53.           A commissioned turret officer was not in turret two at the time of the casualty, and apparently in NEWPORT NEWS they are in general not assigned.  This too was not explicitly a factor in this casualty.  But nevertheless we consider that any 6”/47 or larger turret should have a qualified commissioned turret officer regularly assigned, and that he should be in the turret during all occasions of expected firing.  This was a Navy standard for years, and we see no justification for degrading it.  His presence, judgment, and decision should surely ameliorate many a difficult situation, in many ways, some perhaps imponderable.  Or else he’s not worthy of his uniform.  The assignment would provide the officer an additional opportunity to develop and demonstrate naval leadership.  And if his men are to die in a casualty, he dies with them – in the tradition of a Navy that fights and wins.

CONCLUSIONS 

54.           Throughout our inquiry we have been impressed by the thoroughness, vigor, and initiative of COMNAVORDSYSCOM in addressing every element of the ammunition safety problem which is within his authority; and by his effectiveness in gaining the support and assistance of other technical agencies also involved in the problem, but not under his command and control.

55.           We have been equally impressed by the comprehensive approach of COMSERVGRU THREE to the formal investigation of the casualty, which was a principal factor in the recovery of substantial information and material evidence which otherwise would not have been available.

56.           This casualty resulted from a high order projectile detonation which occurred within a fraction of a millisecond after propellant charge ignition in normal gun firing sequence.  The detonation was caused by premature firing of the ADF Mk 55-0, which in turn resulted from the fuze rotor being in the armed position at the instant of gun firing.

57.           The ADF concerned was manufactured by Bermite Powder Company in 1968 or 1969.  Its design is adequate.  Its premature functioning reflects faulty manufacture, including manufacturer’s quality control, and ineffective government inspection by DCAS, in response to inadequate criteria specified by NAVORDSYSCOM.

58.           The ADF Mk 54 (Mods), in service in 5”/38, 5”/54 and 6”/47 projectiles, is similar in design to the Mk 55, and vulnerable to the same lethal defects which can result from manufacturing errors or inspection inadequacies.

59.      Various additional manufacturing/inspection errors currently encountered are also potential causes of premature projectile detonations in bore, of which the most significant appear to be BDF

            (page 18)

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