by the Falcon; (7) by buoys made fast to the 4-inch descending line which was attached to the S-4; (8) by buoys made fast to the air hose which was connected to the ballast tank air salvage line of the S-4. DESCENDING LINE MISSING 131. When the Falcon moored over the wreck on Wednesday, all of the above buoys had been carried away by the gale, with the exception of one yellow can buoy, placed by the Wandank off the starboard quarter of the S-4, and the buoys attached to the air hose connected with the S-4. 132. In taking in the slack of the air hose it was found to be unattached, and when hauled on board it was found to have been chafed during the gale, so that it parted while the slack was being hauled in. 133. Soundings with the lead were made from the Falcon, and divers were immediately sent down and available boats gotten out to drag with grapnels, in order that a descending line might again be attached to the S-4. 134. One of the Falcon's boats hooked the S-4 with a grapnel at 5.30 p. m., Wednesday the 21st. 135. Divers were then sent down to make fast a descending line to some point over the torpedo room. CONNECTION OF SC TUBE 136. This being accomplished, divers were sent down to connect an air hose to the SC tube and this was completed at 10.05 p. m., when air was immediately forced into the torpedo room. 137. Air was successively vented from and forced into that compartment for the following 45 hours. 138. A second air hose was connected to the other branch of the SC tube and also used. 139. The first sample of air taken some time after the hose was connected to the SC tube, showed 7 per cent carbon dioxide content. After forcing air into and venting it from the compartment for 24 hours, the carbon dioxide content was reduced to one-half of 1 per cent. TUNNEL OPERATIONS 140. After the connections were made to the SC tubes, divers began to wash a tunnel under the S-4 at frame 20, for the purpose of passing chains under the S-4 for lifting the bow by pontoons. 141. Rescue operations were continued until 2 p. m., Saturday, December 24. SCENE GUARDED 142. From the time of the sinking of the S-4, at 3:37 December 17, the scene of the disaster has been continuously guarded. BODIES RECOVERED 143. When the divers, about two weeks after the date of the collision, entered the S-4, the bodies of 32 of the 40 persons who had been on board were found in the engine and motor rooms. None were found in the central operating compartment (control room). Six were known to be in the torpedo room, thus leaving two unaccounted for. The 32 bodies were all found in a recumbent position, stretched along the floor from the forward end of the engine room to the after end of the motor room. There were none found in the high parts of these compartments, such as on top of main engine cylinders, air compressors, or exhaust pipes. None of the bodies showed external marks of burns or other injury. 144. Post-mortem examinations were made on all and autopsies performed on eight of the bodies. Death in each case was held to have been caused by asphyxiation by immersion (drowning). 145. No written records were found within the S-4, nor on the bodies recovered therefrom, having any bearing on the cause of the accident or conditions within the S-4 subsequent to the accident. TIME OF DEATH 146. Six watches were found upon the bodies taken from the S-4. Three of them were run down. The first of the remaining three stopped at 2:17, having 18 hours more to run. The second stopped at 3:11, having run 32 hours and having 6 more to run. The third stopped at 3:50, having run 18 hours and having 18 hours more to run. All the watches that did not run down were stopped by the entrance of water into the cases. 147. Over two weeks after the sinking of the S-4 divers knocked out a bolt in the top of the engine room. Water immediately entered through the bolt hole with strong force, showing that the compartment was not flooded and that the pressure in the engine room was less than on the outside of the boat. 148. Examination of the S-4 thus far made by divers indicates that the ship was secured for normal submerged operation at periscope depth. The following conditions were found: HULL CONDITIONS INSIDE (1) The water-tight door between the battery room and the central operating compartment was closed but held by only three dogs loosely set up. (2) The two flap valves in the battery ventilation exhaust line, passing through the bulkhead between the battery room and the central operating compartment were both open; the voice tube valve on the after side of that bulkhead was partially closed; the small drain valve from the washbasin through this bulkhead was open. (3) The water-tight door in the bulkhead between the central operating compartment and engine room was closed with all dogs secured; all valves in this bulkhead were closed. (4) There is no indication of a rupture in the pressure hull of the central operating compartment. (5) The prompt and free escape of the divers' exhaust air from the battery room, when that compartment was entered by a diver, proves that the pressure hull is ruptured overhead in that compartment. HULL CONDITIONS OUTSIDE (6) The S-4 lies on the bottom on about an even keel, heading about 260° true. (7) The vertical rudder is about 15° left; the bow planes are approximately horizontal; the stern planes are about 15° rise (forward edges down). (8) The superstructure of the S-4 is carried away from just forward of the gun to frame 52; the extent of the rupture in the pressure hull has not yet been determined. (9) The periscopes were both partially lowered; the forward periscope is lowered to opposition where the eyepiece is about 9 inches below the deck in the periscope well; the after periscope is lowered to a position where the eyepiece is about 22 feet below the deck in the periscope well. AIR PURIFIERS 149. Under the title "Desirable alterations," the commanding officer of the S-4, under date of June 20, 1927, requested the following alterations be made: "Install air purifiers and complete arrangements for oxygen storage." In acting upon this request the Bureau of Construction and Repair stated that it was contemplated to accomplish this desirable alteration during the fiscal year beginning on the 1st of July, 1928. 150. The purpose of the air purifier installation is to circulate air through or over soda lime. The operation of the air purifier is dependent upon the circulation of air by electric blowers. SODA-LIME 151. The allowance list of the S-4 provides for 50 pounds of soda-lime for each man of the crew. 152. There was in store at the navy yard, Portsmouth, at the time of the departure of the S-4 from that yard, two days before the collision, soda-lime for issue upon the request of the commanding officer of any submarine. 153. No definite evidence could be obtained as to whether or not there was soda-lime on board the S-4 at the time of the collision. CHARACTERISTICS OF SODA LIME 154. Soda-lime is a mixture of the two alkalis popularly known as quicklime and caustic soda. 155. In the presence of carbon dioxide these alkalis break up that gas and are themselves converted into salts popularly known as bicarbonate of soda or cooking soda and carbonate of lime. 156. When these alkalis are thus converted into salts they become inert; and as salts are useless for purification of air. 157. Quick lime and caustic soda attack the skin, clothes, leather, and organic material. When placed in containers they are apt to corrode the containers and cause breakage. 158. The amount allowed the S-4 is about 2,000 pounds or about 10 barrels. In actual practice this amount is placed in 50 pounds metallic containers and distributed where possible. 159. The problem of stowing 10 barrels of soda-lime in a submarine has been constantly studied for many years and has not yet been satisfactorily solved. Its stowage means a sacrifice of living space, food supply or efficient machinery and affects the comfort of the crew. 160. The Bureau of Construction and Repair's Manual directs that if submergence is for a greater period than 17 hours, soda-lime purifications should be employed on vessels of the S class. 161. The most recent medical opinion holds that with 7 per cent of carbon dioxide in the air, human life can not be maintained in the average person; that until the per cent of CO2 can be markedly reduced below 7 per cent neither ordinary air nor oxygen added thereto will support human life. Moreover, that with the oxygen below 16 per cent the removal of the excess CO2 is valueless. 162. That the free air contained in the torpedo room would normally support life in six men from 65 to 72 hours, and in the engine and motor room would normally support life in 32 men for about 25 hours. OPINION COLLISION 1. The collision was caused by failure on the part of the S-4 to take proper action, after the Paulding had changed course to 94° true, to clear that vessel; and by failure on the part of the Paulding to sight and to recognize as a submarine the S-4 in time to take action necessary to clear her. 2. The cause of the failure of the U. S. S. S-4 to take proper action prior to the collision (when the destroyer was 75 yards away) can not be determined absolutely. 3. The cause lies with the commanding officer of the S-4, due either to his lack of vigilance; or to the quality of his observations while the Paulding was approaching from 2,000 yards to 75 yards, from which observations flowed an action which by an error of judgment (possibly as to the speed and distance of the Paulding) failed to insure the safety of the vessel. 4. The inefficient lookout on the Paulding, whereby the S-4 was not sighted until only 75 yards away, was due to the lack of a proper lookout solely charged with that duty, especially at a time when the Paulding was approaching at a high rate of speed the submarine trial course. 5. It is elemental in navigation and in good seamanship, and it has been repeatedly so held by the court, that a proper lookout must have no other duties than that of lookout and must be so stationed as to have an unobstructed view. 6. Under the weather conditions existing at the time of the collision the Paulding could and should have sighted the periscopes and the wake of the periscopes of the U. S. S. S-4 in ample time to have avoided the collision. 7. The actions taken by the commanding officer of the Paulding after sighting the U. S. S. S-4 were proper and correct; but at that time the collision was inevitable. 8. Standardization trials over the Provincetown course offered no unusual condition or hazard. A tender showing a submarine warning flag in the vicinity of the S-4 operating submerged on that course was neither desirable nor necessary. 9. The legend on the monthly pilot charts published by the Hydrographic Office of the Navy relative to submarine warning flags may be misleading. 10. The bodies of two men of the U. S. S. S-4 are still missing. Six others are believed to be in the torpedo room, and they probably lost their lives by exposure, lack of food and water, and asphyxiation by carbon dioxide. 11. The 32 men whose bodies were found in the engine and motor rooms were unconscious before 1.30 p. m., Sunday, December 18. 12. These 32 men probably died by asphyxiation from carbon dioxide; though it is possible that asphyxiation by immersion was a contributing cause in some cases. 13. The water had reached the floor plates of the engine room and motor room before 7.30 a. m., December 19. 14. The death of all the 40 men on board occurred in the line of duty and not as a result of their own misconduct. RESCUE 15. That prompt and appropriate action was taken— (a) By the commanding officer of the United States Coast Guard destroyer Paulding in reporting the collision to higher authority, in lowering a boat to save life if possible, and in marking the wreck. (b) By the Coast Guard officer and crew at Wood End Station in attempting to save life and to mark the wreck from 3.37 p. m., December 17, until 11 a. m., December 18, when the grapnel which they had hooked to the U. S. S. S-4 was turned over to the U. S. S. Falcon and diving operations begun by the Navy. 16. The commandant, first naval district, most expeditiously took all possible steps to assemble at the scene of the disaster rescue personnel and material. 17. The commandants of the third naval district, of the navy yard, Portsmouth, and of the submarine base at New London, and the commanding officer of the torpedo station, Newport, and the commander of the control force all dispatched with the greatest possible expedition all appropriate personnel and material available under their respective control to the scene of the disaster. 18. The Navy Department assembled at Provincetown in the shortest time possible all officers and men in the Navy best qualified in deep-sea rescue and salvage operations, including Mr. Ellsberg, the foremost expert in the United States and probably in the world on deep-sea rescue work, who had promptly volunteered his services. 19. The operations to rescue the crew of the U. S. submarine S-4 were logical, sound, and the most promising of early success. 20. No known devices or equipment not employed in the rescue operations, either in the Navy or owned by commercial organizations, could have saved the lives of those on board the S-4. 21. Everything was done to save the lives of those on board the S-4 that could have been done under the weather conditions that existed; but rescue under those conditions was beyond human power. 22. The continuous bad weather with rough seas and wind, gale force, which prevailed from 10 p. m., December 17, until 6 a. m., Wednesday the 21st, made diving first hazardous and then impossible, and consequently the crew of the S-4 could not be saved by any known external device. 23. The personnel of the U. S. submarine S-4, from some undetermined cause, were driven from the central operating compartment very shortly after the collision. They were, therefore, deprived of the use of practically all of the ship's facilities for raising the vessel themselves or for aiding in attempts at their rescue. 24. The air purifier requested by the commanding officer but not yet installed on the S-4 would have been of no avail, as the accident had rendered the power plant useless. 25. Though the court is not able to determine with certainty whether or not soda lime was used by the crew of the S-4, such use would not have saved any life, but might have prolonged the lives of some for a few hours The allowance list of the S-4 provides for 50 pounds of soda lime per man, and it is available for issue at the navy yard, Portsmouth, from which yard the S-4 departed but two days before the collision. Because of its strong corrosive effect and the difficulty of stowing it on submarines, mostly for emergencies, the value of such large quantities is considered by many submarine officers to be outweighed by its objectionable features. 26. The use of soda lime was developed as a war need where submarines went on a station or patrol and were forced to remain submerged for many hours for safety. By use of soda lime they could remain down several hours longer. Soda lime is primarily a war allowance; a rescue allowance is indeterminable. 27. Finally, the court is of the opinion that safety lies, and lies only, in the constant care and attention to minute details by officers in command of these boats and being in this duty ably supported by their crews. RESPONSIBILITY The court finds that the commanding officer of the U. S. S. S-4, the late Lieut. Commander R. K. Jones, United States Navy, and the commanding officer of the U. S. Coast Guard destroyer Paulding, Lieut. Commander John S. Baylis, United States Coast Guard, are jointly responsible for the collision between the Paulding and the S-4 and that serious blame was incurred by them. The court recommends that 1. In view of modern practice the submarine warning flag and legend now on Monthly Pilot Chart be omitted from future publication of that chart as misleading. 2. Trial courses used by submarines be plainly indicated on all charts and buoy lists of those areas with a warning to mariners to approach such trial courses with caution. 3. A conference be held by the Navy Department and the Treasury Department to consider the exchange of information concerning the movements of vessels under their respective control and to draw up any additional regulations deemed necessary or desirable. 4. A copy of the proceedings, findings, and recommendations of this court of inquiry be furnished the Secretary of the Treasury for his information and such action as he may deem appropriate. 5. A technical board be appointed to study the subject of rescue and salvage fittings, safety devices, and equipment and recommend such changes in or modifications of submarines, tenders, and rescue vessels as may be deemed advisable. 6. Rear Admiral Frank H. Brumby, United States Navy, has been in command of the control force, including all submarines in the Atlantic, since August 1, 1927, and was in command of the forces employed in rescue operations on the S-4 from December 18, 1927, until such operations were discontinued. Rear Admiral Frank H. Brumby's testimony before this court showed that he had not the familiarity with the essential details of construction of submarines and the knowledge of rescue vessels, and the knowledge of the actual work being carried on by his subordinates necessary to direct intelligently the important operations of which he was in charge. While the plans he approved, conceived by an expert staff of which Captain King was the senior, were logical, intelligent, and were diligently executed with good judgment and the greatest possible expedition, yet Rear Admiral Brumby failed to contribute that superior and intelligent guidance, force, and sound judgment expected from an officer of his length of service, experience, and position. The court therefore recommends that Rear Admiral Frank H. Brumby, United States Navy, be detached from the command of the control force. NAVY DEPARTMENT, Washington, D. C., February 6, 1928. Present: Rear Admiral R. H. Jackson, United States Navy; Rear Admiral Julien L. Latimer, United States Navy; Capt. Joseph V. Ogan, United States Navy, members; and Commander Leslie E. Bratton, United States Navy, judge advocate. The record of the proceeding of the fourteenth day of the inquiry was read and approved, and the court having finished the inquiry, then at 5 p. m., adjourned to await the action of the convening authority. R. H. JACKSON, Rear Admiral, United States Navy, President. LESLIE E. BRATTON, Commander, United States Navy, Judge Advocate. 104672-28- -5 |