RESTRICTED

      HMS   ARTEMIS

        LESSONS   LEARNT

                      Office of Flag Officer Submarines

                           20th January, 1972 HMS DOLPHIN.

 

 

 

RESTRICTED

 

HMS ARTEMIS – The Lessons Learnt

INTRODUCTION

 

Investigation  into the sinking of HMS/M Artemis  alongside at Trot 1, HMS DOLPHIN, on 1st July 1971 showed

that responsible ship's personnel were unaware of the circumstances prevailing in their submarine at the

time, and of the dangers towards which they were heading.  No evidence was produced – or could be produced -

 to show that the sinking was caused by failure of a submarine system, a structural failure or a fault in a

mechanical system.  None of these factors in any way contributed to -the loss.

Negligence or lax performance of duty by several personnel caused it.  In the summary which follows there are

many lessons to be learnt from events which in themselves would not necessarily lead to a disaster such as

 happened in the case of HMS ARTEMIS.  These lessons must be learnt and thoroughly understood if a repetition

of such disaster, or Indeed other accidents, is to be prevented.

BACKGROUND

ARTEMIS recommissioned after-refit in October 1969 and completed her work up and inspection in November

 1969  She was inspected in August 1970 by the Captain First Submarine Squadron, following which all except

one of her Officers were changed.  The Commanding Officer was in his first command and had been in

submarines for 9 years. The First Lieutenant had little experience of conventional submarines, having served

in an SSBN for 2 years before joining ARTEMIS 3 months before she sank.  The other Officers' submarine

experience varied between two years for the Engineer Officer to four months for the sixth hand. The senior

ratings all had at least five years con­ventional submarine experience, and the CMEA(P) and CMEM over fourteen

 years.  The CMEM had a total of five years service in HMS ARTEMIS.  From the fore­going it is apparent

the Wardroom was somewhat lack­ing in patrol submarine experience, but they were supported by experienced

senior rates.

 

THE INCIDENT

Artemis was in a combined Leave/Maintenance period, including a docking in AFD 26 - Portsmouth Dockyard - in order to

fit trials equipment prior to detached service in the West Indies„  Other docking maintenance was also planned for the five

day (Monday to Friday) docking period. In the event the submarine was undocked on the Thursday forenoon one day early.  The bringing forward of the undocking by twenty-four hours set in chain a pattern of events, and errors, which was to

 end with the submarine sinking at 1907 on Thursday 1 July 1971-

TURNOVER OF RESPONSIBILITIES FOR THE LEAVE PERIOD

At the start of the maintenance period the First Lieutenant took the Third Hand through the submarine and showed him

the work to be carried out by the sea­men.  He made no mention of any other duties which the Third Hand should carry

out.  The Coxswain was on sea­sonal leave at the same time as the First Lieutenant -consideration of the soundness of

this arrangement should be made for all leave/maintenance periods.

It was assumed by the Third Hand that he was the Trimming Officer but no formal turnover of this duty took place. 

Either the Third Hand or the Engineer Officer may be the better qualified to be Trimming Officer in the First

Lieutenant's absence.  Which of .them is to perform the duty should be decided by the Captain and clearly laid down by

 him.  Similarly, there should be a clear definition of how the remainder of the First Lieutenant's standing duties are

allocated during a leave period.

 

 

'During the maintenance period no copy of the maintenance work plan existed in the submarine, and both the Engineer

Officer and Third Hand ran their own programmes.  The Commanding Officer relied on individual reports from Officers to

 keep aim inform­ed about the progress of the Maintenance Period and the state of the submarine, appearing to be under

the impression that adequate interdepartmental co­ordination was being achieved between the Officers concerned without

the need for a daily (or regular) meeting of them all with him in the absence of the First Lieutenant.  This was a

potentially dangerous assumption if no other officer had been designated the coordinator of the maintenance work. 

 Had there been a habit of regular coordination between departments it is possible that a dangerous situation would

not have developed later.

 

DOCKING DOWN - MONDAY 28 JUNE

The Submarine was docked under the Command of the Third Hand, who was under report.  The First Lieutenant was on seasonal leave, and the Commanding Officer told the Officer concerned on the previous Friday that he was to be in charge.  This instruction was apparently given in the belief that Docking down could be regarded as a sufficiently trivial manoeuvre to allow its supervision to be left to a Third Hand. The Third. Hand was neither qualified nor competent to perform what in fact is an exacting task, and appreciated little of the problems which might arise The succession of organisational and personal fail­ures which occurred during the next few days may well have stemmed from this first unacceptable decision alone.Prior to docking, the submarine had not dived for three weeks, and that was the last occasion on which he state of the tanks and variable weights had been recorded in the Trim Book.  All external fuel was removed and the tanks blown empty before going into dock.  In order to achieve a docking trim, the following trim changes were made:

a.      The forward trim and torpedo tanks were emptied,

b.      The after trim tanks, were completely filled.

C      Five Main Ballast Tank was flooded to the waterline.

Although the trim changes were sound practice the initial weights were not recorded in the Trim Book before docking,

nor were the draught mark readings taken, or obtained (though they were readily available) from the Dock Master. 

Attention to detail in trim supervision and preparation for Docking was thus very poor.

IN AFD 26 OVER PERIOD MONDAY 28th TO WEDNESDAY 30th JUNE

Several jobs were undertaken, and several lessons rise from them:-

A number of external tanks were opened for the installation of test equipment and repairs. None of these tanks was

tested after boxing up.
In particular, the For'd Fuel Tank inside No. 2 Ballast Tank was not tested; yet a leak on No. 2 Fuel Tank cover would have

put oil into the Ballast Tank and thereby affected operational efficiency.

B.       Torpedo tube interlocks were broken (the hydraulic supplies to the outer tubes were isolated) so that both doors could be opened together.  Satisfactory completion of the work on the tubes by the SMU staff was accepted by a Leading Seaman.  The responsibility for accepting completion of work done by outside agencies on underwater fittings is the Engineer Officer's, and where delegation of the task to a rating is

Essential, a First Class Artificer or Mechanician of the ships department involved is the most junior rating who should be allowed to do it. Failure to ensure this is a dereliction of duty on the part of the Engineer Officer (MEO or WEO) con­cerned.

C.       On completion of the work, the hydraulic supplies were checked open by the Torpedo Officer, but the correct interlocked

operation
of the doors was not checked by him.

D.       Before the interlocks were restored to normal, an MEA used the after tubes, without the Weapon Staff's knowledge, as

access to the rudder crosshead. Without isolating the hydraulic supplies to the rudder, he worked .on the crosshead.  This was a

suicidal practice which might well have resulted in very serious consequences.

VACUUM TEST - WEDNESDAY 30 JUNE

All the docking work was complete by the after­noon of the 30 June and following normal practice, a vacuum test was

carried out with a Safety Officer on the bridge. Notwithstanding, the actual conduct of the test was poor. The Engineer

 Officer was onboard but showing Army visitors around the submarine during the test. He should have been supervising

the vacuum Test. This was no time for the submarine to accept visitors; submarines must exclude visitors at impor­tant

times like this, by command decision (OOD if appropriate). The Chief MEA tested forward, while the 'stand-in' Outside

MEA did aft. The lower conn­ing tower hatch leaked because of paint chippings, but was not re-tested after being cleaned.

No Officer was responsible for this test or personally checked that a vacuum was held.

AFTER THE VACUUM TEST - WEDNESDAY EVENING 30th JJUNE

The interlocks were broken on three of the for'd tubes to allow air circulation to dry them out.  This was done without the authority of,

or informing the Engineer Officer, who was responsible for watertight integrity of the submarine hull.  The Torpedo Officer

again checked the hydraulics opened up, but did not operate the interlocks, when he shut the tubes doors before

Harbour Stations on Thursday 1 July.

At about 1300 on Wednesday 30 June the Commanding Officer, and the Sonar Officer (Third Hand) were in­formed at RAF,

Boscombe Down that the undocking of HMS ARTEMIS was being brought forward to the following day. The Commanding

 Officer told the Third Hand to return early next morning in order to undock the Submarine.

The Commanding Officer decided to complete his discussions at Boscombe Down during Thursday forenoon and to return to

 

HMS DOLPHIN at mid-day, by which time his submarine would be alongside,. He did not brief the Third Hand on what was i

nvolved j,n an evolution such as undocking. His words of wisdom amounted to saying "If you are unhappy seek SOO's

assistance" (presumably by telephone), Three importance lessons-arise from this:

a.        The Commanding Officer should have either returned himself or contacted Commander SM for assistance of another fully qualified officer.

b.       During leave periods it is not always poss­ible to delegate downwards sometimes it must be done upwards,

C    Squadron Officers must be watchful to ensure that standards of   performance and judgement in submarines

attached are maintained at an appro­priate quality.

Notes :(i)  'Ignorance is Bliss !!  A man who does not know very much, will be in no position to judge whether he is unhappy with a

given situation, and when he appreciated he is in trouble it is pro­bably too late to request assistance.

d) Undocking is a major evolution, which nor­mally passes without incident -  However if an incident occurs, it requires knowledgeable

corrective actions to be taken.  Docking and undocking.' of submarines are such frequent evol­utions that familiarity may breed contempt.

The temptation for this to happen must be resisted. The First Lieutenant is the minimum command level which should be used

unsupervised, and then only if he has previously docked a submarine under supervision or at least been present dur­ing a previous docking of the submarine by his own Captain-  If not, more experienced help should be sought from the Squadron in the Captains absence.

- 1st JULY

The Engineer Officer signed the Ship's Undocking Certificate on behalf of the Commanding Officer certifying that there had been

no changes in weight or, if there had been, they had been reported to the Dockyard Authority.  He was in no position to

sign this with any degree of accuracy as he had no record of the weights immediately prior to docking, and no changes or

 checks recorded at the end of the docking period-

The Third Hand arrived onboard at 0835 Thursday 1 July and the crew went to Harbour Stations approx­imately fifteen

 minutes later.   It is very doubtful if an inexperienced Officer could assimilate the situation in that time-.  No turnover was

obtained from the previous OOD, and the Third Hand took com­mand of the submarine without satisfying himself of the true

state of

The trim or the stationing of the personnel.

The CMEA(P) would have been available for the un­docking if it had been on the Friday as planned. As it was he was away on

course. Flooding up started and the Engineer Officer reported at the submarine when various hull openings were covered.

He should have been in the submarine. He only returned to the casing just before the sub­marine floated, and went below

 for the first time since flooding started, after it had floated off the blocks.

The Dock Master had asked for No. 5 Main Ballast Tank to be flooded to the waterline with the vent open to achieve the

correct undocking trim. When the water rose above No. 4 Main Ballast Tank inlets, the Kingston valves were opened. 

This is a correct and standard practice, to open the Kingstons on No. 4 Main Ballast Tank at this time. Unfortunately, the

syphon pipes to the after fuel group had been left open after defuell-ing, through negligent bad practice, although the

state of the siphon valves was known-by ship's personnel. The result was that No. 4 Main Ballast Tank vented in­to the

after external fuel group, and No. 4 Main Ball­ast Tank was partially flooded.  Thus, through negligence, the submarine

was considerably heavier at undocking than it had been when docked.  The submarine floated off with a half degree list,

 possibly due to uneven flooding of No. 4 Main Ballast Tanks.

(For those unfamiliar with the 'A' Class, numbers 1 and 5 Main Ballast Tanks are single tanks forward and aft respectively.

 Numbers 2 and 3 Main Ballast Tanks are Port and Starboard ballast tanks.  No. 4 Port and Starboard Main Ballast Tanks

are Kingston fitted ballast tanks which can be connected to the after external fuel group),

9   When HMS ARTEMIS -was afloat- numbers 1, 2, 3 and 5 Main Ballast Tanks were Blown round to full buoy­ancy.  No. 4 Main Ballast Tanks

were left- in the undocking state.  The Dock Master read the draught marks after blowing round. However, it is difficult to establish

 exactly when this was done. In this regard, it must be noted that draught marks should be read several times during the quarter to half an

hour after first flotation to ensure that the submarine is floating steadily.  The draught should be related to the known tank

state to ensure that all is well.

 

Note;    ARTEMIS was almost certainly drawing

Approximately three inches deeper draught at this stage than when docked.

During the undocking of any ship, every com­partment below the waterline must be inspected for watertight integrity.  'This is

the responsibility of the MEO. Or in nuclear submarines, the SEO.  It can only be done effectively by organising beforehand a

system of sentries who have been briefed about their duties, to report to the MEO during the flotation process.  Once the ship

is afloat, the MEO should do rounds himself as a final check on watertight integrity.  In ARTEMIS there was no such organisation;

 the MEO was outside the submarine, and supervision below was left to the MEA (Hmself a stand-in) on the diving panel.

Note; although one stern gland had been re-packed, no Artificer or Mechanician inspected it until the submarine had been

 afloat for at least four hours.  It was left to an LMEM who happened to be doing greasing routines in the gland space.

While undocking, there was a leak on the after services from an open-ended pipe.  Jamming off all the hull valves 'more or less'

stopped the leak.  It would appear that the state of the hull valves was poor.

An efficient technical staff would have stopped the flooding up to inspect which valves were Leaking particularly as some sections of the

 piping are not

tested to full diving depth. It should be noted that at no time were the isolating valves to the open sea water pipe lashed shut

The chapter of undocking errors and omissions continued when the checking of the 719 Keel sonar set watertight chamber was left

to an Able Seaman,  The Engineer Officer only checked it after the submarine was afloat.

Note:  The 719 Sonar chamber balancing arrangements should be checked well before flooding up completes, to save the necessity to

dock down again after finding if anything is wrong.

On completion of the blowing round of numbers 1, 2, 3 and 5 Main Ballast Tanks mentioned, above, the Dock Master

remarked upon the submarine's light trim. His remark was accepted apparently without question by the Ships Officers, In fact, at this time

the draught was 15 ft., 9 ins. forward and 16 ft. 10 ins. aft -considerably more than when ARTEMIS had docked on Monday 28 June,

and the Ships Officers should have been in a position to know this and say so.  It is easy to see however, how relatively

 inexperienced officers might feel that the Dock Master would know more about the required Submarine Draught than

they, and allow themselves to be swayed by him  This is a risk inherent in the use of men to do jobs for which they are not

qualified-

Note; At this stage the Engineer Officer did not know with certainty either the docking OR undocking draught readings. Had

he checked them he must have concluded that ARTEMIS was already consider­ably heavier than when originally docked-

Unaware of the facts as he was. the Engineer Officer advised the Third Hand to flood No. 5 Main Ballast Tank to return the

boat to what he thought was the Docking trim,  The Third Hand accepted the Engineer Officer's advice without question,

and flood­ed No- 5 Main Ballast Tank.  The resultant trim/draught must now have been about 15 ft- 7^ ins- forward and 17 it.

2 ins- aft, though no precise check of it was made-

Note:     The Third Hand's acceptance of the Engin­eer Officer's advice without questioning the reasoning behind it illuminates just

how little qualified he was to be supervising the undocking operation, and the poor judgement inherent an the command decision to put

 him in that posi­tion,  The advice given him by the Engineer Officer, in the other hand was both superficial and careless.

One reason given subsequently by the Engineer Officer for flooding No, 5 Main Ballast Tank was that the Submarine General

Memorandum 1205 states the minimum mean draught for 'A! Class submarines should never be less than 15ft. 6 ins. 

As stated above, ARTEMIS must have been well inside this safety limit