San Antonio Findings

(b)(6)
(b)(6)
(b)(6)
(b)(6)
(b)(6)
(b)(6)
(b)(6)
(b)(6)
(b)(6)
(b)(6)
(b)(6)
(b)(6)
Subj: COMMAND INVESTIGATION OF DIESEL ENGINE AND RELATED
MAINTENANCE AND QUALITY ASSURANCE ISSUES ABOARD USS SAN
ANTONIO (LPD 17)
(31) (b)(6) Summary of Interview

(32) NR 1B MPDE Photos
(33) Work Item 233-11-001, Reservation Task Request 33
(34) SAN ANTONIO Engineering Log of Nov 09
(35) NR 2A MPDE Summary of Inspection
(36) NR 2A MPDE Photos
(37) MARMC Lab Rpt #2009NN03572 of 4 Dec 09
(38) MARMC Lab Rpt #2010NN00038 of 7 Jan 10
(39) MARMC Lab Rpt #2009NN03466 of 23 Nov 09
(40) MPDE Lube Oil Wetted Parts List
(41) LO Service System Description and Diagram
(42) (b)(6) E-mail of 10 Nov 09
(43) LO Piping Material Specification
(44) LO Pump Parts List
(45) LO System Valve Assembly
(46) LO Service System 6 Inch Valve Diagram
(47) LO Service System H Valve Diagram
(48) S9233-DL-010
(49) MRC 2331 W-1R
(50) Investigator Notes (CoS)(3M Program Review)
(51) Maintenance Bucket Pictures
(52) SAN ANTONIO LO Log Aug 09
(53) SAN ANTONIO Engineering Log of Sep 09
(54) SAN ANTONIO LO Log Sep 09
(55) SAN ANTONIO LO Log Oct 09
(56) SAN ANTONIO LO Log Nov 09
(57) (b)(6) memo 5830 of 14 Jan 10 (Muslin Bag)
(58) Muslin Bag LO Flush Photos
(59) LO Flush Manual
(60) NSTM 233
(61) CLARUS Reports
(63) Fairbanks Morse Condition Reports
(64) (b)(6) memo 5830 of 14 Jan 10 (Bearing
Inspection)
(65) Bearing Damage Photos
(66) (b)(6) E-mail of 15 Jan 10
(67) JFMM Volume IV Chapter 4
(68) (b)(6) memo 5830 of 17 Dec 09 (MPDE Material
History Logs)
(69) EM01 Quarterly Schedule
(70) MRC Card 2640 M-2
(71) MRC 2331 18M-12R
(72) EM02 Quarterly PMS Schedule
(73) MRC 2331 R-12W
FOR OFFICIAL USE ONLY

ANTONIO (LPD 17)
(74) (b)(6) memo 5830 of 17 Dec 09 (3M Program)

(75) MRC 2331 R-13W
(76) MRC 2331 R-14M
(77) MRC 2331 U-35
(78) MRC 2620 U-1
(79) MRC 2620 U-3
(80) (b)(6) memo 5830 of 15 Jan 10 (LOQM)
(81) SAN ANTONIO SAMM Oil Sample DB 6 Dec 09
(82) EOCC Procedures
(83) (b)(6) memo 5830 of 15 Jan 10 (Eng Dept Trng)
(84) Investigator Notes (CoS) (Training Program Review)
(85) (b)(6) E-mail of 22 Dec 09
(86) (b)(6) E-mail of 29 Dec 09
(90) ECS PP Brief
(91) (b)(6) E-mail 13 Oct 06
(92) PRESINSURV NORFOLK VA 132000Z Apr 07
(93) PRESINSURV NORFOLK VA 061500Z Dec 07
(94) CASREP 07075 08099 Summary
(95) (b)(6) e-mail of 16 Nov 07
(96) CRO Predeployment PowerPoint of Aug 08
(97) LPD 17 Deployment Status Report 27 Nov 08 to 12 Dec
08
(98) (b)(6) ail of 15 Dec 08
(99) (b)(6) E-mail of 12 Oct 06
(100) (b)(6) E-mail of 22 Oct 06
(101) Post FOA Support PowerPoint
(102) (b)(6) e-mail 5 Sep 07
(103) SAN ANTONIO TSO List
(104) (b)(6) E-mail of 5 Jan 10
(105) (b)(6) E-mail 8 Jan 10
(106) NAVSEA Philadelphia Code 911 LPD 17 Class ICAS
Status Update
(107) ICAS PP Brief
(108) (b)(6) memo 5830 of 15 Jan 10
(109) LPD 17 Class NTSP 1 Jul 09 (Final-Approved)
(110) Letter of Promulgation for the Management
Responsibilities
(111) LPD Training POM 12 PP Brief
(112) PSMD LPD 17 6 Jan 04
(113) PSMD LPD 17 Change One 25 Feb 05
(114) PSMD LPD 17 Change Two 9 Apr 07
(115) (b)(6) E-mail of 11 Jan 10

ANTONIO (LPD 17)
(116) PEO Washington DC 301804Z Mar 09 LPD 17 Class FY09

Interim Training Plan for Main Propulsion
(117) PEO Washington DC 171810Z Oct 09 LPD 17 Class FY10
Interim Training Plan for Main Propulsion
(118) LPD 17 Class MPDE-SSDG-ECS Interim Training PP
(119) (b)(6) E-mail of 18 Dec 09
(120) EOOW PQS NAVEDTRA 43104
(121) Engineering Collaterals and Qualifications PQS
NAVEDTRA 43704
(122) CO, USS SAN ANTONIO (LPD 17) ltr 5100 Ser 00 of 26
Mar 08
Jun 09
Sep 09
PRELIMINARY STATEMENT
1. Pursuant to enclosure (1), and in accordance with reference

(a), I conducted a command investigation into the facts and
circumstances surrounding the discovery of metal shavings on the
oil side of three of four of USS SAN ANTONIO (LPD 17) Main
Propulsion Diesel Engines (MPDE) and a review of the maintenance
performance and quality control efforts by shipyard facilities,
intermediate maintenance activities, and SAN ANTONIO. Enclosure
(2), a list of relevant acronyms and abbreviations, is included
to assist in a review of the investigation.
2. Executive Summary
a. Metal Shavings
(1) In October 2008, MARMC/NNSY voyage repair team

conducted significant repairs to the MPDE lube oil service
system piping onboard SAN ANTONIO due to failure of several
welded joints. The repair included a partial use of carbon
steel piping. Starting June 2009 during CNO PMA, NNSY conducted
permanent repairs of the piping that included the replacement of
approximately 80% of the existing external lube oil service
piping with new 300 series stainless steel piping. After the
completion of the piping repairs, CLARUS using the NAVSEA
procedure conducted a flush of the piping. However, as designed
the flushing procedure was inadequate to completely remove
contaminants from the lube oil service system.

ANTONIO (LPD 17)
(2) In November and December 2009, NSSA Diesel

Inspectors and SAN ANTONIO personnel discovered foreign matter
in the lube oil service system for NR 1A, 1B, and 2A MPDE. The
foreign matter included 300 series stainless steel. The
probable source of the 300 series stainless steel found in NR
1A, 1B, and 2A MPDE lube oil service systems was the byproducts
of the production and installation of stainless steel lube oil
service system piping. The cause of the stainless steel was
potentially the result of poor weld joint fit up during new
construction that created contaminate traps that could allow for
an intermittent release of contaminates.
(3) In November 2009, NSSA determined that depot level

maintenance was required to address excessive crankshaft main
bearing and thrust bearing wear in 1A MPDE, 1B MPDE, and 2A
MPDE. This bearing damage is the primary component of MPDE
corrective maintenance since completion of the PMA in October
2009. This damage is not related to the metal shavings found in
the MPDE lube oil service systems. Bearing failure root cause
is lube oil contamination that occurred during the Shipbuilding
process to include all repairs and maintenance prior to the PMA.
Total estimated cost of this additional MPDE corrective
maintenance is $7.5M. The operational impact is such that
repairs may preclude SAN ANTONIO executing her next scheduled
deployment.
(4) An alternate means of contamination causing bearing

damage based on technical evaluation of bearing failures on LPD
17 and LPD 21 has been proposed by NAVSEA during a recent video
teleconference with Fleet Forces Command, Second Fleet,
Commander Naval Surfaces Forces Atlantic and Expeditionary
Strike Group Two on 8 January. This hypothesis suggests that
the lube oil contaminates that are circulated back to the MPDE
sump via the self-cleaning pre-filter are continuously reduced
in physical size by the macerating action of the lube oil
service pumps until the contaminates are small enough to pass
through the filter and duplex strainers. Contaminates that pass
through the filter and strainer complex could still be large
enough to cause bearing damage. NAVSEA is considering an
emergent alteration to eliminate this mechanism of contaminate
introduction into the diesel complex by filtering out
contamination discharged by the filter back to the sump.
(5) Ship’s Force was slow to recognize lube oil

contamination for a variety of long term issues. Command

ANTONIO (LPD 17)
leadership failed to effectively execute basic engineering

program, specifically the Lube Oil Quality Management Program,
which was determined to be ineffective.
c. LPD 17 Engineering Systems
(1) SAN ANTONIO was designed to be manned and operated

presuming that all automated control and monitoring systems were
properly operating.
(2) With ECS, ICAS, and SAMMS not functioning as

designed, the ship was unable to effectively operate and
maintain the engineering plant.
2. Evidence
a. The Investigating Officer collected all reasonably

available evidence in order to complete this investigation.
b. All documentary evidence included herein, is hereby

certified to be a true copy that is a true and accurate
representation of the original document.
c. During the course of this investigation, the

Investigating Officer and participating members performed the
following:
(1) An audit of all Norfolk Naval Shipyard (NNSY)

production work on the MPDEs,
(2) An audit of contracted depot level work completed

during the CNO PMA by a local Master Ship Repair (MSR) company
and associated subcontractors to determine if pre or post flush
production work could have contaminated the MPDE lube oil
systems,
(3) Interviews with appropriate Norfolk Ship Support

Activity (NSSA) PMA project team personnel and on scene Diesel
Inspectors,
(4) A technical evaluation of the adequacy and execution

of the MPDE flush procedure,
(5) An external and internal evaluation of ship's force

maintenance, operational procedures and training. This
evaluation focused on the ability of ship's force to operate,
monitor and maintain MPDE lube oil and associated systems. This
was done in part to determine the likelihood that ship's force
introduced contamination or was slow to recognize if lube oil
quality was jeopardized,
6

ANTONIO (LPD 17)
(6) An external review to validate if Sailor/Officer

training and NAVSEA conditioned based maintenance reach back
systems were in place to support the lead ship of a new class
that had a crew that was "right sized" with these external
assumptions in place,
(7) A review of the automated systems designed to support

shipboard operations including the Engineering Control System
(ECS), Integrated Condition Assessment System (ICAS) and Total
Ship Training System (TSTS) was conducted to evaluate the
effectiveness of these systems to support ship's force's ability
to operate the propulsion plant per the current ship's manning
documents,
(8) An audit by using the appropriate Technical Work

Documents (TWD) and associated Objective Quality Evidence (OQE)
against Joint Fleet Maintenance Manual (JFMM), NAVSEA Standard
Items, Specification Items, and other appropriate technical
guidance to assess Depot and MSR corrective maintenance
performance,
(9) A review of ship's force corrective and preventive

maintenance by examining preventive maintenance scheduling and
execution,
(10) Oral interviews with the chain of command,
(11) A review of NAVSEA technical documentation

describing how SAN ANTONIO class ships are to manned, trained and
provided external support was reviewed to determine completeness
and effectiveness of execution,
(12) A briefing from NAVSEA representatives on the

Engineering Control System (ECS) and Integrated Condition
Assessment System (ICAS), and
(13) A review of the syllabus for training provided by

Surface Warfare Officer School (SWOS) to prospective SAN ANTONIO
class Commanding Officers, Executive Officers and Chief
Engineers.
4. The Investigating Officer has the following prior

engineering/maintenance experience: USS HUNLEY (AS 31) Planning
and Estimating Officer (12 months), Repair Duty Officer (12
months), and Auxiliaries Officer (11 months); USS LEXINGTON (AVT
16) Main Engines Officer (19 months); Steam Engineering Officer
of the Watch (EOOW) Instructor and Course Coordinator (30

ANTONIO (LPD 17)
months); and USS MOUNT HOOD (AE 32), Chief Engineer (CHENG) (20
months).
5. The following personnel assisted in the conduct of the

investigation (prior engineering/maintenance experience listed):
a. (b)(6) Chief of Staff, Expeditionary

Strike Group TWO: BS Mechanical Engineering, University of
Wisconsin 1983; MA Systems Engineering, Naval Postgraduate
School 1991; Nuclear Power School 1984; Nuclear Power Training
Unit, Idaho Falls (A1W Prototype) 1985; USS LONG BEACH (CGN 9),
Number Two Engine Room Division Officer (36 months); USS
ARKANSAS (CGN 41), Main Propulsion Assistant (MPA) (16 months);
USS TRUXTUN (CGN 35), CHENG (22 months); Atlantic Fleet Nuclear
Propulsion Examination Team (NPEB), Junior Team Member (28
months); and USS EISENHOWER (CVN 69) Reactor Officer (28
months).
b. (b)(6) N4, Expeditionary Strike Group

TWO: USS SCOTT (DDG 995), MPA (30 months); USS CHINOOK (PC 9),
CHENG (36 months); Mk 5 Special Operations Craft, Officer in
Charge/Assistant Officer in Charge (38 months); USS KEARSARGE
(LHD 3), MPA (24 months); USS WASP (LHD 1), CHENG (18 months);
and Auxiliary Floating Dry Dock Dynamic, Commanding Officer (23
months).
c. (b)(6) N43, Naval Surface Force

Atlantic: USS NASSAU (LHA 4), Assault Officer (24 months),
Auxiliaries Officer (18 months), and Repair Officer (six
months); Afloat Training Group, Atlantic, Training Liaison
Officer (24 months); and USS OAK HILL (LSD 51), CHENG (13
months).
d. (b)(6) Engineering Support,

Expeditionary Strike Group TWO: OAK HILL, Electrical Officer (28
months).
e. (b)(6) Engineering Support,

Expeditionary Strike Group TWO: NASSAU, Electrical Officer (17
months).
f. (b)(6) Diesel Engine Inspector

(Code 216.5) Diesel Engine Inspector, Norfolk Naval Shipyard:
USS MESA VERDE (LPD 19), Top Snipe (24 months); USS SAN ANTONIO,
Pre-Commissioning Unit (PCU) for MESA VERDE (six months); USS

ANTONIO (LPD 17)
NEW ORLEANS, PCU for MESA VERDE (six months); USS CARTER HALL
(LSD 50), PCU for MESA VERDE; OAK HILL, M-Division Leading Chief
Petty Officer (eight months); and HSV-X-1, Lead Engineman (12
months).
g. (b)(6) Maintenance and Material

Management System Chief Petty Officer, Amphibious Squadron SIX:
USS REID (FFG-30) (36 months); USS MCKEE (AS-41) (24 months);
and USS CORMORANT (MHC 57), EA01 Leading Petty Officer (48
months).
h. (b)(6) , Norfolk Ship Support Activity (NSSA):

Merchant Marine Officer (9yrs)– U.S Coast Guard licensed
Engineering Officer on medium speed diesel powered ships; U.S.
Navy Port Engineer (12 years) – DDG Class/CG Class Class
maintenance management; NSSA LSD/LPD Class Team Leader (three
years) – Managed RMC Waterfront Operations Department LSD/LPD
4/LPD 17 Class Maintenance Teams; NSSA CVN/Amphibious Ship
Division Manager (one year) - Principal Waterfront Operations
Department advisor in matters relating to CVN and amphibious
ship maintenance.
i. (b)(6) , Code 212.5, Nondestructive

Testing Level III, Quality Assurance Supervisor, NSSA: Retired
HTC; engineering plant operator/watch stander (MMOW) (four
years); ship/submarine maintenance, repair and quality assurance
(22 years); and contractor oversight (seven years).
j. (b)(6) Quality Assurance

Specialist with Code 212.5, Norfolk Naval Shipyard Engineering
and Technical Fleet Support Department: Retired HTC; NAVSEA
certified NDT Level II Inspector (22 years); and NAVSEA
certified NDT Level III Examiner (eight years).
k. (b)(6) Project Team Leader, Norfolk Naval

Shipyard (NNSY), USS BATAAN (LHD 5): prior experience as
Supervisory Assistant Project Superintendent: SAN ANTONIO, WASP,
USS NASSAU, and USS GEORGE WASHINGTON (CVN 73); NNSY Production
Department (30 years).
6. (b)(6) Expeditionary Strike

Group TWO, and (b)(6) Expeditionary Strike
Group TWO provided administrative support in the course of this
investigation.

ANTONIO (LPD 17)
7. (b)(6) provided legal

guidance in the course of this investigation.
FINDINGS OF FACT
Metal Shavings Discovery and Causation

Introduction
1. During a deployment to Fifth Fleet Area of Operations
between 9 October and 25 October 2008, SAN ANTONIO suffered
repetitive weld joint failures in the MPDE lube oil service
system piping. [Encls. 3, 4, 5)]
2. The weld joint failures were a result of poor weld

techniques. [Encls. (5, 6)]
3. The poor weld techniques during new construction caused

excessive oxidation and stainless steel globules inside the lube
oil service system piping. [Encl. (6)]
4. The poor weld joint fit up during new construction created

traps. [Encls. (5, 6)]
5. From 2 to 23 November 2008, MARMC/NNSY voyage repair team

conducted repairs on the lube oil piping inport Bahrain. [Encls.
(3, 4)]
6. The repair included piping replacement using 304 stainless

steel and carbon steel piping. [Encls. (3, 4)]
7. The repairs did not include a flush of the lube oil system.
[Encls. (3, 4)]
8. Upon completion of repairs, the lube oil service system

serving each engine was operated in normal configuration. [Encl.
(7)]
9. Ships force continued to monitor lube oil duplex strainer

content until the baskets were clear of foreign material and
particulate. [Encl. (7)]
10. On 27 March 2009, SAN ANTONIO returned from the deployment.

[Encl. (8)]
10

ANTONIO (LPD 17)
11. On 17 June 2009, SAN ANTONIO began a Chief of Naval

Operations Planned Maintenance Availability (CNO PMA). [Encl.
(8)]
12. During the CNO PMA, NNSY replaced approximately 80% of the
existing external lube oil service system piping serving all
four MPDEs with new 300 series stainless steel piping. [Encls.
(9-15)]
13. After completion of the lube oil service system piping

repairs, a flush of the lube oil system occurred. [Encl. (9)]
14. During the CNO PMA, contract personnel conducted the

following MPDE repairs: NR 2A1 lube oil service pump, NR 1A and
NR 1B MPDEs valve cover software replacement, NR 1B MPDE
crankcase fan oil seal, and NR 2A MPDE low pressure air line
line. [Encl. (9)]
15. On 2 October 2009, SAN ANTONIO completed a light off

assessment (LOA). [Encl. (8)]
16. On 7 October 2009, SAN ANTONIO conducted sea trials.

[Encl. (8)]
NR 1A MPDE Foreign Matter Discovery Timeline

17. On 29 July 2009, work started to replace NR 1A MPDE
cylinder head (16 total) valve cover gaskets and software
crankcase in accordance with NSTM S9233-DL-MMM-020 (Chapter 7)
and NSTM S9233-DL-MMM-010. [Encl. (16)]
18. On 19 August 2009, (b)(6) CHENG, closed out NR 1A MPDE

lube oil sump. [Encl. (17)]
19. On 11 September 2009, work completed to replace NR 1A MPDE

20. If normal cleanliness standards are adhered to during the

execution of the work, a comprehensive lube oil service system
flush is not required. [Encl. (18, 19)]
21. Normal cleanliness standards were met prior to commencement

of production work. [Encl. (20)]
11

ANTONIO (LPD 17)
22. On 7 October 2009 at 1903 while operating, NR 1A MPDE

suffered an engineering casualty: unusual noise and vibration
on NR 9 cylinder. [Encl. (21)]
23. On 7 October 2009 at 1955, a lube oil casualty sample was

taken from NR 1A MPDE. [Encl. (21)]
24. On 14 October 2009, CASREP submitted on NR 1A MPDE

regarding loud metallic noise. [Encl. (22)]
25. The CASREP indicated no unusual conditions were noted on NR

9 cylinder. [Encl. (22)]
26. On 21 October 2009, CASCOR submitted on NR 1A MPDE

regarding loud metallic noise. [Encl. (22)]
27. On 22 November 2009, Naval Surface Warfare Center Carderock

Division-Ship Systems Engineering Station Philadelphia (NSWCCD-
SSES Philly) reported abnormal wear levels in NR 1A MPDE based
on a lube oil sample submitted on 7 October 2009. [Encl. (23)]
28. Due to the abnormal wear levels, NSWCCD-SSES Philly

recommended an inspection of NR 1A MPDE. [Encl. (23)]
29. On 25 November 2009, the Commanding Officer, SAN ANTONIO,

requested (b)(6) Port Engineer, and (b)(6) , CHENG,
consult with (b)(6) NSWCCD-SSES Philly, for MPDE
inspection recommendations. [Encl. (23)]
30. On 25 November 2009, (b)(6) requested (b)(6)

(b)(6) and (b)(6)Norfolk Naval
Shipyard Diesel Inspectors, provide inspection recommendations.
[Encl. (23)]
31. On 25 November 2009, (b)(6) conducted the inspection

of the lube oil service system and an inspection of NR 1A MPDE.
[Encls. (23-25)]
32. During the inspection of NR 1A MPDE, the engine remained

static and was not barred over. [Encl. (25)]
33. The inspection of NR 1A MPDE included a visual inspection

of cam bearing and journals, and rod bearing and journals, and
main bearing and journals. [Encl. (25)]
12

ANTONIO (LPD 17)
34. The online strainer exhibited no particulates. [Encls.

(25, 26)]
35. The off-line strainer exhibited ferrous particulate (fine)

on the magnet that if accumulated would be less than 1% of the
magnet cylinder surface. [Encls. (25, 26)]
36. The back-flushing filter exhibited particulate: metal

shavings, paint chips, gasket material, fine debris located in
remnants of fibrous material in 20 candles of 66. [Encls. (25,
26)]
37. The cam covers accesses exhibited no debris or

particulates. [Encls. (25, 26)]
38. The dry sump exhibited no solid material. [Encl. (25)]
39. In the dry sump, there was free water standing in the oil.
[Encl. (25)]
40. (b)(6) recommended the wet sump be pumped out and

certified gas free for further inspection. [Encl. (25)]
41. On 1 December 2009, wet sump cleaned and gas freed. [Encls.
(25)]
42. During the initial visual inspection of the wet sump, the
wet sump exhibited a higher than expected amount of babbitt
material. [Encl. (25)]
43. In the wet sump, there was free water standing in the
residual oil. [Encl. (25)]
44. On 15 December 2009, on-line and off-line Rocker Duplex

Strainers removed by Ships Force and inspected by DEI (b)(6)
(b)(6) . [Encl. (24)]
45. On-line and Off-line Rocker Strainers exhibited free water,

dirt, and paint chips (white, terracotta, and yellow). [Encl.
(24)]
46. Rocker Sump opened by Ships Force and inspected by DEI

(b)(6) [Encl. (24)]
13

ANTONIO (LPD 17)
47. Rocker Sump exhibited free water, dirt, and paint chips.
[Encl. (24)]
NR 1B MPDE Foreign Matter Discovery Timeline

48. On 21 July 2009, work tasked to repair NR 1B MPDE crankcase
fan oil seal. This repair had an estimated start date of 27
July 2009 and was signed complete on 25 August 2009. [Encl.
(27)]
49. On 27 July 2009, work started to repair NR 1B MPDE

crankcase fan oil seal. [Encl. (27)]
50. On 29 July 2009, work started to replace NR 1B MPDE cylinder

head (16 total) valve cover gaskets and software crankcase in
accordance with NSTM S9233-DL-MMM-020 (Chapter 7) and NSTM
S9233-DL-MMM-010. [Encl. (28)]
51. On 25 August 2009, work completed on NR 1B MPDE crankcase

fan oil seal. [Encl. (27)]
52. On 26 August 2009 at 1140, (b)(6) Chief Engineer,

closed out NR 1B MPDE lube oil sump. [Encl. (17)]
53. On 11 September 2009, work completed to replace NR 1B MPDE

54. If normal cleanliness standards are adhered to during the

execution of the work, a comprehensive lube oil service system
flush is not required. [Encl. (18, 19)]
55. Work would not have commenced prior to cleanliness

standards being met. [Encls. (29-31)]
56. On 7 October 2009 at 1010 while operating NR 1B MPDE, NR 1B

MPDE suffered an engineering casualty: hot bearing on NR5 main
bearing (172 degrees F). [Encl. (21)]
57. The hot bearing was a 21 degree spread from the next
highest bearing temperature. [Encl. (21)]
58. On 7 October 2009 at 1010, NR 5 main bearing (172 degrees

F) was 21 degrees F higher than the next highest bearing
temperature. [Encl. (21)]
14

ANTONIO (LPD 17)
59. On 1 December 2009, filter removed for NR 1B MPDE due to

issues with NR 1A and 2A MPDE. [Encl. (24)]
60. Lube oil results for NR 1B had been satisfactory (did not
indicate need to conduct inspection). [Encl. (24)]
61. Filter element removed. Set on work bench. Amount of

babbitt material on filter and filter candles. Had fibrous
material as well. No further inspection. [Encl. (24)]
62. On 15 December 2009, on-line and off-line strainers were

removed by ships force and inspected by DEI (b)(6) [Encl.
(24)]
63. On-line strainer exhibited fine ferrous particulate on the

magnet, accumulated debris did not exceed the circumference of a
dime. [Encls. (24, 32)]
64. Off-line strainer exhibited fine ferrous particulate on the

magnet, accumulated debris did not exceed the circumference of a
dime. [Encls. (24, 32)]
65. On 15 December 2009, on-line and off-line Rocker Duplex

Strainers removed by Ships Force and inspected by DEI (b)(6)
(b)(6) [Encl. (24)]
66. On-line and Off-line Rocker Strainers exhibited dirt,

gasket material, paint chips and free water. [Encls. (24, 32)]
67. Rocker Sump opened by Ships Force and inspected by DEI

(b)(6) [Encl. (24)]
68. Rocker Sump exhibited free water, dirt, and paint chips.
Sump bottom was coated with a large amount of fine bronze
material and non-ferrous matter similar to babbitt. [Encls. (24,
32)]
69. On 16 December 2009, 1B MPDE lube oil sump pumped, 600

gallons of lube oil remained at the pump end of the sump. [Encl.
(24)]
70. On 17 December 2009, 1B MPDE lube oil sump opened for

inspection. [Encl. (24)]
15

ANTONIO (LPD 17)
71. At the sump cover opening ferrous particulate, paint chips,

dirt and carbon were immediately visualized before entering the
sump. [Encls. (24, 32)]
72. The DEI hand skimmed the oil layer at the sump cover
opening; this revealed fine particulate (bronze in color), non
ferrous particulate resembling babbit. [Encls. (24, 32)]
NR 2A MPDE Foreign Matter Discovery Timeline

73. On 22 July 2009, work tasked to replace NR 2A MPDE low
pressure air line serving the engine barring gear (turning
gear). [Encl. (33)]
74. On 25 July 2009, work started and completed to replace NR

2A MPDE low pressure air lube oil line serving the engine
barring gear (turning gear). [Encl. (33)]
75. The low pressure air line consisted of 3/8 inch stainless
steel tube. [Encl. (33)]
76. On 13 August 2009, (b)(6) , Chief Engineer, closed out NR

2A MPDE lube oil sump. [Encl. (17)]
77. On 14 August 2009 at 1815, NR 2A MPDE lube oil strainer

check point complete by Engineering Duty Officer in preparation
for engine flush. [Encl. (17)]
78. On 6 October 2009 at 0750, NR 2A MPDE emergency stopped due

to NR 8 hot bearing. [Encl. (21)]
79. On 6 October 2009 at 0822, casualty sample taken for NR 2A

MPDE. [Encl. (21)]
80. On 6 October 2009 at 1210 NR 2A MPDE lube oil strainer

opened and inspected SAT. [Encl. (21)]
81. On 6 October 2009 at 1250, NR 2A MPDE lube oil service

system duplex strainer tested satisfactory. [Encl. (21)]
82. On 6 October 2009 at 1315, DEI, (b)(6) and (b)(6)

verified positive lube oil flow on NR 2A MPDE NR 8 bearing.
[Encl. (21)]
83. On 6 October 2009 at 1734, bearing inspection on NR 2A MPDE

NR8 bearing revealed no apparent damage. [Encl. (21)]
16

ANTONIO (LPD 17)
84. DEI, (b)(6) and the CHENG closed out NR 8 bearing.

[Encl. (21)]
85. On 2 November 2009 at 1043, NR 2A MPDE stopped due to hot

bearing casualty. [Encl. (34)]
86. On 2 November 2009 at 1102, casualty sample drawn on NR 2A

MPDE NR 2 bearing. [Encl. (34)]
87. On 2 November 2009 at 1154, Diesel Engine Inspector (b)(6)

(b)(6), CHENG, and (b)(6) inspected NR 2A MPDE NR 1 and
NR 2 main bearing. [Encl. (35)]
88. SAN ANTONIO personnel and (b)(6) found a quarter of

an inch ferrous metal sliver and several non-ferrous particles.
[Encls. (35, 36)]
89. On 2 November 2009, NR 2A MPDE lube oil service system

tagged out for inspection of strainer and back-flushing filter.
[Encls. (35, 36)]
90. The strainer candles were dislodged. [Encl. (35)]
91. The strainer exhibited ferrous particulate (fine) on the

magnet that if accumulated would be not exceed the area of a
dime. [Encls. (35, 36)]
92. The back-flushing filter exhibited ferrous and non-ferrous

over 75% of the candles. [Encl. (35)]
93. The ferrous particles exhibited on the back-flushing filter

measured under one half inch when stretched. [Encls. (35, 36)]
Identification of Foreign Matter

NR 1A MPDE
94. The foreign debris removed from NR 1A MPDE sump included
organic and metallic materials. [Encl. (37)]
95. The organic materials consisted of items similar to paint,

textile floor coverings, synthetic polymer Nylon, rubber,
hydraulic oil, Kevlar, glass fibers, hair, polypropylene, and
cellulose fibers. [Encl. (37)]
96. The metallic materials consisted of material similar to a

300 Series Stainless Steel alloy. [Encl. (37)]
17

ANTONIO (LPD 17)
97. Three of the metallic samples provided appear to be from a

machining operation. [Encl. (37)]
98. For comparison MARMC personnel analyzed known standards of

304 Series Stainless Steel, 316 Series Stainless Steel, 321
Series Stainless Steel, and 347 Series Stainless Steel alloys.
[Encl. (37)]
99. MARMC personnel cannot identify the precise composition of

the metallic materials due to possible contamination. [Encl.
(37)]
NR 1B MPDE
100. The debris removed from NR 1B MPDE are consistent with
carbon steel of undetermined origin, and 300 Series Stainless
Steel alloys from a machining operation. [Encl. (38)]
NR 2A MPDE
101. The metallic debris removed from NR 2A MPDE lube oil
service system back-flushing filter consisted of a material
similar to a 300 Series Stainless Steel alloy from a machining
operation. [Encl. (39)]
Internal Source of the Foreign Matter

MPDE
102. There are no parts of the MPDE wetted by lube oil that
contain stainless steel. [Encl. (40)]
LO Service System
103. Each MPDE has its own lube oil sump, lube oil service
pumps, self-cleaning filter, heat exchanger and duplex strainer.
Lube oil is drawn from the sump via the installed positive
displacement lube oil pumps. [Encl. (41)]
104. Lube oil discharged from the lube oil service pumps enters
a self-cleaning filter. [Encl. (41)]
105. The self-cleaning filter filtration is 30 micron absolute

and is equipped with an external (15PSID) and internal (29PSID)
bypass that ensures the MPDE is not starved for oil if a high
differential pressure condition occurs in the filter. [Encl.
(421)]
106. The external bypass valve has been recently directed by

appropriate technical authority to be disabled via a blank
18

ANTONIO (LPD 17)
flange to prevent contaminates bypassing the filter. [Encl.

(41)]
107. The filter has a rotating set of internal elements that

alternately filter the lube oil when in service. [Encl. (41)]
108. When the internal elements are not in service, they are
flushed with lube oil discharged from the lube oil service
pumps. [Encl. (41)]
109. The filter effluent is discharged directly back to the

sump, which results in the total mass of contaminates remaining
constant in the MPDE sump. [Encl. (6, 41)]
110. The filtered lube oil discharged from the self-cleaning

filter flows through a heat exchanger, header pressure
regulating valve, a duplex strainer (55 micron absolute), and
then into the diesel complex where the lube oil is ultimately
discharged into the MPDE lube oil sump. [Encl. (41)]
111. The attached transfer pump and purifier bowl assembly of

the lube oil purifier come into contact with the lube oil.
[Encl. (42)]
112. The transfer pump has carbon steel rotors and a bronze
housing. [Encl. (42)]
113. The purifier bowl is made of a special stainless steel

alloy. [Encl. (42)]
114. The paring disc is made of 316 Series Stainless Steel.

[Encl. (42)]
115. If the paring disc and purifier bowl come into contact,
this would cause noticeable sound and vibration. [Encl. (42)]
116. Any contact will be evident on the paring disc top and
bottom surfaces. [Encl. (42)]
117. The lube oil piping system contains 304 Series Stainless
Steel, 316 Series Stainless Steel alloy and Carbon Steel (from
voyage repair). [Encl. (43)]
19

ANTONIO (LPD 17)
118. MPDE lube oil service pump special washers used to fasten
the pump casing to its suction inlet bell and mechanical seal
cover assembly are made from stainless steel. [Encl. (44)]
119. MPDE lube oil service pump special washers do not come in
contact with lube oil during the normal operation of the lube
oil service system. [Encl. (44)]
120. The valves in the lube oil service system do not contain
stainless steel. [Encls. (45-47)]
MPDE Bearings
121. The MPDE bearings consist of a steel backing, top layer
tin overlay, babbit, and copper. [Encl. (48)]
Internal Cause of Foreign Matter Introduction Into the LO System

LO Service System Filling/Strikedown Procedures
122. MRC 2331 W-1R requires the drain and refill of the MPDE
lube oil loop seals. [Encl. (49)]
123. During the performance of MRC 2331 W-1R, SAN ANTONIO

personnel indicated the use of a blue plastic bucket to perform
the maintenance check. [Encls. (50, 51)]
124. The blue plastic bucket is used to perform other tasks in

the propulsion spaces. [Encls. (50, 51)]
NR 1A MPDE
125. On 18 August 2009, the lube oil quality management (LOQM)
log annotated zero gallons in the NR 1A MPDE lube oil sump.
[Encl. (52)]
126. On 9 September 2009 at 1738, the prior to transfer (PTT)

sample on lube oil tank 6-65-2-F was satisfactory. [Encl. (53)]
127. On 9 September 2009 at 1855, a lube oil transfer from lube

oil tank 6-65-2-F to NR 1A MPDE lube oil sump commenced. [Encl.
(53)]
128. On 9 September 2009 at 2113, a lube oil transfer from lube

oil tank 6-65-2-F to NR 1A MPDE lube oil sump of 1647 gallons
completed. [Encl. (53)]
129. On 10 September 2009, the LOQM log annotated 2000 gallons

in the NR 1A MPDE lube oil sump. [Encl. (54)]
20

ANTONIO (LPD 17)
130. On 15 September 2009, the LOQM annotated 1750 gallons in

the NR 1A MPDE lube oil sump. [Encl. (54)]
131. On 18 September 2009 at 0915, the PTT sample on lube oil

tank 6-68-2-F was satisfactory. [Encl. (53)]
132. On 18 September 2009 at 1350, there was 538 gallons of oil

transferred to NR 1A MDPE lube oil sump from lube oil tank 6-68-
2-F. [Encl. (53)]
133. On 8 October 2009 at 0329, the PTT sample from lube oil
tank 6-122-1-F satisfactory. [Encl. (21)]
134. On 21 October 2009 at 1340, the PTT sample on lube oil

135. On 22 October 2009, the LOQM log annotated 1640 gallons in

the NR 1A MPDE lube oil sump. [Encl. (55)]
136. A lube oil transfer is not documented in the engineering

log. [Encl. (21)]
137. On 23 October 2009 at 0639, the PTT sample on lube oil

138. On 4 November 2009 at 1548, NR 2 40WT lube oil purifier

started purifying NR 1A MPDE sump to 6-117-1-F IAW PTLO. [Encl.
(34)]
139. On 19 November 2009, the LOQM log annotated 1657 gallons

in the NR 1A MPDE lube oil sump. [Encl. (56)]

log. [Encl. (34)]

transfer pump started taking suction from NR 1A MPDE lube oil
sump discharging to lube oil tank 6-63-2-F IAW PTLO. [Encl.
(34)]

transfer pump secured IAW PTLO. [Encl. (34)]
21

ANTONIO (LPD 17)
143. On 30 November 2009 at 1453, a 1355 gallon transfer from

NR 1A MPDE lube oil sump to lube oil tank 6-63-2-F completed.
[Encl. (34)]
NR 1B MPDE
144. On 18 August 2009, there was a 10 gallon increase in 1B
MPDE sump (280 gallons to 290 gallons). No Prior to Transfer
sample taken. [Encl. (52)]

log. [Encl. (17)]

147. On 9 September 2009 at 1309, NR 1 40 WT lube oil purifier

taking suction from lube oil tank 6-68-2-F to NR 1B MPDE. [Encl.
(53)]

149. On 9 September 2009 at 1329, a lube oil transfer commenced

from lube oil tank 6-68-2-F to NR 1B MPDE sump. [Encl. (53)]

151. On 9 September 2009 at 1729, a transfer of 2118 gallons of

lube oil to NR 1B MPDE was completed. [Encl. (53)]

in NR 1B MPDE sump. [Encl. (54)]


log. [Encl. (53)]


log. [Encl. (53)]
22

ANTONIO (LPD 17)

NR 1B MPDE lube oil sump. [Encl. (55)]

log. [Encl. (21)]
159. On 23 October 2009 at 0639, the sample on lube oil tank

6-121-1-F was satisfactory. [Encl. (21)]

NR 1B MPDE lube oil sump. [Encl. (55)]

log. [Encl. (21)]
NR 2A MPDE
162. On 4 August 2009, the LOQM log annotated 380 gallons in NR

log. [Encl. (17)]
164. On 8 August 2009, the LOQM log annotated 280 gallons in NR


log. [Encl. (17)]
166. On 11 August 2009, the LOQM log annotated zero gallons in

NR 2A MPDE lube oil sump. [Encl. (52)]

log. [Encl. (17)]

169. On 15 September 2009 at 0923, NR 2 40WT lube oil purifier

aligned and started filling NR 2A MPDE. [Encl. (53)]

in NR 2A MPDE lube oil sump. [Encl. (54)]

log. [Encl. (53)]
23

ANTONIO (LPD 17)

in NR 2A MPDE lube oil sump. [Encl. (54)]

log. [Encl. (53)]
174. On 7 October 2009, the LOQM annotated 1421 gallons in NR


log. [Encl. (21)]
176. On 8 October 2009 at 0329, the PTT sample on lube oil tank
6-122-1-F is satisfactory. [Encl. (21)]
177. On 8 October 2009 at 0340, NR 2 40WT lube oil transfer

pump aligned and started taking suction from 6-122-1-F and
discharging to NR 2A MPDE sump IAW PTLO. [Encl. (21)]
178. On 8 October 2009 at 0407, secured from transfer of lube

oil to NR 2A MPDE Sump IAW PTLO. [Encl. (21)]
179. On 9 October 2009, 1657 gal annotated in LOQM Logs, +237

gal from previous day. [Encl. (55)]
180. The lube oil transfer is documented in the engineering log

as occurring two days earlier and accounts for the 179 gallon
increase. [Encl. (21)]
181. On 16 October 2009 at 1236, a PTT sample on lube oil tank

6-122-1-F was satisfactory. [Encl. (21)]
182. On 23 October 2009 at 0639, a PTT sample on lube oil tank

on 6-121-1F was satisfactory. [Encl. (21)]
183. On 23 October 2009 at 0702, NR 2 40WT lube oil purifier

aligned and started suction from 6-122-1-F discharging to NR 2A
MPDE sump. [Encl. (21)]
184. On 23 October 2009 at 0742, secured from transferring 40WT

lube oil to NR 2A MPDE Sump. Transferred 445 gal. [Encl. (21)]
24

ANTONIO (LPD 17)
Possible External Source of the Foreign Matter

LO System Flushing Components
185. The flushing procedure involves the use of muslin bags
that contain kevlar to catch debris. [Encls. (57, 58)]
External Cause of the Foreign Matter Introduction Into the LO

System
Lube Oil Service System Flushing Process
186. The flushing process for the LPD 17 Class is NAVSEA S9233-
DM-HBK-010-007 Diesel Engine Maintenance Standard Flush LPD 17,
MPDE Lube Oil System and Engine. [Encl. (59)]
187. The flushing procedure consists of the following steps:
a. The MPDE sump is drained and refilled with a high

detergent, low viscosity special diesel lube oil.
b. The installed lube oil service pumps, self-cleaning

filter element and duplex strainer elements are removed to
prevent a low flow area that could allow the accumulation of
contaminants.
c. A flush rig with pumps, heaters, filters and associated

manifolds are installed as a temporary system.
d. The pumps provide a pressure source for the lube oil,

the heaters maintain lube oil temperature/viscosity at the
required value and the manifolds aligned flushing lube oil to
the appropriate components.
e. Muslin bags are installed in the temporary filter and

are used to capture any contaminants.
f. The individual flushes are timed flushes that are

complete once the contamination found in the muslin bags meets
acceptance criteria.
g. The temporary pumps take suction from the main sump and
in series with the filter discharge clean oil into the external
and/or internal piping where the contaminants in the piping are
discharged into the sump.
h. The general sequence is that the external lube oil

piping is flushed, then the MPDE internal lube oil
25

ANTONIO (LPD 17)
piping/components are flushed followed by a combined (external

and internal) flush.
i. Upon completion of the flushes the sump is pumped down

and cleaned.
j. The LO Cooler flush can be accomplished at anytime

during the flushing evolution.
k. In addition to the temporary manifold installed to align

flushing lube oil to the external and/or internal piping, two
temporary valves were installed to bypass both pressure
regulating valves serving the lube oil system.
l. The government approved procedure fails to indicate the

required position of these valves at the start of the external
piping flush.
[Encl. (60)]
188. NAVSEA S9233-DM-HBK-010-007 Note 2 (page 6) states the

manual exceeds the requirements of NAVSEA S9086-HB-STM-010 NSTM
Chapter 233 Diesel Engines. [Encl. (59)]
189. NAVSEA S9233-DM-HBK-010-007 does not contain a requirement

for the lube oil sump to be cleaned prior to commencing the
flush. [Encl. (59)]
190. NSTM Chapter 233 paragraph 233-8.21.12.f states that prior

to flushing the engine sump shall be drained and wiped clean
with lint free rags. [Encl. (60)]
191. NAVSEA S9233-DM-HBK-010-007 does not indicate location or

amount of quadraplex filters required or installed during
flushing. [Encl. (59)]
192. NSTM Chapter 233, Figures 233-8-1 and 233-8-2 depict

filters installed immediately downstream of the flushing pump
and immediately upstream of the sump. [Encl. (60)]
193. NAVSEA S9233-DM-HBK-010-007 Note 18 states that all

checkpoints shall be verified, logged on enclosure (4) of the
procedure and signed by performing activity representative and
DEI before the next step can be performed. Verify with ship’s
force representative only if required. [Encl. (59)]
26

ANTONIO (LPD 17)
194. NAVSEA S9233-DM-HBK-010-007 Checkpoint 2 states that DEI

or Ship Representative and the contractor shall inspect all
accessible engine areas to verify all foreign material and
debris has been removed. [Encl. (59)]
195. NAVSEA S9233-DM-HBK-010-007 Temporary valves (TV 1 and 2)

are installed in the external piping, however the alignment of
these valves are not indicated in Table 1 (Valve Alignment).
Paragraph 3-1.13.1 requires that TVs be opened for a minimum of
5 minutes; however this occurs during the flushing process
allowing the potential for the valves to be improperly aligned
at the start of the flush. [Encl. (59)]
196. NAVSEA S9233-DM-HBK-010-007, paragraphs 1-5.1 and 1-5.4

require removal of number 1 and 2 LO service pumps respectively,
prior to commencing flush. [Encl. (59)]
197. The lube oil pumps were not removed prior to the flush.
[Encls. (61, 62)]
198. NAVSEA S9233-DM-HBK-010-007 does not require the

contractor to document the foreign material found during the
flush of the system. [Encl. (60)]
Damage Caused to the MPDE Bearings (to include cost)

Bearing Inspection Results
199. An inspection of the following bearings has been
conducted: NR 1A MPDE-Nr 2, 4, 6, and 8 main bearings and thrust
bearing; NR 1B MPDE-all main bearings and thrust bearing; and NR
2A MPDE-all main bearings and thrust bearing. [Encl. (63, 64)]
200. The bearing inspections revealed that all bearing surfaces

showed debris passed through. [Encl. (63-65)]
201. The bearing surfaces reflected debris similar to the

following items: industrial, bead blasting material, material
consistent with pipe welding process, dirt and sand, and water.
[Encl. (63-65)]
202. All main bearing backings reflected fretting at the shell

back ends with oil was found on the lower bearing steel-backs
during the removal due to inadequate bearing crush. [Encl. (63-
65)]
27

ANTONIO (LPD 17)
203. NR 1A MPDE thrust bearing lower shell exhibited high heat

marks on the steel backing, which reflect a previous hot bearing
during operation. [Encl. (63-65)]
204. The date and time of the damage to NR 1A thrust bearing

cannot be determined due to no ICAS records, i.e., system
inoperable or switched off. [Encl. (63, 64)]
205. NR 1B MPDE thrust bearing surfaces exhibited the passing

of large and small debris. [Encl. (63-65)]
206. A 3 millimeter wide and 2 millimeter deep groove was

visualized in the babbitt surface and embedded debris remained
in the bearing surface and journal. [Encl. (63-65)]
207. The thrust journal has grooves and cuts matching the
debris tracks in the bearing surface. [Encl. (63-65)]
208. The thrust bearing face showed wear consistent with

Geisling mis-alignment/improper spacing. [Encl. (63-65)]
209. NR 2A MPDE thrust bearing surfaces exhibited the passing

of small debris. [Encl. (63-65)]
210. The wear patterns were not consistent with the low
operating hours. [Encl. (63, 64)]
211. All bearings removed and inspected meet the discard

criteria in Chapter 4 of the LPD17 Class PC2.5 STC Volume 1
Technical Manual. [Encl. (63, 64)]
212. The current cost estimate to repair NR 1A, 1B, and 2A MPDE
is $7.5 million dollars. [Encl. (66)]
Maintenance Performance and Quality Control Efforts

Shipboard Engineering Programs
MPDE Material History
213. The Joint Fleet Maintenance Manual, Volume IV, Chapter 4
Diesel Engines, paragraph 4.4b requires that the Commanding
Officer shall “ensure that each inspection/assessment is entered
in the applicable machinery history with a brief description of
any repair before operating conditions found at the conclusion
of the assessment/inspection.” [Encl. (67)]
28

ANTONIO (LPD 17)

Diesel Engines, paragraph 4.5d requires that “Engine Operation
Hours since Overhaul and Engine Operating Hours since
Commissioning, at a minimum, shall be kept for all MPDEs, SSDGs,
and EDGs. For Colt Pielstick Engines on LSD-41/49, LPD-17, and
LHD-8 Class ships, operating hours since cylinder head
refurbishment and individual power pack change outs shall also
be kept.” [Encl. (67)]

Diesel Engines, Paragraph 4.6b(4) Commanding Officers shall
ensure all diesel records are readily available to include
“Diesel Maintenance/history records to include all maintenance
and significant items accomplished on the engine since last
engine overhaul.” [Encl. (67)]
216. SAN ANTONIO maintained material history logs using

standard green hardback log books. [Encl. (68)]
217. The material history documented hours for each MPDE.

[Encl. (68)]
218. The material history did not document inspection or

assessment for each MPDE. [Encl. (68)]
3M Program
219. On 19 September 2009, EM01 conducted PMS Check: 2331-017-
49 U-11 Change Main Engine Lube Oil System Lubricating Oil.
[Encl. (69)]
220. The 13 Week Accountability Log does not clearly record the
individual that conducted the check. [Encl. (69)]
221. On 20 September 2009, EM01 conducted PMS Check: 2331-017-

49 U-35 Clean and Inspect Rocker Arm Lube Oil Strainer. [Encl.
(69)]
223. On 20 September 2009, EM01 completed PMS Check: 2331-017-

49 U-11 Change Main Engine Lube Oil System Lubricating Oil.
[Encl. (69)]
29

ANTONIO (LPD 17)
225. On 20 September 2009, EM01 completed PMS Check: 2331-017-

49 U-35 Clean and Inspect Rocker Arm Lube Oil Strainer. [Encl.
(69)]
227. On 22 September 2009, EM01 conducted PMS Check: 2640/006-

98 M-2 Clean and Inspect Diesel Engine Purifier Bowl. [Encl.
(69)]
229. The check requires a tag out. [Encl. (70)]
230. On 1 October 2009, EM01 completed PMS Check: 2331-017-49

18M-8R Measure and Record Crankshaft Deflection Readings. [Encl.
(69)]
232. On 29 October 2009, EM01 completed PMS Check: 2640/006-98

M-2 Clean and Inspect Diesel Engine Purifier Bowl (Tag Out # E-
1281). [Encl. (69)]
234. On 29 October 2009, EM01 conducted PMS Check: 2640/006-98

M-2 Clean and Inspect Diesel Engine Purifier Bowl. [Encl. (69)]
236. On 12 November 2009, EM01 conducted PMS Check: 2331/017-49

18M-12R Test Injector Nozzle. [Encl. (69)]
30

ANTONIO (LPD 17)
238. The check requires a tag out. [Encl. (71)]
239. The 13 Week Accountability Log has “N/A” annotated for the
tag out number. [Encl. (69)]
240. On 25 November 2009, EM01 conducted PMS Check: 2640/006-98

242. On 27 October 2009, EM02 conducted PMS Check: 2640/006-98

244. MRC 2331 R-12W MPDE Sump Samples is required: weekly in

use. [Encl. (73)]
245. SAN ANTONIO personnel last performed the check in March

2009. [Encl. (50, 74)]
246. SAN ANTONIO personnel lined out MRC 2331 R-12W on MIP.
[Encl. (50, 74)]
247. MRC 2331 R-13W MPDE Rocker Arm LO Viscosity Sample using
OTC is required: weekly in use. [Encl. (75)]
248. SAN ANTONIO personnel last performed the check in March

2009. [Encl. (50, 74)]
249. SAN ANTONIO personnel lined out MRC 2331 R-13W on MIP.
[Encl. (50, 74)]
250. MRC 2331 R-14M MPDE Sump Shore Lab Samples is required:
Monthly in use. [Encl. (76)]
251. SAN ANTONIO personnel typically performed the check but

did not take credit for performance of the check for PMS
purposes. [Encl. (50)]
252. MRC 2331 U-35 C/I Rocker Arm LO Strainer is required: (a)
>5 PSID; and (b) Change Rocker Arm LO. [Encl. (77)]
31

ANTONIO (LPD 17)
253. SAN ANTONIO personnel did not document the check for NR 2A
MPDE, following change out of lube oil in August 2009, in 3M
Program. [Encl. (50)]
254. MRC 2620 U-1 C/I Duplex LO Strainer is required: (a) >15
PSID; (b) LO Change; and (c) 1/watch 1st 48 hours after
maintenance. [Encl. (78)]
255. SAN ANTONIO personnel did not perform check after lube oil
change out or after maintenance. [Encl. (50)]
256. MRC 2620 U-3 Renew LO Filter Elements is required: (a) >15
PSID; (b) As directed by results of LO analysis; and (c) Change
LO. [Encl. (79)]
257. SAN ANTONIO personnel did not document the check in

conjunction with a lube oil change out. [Encl. (50)]
258. Ship’s Force provided Memorandum of Record reporting

completion of MRC. [Encl. (50)]
Lube Oil Quality Management Program

259. SAN ANTONIO personnel made no meaningful attempt to
monitor JOAP/NOAP monthly preventive maintenance lube oil
samples. [Encl. (81)]
260. Chain of command review of the LOQM logs were cursory and
not performed on a daily basis. [Encl. (81)]
261. Quarterly calibration of the onboard KITTEWAKE lube oil

analysis equipment was not performed. [Encl. (81)]
262. Over the period of February to May 2009, the SAMM Database
consistently revealed high levels of engine wear products to
include Iron (Fe) in NR 1A, 1B, and 2A MPDE lube oil. [Encl.
(80, 81)]
263. EOCC Procedure Hot Bearing in a Main Engine (MHMEB) does

not require a visual inspection of the strainers or filter media
for the presence of babbit which would provide an immediate
indication of bearing failure. [Encl. (82)]
264. EOCC Procedure Unusual Noise and Vibration in a Main

Propulsion Diesel Engine (MNVME) does not require a visual
inspection of the strainers or filter media for the presence of
32

ANTONIO (LPD 17)
babbit which would provide an immediate indication of bearing

failure. [Encl. (82)]
Training Program
265. An audit of FLTMPS TYCOM required courses associated with
lube oil systems was conducted and the following deficiencies
were noted:
a. One of fifty required Sailors have completed the LPD 17

Class Lube Oil System Familiarization Course (LPD-005)
b. Zero of two required Sailors have completed the

Propulsion Alarm and Indication Course (A-651-0047)
c. One of fifty required Sailors have completed the LPD 17

Class Fuel Oil System Familiarization Course (LPD-004)
d. Five of twenty-three required Sailors have completed the

LPD 17 Class Electrical Systems Familiarization Course (LPD-006)
e. Two of sixty-five required Sailors have completed the

LPD 17 Class Electrical Generation and Distribution Course (LPD-
007)
f. One of twenty-three required Sailors have completed the

LPD 17 Class AC and Refrigeration Course (LPD-014)
g. Two of fifty-eight required Sailors have completed the

LPD 17 Class Reverse Osmosis Familiarization Course (LPD-017)
h. Six of eighty-nine required Sailors have completed the

LPD 17 Class Compressed Air System Familiarization Course (LPD-
019)
i. Five of eighty-eight required Sailors have completed the

LPD 17 Class Engineering Control System (ECS) Course (LPD-032)
j. Two of forty-five required Sailors have completed the

LPD 17 Class Shipboard Status Monitor System Course (LPD-036)
k. Three of forty-two required Sailors have completed the

LPD 17 Class Main Propulsion Diesel Engine Operation Course
(LPD-103A)
33

ANTONIO (LPD 17)
l. Two of fifty-eight required Sailors have completed the

LPD 17 Class Ships Service Diesel Generator Operation Course
(LPD-103B)
m. One of seventy-four required Sailors have completed the

LPD 17 Class Steering Gear Machinery System Operation Course
(LPD-103D)
n. Two of twenty-five required Sailors have completed the

LPD 17 Class Controllable Pitch Propeller Operation Course (LPD-
103E)
o. Two of twenty-five required Sailors have completed the

LPD 17 Class Fuel Oil Purifier Operation Course (LPD-104)
p. Two of twenty-five required Sailors have completed the

LPD 17 Class MPDE LO Purifier Operation Course (LPD-105A)
q. Two of twenty-five required Sailors have completed the

LPD 17 Class Reduction Gear LO Purifier Operation Course (LPD-
105B)
r. Two of seventeen required Sailors have completed the LPD

17 Class Electrical System Operation Course (LPD-106)
s. Three of fifteen required Sailors have completed the LPD

17 Class Refrigeration Plant Operation Course (LPD-114B)
t. One of twenty-five required Sailors have completed the

LPD 17 Class Reverse Osmosis Operation Course (LPD-117)
u. Three of forty-five required Sailors have completed the

LPD 17 Class Shipboard Status Monitor Subsystem Operation Course
(LPD-136)
v. One of thirty-eight required Sailors have completed the

LPD 17 Class Steering Gear Machinery Maintenance Course (LPD-
203D)
w. Three of forty-eight required Sailors have completed the

LPD 17 Class Controllable Pitch Propeller Maintenance Course
(LPD-203E)
x. Zero of thirty-five required Sailors have completed the

LPD 17 Class Fuel Oil Purifier Maintenance Course (LPD-204)
34

ANTONIO (LPD 17)
y. One of thirty-five required Sailors have completed the

LPD 17 Class Main Reduction Gear LO Purifier Maintenance Course
(LPD-205A)
z. Two of twenty-five required Sailors have completed the

LPD 17 Class Fuel Oil Purifier Operation Course (LPD-104)
[Encl. (83)]
266. Engineering Department has not completed many required NKO

courses including courses associated with ship control systems
(ECS/MCS), main propulsion and lubricating oils. [Encl. (84)]
267. Three months of training records for the period of

February to December 2009 were unavailable. [Encl. (84)]
268. Despite a post deployment leave period in March/April

2009, MP Division reported 100% attendance at all documented
training (typical reports stated that 25 of 25 Sailors attended
training). [Encl. (84)]
269. All MP Division training conducted since February 2009 was

documented as being conducted by the same second class petty
officer. [Encl. (84)]
270. The SAN ANTONIO Training Instruction requires that a

Subject Matter Expert conduct the training. [Encl. (84)]
271. Since February 2009, MP Division conducted training three

times on a system that did not exist on SAN ANTONIO: Diesel
Engine Brake System. [Encl. (84)]
272. From February to December 2009, training was not conducted

on MPDE bearing high temperature casualties, loss of lube oil
pressure or loss of lube oil cooling casualties. [Encl. (84)]
273. Two lesson plans (Lubricating Oil Storage, Transfer and

Purification and Diesel Engine Clutch and Brake System) were
dated December 2000. [Encl. (84)]
274. Five lesson plans (Lubricating Oil Quality Management,

Diesel Main Reduction Gear, Bearing Records, Air System
Casualties and Diesel Engine Lube Oil System were dated 2005
(various months). [Encl. (84)]
275. The Diesel Lube Oil System lesson plan:
35

ANTONIO (LPD 17)
a. Did not address the self-cleaning filter or strainer

inspection criteria and potential sources/types of
contamination, or typical lube oil casualties (low level, low
pressure, loss of cooling (high temperature)
b. Had incorrect or incomplete criteria for the shift clean

and inspection of the lube oil strainers
[Encl. (84)]
276. The Lube Oil Storage, Transfer and Purification System

lesson plan did not address required samples or appropriate lube
oil log entries in support of transfers. [Encl. (84)]
277. The Lube Oil Quality Management lesson plan did not
address NSTM requirement to periodically test lube oil analysis
equipment, or weekly lube oil sample analysis when in operation,
or the means to obtain the lube oil test results via the SAMMs
database and the requirement to maintain lube oil in
specification. [Encl. (84)]
SAN ANTONIO Class Engineering Systems

Shipboard Automated Maintenance Management System
278. Shipboard Automated Maintenance Management (SAMM) System
provides electronic means for ship’s force to track lube oil
analysis results. Ship’s force samples are sent to the lab.
Results are posted on the internet in the SAMMS folder. [Encl.
(85, 86)]
279. Based on oil sample results, recommendations to ship's

force are developed by NSWC Philadelphia and forwarded to the
ship via email. [Encl. (85, 86)]
280. PREDICT is contracted by the Navy to conduct lube oil

sample analysis. The lab is required to provide analysis of
samples two working days after the sample is received at the
lab. [Encl. (85, 86)]
281. Currently NSWC Philadelphia has tasked PREDICT to conduct

ferrography analysis on samples for LPD 17 class ships. [Encl.
(85, 86)]
282. Lube oil sample shipping costs are paid for by the program
under NSWC Philadelphia. [Encl. (85, 86)]
36

ANTONIO (LPD 17)
283. Based on location of the ship, and the methodology used to

ship samples (transfer to support ship, inport, etc) samples may
be received in the PREDICT lab out of sequence. [Encl. (85, 86)]
284. SAN ANTONIO has a stand alone version of SAMMS. Instead

of automatically sending data to SAMMS, ship’s force must
download information to a disc, and send information via the
internet. [Encl. (85, 86)]
285. With a stand alone system, ship’s force does not have
direct access to the SAMMS folder or lube oil analysis trend
data. [Encl. (85, 86)]
286. NSWC Philadelphia calibrates Kittiwake equipment onboard

ships every two years. [Encl. (85, 86)]
287. Training on SAMMS is scheduled for ships, and additional

training is available upon request. [Encl. (85, 86)]
288. Crew members from SAN ANTONIO received SAMMS training in

April 2008, July 2008, and August 2008 prior to the ship’s
deployment. [Encl. (85, 86)]
289. Ship’s force had the capability via their Port Engineer to
gain access to the monthly lube oil samples but did not attempt
to do so because of their level of knowledge of the system.
[Encl. (87-89)]
290. The current work around is that based on oil sample

results recommendations to ship's force are developed by NSWC
Philadelphia and forwarded to the ship via email. [Encl. (87-
89)]
Engineering Control System

291. LPD 17 class Engineering Control System (ECS) is a
microprocessor-based real-time distributed data acquisition,
control, processing, and display system that:
a. provides remote monitoring and control of propulsion,

electrical, auxiliary, fuel, damage control, and ballast systems
b. consists of 20 operator Multi-Function Workstations

(MFWS) and 35 Data Acquisition Units (DAUs)
37

ANTONIO (LPD 17)
c. uses the Shipboard Wide Area Network (SWAN) to

distribute data to and from ECS consoles
[Encl. (90)]
292. SWAN and ECS are commercial off the shelf systems
integrated and maintained by Raytheon Incorporated during the
new construction process. [Encl. (90)]
293. DAU circuit boards, also called VME Remote Terminal Units
(VRTU), are the interface between engineering plant sensors and
ECS and are designed to accept inputs from multiple sensors.
[Encl. (90)]
294. The DAU configuration allows interruption of multiple

sensor signals if one sensor electrically fails. [Encl. (90)]
295. Troubleshooting of the DUA is complex and tedious because

the technician must search each signal wired to the VRTU for the
failed sensor. [Encl. (90)]
296. After ship delivery in 2006, SAN ANTONIO and an outside

maintenance community documented problematic ECS operation,
troubleshooting, and repair. [Encl. (91)]
297. PREINSURV findings during Final Contract Trials held from

26-30 March 2007 included:
a. Significant deficiencies associated with the SWAN that

negatively impacted ECS operation.
b. LPD 17 Class integrated support was marginal at best.

[Encl. (92)]
298. PREINSURV findings during Material Inspection (MI)

completed 26-30 November 2007 included:
a. Ships force lacked the fundamental troubleshooting tools

to attain self-sufficiency in effectively maintaining the SWAN
and ECS because of system software upgrades and installation of
alterations without supporting technical documentation
b. Technical documentation was not available because of

proprietary rights (i.e., MPDE engine controls technical
documentation)
38

ANTONIO (LPD 17)
c. Integrated logistic support necessary to troubleshoot

analog and digital signals between installed equipment and ECS
DAUs did not exist
d. At the start of the MI, ships force and NSSA technicians

were actively troubleshooting 55 out of service faults and 71
unknown faults displayed at ECS consoles
e. Optimal manning, existing level of knowledge, and lack

of technical documentation had combined to exceed available
ships force resources to operate the engineering plant
f. During underway portion the MI, an average of 20 alarms

per minute displayed by ECS during underway operations.
g. Watchstanders had become conditioned to ignore alarms.

[Encl. (93)]
299. ECS maintenance after INSURV focused on correcting shore

power interface problems and restoring DAU circuit boards to
reduce the number of ECS faults in support of the February 2008
OPEVAL. [Encl. (94, 95)]
300. Significant post OPEVAL maintenance included the

intermittent loss of speed and heading at the Bridge and
Steering Helm console. [Encl. (94)]
301. Technical community approach was to complete a system wide

assessment of SWAN to determine root cause of signal failure.
[Encl. (96)]
302. NAVSEA PMS 317 funded an onboard SWAN subject matter

expert for the entire deployment to assist ships force with
troubleshooting/repair and defining SWAN/ECS interface problems.
[Encl. (97, 98)]
303. LPD 17 Class precommissioning crews received SWAN and ECS

training directly from Raytheon during the commissioning
process. [Encl. (91)]
304. Upon ship arrival in Norfolk, no RMC technicians were

trained in the ECS system. [Encl. (91)]
305. NAVSEA-Philadelphia Code 955 has been designated as In

Service Engineering Agent for ECS. [Encl. (91)]
39

ANTONIO (LPD 17)
306. Access to Raytheon for shipboard ECS technical support was

convoluted due lack of a contract vehicle that could be used by
the Regional Maintenance Centers (RMCs) for emergent
troubleshooting and repair. Raytheon support is funded by
NAVSEA PMS 317. [Encl. (100)]
307. A post delivery support assist process was used by the RMC
Maintenance Team to interface with PMS 317 and Raytheon on a
case by case basis. This process resulted in delays in system
restoration. [Encls. (101, 102)]
308. ECS reliability issues caused SAN ANTONIO to set on

average three additional engineering watch standers during
normal operation. [Encl. (87, 88)]
309. In mid-December 2009, the Commanding Officer had approved

approximately fifty Temporary Standing Orders (TSOs) that
authorized ship’s force to modify EOSS or add additional duties
to watch standers to locally monitor, operate or verify the
proper operation of equipment vice remote operation and
monitoring via the Engineering Control Systems (ECS). [Encl.
(87, 89, 90, 103)]
ICAS
310. ICAS provides a distributed set of six personal computers
(PC) workstations and associated Portable Data Acquisition
(PDA), Portable Data Terminal (PDT) and Data Acquisition Set-64
(DAS-64) capable of obtaining and displaying engineering plant
equipment status data. [Encl. (104)]
311. ICAS maintains records of individual plant equipment in a

ship unique Configuration Data Set (CDS), for monitoring and
trend analysis functions. [Encl. (104)]
312. ICAS is a non-mission critical subsystem that only runs as

a stand alone application on the unclassified side of the SWAN
network. [Encl. (104)]
313. The Channel B connection (dual hone) to SWAN modifications

for each ICAS work station were completed during the Post
Shakedown Availability (2 April 2007 – 25 June 2007). [Encl.
(105)]
314. During the PSA sea trials, the Main Machinery Room NR 1
ECS console and ICAS console desynched a total of three times:
40

ANTONIO (LPD 17)
ECS console desynched one time; ICAS console desynched two

times. [Encl. (105)]
315. The desynchronization of one console did not affect the

other console. [Encl. (105)]
316. NAVSEA ICAS and ECS representatives were onboard during

sea trials. [Encl. (105)]
317. On 18 July 2007, NAVSEA ICAS representatives left SAN

ANTONIO with all five ICAS workstations and one ICAS viewport
operational. [Encl. (105)]
318. In October 2007, NAVSEA ICAS representative (b)(6)

participated in an ICMP assessment aboard SAN ANTONIO. [Encl.
(105)]
319. In October 2007, NAVSEA ICAS representative (b)(6)

visited SAN ANTONIO to update logsheets and install new ECS
software. [Encl. (105)]
320. On 1 March 2008, NAVSEA ICAS representative (b)(6)

received email from (b)(6) stating ICAS was up and running,
but needed to install a new logsheet. [Encl. (105)]
321. On 7 March 2008, NAVSEA ICAS representative (b)(6)

received email stating that during an OPEVAL: "ICAS fault
caused ECS to desync during ballast operations with a LCU in the
well delaying the evolution." [Encl. (105)]
322. In July 2008, NAVSEA ICAS representative (b)(6)

attempted to further assist ship via distance support (email)
but lost communication. [Encl. (105)]
323. The LPD 17 Class de-synchronization issue is caused by the

Ship Wide Area Network’s (SWAN) handling of network
communications amongst the various ECS consoles. [Encl. (106)]
324. The de-synchronization problem was initially encountered

during SAN ANTONIO’s builder trials (prior to ICAS
installation). [Encl. (106)]
325. The recommended solution was the five ICAS workstations

become dual honed with a Channel B connection and network card.
[Encl. (106)]
41

ANTONIO (LPD 17)
326. The installed solution differed in that a “shared” Channel

B connection with the neighboring ECS console was implemented.
[Encl. (106)]
327. The five ICAS consoles thus shared a pre-existing channel

B connection with a neighboring ECS console. [Encl. (106)]
328. The installation of the GIG E network onboard USS NEW

ORLEANS (LPD 18) in Spring 2008 has further mitigated the
potential of de-synchronization since it is more robust than the
original ATM solution. [Encl. (106)]
329. NEW ORLEANS has been using ICAS since Spring 2008. [Encl.
(106)]
330. Although SAN ANTONIO received the GIG E upgrade in (fall

2009) she is reluctant to utilize the ICAS consoles for fear of
desynchronizing the entire control system. [Encl. (106)]
331. NAVSEA ICAS representatives believe that SAN ANTONIO has

lost confidence in ICAS and will provide her training and a ship
rider during her upcoming trial in January 2010. [Encl. (106)]
332. Ship’s force has mitigated the risk associated with ICAS
being secured on SAN ANTONIO by setting additional watches and
manually logging and trending propulsion plant parameters.
[Encl. (88)]
333. Operating parameters and other equipment information

monitored by ICAS is designed to be automatically sent off ship.
[Encl. (107)]
334. This interface has not been enabled on LPD 17, so ship’s
force would conduct a manual push of the data off ship on a
periodic basis if ICAS was operational. [Encl. (107)]
335. Off ship subject matter experts would review the data and
make recommendations with regard to operations and condition
based maintenance. [Encl. (107)]
336. Until recently, only automated reports associated for air

conditioning systems has been funded and available for ship’s
force although ICAS is designed to monitor the entire propulsion
plant. [Encl. (108)]
42

ANTONIO (LPD 17)
337. ICAS support would be in place to monitor MPDE performance

for LPD 19 deployment. [Encl. (5)]
Navy Training System Plan

338. The NTSP for USS San Antonio (LPD 17) Class Amphibious
Transport Dock Ship is NSTP N85-NTSP-S-30-9603B (01 Jul 09).
[Encl. (109)]
339. NSTP N85-NTSP-S-30-9603B page xii states that the 01 July

2009 version was prepared to document changes since the
previously approved NSTP in May 2003. [Encl. (109)]
340. NSTP N85-NTSP-S-30-9603B pages I-3 to I-4 states: “LPD 17

Class ships were introduced into the Fleet beginning with the
commissioning of USS SAN ANTONIO in January 2006. Despite the
relative newness of the Class, modest improvements,
modernization and changes have already been made that
necessitate updating this NTSP. These ships were built with the
primary goal of reducing the total ownership cost (TOC) while
maintaining and improving readiness and reducing manning through
greater emphasis on technological enhancements, distance
learning, continuous learning systems, job/training aids,
distributed/joint learning, virtual reality, and multi-media
training. Introduction of these technologies provides the crew
and embarked forces with training tools that provide the
flexibility to adjust to meet mission objectives. The use of
electronic media has greatly improved the overall capacity for
the ship to train itself. This advance “training technology
insertion, combined with implementation of advance Condition
Based Maintenance technologies and the use of Integrated
Condition Assessment System (ICAS) to eliminate work and
increase system readiness, provides the LPD 17 class with a
comprehensive program that reduces TOC and meets reduced manning
requirements.” [Encl. (109)]
341. NSTP N85-NTSP-S-30-9603B page I-5 states: “TSTS. The

TSTS provides the LPD 17 Class ships with centralized
coordination and management of training. It maintains the
individual and team training records including courses/events
required and completed, qualifications attained, and evaluations
of training effectiveness. ICW courses can be taken from any
work station computer or tactical console with the results
interfacing directly with TSTS. TSTS also supports and records
the results of stand alone training exercises using the embedded
training features of specific systems. The Navy Integrated
43

ANTONIO (LPD 17)
Application Product Suite (NIAPS) and Navy Knowledge Online

(NKO) Afloat will replace TSTS functionality once the LPD 17
Class ICWs and IETMs are compatible with and hosted on NKO.”
[Encl. (109)]
342. The Ship’s Electronic Classroom was never finished and is

currently used as the ship’s gym. [Encl. (83, 88)]
343. The TSTS Server is located in the Learning Resource Center

(LRC) but is not connected to the ship’s LAN or desk top
computers in the LRC. [Encl. (83, 88)]
344. The work around for TSTS is that classes that should be
resident on the TSTS are available via Navy Knowledge Online
(KNO). Course completion is automatically posted to FLTMPS
database. Qualifications are manually tracked using onboard
data bases. [Encl. (83, 87, 88)]
345. Engineering Department has a low completion rate of NKO

courses. [Encl. (83)]
346. In the opinion of the Training Officer, (b)(6)

the training department is too small (approximately four
(b)(6)
Officers/Sailors) to track and record training. [Encl. (83)]
347. The ship’s training instruction was signed by the current

Commanding Officer in February 2009. [Encl. (83)]
348. The Training Officer was unfamiliar with several aspects

of the ship’s training instruction including lesson plan
approval, record keeping requirements and monthly training
reports. [Encl. (83)]
349. NSTP N85-NTSP-S-30-9603B page I-7 under “Organizational

Level states: “The LPD 17 maintenance strategy calls for the
maximum use of onboard O-Level maintenance capabilities through
state of the art maintenance aids such as the Module Test and
Repair capability, ICAS, ETMs, and IETMs. PM is accomplished in
accordance with the ship’s Planned Maintenance System (PMS)
Schedule. The performance of PM maximizes the service life and
minimizes equipment down time. PM tasks include condition
directed and time directed tasks. Every effort should be made
to reduce the number of time driven tasks and make optimum use
of condition monitoring equipment instead…” [Encl. (109)]
44

ANTONIO (LPD 17)
350. NSTP N85-NTSP-S-30-9603B page I-7 under “Corrective

Maintenance states: “CM incorporates the use of ETMs/IETMs and
interactive diagnosis to reduce MTTR. The installation of ICAS
affords “shore based” knowledge aboard ship, thereby reducing
trouble shooting time and maintenance-induced failures and
improving the operational efficiency of the ship.” [Encl. (109)]
351. NSTP N85-NTSP-S-30-9603B Appendix A discusses a “LPD 17

Class Stakeholder meeting and training summit” held 22 January
2008. [Encl. (109)]
352. “The Stakeholder’s meeting identified five major systems

aboard the LPD 17 Class ships that presented critical operation,
maintenance and training concerns. These systems included the
Main Propulsion Diesel Engines (MPDE), the Ship Service Diesel
Generators (SSDG), the Engineering Control System (ECS), the
Ship Wide Area Network (SWAN), and the MK 46 MOD ½ 30mm Gun
Weapon System(GWS). All of these systems except the MK 46 GWS
are commercial off the shelf systems that are unique to LPD 17
Class and for which no Equipment/System/Subsystem (E/S/S) Navy
Training System Plan has yet been developed and no formal Navy
schoolhouse/pipeline training currently exists. A major outcome
of this meeting was that TEAM SHIPS and all the Stakeholders
established, in accordance with OPNAVINST 1500.76A, a Training
Planning Process Methodology (TRPPM) Advisory Board to plan the
way ahead to determine the long term training solution and
update this LPD 17 Class NTSP.” [Encl. (109)]
353. “The LPD 17 Class training summit was called to address

the action items identified during the Stakeholder’s Meeting.
The four main tasks assigned were to:
a. Describe the immediate training requirements for USS SAN

ANTONIO (LPD 17)
b. Describe initial training for LPD 17 Class Pre-

Commissioning Crews
c. Determine what the interim training plan for LPD 17

Class follow-on crews should be
45

ANTONIO (LPD 17)
d. Develop the process for determining the formal long term

training solution for the LPD 17 Class and brief the “Way
Ahead.”
[Encl. (109)]
354. “The following paragraphs provide the individual working

group’s recommended short-term training solutions. These remain
recommendations until vetted by the LPD 17 Class TRPPM Advisory
Board. To determine the Follow-on/Life Cycle Training Solutions
Front End Analysis (FEA) must be funded and performed for each
of the below systems and vetted by the TRPPM Advisory Board to
implementation… [Encl. (109)]
355. Recommendations of the HM&E working group: the consensus

of the working group membership is to create a training pipeline
for the LPD 17 Class propulsion system that is similar to the
existing one for LSD 41/49 Class leading to the assignment of a
Navy Enlisted Classification (NEC) codes for LPD 17 Class
propulsion technicians and LPD 17 Class Engineering Control
System (ECS) Operation and Maintenance Technicians…” [Encl.
(109)]
LPD 17 Title 10 Training/Budget

356. 17 March 2009 Memorandum of Agreement for LPD 17 Manpower,
Personnel, and Training (MPT) requirements was signed by
representatives from OPNAV N85, OPNAV N151, PMS 470, PMS 317,
and LSD/LPD CLASSRON. [Encl. (110)]
357. Per the MOA, PMS 317 shall maintain the management,
execution and fiscal responsibility for developing and
implementing initial new construction crew familiarization,
indoctrination, including counterpart training. PMS 317 shall
also be responsible for interim training for SWAN, ECS, MPDE,
SSDG, and the MK 46 GWS, as well as other systems as funded by
OPNAV through FY 11. PMS 317 shall coordinate with PMS 470 and
the LSD/LPD 17 CLASSRON to ensure lifecycle/follow-on training
plan is developed that meets the MPT requirements of the fleet.
[Encl. (110)]
358. Per the MOA, PMS 470 shall maintain the management,
execution and fiscal responsibility for developing and
implementing the life cycle/follow-on training requirements, to
include the development of any necessary system level Navy
Training System Plans and the associated training solutions.
[Encl. (110)]
46

ANTONIO (LPD 17)
359. Per the MOA, PMS 470 shall coordinate with Training
Planning Process Methodology (TRPPM) stakeholders to ensure
lifecycle/follow-on training plan is developed that meets the
MPT requirements of the fleet. [Encl. (110)]
360. Per the MOA, starting in FY12, PMS 470 shall assume all
LPD 17 interim MPT requirements. [Encl. (110)]
361. According to POM 12 Budget (internal CNO staff documents)

formal or school house training does not exist for Mission
Critical Hull Material Electrical Systems, SWAN GIG E, IC
systems, Video Systems, Mine Signature Control System, and
Navigation Data Distribution System. [Encl. (111)]
362. Proposed POM 12 submission by N85 proposes additional

funding to meet life cycle training requirements for SWAN,
Navigation Data Distribution System, Engineering Control System,
Ship Service Diesel Generator, Main Propulsion Diesel Generator,
Electric Plant, Steering Control System, Interior Voice
Communications, and Magnetic Signature Control System. [Encl.
[Encl. (111)]
LPD 17 Class Manpower and Training

363. Initial manpower estimates for a ship class are developed
by the program office. The Preliminary Ship Manpower Document
(PSMD) generated by the program office is refined by NAVMAC into
a Ship Manpower Document after the ship's first deployment (1-2
years after commission). [Encl. (112-114)]
364. The Navy Training System Plan (NTSP) for LPD 17 was based
on the premise that training would occur onboard the individual
ships in lieu of traditional classroom/schoolhouse training.
However, all the new systems, manpower, and training were not
linked in the current NTSP even though the new systems and
onboard training were factors in reducing total ownership cost
and manpower. [Encl. (112-114)]
365. The resource sponsor (N85) recommended a review of the
current NTSP due to insufficient detail to execute the described
shipboard training for all systems and sub-systems. [Encl. (112-
114)]
366. PMS 317 is conducting a training requirements solution

analysis using Training Planning Process methodology (TRPPM) to
generate new NTSPs for each subsystem (ECS, MPDE, SSDG, MK-46,
47

ANTONIO (LPD 17)
MPDE, SWAN, etc). (Expect delivery to N85 in Mar 2010) [Encl.

(112-114)]
367. LPD 17's Preliminary Ship's Manpower Document was released

by PMS 317 in January 2004 and was updated in February
2005(Change 1), April 2007(Change 2), August 2008 (Change 3),
and November 2009 (Change 4). [Encl. (112-114)]
368. NAVMAC validation process of the Ship's Manpower Documents

is in progress. The document is expected to be ready for review
by the Fleet in June/July of 2010. [Encl. (112-114)]
369. NAVMACs validation does not include the manpower

associated with the requirement for the crew to self-train.
Counting "self-train" time would conflict with the afloat
wartime Navy Standard Workweek (NSWW) which already contains
seven hours per week per requirement provided for sustainment
training to maintain readiness. This time is not earmarked for
"initial" training and qualification/certification. To add in
classroom time would result in a double-counting of training
hours and increase manpower requirements by including
unqualified personnel in the document. NAVMAC builds manpower
documents that reflect fully qualified requirements in a wartime
environment - not a training environment. [Encl. (112-114)]
NAVSEA Training
370. NAVSEA provides training to PRECOM crews on ICAS, ECS,
SWAN, SSDG, MPDEs, and the MK 46 Gun Weapon System. Courses are
taught either by NAVSEA or with Original Equipment Manufacturer
(OEM) contracted support. [Encl. (115-118)]
371. NAVSEA interim training requires students complete

prerequisite Interactive Course Ware (ICW) before attending the
courses. Interim training is referred to as “Delta.” Delta
courses are geared to students who are expected to be more
senior in ratings with the associated experience base to benefit
from the training. [Encl. (115-118)]
372. MPDE/SSDG/ECS interim training consists of a combined one

week course conducted simultaneously using two classrooms ashore
plus shipboard systems for hands-on training. The MPDE/SSDG
interim training session is for the Engineman rating. It
includes one and one-half days on SSDG, one-half day on ECS and
two days on MPDE followed by one day hands-on aboard ship. The
electric plant/ECS training session is for the EM, ET and IC
48

ANTONIO (LPD 17)
ratings. It includes two days on electric plant, one day on ECS

and two days hands-on aboard ship. [Encl. (115-118)]
373. SWAN interim training is conducted in two stages. Stage

1/SWAN operations and maintenance hands-on orientation course:
two weeks of hands-on orientation training conducted by Raytheon
in their sustaining engineering environment (see) lab in San
Diego, California. Stage 2/SPAWAR SWAN system administrator
Delta course is two weeks in length. [Encl. (115-118)]
374. Mk46 Mod2 GWS interim training course is three weeks. The
course consists of an overview, operations and basic maintenance
training for GM/FC ratings. [Encl. (115-118)]
375. Interim training is provided on both coasts. The intent of

the interim training is to cover the rotation of initially
trained crews of the LPD 17 class until the pipeline training is
either ready for training (RFT) or the necessary updates have
been incorporated. Classes are open to all LPD 17 commands.
[Encl. (115-118)]
376. Twenty San Antonio Sailors completed MPDE/SSDG/ECS interim

training in June 2009. [Encl. (115-118)]
LPD 17 Training and Qualification

Pipeline Training
377. PCO and PXO pipeline training does not include LPD 17 ECS
and ICAS. [Encl. (104)]
378. LPD 17 Class Chief Engineers are second tour 1110

Department Heads. [Encl. (104)]
379. As of 15 December 2009, with the exception of one officer,

all other LPD 17 Class Chief Engineers’ first department head
tour was aboard a diesel platform. [Encl. (104)]
380. The excepted officer’s first department head tour was

aboard a gas turbine platform. [Encl. (104)]
381. Prior to reporting, LPD 17 Class Chief Engineers complete

Surface Warfare Officer Prospective Engineering Officer Diesel
Course (A-4H-0063). [Encl. (104)]
49

ANTONIO (LPD 17)
382. Prior to reporting, LPD 17 Class Main Propulsion

Assistants and Auxiliary Officers complete Advanced Diesel
Engineering Course (A-4H-0160). [Encl. (104)]
383. The curriculum for Surface Warfare Officer Prospective

Engineering Officer Diesel Course (A-4H-0063) and Advanced
Diesel Engineering Course (A-4H-0160) are similar. [Encl. (104)]
384. Weeks one through three (Common Core) cover an in-depth

explanation of engineering theory and engineering management
programs including Maintenance University (two days) and
Advanced Shipboard Firefighting (two days). [Encl. (104)]
385. Weeks four through seven (Specialty) cover Main

Propulsion, Auxiliaries, and Electrical systems and includes the
use of a LPD-17 desk top trainer in the execution of engineering
evolutions and casualty control procedures. [Encl. (104)]
386. Prior to week eight’s Engineering Assessment with Afloat

Training Group, students are required to complete an oral board.
[Encl. (104)]
387. During Week 8 (Engineering Assessment), students complete

a mock engineering assessment. [Encl. (104)]
388. To complete the engineering assessment, the student must

satisfactory perform drills and evolutions within the
LPD-17 trainer. [Encl. (104)]
389. Satisfactory performance is 50% for drills and 65% for

evolutions and is in accordance with the SFTM. [Encl. (104)]
390. Week 9 (Ship Ride) consists of a SWOS N74 Instructor led

space walk-through, equipment familiarization, and material self
assessment training on platforms that correspond to their
ultimate duty station. [Encl. (104)]
391. Throughout the course, assessors evaluate every students

level of knowledge through a review of operating logs, records
and management program questions as they conduct evolutions and
drills. [Encl. (104)]
392. The assessors evaluate student performance in a "watch

team" mode noting the students ability and willingness to
provide "forceful backup". [Encl. (104)]
50

ANTONIO (LPD 17)
393. Instruction for ICAS and ECS is approximately 65 hours of

Instructor Led Training (ILT), and a two hour lab/lesson from
(b)(6) NAVSEA Philadelphia Code 951. [Encl. (104)]
394. Instruction includes the traditional methods of main

propulsion system operation and plant monitoring as a back-up to
ICAS. [Encl. (104)]
395. Successful completion of Surface Warfare Officer

Prospective Engineering Officer Diesel Course (A-4H-0063) and
Advanced Diesel Engineering Course (A-4H-0160) includes passing
multiple written tests and level of knowledge oral boards; and
completing homework and the mock Engineering Assessment. [Encl.
(104)]
396. The minimum passing GPA for the Surface Warfare Officer
Prospective Engineering Officer Diesel Course (A-4H-0063) and
Advanced Diesel Engineering Course (A-4H-0160)is 80%. [Encl.
(104)]
397. USS SAN ANTONIO (LPD 17) personnel completed the following
courses of instruction: Surface Warfare Officer Prospective
Engineering Officer Diesel Course (A-4H-0063)- (b)(6)
(b)(6) on July 2007; Advanced Diesel Engineering Course (A-4H-
0160) (b)(6) on July 2007, and (b)(6) on
November 2009. [Encl. (104)]
398. USS NEW ORLEANS (LPD 18) personnel completed the following
course of instruction: Surface Warfare Officer Prospective
Engineering Officer Diesel Course (A-4H-0063) (b)(6)
(b)(6) 4/2007 MGT PEO; Advanced Diesel Engineering Course (A-4H-
0160)- (b)(6) on April 2007. [Encl. (104)]
399. USS MESA VERDE (LPD 19) personnel completed the following
Engineering Officer Diesel Course (A-4H-0063)- (b)(6) on
July 2007; Advanced Diesel Engineering Course (A-4H-0160)-CWO3
(b)(6) on July 2009, and (b)(6) on September
2009. [Encl. (104)]
400. USS GREEN BAY (LPD 20) personnel completed the following
on May 2009 (first tour MGT engineer); Advanced Diesel
Engineering Course (A-4H-0160)- (b)(6) on February
51

ANTONIO (LPD 17)
2008, (b)(6) on December 2007, and (b)(6)

(b)(6) on July 2007. [Encl. (104)]
401. USS NEW YORK (LPD 21) personnel completed the following
on September 2006; Advanced Diesel Engineering Course (A-4H-
0160)- (b)(6) on July 2009, (b)(6) on May
2008, (b)(6) on December 2008, and (b)(6)
on December 2008. [Encl. (104)]
ICAS Training
402. On 7 December 2009, the following USS SAN ANTONIO (LPD 17)
personnel attended ICAS Basic Operator (CIN# A-191-0800): (b)(6)
(b)(6) , (b)(6) , (b)(6) , and (b)(6)
(b)(6) [Encl. (119)]
403. On 8 December 2009, the following USS SAN ANTONIO (LPD 17)
personnel attended ICAS Engineering Supervisor (CIN# A-191-
3001): (b)(6) (b)(6) , and (b)(6)
(b)(6) . [Encl. (119)]
404. From 9 to 11 December 2009, the following USS SAN ANTONIO

(LPD 17) personnel attended ICAS Maintenance Manager (CIN# A-
191-1002): (b)(6) and (b)(6)
[Encl. (119)]
Personnel Qualifications Standard

405. EOOW PQS NAVEDTRA 43104 is divided into three sections:
100 Introduction to Fundamentals; 200 Introduction to Systems;
and 300 Introduction to Watchstations. [Encl. (120)]
406. EOOW PQS NAVEDTRA 43104 Section 100 Introduction to

Fundamentals does not include the main reduction gear or ship
service diesel generator. [Encl. (120)]

Systems does not include the main reduction gear lube oil system
or ship service diesel generator lube oil system. [Encl. (120)]

Systems: Diesel Lube Oil Fill, Transfer, and Purification System
does not include the filter or lube oil cooler components.
[Encl. (120)]
52

ANTONIO (LPD 17)

Systems: MPDE System does not include the lube oil cooler.
[Encl. (120)]
410. Engineering Collaterals and Qualifications PQS NAVEDTRA

43704 is divided into three sections: 100 Introduction to
Fundamentals; 200 Introduction to Systems; and 300 Introduction
to Watchstations. [Encl. (121)]

43704 200 Introduction to Systems includes: 203 Fuel Oil (FO)
Service; and 204 FO Filling, Transfer, and Purification System.
[Encl. (121)]

43704 Watchstation 320 Lube Oil King does not require any 200
Systems prerequisites. [Encl. (121)]

43704 Watchstation 320 Lube Oil King does not require completion
of any 200 Systems (e.g., 207 Lube Oil (LO) Storage, Transfer,
and Purification System) as a prerequisite for the completion of
the watchstation. [Encl. (121)]

43704 Watchstation 335 Fuel Oil King requires completion of 200
Systems: 203 Fuel Oil (FO) Service; and 204 FO Filling,
Transfer, and Purification System, as a prerequisite for the
completion of the watchstation. [Encl. (121)]
415. On 26 March 2008, the Commanding Officer designated (b)(6)

(b)(6) as Assistant Oil King. [Encl. (122)]
416. On 3 June 2009, the Commanding Officer designated (b)(6)

(b)(6) as Oil King. [Encl. (123)]
417. On 1 September 2009, the Commanding Officer designated (b)(6)

(b)(6) as Oil King. [Encl. (124)]
418. The designation letters reference NAVEDTRA 43116-5G, the

PQS for Oil King/Water King for a plant with main propulsion
boilers. [Encl. (122-124)]
53

ANTONIO (LPD 17)
OPINIONS
Metal Shavings Discovery and Causation

Source of the Foreign Material
1. The probable source of the 300 series stainless steel found
in NR 1A, 1B, and 2A MPDE lube oil service systems is the
byproducts of the production and installation of stainless steel
lube oil service system piping. [FoF (1-6, 12, 94, 96-100, 102,
113-120)]
2. A possible, but unlikely, source of the 300 series stainless

steel found in NR 1A, 1B, and 2A MPDE lube oil service systems
is the lube oil service pump. [FoF (1-6, 12, 94, 96-100, 102,
113-120)]
3. Until removal and inspection, the lube oil service pump

cannot be eliminated as a source of the 300 series stainless
steel found in NR 1A, 1B, and 2A MPDE lube oil service systems.
[FoF (1-6, 12, 94, 96-100, 102, 113-120)]
4. A possible, but improbable, source of the 300 series

stainless steel found in NR 1A, 1B, and 2A MPDE lube oil service
systems is the lube oil purifier. [FoF (1-6, 12, 94, 96-100,
102, 113-120)]
5. The source of the babbitt found in NR 1A, 1B, and 2A MPDE

lube oil service systems is from the MPDE’s bearings. [FoF
(121)]
6. The probable source of the ferrous materials found in NR 1A,

1B, and 2A MPDE lube oil service systems is engine wear
products. [FoF (5, 27-29, 35, 36, 63, 64, 71, 88, 91-94, 96-
101)]
7. The possible, but unlikely, source of the ferrous materials

found in NR 1A, 1B, and 2A MPDE lube oil service systems is the
byproducts of the production and installation of carbon steel
lube oil service piping. [FoF (5, 27-29, 35, 36, 63, 64, 71, 88,
91-94, 96-101)]
8. The probable source of the fibrous materials and kevlar

found in NR 1A, 1B, and 2A MPDE lube oil service systems is the
byproducts of MPDE lube oil flush materials, i.e., muslin bags.
[FoF (36, 61, 95, 183, 185)]
54

ANTONIO (LPD 17)
Introduction of the Foreign Material

9. The poor weld joint fit up during new construction created
contaminate traps that could allow for an intermittent release
of contaminates. [FoF (2-4)]
10. The poor weld joint fit up during new construction

contributed to the introduction of the foreign material into the
lube oil service system. [FoF (2-4)]
11. The poor weld joints have shown visual indications of poor
weld techniques that result in stainless steel globules that
could break off and propagate through the lube oil service
system. [FoF (2-4)]
12. If these poor joints exist between the lube oil strainers
and the diesel complex, then the bearings would not be protected
from damage. [FoF (2-4, 102-111)]
13. Neglecting to flush the lube oil service system following

the Fall 2008 voyage repairs and an inadequate flush during the
CNO PMA contributed to the introduction of the foreign material
into the lube oil service system. [FoF (4, 6, 7, 184-196)]
14. The post-flush production work that occurred during the CNO
PMA (NR 1A and NR 1B MPDEs valve cover software replacement, NR
1B MPDE crankcase fan oil seal, and NR 2A MPDE low pressure air
line) is unlikely to have introduced foreign material in the
lube oil service system. [FoF (18-21, 48-50, 52-55)]
15. The blue bucket used for the performance of MRC 2331 W-1R
Loop Seal Fill may have contributed to the introduction of
foreign material in the lube oil service system. [FoF (120-122)]
16. Until the lube oil storage tanks are inspected, the
transfer procedures used by SAN ANTONIO personnel of lube oil
from storage tanks to the lube oil service system cannot be
eliminated as a contributing factor of the introduction of
foreign material in the lube oil service system. [FoF (123-182)]
17. There is no evidence to support a malicious introduction of

foreign material into the lube oil service system. [FoF (1-196)]
Removal of the Foreign Material

Diesel Engine Maintenance Standard Flush LPD 17, MPDE Lube Oil
System and Engine (NAVSEA S9233-DM-HBK-010-007)
55

ANTONIO (LPD 17)
16. All foreign material will not be removed from the lube oil
service system because the procedure discharges the flushing
medium into the main engine lube oil sump without being
filtered. [FoF (184, 188, 189)]
17. The failure to designate the alignment of temporary valves

prior to commencing the flush potentially resulted in diminished
flow to piping or caused external piping dead legs with no lube
oil flow resulting in contamination being released upon MPDE
operation. [FoF (184)]
18. The procedure did not meet the requirements of NSTM Chapter
233. [FoF (187-190)]
19. The procedure does not provide a true indication of the

level of contamination remaining in the lube oil service system
piping at the conclusion of the flush. [FoF (184, 185)]
20. The procedure as executed during the CNO PMA was inadequate
as the permanent lube oil service pumps were not removed. [FoF
(192, 193)]
21. The procedure should require documentation of the

contamination in muslin bags and sump to assess procedure
effectiveness. [FoF (190, 194)]
22. The permanent lube oil service pumps were not removed prior
to flush commencement preventing thorough inspection and
cleaning of pump parts and draw box potentially leaving
contamination in these areas. [FoF (192-193)]
Lube Oil Service System Design

23. The location of the self-cleaning filters upstream of the
duplex strainers will dump contaminated oil back to the MPDE
sump. [FoF (59-61, 70-72, 101, 104-110)]
24. Particulate smaller than 25 microns will pass through the

self-cleaning filter. [FoF (59-61, 70-72, 101, 104-110)]
25. The lube oil contaminates that are circulated back to the
MPDE sump via the self-cleaning filter are continuously reduced
in physical size by the macerating action of the lube oil
service pumps until the contaminates are small enough to pass
through the filter and duplex strainers. [FoF (102-111)]
56

ANTONIO (LPD 17)
26. Contaminates that pass through the filter and strainer

complex could still be large enough to cause bearing damage.
[FoF (102-111, 199-212)]
Bearing Damage
27. The damage to the main and thrust bearings occurred prior
to CNO PMA. [FoF (34-39, 42-45, 47, 63, 64, 66, 68, 71, 72, 85,
86, 88, 90-101, 199-212, 259-262)]
28. The primary cause of the damage to the main and thrust
bearing was the result of a lack of adherence to cleanliness
standards during the assembly and installation of the MPDEs and
lube oil support systems during new construction. [FoF (34-39,
42-45, 47, 63, 64, 66, 68, 71, 72, 85, 86, 88, 90-101, 199-212,
259-262)]
29. The 300 series stainless steel found in NR 1A, 1B, and 2A
MPDE lube oil service system did not cause the bearing damage.
[FoF (34-39, 42-45, 47, 63, 64, 66, 68, 71, 72, 85, 86, 88, 90-
101, 199-212, 259-262)]
Maintenance Performance and Quality Control Efforts

Shipboard Engineering Programs
30. SAN ANTONIO MPDE material history program is ineffective.
[FoF (213-218)]
31. SAN ANTONIO 3M program is partially effective. [FoF (219-

258)]
32. SAN ANTONIO Lube Oil Quality Management program is

ineffective. [FoF (122-184, 259-262)]
33. SAN ANTONIO Engineering Department training program is not

effective. [FoF (265-277)]
34. Had the Lube Oil Quality Management program been effective,
SAN ANTONIO personnel may have recognized the damage to the MPDE
main and thrust bearings sooner. [FoF (34-39, 42-45, 47, 63, 64,
66, 68, 71, 72, 85, 86, 88, 90-101, 122-184, 199-212, 259-262)]
LPD 17 Class Engineering Systems

35. SAMMS as a standalone system creates obstacles for ship’s
force to obtain and integrate lube oil sampling data into
material history. [FoF (216-218, 262, 278-290)]
57

ANTONIO (LPD 17)
36. Ship’s force’s ability to operate the plant during normal

and casualty operations is severely handicapped by the failure
of installed monitoring and control systems to operate properly.
[FoF (278-355)]
37. EOCC procedures for MPDE high bearing temperature casualties

are lacking in immediate and supplemental actions. [FoF (263,
264)]
38. Several systems: ICAS, ECS, and TSTS have not reached full
maturity or are not functioning. In addition, the ship’s crew
has not demonstrated the wherewithal to properly mitigate the
impact of operating a ship with diminished systems. The size of
the crew is a significant factor in the capacity to address
system challenges. The pre-commissioning training pipeline and
interim training courses appear insufficient to bring the crew
to the requisite level of knowledge to manage the propulsion
plant correctly. The reduction of manpower and the
incompleteness of designed support are contributing factors in
the operational unavailability of the LPD 17 class. [FoF (278-
377, 393, 394, 402-404)]
39. Several stakeholders recognize the lack of depth in

concerning the NTSP approach of self training, and have
recommended returning to traditional schoolhouse training as a
resolution. The process of how the crew will self-train is
inadequately discussed in the NTSP, and NAVMAC is not charted to
account for self-training in the accounting of personnel work
load. The stakeholders way ahead is to budget for the
infrastructure and instructor base in POM 12. [FoF (346, 349-
376)]
40. Training for the LPD17 class has not seen the rigor and
follow-up that is necessary to support long term sustainability
of level of knowledge necessary to support the life of the ship
sailor and maintenance. [FoF (265-277, 289, 303, 304, 338-418)]
41. Engineering PQS across all watchstations requires further

review and tailoring to account for major LPD 17 components and
systems. [FoF (405-418)]
42. EOOW PQS NAVEDTRA 43104 and Engineering Collaterals and

Qualifications PQS NAVEDTRA 43704 do not adequately address the
level of knowledge of engineering watchstanders for lube oil
systems and the associated engineering equipment supported by
the lube oil system. [FoF (405-418)]
58

ANTONIO (LPD 17)
RECOMMENDATIONS
1. SAN ANTONIO develop a comprehensive POAM in accordance with

EDORM to assess, correct and train engineering department in
critical programs to include QA, LOQM and LEGAL records by 1
February 2010.
2. SAN ANTONIO require all Lube Oil Kings re-qualify their

watchstations by 15 March 2010. Until complete all lube oil
analysis will be monitored by the ISIC.
3. SAN ANTONIO add roving watches to log and monitor plant

operations until ECS and ICAS operation has returned to normal
operation.
4. Revise SAN ANTONIO Engineering Department training program

to conform with the Surface Force Training Manual and Ship’s
Instruction by 15 March 2010.
5. Temporarily increase LPD 17 ship’s force manning/training

for ECS/ICAS/SAAMS/TSTS, until off-ship subject matter expert
support of propulsion plant systems is in place to support ICAS.
6. ISIC audit and correct SAN ANTONIO Engineering Department

preventive maintenance system deficiencies by 15 March 2010.
7. LSD/LPD CLASSRON audit engineering watch station PQS for

completeness and adequacy for the LPD 17 Class with
recommendations for changes to the Chief Readiness Officer (CRO)
by 15 March 2010.
8. Recommend scheduling of a diesel engine lube oil flush

completion only when all repairs and maintenance have been
completed.
9. LSD/LPD CLASSRON audit all ECS and ICAS alarm set points
against EOSS/Tech Manual Guidance/Class Advisories by 15 March
2010.
10. LPD CLASSRON standardize guidance on watchstation manning.
11. LSD/LPD CLASSRON in coordination with the Afloat Training

Group develop a LPD 17 master lesson topic guide list that
includes standandardized lesson plans.
59

ANTONIO (LPD 17)
12. Revise the Surface Force Training Manual providing TYCOM

guidance on long/short term training schedules; lesson plan
development, authorization and retention; use of subject matter
experts (especially Chief Petty Officers) for divisional
training; monitoring requirements; etc. that uses SUBLANT Joint
Training Manual and the AIRLANT Reactor Training Manual
requirements as guidelines.
13. Increase the number of DEIs commensurate to support

additional diesel plant platforms operation and maintenance.
14. NAVY QA Representative and Diesel Engine Inspector be

present during testing for verification prior to delivery to the
Ship Builder to create a build sheet of the engine assembly
process providing pertinent data will provided for engine
material history (web deflections, bearing presses, thrust,
saddle torque pressure, main bearing cap pressure, fuel nozzle
data are examples).
15. Schedule Certified Diesel Inspectors to inspect diesel

engines and engine support systems prior to the Shipbuilder
Engine Light-off and again prior to Ship Delivery in accordance
with COMFLTFORCOMIST 4790.3 REV-A Change-6 3.3.10.
16. NAVSEA and the LSD/LPD CLASSRON conduct a thorough

review/validation of all LPD-17 CLASS EOSS (EOCC, EOP)
procedures to include recent class feedback reports, class
advisories, etc. by 1 May 2010.
17. NAVSEA S9233-DM-HBK-010-007 Diesel Engine Maintenance

Standard Flush LPD 17 be rewritten to NSTM Chapter 233
requirements prior to the next MPDE lube oil flush onboard a LPD
17 Class ship.
18. NAVSEA 04Y research technical documents related to diesel

engine maintenance and repair for any existing foreign material
exclusion requirements; where requirements are found take action
to insure that contracted maintenance adheres to these
requirements.
19. NAVSEA 04Y reiterate Project Execution Maintenance Team

roles and responsibilities to Project Manager, Port Engineer,
Ship Building Specialist, Quality Assurance Specialist (QAS),
and Diesel Engine Inspector personnel. Emphasis should be
placed on oversight, checkpoints, and product verification
60

ANTONIO (LPD 17)
inspection of diesel engine maintenance and repair.

Additionally, determine requisite knowledge required of SBS/QAS
personnel to provide effective oversight of contracted diesel
engine maintenance.
20. Improve the training and quantity of RMC ECS/ICAS

technicians.
21. Develop fleet concentration area training for LPD17 class

to cover ECS/ICAS training and other key areas.
22. Review manning of LPD 17 class to include possible

development of a new (integrated systems) division to maintain
the ECS/ICAS system.
23. Expeditiously complete manning review of LPD 17 class to

include possible development of a new (integrated systems)
division to maintain the ECS/ICAS system. Direct NAVMAC to
consider and account for NTSP self -training premise in the
manpower analysis.
24. NAVSEA/Technical Warranty Holder follow-up on ECS/ICAS

assessment held in December 2009/January 2009 and provide a
clear path for completion of remaining outstanding items of
priority by 28 February 2010.
25. NAVSEA collaborate with NETWARCOM and SPAWAR to ensure

SAMMS can function as intended on LPD 17 class ships.
26. NAVSEA determine the causation of LPD 17 Class MPDE bearing
failures.
27. Stakeholders fund traditional school house and instructor

training for LPD 17 critical systems.
28. Improve LPD 17 Class oversight to ensure the maturation of

the training program, and ensure rigor is reinstated to the
process of ship building.
29. Conduct bottom up, top down review of SUPSHIP Gulf Coast
quality control process, and implementation of necessary changes
to increase rigor and develop a product that supports fleet
operations upon delivery.
61

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(b)(6)

(31) (b)(6) Summary of Interview

FOR OFFICIAL USE ONLY

(74) (b)(6) memo 5830 of 17 Dec 09 (3M Program)

FOR OFFICIAL USE ONLY

(116) PEO Washington DC 301804Z Mar 09 LPD 17 Class FY09

1. Pursuant to enclosure (1), and in accordance with reference

(1) In October 2008, MARMC/NNSY voyage repair team

FOR OFFICIAL USE ONLY

(2) In November and December 2009, NSSA Diesel

(3) In November 2009, NSSA determined that depot level

(4) An alternate means of contamination causing bearing

(5) Ship’s Force was slow to recognize lube oil

FOR OFFICIAL USE ONLY

leadership failed to effectively execute basic engineering

c. LPD 17 Engineering Systems

(1) SAN ANTONIO was designed to be manned and operated

(2) With ECS, ICAS, and SAMMS not functioning as

a. The Investigating Officer collected all reasonably

b. All documentary evidence included herein, is hereby

c. During the course of this investigation, the

(1) An audit of all Norfolk Naval Shipyard (NNSY)

(2) An audit of contracted depot level work completed

(3) Interviews with appropriate Norfolk Ship Support

(4) A technical evaluation of the adequacy and execution

(5) An external and internal evaluation of ship's force

FOR OFFICIAL USE ONLY

(6) An external review to validate if Sailor/Officer

(7) A review of the automated systems designed to support

(8) An audit by using the appropriate Technical Work

(9) A review of ship's force corrective and preventive

(10) Oral interviews with the chain of command,

(11) A review of NAVSEA technical documentation

(12) A briefing from NAVSEA representatives on the

(13) A review of the syllabus for training provided by

4. The Investigating Officer has the following prior

FOR OFFICIAL USE ONLY

5. The following personnel assisted in the conduct of the

a. (b)(6) Chief of Staff, Expeditionary

b. (b)(6) N4, Expeditionary Strike Group

c. (b)(6) N43, Naval Surface Force

d. (b)(6) Engineering Support,

e. (b)(6) Engineering Support,

f. (b)(6) Diesel Engine Inspector

FOR OFFICIAL USE ONLY

g. (b)(6) Maintenance and Material

h. (b)(6) , Norfolk Ship Support Activity (NSSA):

i. (b)(6) , Code 212.5, Nondestructive

j. (b)(6) Quality Assurance

k. (b)(6) Project Team Leader, Norfolk Naval

6. (b)(6) Expeditionary Strike

FOR OFFICIAL USE ONLY

7. (b)(6) provided legal

Metal Shavings Discovery and Causation

2. The weld joint failures were a result of poor weld

3. The poor weld techniques during new construction caused

4. The poor weld joint fit up during new construction created

5. From 2 to 23 November 2008, MARMC/NNSY voyage repair team

6. The repair included piping replacement using 304 stainless

8. Upon completion of repairs, the lube oil service system

9. Ships force continued to monitor lube oil duplex strainer

10. On 27 March 2009, SAN ANTONIO returned from the deployment.

FOR OFFICIAL USE ONLY