A misinterpreted navigation system, a sleep-deprived skipper, faulty equipment and an inexperienced bridge team led to the grounding of the Navy guided missile cruiser Port Royal on the night of Feb. 5, according to a Navy Safety Investigation Board report.

The very visible and very embarrassing four-day grounding of the Port Royal in 14 to 22 feet of water off the Honolulu airport's reef runway caused an estimated $25 million to $40 million damage to the ship.

Capt. John Carroll, skipper of the Navy's guided missile cruiser, had only 4 1/2 hours of sleep in 24 hours, and 15 hours of sleep over three days as he pushed to get the warship under way after shipyard repairs.

Carroll was qualified for the job, but was not proficient, the report said. He was at sea in command for the first time in nearly five years.

The 9,600-ton cruiser's fathometer, which measures water depth, was broken, and both radar repeaters, or monitors, on the bridge were out of commission.

A shift in the ship's navigation system led to erroneous information on the ship's position. The switch from a Global Positioning System to a gyroscope caused a 1.5-mile discrepancy in the ship's position and set off alarm bells that were continuously disregarded.

During the transfer of personnel back to shore that night using a small boat, the operations officer took a binocular bearing to the harbor landing from the boat deck and noted a discrepancy.

He tried unsuccessfully to radio others and then headed back to the bridge, where he immediately realized the cruiser was in the wrong spot.

Waves were breaking forward of the bow, and silt was visible in the water.

At 8:03 p.m., the Pearl Harbor ship was "soft aground" with the bow's sonar dome on the reef a half mile south of the reef runway.

Waves forced the 567-foot ship firmly onto the reef as the crew tried to free it. "Backing bell" and "twist" maneuvers using one screw, or propeller, failed.

The board found many equipment malfunctions and human errors — but said there were enough working sensors and visual cues to prevent the grounding.

"Bridge watch team, navigation, and (Combat Information Center) team did not work together to assess situation and keep the ship from standing into danger," the report says.

The safety investigation report, obtained by The Advertiser, said the ship ended up shifting two miles to the east.

The officer of the deck had been qualified for only three months, and had no experience operating at night in the vicinity of the reef.

According to the internal report, the quartermaster of the watch had stood three months of watch on a deployment a year earlier, but could not plot fixes in near-shore waters, so another sailor, a navigation evaluator, took over to plot the ship's position.

The navigation evaluator subsequently lost "situational awareness," officials said.

Qualified lookouts were on board for watch duty the night of the grounding, but they were working in the mess as food service attendants and were not allowed to assume the watch.

Set and drift were not calculated, the report states.

Carroll, the captain, "did not receive forceful recommendations to improve the navigation picture."

SUBJECT TO CHANGE

Names were not included in the report, the purpose of which is to enhance safety. The report says the information is still in the endorsement process and subject to change.

Capt. W. Scott Gureck, a spokesman for U.S. Pacific Fleet, yesterday said he would not comment on the safety board report.

Gureck said the report was not intended to be released to the public.

Norman Polmar, an analyst, author and authority on naval issues, said the safety investigation reveals a series of red flags that indicated that the Port Royal was potentially straying into danger.

"Three things should have caused an alarm bell in the skipper — no matter how little sleep he had," Polmar said.

"One is if you are operating in that area without a fathometer, you are in trouble.

"Item two, when you switch from one (navigational) system to another and it shows a significant discrepancy, you are in trouble.

"... And the third thing is when the operations officer came in, what he should have done is just dropped anchor right there (and) turned on all the lights."

Polmar also was incredulous that Carroll, the Port Royal's skipper, hadn't been to sea in command in nearly five years.

"That's the system that's wrong," Polmar said. "The system should have said if you are not at sea in three or four or five years ... he should have gone out in an identical ship with another captain. He should have been a rider for a day or two."

According to the report, the Port Royal was in the shipyard since Sept. 24, 2008, for maintenance and repairs. It was originally scheduled to leave dock Jan. 21, but the sea trials were delayed for two weeks, and scaffolding on the bridge wing was not removed until 30 minutes before the ship got under way on Feb. 5.

Carroll said he had 15 hours of sleep in three days before the ship got under way, and admitted that he was tired and the subsequent small boat operations added to his fatigue, according to the report.

Carroll appeared at a Navy hearing on the grounding and was given "nonjudicial punishment for dereliction of duty and improper hazarding of a vessel," the Navy said in June.

CONSEQUENCES

Carroll was relieved of his command soon after the grounding and was reassigned to the Pacific Fleet staff. He was appointed captain of the Port Royal in October 2008 and had commanded the frigate Rodney M. Davis out of Everett, Wash., in 2002.

Along with Carroll, executive officer Cmdr. Steve Okun appeared at the hearing and was given nonjudicial punishment for dereliction of duty, the Navy said.

Two officers and an enlisted sailor appeared at a separate hearing and also were given nonjudicial punishment for dereliction of duty and improper hazarding of a vessel, the Navy said. Their names were not released.

Damage to the Port Royal was estimated at $25 million to $40 million. That does not include damage to the reef, which the Navy has begun to repair.

Checks were commenced 72 hours prior to the under way. At sea, the ship performed under full power, steering and helicopter flight operation checks. Carroll spent most of his time on the bridge or in the Combat Information Center, the report states.

To foster a "strong relationship" with aviation assessors, who were requested on short notice, the ship's command added boat operations at night to return the passengers to shore, the report states.

The earlier navigation shift in the ship's "Voyage Management System" meant the Port Royal had a position error throughout its time at sea. The bridge team did not recognize the input difference, officials said.

The report also said bridge watchstanders silenced or ignored alarms calling attention to the position discrepancy.

The Port Royal is expected to remain in drydock into September for repairs including the refurbishment of the shafting, running gear, propellers, painting of the underwater hull, replacement of the bow sonar dome and its internal elements, and repairs to damaged tanks and superstructure cracks, U.S. Pacific Fleet said.

The Safety Investigation Board concluded that training was inadequate in a number of areas.

Its recommendations included a supervisory-level navigation course, as well as an "operational pause" of at least 96 hours between shipyard availabilities and sea trials to ensure crews are adequately rested and prepared for underway operations.