EXPLOSION IN TURRET TWO
Investigation Continued

     White Oak and NWL Dahlgren to COMNAVORDSYSCOM command; return of ammunition procurement responsibility from COMNAVSUPSYSCOM to COMNAVORDSYSCOM; and so far as feasible pending other actions noted in subparagraph b. below, assignment to COMNAVORDSYSCOM of the inspection responsibility for contractor-procured gun ammunition components, with NAVORDSYSCOM inspection capabilities expanded accordingly.

b.     Initiate actions in appropriate Navy Department and OSD channels to return from DCAS to COMNAVORDSYSCOM the inspection responsibility for contractor-procured naval gun ammunition components, and to adjust staff and money to correspond.

c.      Initiate actions in appropriate Navy Department and fleet channels to establish technical control and direct liaison authority for COMNAVORDSYSCOM, with respect to all technical gun ammunition matters, for ammunition and ammunition facilities which are under fleet control.

69.           We recommend that COMNAVORDSYSCOM take or continue the following actions (of which we understand those in subparagraphs a, b, d, e, f, g, h, and l are already in process):

a.      Review, and modify as appropriate, his organization, to see that it gives him the direct staff support he needs to carry out his responsibilities for providing safe and effective gun ammunition to the fleet.  This recommendation applies with respect both to his present responsibilities, and to the broader span reflected in paragraph 68 above.

b.     Review, clarify, and strengthen as appropriate, all contracts and similar documents, assembly, and inspection of ammunition and components, with particular attention to all aspects involving safety for the fleet user.  The latter aspects should include, in particular, fuze safety features, projectile base sealing, and explosive filler gaps.  Ammunition-related agencies whose activities are to be covered by the documents here concerned include facilities under the command of COMNAVORDSYSCOM, as well as those now under other DOD agencies, and civilian contractors.

c.      In connection with subparagraph b. above, establish requirements for 100% inspection, at several successive phases of manufacture and assembly, of all ammunition features bearing on user safety; and further establish a planned follow-up on defects found, to determine accountability.

d.   Pending shift from DCAS to COMNAVORDSYSCOM of the responsibility for inspection of contractor-procured naval gun ammunition and components per paragraph 68, establish the interim requirement for 100% back-up inspection by X-ray, of all ADF Mks 54 and 55, and all BDF, to be done at naval ordnance facilities before the fuzes are assembled into projectiles.

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