential
Review Critical Stability
Floodable Length
Negative GM
Listing to the Danger Angle
Damage in Bad Weather
Battle Recommendations
BIG Damage
Conventional DC Organization / Procedures can’t handle over time; improvisation dominates
Can involve mass casualties
Battle Damage Considerations
Confusion/Shock !!!!
Lack of Timely Information
False Information
High Stress
Loss of Key Personnel due to Injury
Damage to Communication Systems
Reduced Internal Access
Battle Damage Complications
DC Readiness
87% Gen DC Qualified
61% Recent live Firefighting training
3 former DCAs
14 DCTT members
DC Equipment
34 OBAs/331 canisters (18/108 required)

100% Repair locker inventory
Not yet in the fleet
NFTI, PECU, FFE
Smoke curtains
Photo luminescent paint
Interesting STARK Facts
17 May 1987
Battle Damage Summary
Total Loss
Engine Room – Flooded to Sea Level
Fuel/Ballast Tank 5-250-1-F
Oil Sump Tank for CPP 5-270-0-F
Lube Oil Sump Tank 5-276-0-F
B Fires in Engine Room, Intakes plus Uptakes from Ruptured DFM Tanks and JP-5 Fuel Line Under GTM 1B
Questions?
12 Oct 2000
Don't Give Up the Ship!
Case Study Discussion
Two Different Perspectives -
The Conditions to the Left of the Attack
Conditions after STARK is hit by the Iraqi Missiles
PREPARATION/PREVENTION
DAMAGE CONTROL
Theater Situation
Iran-Iraq War was in progress
September 1980 - May 1988
STARK had been in theater since 28 February 1987
STARK was operating in International Waters - "Well outside the Iraqi and Iranian declared war zones"
The attack on USS STARK was "unprovoked and indiscriminate"
USS STARK never fired a weapon nor employed a countermeasure, either in self defense or in retaliation.
Thirty seven members of STARK's crew died as a result of the attack
Situation on USS STARK
Key Players
After gaining radar contact and ESM, CIC kept a constant, real time track of the aircraft.
Changed course several times
Continued closer to STARK
At 30nm turned east and flew toward STARK
Less than 5 minutes later - Attack
Commanding Officer
Executive Officer
TAO
CIC Watch Team
WCO/CIWS FC
Problems
Rules of Engagement?
MAREP vs Engagement
Who is reading the Intel
Weekly Intentions Messages
Bi-monthly or As-necessary Force Intelligence Advisory
Complacency?
Timeline
Underway 0800, 17 May 1987
Two SAP were flown by Iraqi aircraft on the morning of 17 May 1987 - south of Farsi Island
AWACS/COONTZ tracking Iraqi F-1, Track Number 2202
2015 - CO Stops into Combat
Briefed that there was an Iraqi aircraft flying over water
Told TAO to "keep a close eye on track 2202"
2024 - Commenced Full Power Run
2031 - Captain is on the Bridge
Timeline
2050 - FC3 who was WCC-1 Operator and CIWS Operator steps out of CIC for "head break"
2055 - CO asks JOOD "why don't we have video"
OS1 reaches over and puts the SPS-49 in 80nm mode
2057 - Full Power Run - Unsuccessful
2057 - Captain is off the Bridge
2058 - CMEF asks for ESM
2100 - Surface Contact reported to the Bridge
2101 - OS1 has radar contact correlating to 2202
Timeline
OS1 Enters "Air Unknown" symbol into NTDS
Directs OS3 to "assume responsibility for tracking"
OS1 remains at the ASAC consol and "prepared to record data for the MAREP regarding the aircraft"
OS3 maintains continuous real time track of the aircraft until first missile hits
2103 - F-1 is 43nm from STARK - OS1 wants to do a "standard warning" on MAD - TAO "No wait"
2104 - XO is in Combat - notices that the TAO "was busy" and stands by the chart table
2104 - FC2 sends OSSN to find FC3
Timeline
2104 - CMEF asks "WTF"
2105 - F-1 turns toward STARK - Range 32.5nm - CPA "nearly overhead"
2107 - First Exocet Away
2107 - Forward Lookout reports "bright light on the horizon" - Identified as a surface contact
2107 - FC2 detects radar video (CAS search) and correlates it to the F-1
2107 - TAO wakes up - "OS1 Issue Warnings. CICWO call the Captain
Timeline
2107 - Can't reach the CO
2107 - TAO orders CICWO to man the WCO console - XO is in the way - XO gets up and the CICWO began to initialize the console
2108 - Second Exocet Launched
2108 - OS1 makes the initial warning via MAD, NIAW the CMEF guidance
2108 - EWSN requested permission to go topside to "arm the SRBOC launchers
2108 - OS1 makes another warning
Timeline
2109 - Forward lookout calls "Missiles Inbound" via the JL - Report gets to the Bridge and phone-talker in CIC but not the TAO
2109 - JOOD also sees the missiles inbound
2109 - FC2 locked onto the Iraqi aircraft with CAS it was about 10nm away
2109 - XO sends radio call to CMEF
2109 - SUPPO leaves CIC / Captain Enters
What Went Wrong
Watchstanding/Watchstander Errors
Never maneuvered to unmask batteries
No orders to assign weapons or engage the Fighter
Weapons systems were available but no ordnance was fired "in defense of STARK or in retaliation for the attack
The Commanding Officer was never informed that the ship had gained radar contact or ESM on the Iraqi Aircraft
Watchstanders = COND III/White vs CO = COND III/Yellow
Executive Officer
Authorized to direct the TAO in time of danger but never did
Took no action to determine the tactical situation
Took no steps to redirect the TAO
Material Issues
CIWS had intermittently failed SOT number five. Problem existed when STARK got underway on 17 May 1987. CO and CSO were aware but NO CASREP.
Not CASREPed because it could work in Battle Short Mode and parts are on order
STARK had not conducted a PAC fire since 22 Mar 87 (R-1M)
STARK personnel thought that there were restrictions on CIWS unless in a Gunnery Area
Video Processing / Automatic Detection and Tracking (RVP/ADT) was out of commission and not used but not CASREPed
STARK was "pre-occupied with readying for an upcoming Atlantic Fleet Mobile Training Team Exercise
Pre-occupied?
Ultimately 1,200 Canisters would be used
Full transcript