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Board of Inquiry - Explosion July 23, 1944

Opinion, Findings, Statements

Shortly after returning to Pearl Harbor on July 23, 1944, orders were issued to conduct an investigation into an accidental explosion aboard the USS BUSH that same day. The initial inquiry began on July 27th and concluded on July 29th. These proceedings were held aboard ship.

The explosion occurred when a 5-inch shell fired from the #3 5-inch gun struck the ship's antenna spreader. The investigative reports indicate that the type of shell fired (AA Common) had a base fuse that would detonate upon impact "against about inch mild steel plate". It also had an auxiliary detonating fuse that would explode upon impact with about the same or slightly greater thickness of plate. (This type of AA Common projectile was distinct from those with "nose" (proximity) fuses used against enemy aircraft and did not require an impact to detonate.)

Further the 5-inch guns had "stop cams" that were designed to prevent the gun from aiming and firing at structures on the ship. These stop cam settings were required to be periodically checked, and it appears the USS BUSH complied with these rules.

The records indicate that the primary cause for the explosion was the interpretation of written instructions from the Navy's Bureau of Ordnance. These instructions read, "The Bureau of Ordnance does not recommend designing firing stop cams for wartime use to prevent firing into forestays, halyards, antennae, and similar material .... When all this as been done, there must remain a slight acceptable hazard during wartime." The problem arose in the use and interpretation of the word "antennae".

The term "antennae" had been interpreted aboard the USS BUSH include the antenna spreader, which was a reasonable interpretation of the written instructions according to the Vice-Chief of Naval Operations. With the wisdom of hindsight, the antenna spreader should have been excluded from ship's "line of fire". The investigation judged that the spreader was not "linear" in nature - that it was substantial enough to cause the detonation of a 5-inch (AA Common) projectile.

After determining the reason for the accident, the Commander Destroyers, Pacific Fleet issued instructions clarifying the method of checking gun cut-out cams.

What follows are excerpts from the report filed by the investigating officer, Commander Herald F. Stout. His summary, along with statements from some of the ship's personnel, provide new insights into this tragic event. Beyond the investigation itself, the documents include some interesting information about how the ship's 5-inch guns were designed to operate and the explosive power of such weapons.

Editor's Note:
A special THANK-YOU goes out to the U.S. Navy and the Navy's Judge Advocate General's office. Without their assistance (and great recordkeeping!) this information would not be been available. Their helpfulness and support in documenting the USS BUSH experience was most appreciated.

To Investigating Officer's Opinion Statement

To Investigating Officer's Statement of Facts

Statements from USS BUSH Personnel

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1. That to repair the material damage done to the U.S.S. Bush will necessitate the following:

(a) Renewal of gyro setting shaft, #1 torpedo mount.
(b) Replacement of Mark 41 director completely.
(c) Renewal of #43 40MM director bulwarks.
(d) Patching of miscellaneous holes in decks and stacks.
(e) Renewal of medicine cabinet in emergency cabin.
(f) Renewal of stack cowling #2 stack.
(g) Renewal of antenna crossbar and framework on after side of #2 stack.
(h) Renewal of drain line at frame 72, starboard, main deck.
(i) Realignment of #43 40MM gun.
(j) Minor repairs to #4 boiler.

Estimated time to make repairs is eight days.

2. That the killed and injured personnel met their respective deaths and injuries in line of duty and not due to their own misconduct.

3. That the cut-out cams of all guns were properly checked through the bore but that interpretation of final paragraph of ComDesPac Serial 3283 on 13 October 1943 and paragraph 2a of O.D. 2071 .... was faulty in that a condition was allowed to persist in which gun could fire into the antenna spreader.

4. That no culpable negligence exists on the part of any persons in the naval service.

5. That a safety precaution should be promulgated specifying method of checking gun cut-out cams.

6. No further proceedings are recommended.

Harold F. Stout
Commander, U.S. Navy
Investigating Officer

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After full and mature deliberation, the investigating officer finds as follows:


1. That the cut-out cam of #3 gun, U.S.S. Bush, did permit the gun to be fired into the antenna spreader on #2 stack of said ship altho clearing other solid structure.

2. That the second round fired by #3 gun did in fact strike the outboard end of the starboard antenna spreader.

3. That the firing was conducted with service ammunition (AA Common) with Mark 18 mechanical fuse and Mark 28-7 base fuse.

4. That, because of striking the antenna spreader, the projectile detonated with high order detonation.

5. That the fragmentation of the projectile caused the following material damage:

(a) Miscellaneous dents in #1 torpedo mount; stripping of gyro setting shaft mechanism.
(b) Mark 51 director on starboard side of #2 stack demolished.
(c) Superficial misalignment of #43 40MM mount in train.
(d) Destruction of #43 40MM director platform bulwarks and numerous holes in deck of this platform.
(e) Holes in door 1-72-1, starboard bulkhead frame 72 main deck, overhead of galley deckhouse frames 86-98, after bulkhead emergency cabin, after bulkhead of pilot house and joiner door to pilot house from director trunk compartment.
(f) Holes in medicine cabinet, emergency cabin.
(g) Drain pipe, frame 72, from superstructure to main deck, starboard, ripped open.
(h)Antenna crossbar and braces on after side #2 stack destroyed.
(i) Extensive fragment holes in inner and outer stack, #1 and #2 stack; stack cowling #2 stack damaged beyond repair.
(j)Loose hand-hole superheater plates and a few loose bricks in backwall of #4 boiler.

6. That as a result of this fragmentation the following personnel were killed:

Berry, Forrest D. FC2c
Chotos, Harry Z. S1c
Lockhart, Raymond B. WT1c(T)
Lukowski, Eugene T. TM2c
Skudera, Daniel G. B2c

and the following personnel injured:

Treide, George B. Lieut.
Garnett, Ralph H. CBM(AA)
Robertson, Richard G. WT3c
Pugh, William R. MM2c
Jennings, Joseph StM2c
Pettay, Donald R. F2c
Troyan, Paul T. WT3c
Nordwall, Robert A. GM2c
Rankinen, Stanley P. F1c

7. That no known regulations exist requiring that the settings of the cut-out cams be checked through the bore of the gun.

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Excerpts from USS BUSH personnel statements

as noted in the


Late in the forenoon of July 23rd, the Bush was firing Exercise H, reverse slope firing, of shore bombardment off Kahoolawe Island .... This exercise was to include Exercise G, an Air Attack. The provisions of Exercise G are that the firing ship is to shift from shore bombardment and take the sleeve under fire with all guns which will bear taking care to fire on bearings clear of other vessels .... During Exercise H, the towing plane made two approaches which were such as to endanger the U.S.S. Lamson, which was leaving the immediate area, or result in firing over the island which also was considered dangerous by me. The Bush meanwhile continued to fire shore bombardment. The third approach of the plane was made from starboard in such a manner that firing on the sleeve was safe. Upon seeing that it would be so, I ordered fire checked and shifted to air target which was a sleeve just forward of the starboard beam. The plane before reaching the ship changed course 30 or 40 degrees to the right. When the plane crossed our track I ordered "commence firing" to the main battery and upon seeing the sleeve well within range, Sky Control was ordered to "commence firing". When the sleeve was 20 to 25 degrees on our starboard bow I ordered "cease firing". Just after ordering "cease firing", another salvo was fired. While watching for the result of this salvo a cloud of smoke passed the bridge. I looked aft and saw the results of the explosion. At this time I received word that we had some loaded guns. I picked a safe bearing and ordered them unloaded. I called the Executive Officer who was in C.I.C. and told him to investigate the seriousness of the casualty. I requested from SFCP that the exercise be terminated due to a serious gun casualty which would require assistance of the Lamson's doctor. The ship's doctor, who had first requested assistance of the Lamson's doctor, changed his mind and said he would rather not waste time, but get to Pearl Harbor as quickly as possible. Permission was obtained from the O.C.E. and the ship returned to port at 33 knots.
... Rollin Westholm, Lt. Commander and ship's Captain, July 27, 1944

All guns were in full automatic director controlled. Gun Three fired two rounds of service (AA Common) .... The first anyone knew of the casualty was after firing ceased the word came over the phones from Sky Control to get a doctor. I asked all guns where the casualty was but no one knew. All guns were loaded and were trained on the port beam and permission was requested to unload. Word came from the bridge to unload to starboard, which was done .... The shell that hit the antenna was evidently the second fired by Gun Three on the run .... The cut-out cam on Gun Three was cut before commissioning at Beth Steel in San Francisco, and was plotted by Lt. Zimmerman and myself. I believe that the antenna was added later. The cams have been checked periodically and would allow the gun to fire into the cross arm. The cam was not changed because of the interpretation of the instructions on cut-out cams. It has always been the understanding on this ship that cams should not prevent a gun from firing in stanchions, antenna, etc....It is my belief that the cam was operating properly. The pointer on Gun Three has always been instructed to open his key when the gun trains through the blind. The pointer was looking through his scope at the time and saw nothing but sky. The Checksight Officer says the same. The sight setter states that his dials were matched, although moving so fast he does not remember the settings.
... Harry C. Stanley, Lt. and Gunnery Officer, July 27, 1944

I was safety observer on Gun Three when the casualty occurred. Action starboard was given and we trained to the sleeve at about 50o relative. Both shells were fired to the best of my knowledge with the sleeve below and to the left of the crossed hairs in the sight. We trained toward port to about 15o for the second shot which must have been fired about eight seconds after the first shot ....
Q - Were you actually at the check sight during this firing?
A - Yes, sir.
Q - At any time during the firing of this G practice was a portion of the ship in your check sights?
A - To the best of my knowledge there was not.
... R. H. Buchanan, Ensign and Asst. Engineering Officer, July 28, 1944

The cut-out cams were checked in all mounts approximately three days previous to the accident. I say approximate because the check covered several days. All guns checked satisfactorily. Gun Three was reported as hitting on the yard arm of the main mast and fore mast and also would hit guns #43 and #44 if #43 and #44 were in extreme elevations. Other than that the cams were satisfactory.
... C. B. Jostes, Ensign and Assistant Gunnery Officer, July 28, 1944

I was standing on the gun platform deck of gun #45, slightly to the starboard side. I am the Local Control Officer for gun #45 and the after 20MM's .... Gun Three, which was directly in front of me and training from starboard to port at an elevation of approximately 75o fired. I heard only one report. The gun was trained just over director #43 and as the smoke cleared my eyes were fixed on the after stack as I knew director #43 was manned and I figured they would all be mad about Gun Three's blast what with flying cork and all. My first view showed me that Berry was apparently stunned as he wasn't moving or jumping around. I could see no other men. It was then that I noticed the damage to the after stack and starboard side of the antenna arm. Suddenly I realized that Berry was hurt, that he was unconscious, that he was hanging from the director and that there had been a casualty. I passed the word over the JY circuit that there had been a casualty on the after stack and to have the Doctor sent to director #43 but the word was not acknowledged from Sky Control. My gun had been trained on the starboard beam by the director operator. I tore my phones off and raced forward on the superstructure deck. I was not aware of the seriousness of the casualty until I reached the forward torpedo mount and saw Lukowski .... as there was nothing I could do for him I climbed the ladder to the director platform on the after stack. One man was lying at the top of the ladder against a stanchion which supported the life line. This man was Chotos .... He was dead - killed instantly. Berry was still hanging from the director .... definitely dead, probably killed instantly .... I could do nothing here so I went down the ladder. On reaching the superstructure deck I heard cries of pain and went down to the main deck, starboard side of the quarterdeck, and found three injured men. Two were not injured badly and were in little pain. I told them to go to the Sick Bay and wait for assistance. The other was Jennings. He had a number of small shrapnel wounds and was in pain so I had him lie down in a stretcher and gave him 1 grains of morphine. The Doctor came aft to where Jennings was and ordered Jennings taken to the forward battle dressing station. I then went forward on the quarter deck and helped carry Pugh, who had been placed on a stretcher, to the forward battle dressing station.
... Doble Doyle, Lt. (jg) and Supply Officer, July 28, 1944.

I was in my battle dressing station which is the Officer's Wardroom when notified by a member of the forward repair party that there was some men injured. I went to the scene of the accident and saw each of the casualties, ordering the men who were killed to be placed under the torpedo tubes, and the more seriously injured to the forward battle station. I then went to the forward battle dressing station and began examining and treating the injured and directing the men helping. Our help consisted of three hospital corpsmen and approximately ten other individuals, the majority of which were members of the forward repair party. Treatment of the injuries consisting of multiple wounds from shell fragment, continued until leaving the ship at 1615, at which time the more seriously injured consisting of nine cases, were transferred to the U.S. Naval Hospital, Base No. 8. The Medical Officer and senior hospital corpsman accompanied the injured men to the hospital and then returned to the ship at which time the men who were killed were taken off the ship and removed to the U.S. Naval Hospital, Aiea Heights .... Positive identification of the men who were killed was made .... The injured were identified by dog tags. There were no missing.
... George Johnson, Lt. and Medical Officer, July 28, 1944

Q - State all you know in connection with the subject matter of the investigation.
A - We fired two salvos and at "cease firing" we were still loaded.
Q - Were you using the telescope?
A - Yes, sir.
Q - At any time previous to "cease firing" did you see any portion of the ship's structure in your scope?
A - No, sir, never.
Q - Did you have the sleeve in your sight field during the firing?
A - Yes, sir, I had.
... Norman Kreis, GM2c and Trainer Gun #3, July 28, 1944

"Action Starboard", immediately they switched the gun back into director and jarred us around quite a bit. Upon "commence firing" I closed my key immediately, they put a round in and rammed it. The gun did not fire right away. I am sure that I heard four guns fire before my gun fired. I sat there for a couple of seconds and looked back at the gun crew to see that it was rammed and that the breech block was closed. I wondered why, during those few seconds, it did not fire. At that time the four guns were firing and I stepped on my pedal. Just as soon as I fired I had to kick it out again. These were the only shots fired prior to "cease firing". I only looked through the scope once right after firing the first round. All I could see was sky.
... John Mart, Jr., Cox and Pointer Gun #3, July 28, 1944

I was Assistant Gunnery Officer prior to the commissioning and after commissioning. About ten days prior to commissioning the cam was plotted by Lieutenant Stanley and Lieutenant Zimmerman. It was plotted through sighting through the bore. The sheets were turned into the yard prior to commissioning. I do not recall whether they came back to the ship before or after commissioning. I checked the plots and they cleared. The antenna must have been put on after the plotting of the cams.
... P. A. Lilly, Jr., Lieutenant and Executive Officer, July 29, 1944

The cams were cut before commissioning, approximately 14 to 10 days prior to commissioning. It did the actual plotting assisted by Lieutenant Stanley. At that time Gun Three cleared all the structure. I do not believe that the yard arm antenna was up. I am not completely certain of that. The cam plot was checked through the bore.
... J. E. Zimmerman, Lt. and Radar Officer, July 29, 1944

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