Boards of Inquiry (BOI): SPLIT from USS John S. McCain Collision

[Navy_Pete]

FTFY.  I'm willing to bet that this and the Fitzgerald are quickly becoming case studies already.

It's too bad that our own incident reports don't similarly get published; still have never seen a copy of the ALG/PRO BOI or any kind of executive summary showing what led to the collision.

 

[Blackadder1916]

It's too bad that our own incident reports don't similarly get published; still have never seen a copy of the ALG/PRO BOI or any kind of executive summary showing what led to the collision.

You're obviously not the only one who wanted to see what that BOI said; others have already asked for it and have received it under ATI.

Request Number: A-2015-01941

Organization:  National Defence

Disposition:  Disclosed in part

Year:  2016

Month:  September

Number of Pages:  102

Request Summary:  The Board of Inquiry findings and recommendations, and actions resulting from those recommendations, arising from the collision at sea of HMCS Protecteur and HMCS Algonquin in August 2013

Make an informal request for: A-2015-01941 (DND)

They've already done the hard work, all you have to do is make an informal request by clicking the link and filling out your info in order to receive a copy.

 

[Navy_Pete]

You're obviously not the only one who wanted to see what that BOI said; others have already asked for it and have received it under ATI.


They've already done the hard work, all you have to do is make an informal request by clicking the link and filling out your info in order to receive a copy.

Thanks, that's good to know.  I guess my point is those should be publically available from the get go; keeping them hidden dooms us to repeat the same mistakes.  The same should apply to all the other BOIs (PRO fire comes to mind).  Even within Navy lines, you've got to know a guy.

I like the USN/RAN and other navies approach to this, where they make them public (normally names are redacted) but the sequence of events etc are all there.  That and understanding what info people had when they made the decisions is what makes them useful for learning (either PD or part of research).

 

[FJAG]

You're obviously not the only one who wanted to see what that BOI said; others have already asked for it and have received it under ATI.
. . .

In 1999/2000 I represented the Federal Republic of Germany in an Inquest respecting the 1997 death of a worker at a scrap metal yard who was killed when the shears he was operating detonated a German live 105 mm HEAT-T round recovered as scrap from the Shilo ranges. The round came from a small lot of such rounds fired by the German army in the late 1970s and which had a high blind rate and were immediately restricted from being further fired in Shilo. The round, once fired and weathered was physically similar in appearance to hundreds of thousands of inert 105mmTP-T rounds on the ranges.

The one major issue in this matter was that this wasn't the first time this had happened. In 1980 there was a similar case when a worker at a scrap yard was killed when he cut into an identical live 105 mm HEAT-T round with a welding torch. Following this incident there was also an Inquest and a BoI. None of the people in the 1997 incident chain of command at Shilo, from the lowest ammo tech to the highest range control staff were aware of the first incident or the information contained in the BoI because the BoI was made confidential and the corporate memory very quickly lost sight of the fact that there continued to be several dozen unexploded German 105mm HEAT-T rounds on the ranges. (As an aside I was an artillery officer in Shilo at the time and was aware of the explosion and the death but the anecdotal and false story going around at the time was that it was a Canadian 105mm artillery shell that had exploded.)

There is very little value in conducting a BoI if the information about the necessary corrective action is not disseminated to the end user. A BoI on a shelf in Ottawa does no one any good.

:cheers:

 

[Old Sweat]

In 1999/2000 I represented the Federal Republic of Germany in an Inquest respecting the 1997 death of a worker at a scrap metal yard who was killed when the shears he was operating detonated a German live 105 mm HEAT-T round recovered as scrap from the Shilo ranges. The round came from a small lot of such rounds fired by the German army in the late 1970s and which had a high blind rate and were immediately restricted from being further fired in Shilo. The round, once fired and weathered was physically similar in appearance to hundreds of thousands of inert 105mmTP-T rounds on the ranges.

The one major issue in this matter was that this wasn't the first time this had happened. In 1980 there was a similar case when a worker at a scrap yard was killed when he cut into an identical live 105 mm HEAT-T round with a welding torch. Following this incident there was also an Inquest and a BoI. None of the people in the 1997 incident chain of command at Shilo, from the lowest ammo tech to the highest range control staff were aware of the first incident or the information contained in the BoI because the BoI was made confidential and the corporate memory very quickly lost sight of the fact that there continued to be several dozen unexploded German 105mm HEAT-T rounds on the ranges. (As an aside I was an artillery officer in Shilo at the time and was aware of the explosion and the death but the anecdotal and false story going around at the time was that it was a Canadian 105mm artillery shell that had exploded.)

There is very little value in conducting a BoI if the information about the necessary corrective action is not disseminated to the end user. A BoI on a shelf in Ottawa does no one any good.

:cheers:

Real life incident: In 1963 the regular and reserve force artillery had four premature detonations of 105mm HE just outside the muzzles .05 seconds after firing. I was on the gun position in Gagetown for the first one in May that wounded six soldiers, and worked on the investigation with the ATO. We (really he) deduced the delay element failed just after the round armed. I don't know how well, if at all, this was disseminated, but I know the story on the street was that the round was cracked. There were two more over the summer, both in Petawawa, with one reservists wounded. Finally, a soldier in the RCA Depot was killed and several others wounded in the fourth premature detonation. This finally resulted in action to fix the fuzes - actually the arming mechanism.

As an aside, a few weeks after the first event, an AIG from the School of Artillery told me the first premature obviously was the result of a cracked round that we incompetents had not detected when preparing the ammunition. He obviously was not interested in my account, including the results of the investigation. I still wonder if proper dissemination of the results of the first investigation and some executive action might not have prevented a lot of grief down the road.

 

[Blackadder1916]

Thanks, that's good to know.  I guess my point is those should be publically available from the get go; keeping them hidden dooms us to repeat the same mistakes.  The same should apply to all the other BOIs (PRO fire comes to mind).  Even within Navy lines, you've got to know a guy.

I like the USN/RAN and other navies approach to this, where they make them public (normally names are redacted) but the sequence of events etc are all there.  That and understanding what info people had when they made the decisions is what makes them useful for learning (either PD or part of research).

Well, "they" don't want you to know or at least didn't when this ATI request was made.

Request Number: A-2016-02232

Organization:  National Defence

Disposition:  Nothing disclosed (exemption)

Year:  2017

Month:  February

Number of Pages:  0

Request Summary:  Report of the Board of Inquiry into "HMCS Protecteur Fire," Case No. AISC 14-015, including any draft or interim version if final version not yet complete.

Make an informal request for: A-2016-02232 (DND)

I agree that it would be better if information was more available, but you would probably have to change the military/naval culture quite a bit, not to mention the general attitude of Canadian governments (regardless of the party in power) with regard to providing any information that may reflect poorly on them.  Within the Canadian military, my personal experience had been that the air force was been the best about disseminating safety information and lessons learned, but that may be more a reflection of the same requirement/standard in the civilian aviation community.

 

[Colin Parkinson]

The model exists already http://www.tsb.gc.ca/eng/rapports-reports/marine/

 

[SeaKingTacco]

Very interesting that the PRO BOI is being withheld.

It has been, what, 3 and a half years since the fire and the ship has been cut up for scrap.

Makes you wonder....

 

[Navy_Pete]

The model exists already http://www.tsb.gc.ca/eng/rapports-reports/marine/

Those are great reports, I really don't see any good reason why we shouldn't do something similar, particularly now with the push to adopt industry standards and the new ships being built/maintained to class standards.

 

[Stoker]

The model exists already http://www.tsb.gc.ca/eng/rapports-reports/marine/

Part of my job is part of the DC symposium and I have access. Very interesting reading.

 

[dapaterson]

I wonder if any crew members have requested a copy to support claims with VAC?

 

[Stoker]

I wonder if any crew members have requested a copy to support claims with VAC?

I wasn't aware if there were any claims through VAC, possible I guess. All they would need is a CF 98 and 663 and I believe all crew members received one as a matter of course.