LEARN MORE ON PAGE 2

The Naval Safety Center Magazine for Surface, Submarine and Diving Operations 2017 Vol. 6|No. 2 

“THE END” IS ONLY THE BEGINNING

FAREWELL

LEARN MORE ON PAGE 2
EDITORIAL STAFF

Head, Media Division Evelyn Odango

Editor Michael J. Morris

Art Director Allan Amen

Graphics and Design John W. Williams

Webmaster Darlene Savage

Social Media Manager Leslie Tomaino

EDITORIAL OFFICE

Commander, Naval Safety Center

Attn: Sea Compass

375 A Street

Norfolk, VA 23511-4399

MEDIA DIVISION

Telephone: 757-444-3520, ext. 7870 (DSN 564) / Fax: 757-444-6791

General email: safe-seacompass@navy.mil

Editor's email: michael.j.morris@navy.mil

AFLOAT SAFETY PROGRAMS

To contact a safety analyst by phone, call the main number 757-444-3520 and dial 

the extension at any time during the greeting.

Telephone: 757-444-3520 (DSN 564)

Surface Division ext. 7831

safe-afloat@navy.mil

Submarine Division ext. 7838

safe-submarines@navy.mil 

Report a Mishap: (757) 444-2929 (DSN 564)

ABOUT SEA COMPASS

Sea Compass (ISSN 1550-1434) is published twice yearly (spring-summer and 

fall-winter). The editorial content of this magazine is edited and approved by the Naval 

Safety Center Public Affairs Office. Sea Compass is an authorized publication for 

members of the military services and distributed to ships, submarines, diving commands, shore-based commands, and DoD agencies. Contents and opinions expressed 

are not necessarily the official views of the U.S. Government, the Department of 

Defense or the U.S. Navy and do not imply endorsement thereof. Unless otherwise 

noted, photos and artwork are for illustrative purposes only. Reference to commercial 

products or links to non-DoD resources do not imply Department of the Navy endorsement. Unless otherwise stated, material in this publication may be reprinted without 

permission; please credit the magazine and author.

SUBMISSIONS

Submit your stories or news items to safe-seacompass@navy.mil. Email letters to: 

michael.j.morris@navy.mil or write to: Commander, Naval Safety Center, Attn: Sea 

Compass, 375 A Street, Norfolk, VA 23511-4399. We reserve the right to edit all 

submissions for grammar, clarity, applicability, and length.

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Norfolk, VA 23511-4399. Periodical postage paid at Norfolk, Va. 

Postmaster: Send address changes to Commander, Naval Safety Center, Attn: Sea 

Compass, 375 A Street, Norfolk, VA 23511-4399.

Commander, Naval Safety Center RDML Christopher J. Murray

Deputy Commander Col. Matthew Mowery, USMC

Director, Afloat Safety Programs CDR J. Lee Bennett, USN

Department Head, Media and Public Affairs Maggie Menzies

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2017

VOLUME 6|No. 2
“THE END” IS ONLY THE BEGINNING

FAREWELL

18 22

ACHIEVES SAFEST EPIA IN MORE THAN 

USS NIMITZ(CVN 68)

10years

CONTENTS VOLUME 6|No. 2

4 6

8 10

12 16

2

page

Get a Grip SLIPS, TRIPS & FALLS CAN KILL

COMPLACENCY

CAN BE A SHOCKING EXPERIENCE

DEVIATION CAN RESULT IN 

CATASTROPHE! OVERWATER ZERO ILLUMINATION NIGHT

LESSONS LEARNED

ON AN

ONE SPARK

TO DECLARE AN EMERGENCY OR NOT

TWO SPARK

E-CIGARETTES EXPLODINGIN

POPULARITY 

 & POCKETS
“THE END” IS ONLY THE BEGINNING

FAREWELL

Michael J. Morris

2 SEA COMPASS

HTTP://WWW.PUBLIC.NAVY.MIL/NAVSAFECEN
2011 fair winds and following seas 2016

Editor Sea Compass Magazine

Since1955, Naval Safety Center magazines have reached audiences 

throughout the aviation, afloat, shore, and shipyard communities.

Over the years, we have published 12 magazines, including special 

issues; only four remain in circulation today – Sea Compass, 

Decisions, Approach, and Mech. Publishing these magazines is not just about reaching an 

audience; it’s about being relevant and valuable in our mission to prevent mishaps, to save lives and 

preserve resources. The advice, policies, services, and risk management information and tools the 

Naval Safety Center provides enhance command safety culture, combat readiness, and the Navy’s 

global warfighting capabilities

While printed publications are still available today, many Department of Defense publishers have 

moved their magazine content to an online medium. Two of the driving factors for this shift have 

been the high cost of printing physical publications and general shift in preference by readership to 

receive content from an online or mobile platform. 

For these reasons, effective Spring of FY17, Sea Compass and Decisions magazine will no 

longer be published in hard copy format and the content of these magazines will be consolidated 

into a single online magazine. We anticipate launching a bi-monthly PDF based version of the new 

publication in March of FY17, with an immersive interactive online version to follow.

Our goal from this point forward is to reimagine naval safety publications - boldly looking 

forward to mobile technologies, e-pubs, and social media. We will create an integrated multi-tiered 

network of media that will reach audiences where they read, browse, watch, and listen.

In addition, the safety center will also be launching 360° Safe, our new online safety magazine 

with the primary focus of communicating NAVSAFECEN’s key mission objectives that support 

fleet operational priorities by addressing safety assessments, operational risk management, mishap

reporting, and high velocity learning. The Naval Safety Center’s overall goal is to enhance the 

reader(s) ability to make good decisions and manage risk - at work and off duty.

We would like to thank all the subscribers of Sea Compass for five years of loyal readership. We 

look forward to providing you a fresh take on safety publications coming this Spring. 

Until then... Farewell, “The End” is only the beginning.

3 2017

VOLUME 6|No. 2
AviationOrdnanceman 

Airman Esmeralda 

Silvestre had just 

finished lunch and 

was heading back to her workspace in a magazine on the seventh deck of USS Nimitz (CVN 

68). Access to the magazine was through a vertical trunk that led from the second deck, 

all the way to the bottom. She mounted the ladder and began her descent, just as she had 

done hundreds of times before. This time something would go terribly wrong. 

Image source: USS Nimitz PAO

Get a Grip SLIPS, TRIPS & FALLS CAN KILL

CDR Jason Garrett

4 SEA COMPASS

HTTP://WWW.PUBLIC.NAVY.MIL/NAVSAFECEN
As with any large ship, slips, trips and falls are 

the number one cause of injury on USS Nimitz; 

not surprising considering how many ladder-wells, 

vertical ladders and trunks we have onboard. 

While it’s important to continuously stress the 

necessity for maintaining three points of contact 

anytime a Sailor mounts a ladder, inevitably, 

someone will fall. That’s why it is equally 

important to stress to our Sailors the importance of 

learning how to respond when they are the first o 

the scene of a crisis. 

In this case, the hero of the day, a contractor and 

a prior Navy corpsman, knew exactly what to do. 

He quickly called for help before rendering aid to 

the Sailor. When he determined that her injuries 

were not immediately life threatening, he focused 

on minimizing any further damage. He made sure 

that she remained immobile until medical experts 

were on scene to take charge of the situation. His 

heroic actions may have saved her life; would you 

have responded similarly?

During crisis, heroes don’t rise to the occasion, 

they default to their training, just as the contractor 

did. That is why it’s so important to take advantage 

of the training opportunities offered onboard your 

ship or installation. Whether it is CPR or advanced 

first aid, firefighting or damage control, learn 

how to respond appropriately to a crisis can help 

ensure that you are prepared to do the right thing. 

The training and knowledge you attain can save the 

ship or a shipmate.

The ladder rails that transition past the third deck 

have a cut out. It’s a tricky spot to navigate, even 

if you’re used it. It was at this point that she lost 

her grip before securing her footing and she began 

to fall. Her hands reached out for the ladder rungs, 

but they missed. A petite Sailor, standing just over 

5 feet, she easily slipped through the cut outs in the 

safety nets that were supposed to catch her. She 

plummeted straight down, falling 45 feet before 

impacting the steel deck below. Lucky for her, an 

unlikely hero was nearby.

At the same time she was entering the trunk, a 

civilian contractor was working below, near the 

trunk access on the sixth deck. He looked toward 

the access just as she fell past. An instant later he 

heard the unmistakable sound of her body hitting 

the deck. Only a few years earlier, the contractor 

had been a Navy corpsman and his training 

instantly kicked in. He scrambled toward the trunk 

access and looked down, confirming that there wa 

a Sailor sprawled out on the deck below. He yelled 

up at his partner who was near the top of the ladder 

and told him to go for help. As his partner ran for 

the quarterdeck, the contractor descended to the 

seventh deck. 

Silvestre was conscious and semi-coherent. 

She lay on her side and asked to be rolled onto 

her back. The contractor had been trained for 

this type of crisis so he refused to move her. He 

knew that any movement with a broken back or 

fractured ribs could cause permanent paralysis or 

even death. Instead, he checked her vitals, held 

her hand and kept her company until members of 

the shipyard’s federal fire department arrived. I 

a short time, they had 

extricated her from the 

trunk via a stretcher and 

hoist and then moved her 

to the flight deck. Onc 

on the flight deck, th 

shipyard crane lifted her 

to the pier and an awaiting 

ambulance.

After a potentially fatal 

fall, Silvestre fortunately 

only suffered from a 

concussion and minor contusions. She was sick 

in quarters (SIQ) for several days to recover. Once 

Medical declared her fit for full dut , she was back 

to work shortly after. 

As with any large ship, 

slips, trips and falls are 

the number one cause of 

injury on USS Nimitz... 

5 2017

VOLUME 6|No. 2
Themorning started out like any other morning during our 

busy maintenance availability in the shipyard. There 

were deadlines that had to be met under seemingly 

impossible conditions, systems were being brought 

out of lay-up, sponsons needed preservation, and qualifications and training milestones 

were being pushed. On top of all that, contractors needed to finish up electrical work in 

several controlled spaces that I worked in. My job, at the end of a long nightshift, was 

to simply escort three contractors while they completed their work in my office. It was 

during that one simple task that the following mishap occurred, and why I find myself 

telling you this story. 

COMPLACENCY

CAN BE A SHOCKING EXPERIENCE

Image source: USS Nimitz PAO

FC2(SW) Alexander Thomas

6 SEA COMPASS

HTTP://WWW.PUBLIC.NAVY.MIL/NAVSAFECEN
That morning, I unlocked the spaces where the 

contractors would be working and waited for them 

to arrive. A short time later I found myself shaking 

hands with all three of them as they carried in tools 

ready to get to work. One of the contractors started 

work on an electrical junction box inside a dimly 

lit space that adjoined the office. The junction box 

routed 440-volt electricity to a vent damper system 

that would secure ventilation during a missile 

launch; preventing toxic gases from the missile 

exhaust from entering the skin of the ship and 

endangering the crew. 

I watched the contractor as he worked on the 

junction box. I quickly assumed that he had tested 

the circuit and verified that it was dead as he wa 

working without any electrical safety gloves or any 

other electrical personal protective equipment (PPE). 

As I watched, I thought I could speed things along 

by offering to help. I handed him tools and parts to 

assist with the job. Seeing how easy the work was, 

I decided I could help even more. Being a senior 

technician, trained and experienced in electrical 

work, I went over to the other junction box and 

began performing the same repair. My department 

trains us to tag out all three of the connection boxes 

whenever any of them are being worked on. Since 

the contractor’s junction box was clearly tagged out, 

I assumed all of them were. I assumed wrong.

I got to work, making good progress, finall 

unwiring the third of three wires when the 

unthinkable happened; I got shocked. I felt a surge 

of 440-volts coursing through my body. I dropped to 

my knees and miraculously broke contact with the 

live circuit. Startled and powered by a quick jolt of 

adrenalin, I stood up and ran from the space. 

Moments later I stood in my office where th 

light was better and I began to assess the extent of 

my injuries. My hand felt warm and I saw a chunk 

of burned flesh missing from the palm. I couldn t 

believe it. I called out for the contractors to help 

and thankfully they came quickly, ready to assist. 

One of them called for my Division Officer wh 

was working in the space directly above us. Normal 

procedures for a shock on the ship are to stay where 

you are when shocked and let medical come to you, 

but that probably wouldn’t have worked out well 

in my situation. As soon as my Division Office 

realized what had happened and knew that I needed 

help, she grabbed me by the arm and escorted me to 

Medical herself. She knew from experience that due 

to the very unusual access requirements to get to our 

office space, if Medical had tried to come to us, i 

might have been too late for me. 

Medical personnel quickly checked me over; 

hooking me up to an electrocardiogram monitor to 

make sure my heart wasn’t out of rhythm. They also 

started treating the burns to my hand. As I sat there 

being treated, my mind was racing. All I could think 

about was how lucky I had been to have survived 

the shock. Even though I knew better, I made several 

mistakes that nearly killed me.

First, I assumed that the junction box that I was 

working on was tagged out. Since my earliest 

memory, my mother had told me never to assume 

anything. She taught me to divide the word ‘assume’ 

to understand the true meaning behind it. After being 

shocked, her words never felt truer. If you do, it can 

get you in a lot of trouble. That’s good advice worth 

repeating, never assume anything, instead, always 

know for certain.

Second, I ignored the basic safety practices that 

have been drilled into me since my first day o 

training in advanced electronics. I’ve been taught 

that for anything over 30 volts, do an initial voltage 

verification (IVV) before working on it and use th 

proper PPE. If I had followed those procedures, this 

incident would never have happened. 

It’s never a good idea to rush or cut corners 

when dealing with electricity. I wanted to assist the 

contractors so they could finish their work quickl 

and I could go home. In my haste, I strayed from 

procedural compliance and nearly had a lethalshock. I am not the first person in the U.S. Navy t 

experience an electrical shock of this magnitude and 

live to tell the story, but I also know there are many 

shock victims who were not so lucky, and will never 

be able to share their experience. I hope you take 

heed and avoid making the same mistakes that have 

killed others in the past and that almost killed me. 

My hand felt warm and I 

saw a chunk of burned flesh 

missing from the palm.

7 2017

VOLUME 6|No. 2
Thesun was just starting to peer over the horizon on a 

day that started like any other aboard the USS Carl 

Vinson (CVN 70). Gearing up for our fast-approaching 

workups, the Helicopter Sea Combat Squadron Eight 

(HSC-8) “Eightballers” were stretching our previously idle sea legs on a brief seven-day 

Fleet Replacement Squadron (FRS) carrier qualification detachment. FRS students were 

getting their shot at landing on the carrier, and we were there to provide plane guard 

support for the young pilots as they caught their first wires. 

CAUTION:

DEVIATION CAN RESULT IN 

CATASTROPHE!

AT2 Ruben Navarro

Image source: U.S.Navy

8 SEA COMPASS

HTTP://WWW.PUBLIC.NAVY.MIL/NAVSAFECEN
I thought about the day’s upcoming tasks. Day 

check line personnel were to be sent to the fligh 

deck to start preps, ride brakes, and spread aircraft 

620 for the day’s upcoming flight schedule – al 

standard flight deck procedures. Although the 

HSC Community 4th Quarter Safety Campaign 

emphasized personnel focus on what differs from 

day to day, I wasn’t too concerned. Yes, we were 

spread thin at the time for day check personnel, 

with none of those present personnel having had 

any previous boat experience, but this was a short 

detachment with only three aircraft.

On the flight deck, one of the many benefits 

the MH-60 helicopter is its ability to be completely 

folded, rotor blades swept directly over the fuselage 

and tail pylon tucked to the side of the aircraft. This 

makes the aircraft portable and easily stowed when 

not in use. To unfold the blades was not a lengthy 

procedure, but a pivotal one; if the blades and tail 

are not spread correctly prior to flight, the result 

could damage the aircraft, increasing maintenance 

workload and decreasing squadron readiness. 

On this particular morning, both the tail pylon 

and the rotor blades of aircraft 620 were folded, 

meaning that the day check personnel had to 

execute a full spread evolution. Ashore, this was 

not a common occurrence; we typically only folded 

the rotor blades, and not the tail pylon, for easy 

towing into the hangar on weekends. However, 

this was a straightforward procedure and it was a 

calm and quiet morning on the flight deck. I didn t 

anticipate any problems, which is precisely when 

things started to go wrong.

 As the supervisor began his pre-spread 

inspection on the aircraft, one of the newer airmen 

began to remove the crutches from the rotor blades, 

as he would have at home. But unlike at home, 

the tail pylon was still folded. Unbeknownst to 

my airman, there was a caution statement in a 

maintenance publication for this exact scenario that 

states: “CAUTION: Due to proximity of the No. 

3 blade (yellow) to tail gear box cowling, removal 

of blade restraints [crutches] 

before spreading the tail pylon 

may result in the No. 3 blade 

(yellow) trim tab impacting 

tail gear box cowling.” True 

to the caution statement, the 

removal of the blade crutch gear 

caused the yellow blade to drop 

and hit the tail gearbox fairing, 

bending the trim tab. While the trim tab was bent, 

not broken, it had to repaired, sending the aircraft 

into a ‘Functional Check Flight’ that lasted several 

days. Since we were embarked with three aircraft, 

this severely impacted both the maintenance and 

the operations departments, threatening the smooth 

flow of the flight schedule we were depended up 

to execute. 

This incident was extremely close to being a 

Class D ground mishap. If the HSC-8 maintenance 

team was unable to fix the trim tab and the blad 

needed to be replaced, this incident would have 

cost the Navy over $30,000. Although no lasting 

damage happened this time, it is imperative that 

all squadron personnel review routine procedures 

and brief their personnel on how these procedures 

differ when underway. On this day, I failed to 

challenge my team with, “What is different today?” 

Personnel under my supervision could have set my 

squadron, and the Navy, back thousands of dollars 

but instead increased maintenance hours and 

removed an asset from the flight schedule for thre 

days. 

 The difference was a folded tail in this case. 

What could it be on another day? Another ship? 

A different day check team? Supervisors need 

to supervise their personnel and personnel need 

to identify hazards and meticulously follow 

procedures. We need to work as a team to identify 

and mitigate hazards by pausing to understand all 

aspects of a situation. Prior to our next detachment, 

maintenance will know what to look for and how 

to use operational risk management (ORM) to 

appropriately combat associated risks. 

Although this incident did not cause any 

permanent damage, deviation from standard 

procedure can result in catastrophe. It is imperative 

to follow procedures, heed cautions and warnings, 

and work together to foster a safe working 

environment in an inherently dangerous workplace. 

If the HSC-8 maintenance team 

was unable to fix the trim tab 

and the blade needed to be 

replaced, this incident would 

have cost the Navy over $30,000. 

9 2017

VOLUME 6|No. 2
Atapproximately 2230, on a 0.0 percent illumination night, I 

experienced many firsts as a pilot qualified in model (PQM) for an 

FRS CQ Detachment: my first night plane guard flight, my first time 

taking off Spot 7, and shortly after takeoff, my first real emergency 

in the MH-60 Sierra ‒ a main transmission chip caution. With 0.0 percent illumination and 

without a visible horizon, I quickly learned the necessity of trusting your instruments as 

the primary means of navigating around the ship. After several laps in the Starboard ‘D’, 

and roughly six miles off the carrier’s starboard side trucking towards it, we noticed the 

master warning caution and MAIN XMSN CHIP caution illuminated on our flight display. 

As a crew, it became evident that our mission of flying plane guard had now shifted to 

successfully fighting the emergency at hand and getting the aircraft on deck safely.

OVERWATER ZERO ILLUMINATION NIGHT

LESSONS LEARNED

ON AN

LTJG Eli Sinai

Image source: U.S.Navy

10 SEA COMPASS

HTTP://WWW.PUBLIC.NAVY.MIL/NAVSAFECEN
The helicopter aircraft commander (HAC), LT 

George Meszaros, immediately took the controls, 

contacted Tower, informed them of our main 

transmission caution, declared an emergency, and 

requested a Spot 9 landing. Tower complied and 

ensured that all jets were clear so that we could 

make a safe approach. As a crew, we completed 

all critical memory items and determined our 

landing criteria. LT Meszaros instructed me to turn 

on the auxiliary power unit (APU) and check our 

temperature and pressure indications, which were 

all normal, and we had no additional advisories 

or cautions that would suggest our landing 

criteria was anything other than “land as soon as 

practicable.” I asked our aircrewmen if they heard 

any unusual transmission sounds in the cabin, 

at which point they informed us that they heard 

“zipping and grinding sounds” coming from the 

cabin. Those words changed everything. 

Per Naval Air Training and Operating Procedures 

Standardization (NATOPS), the warning in the 

emergency procedure reads, “Possible indications 

of Main Transmission imminent failure may 

include: yaw attitude excursions with no control 

input, an increase in power required at a fixe 

collective setting, failure of a main generator 

or hydraulic pump, increased noise, increased 

vibration levels, or abnormal fumes in the cabin.” 

This warning 

does not mention 

zipping nor 

grinding, however 

this nonstandard 

description of the 

noise our crew 

was hearing gave 

us enough reason 

to believe that our 

emergency had 

become more than 

a “land as soon 

as practicable” 

scenario. 

We entered a profile of 200 feet above groun 

level (AGL) and 70 knots indicated airspeed 

(KIAS) to minimize power required and LT 

Meszaros informed the crew that he would be 

making a no-hover landing to Spot 9, which we all 

agreed was the smart landing decision. The landing 

itself was safe without issues, and there were 

maintenance personnel awaiting our arrival on Spot 

9 to assist us with fighting the eme gency should 

any unexpected condition arise. 

As we concerned ourselves with shutting down, 

we were delayed because our plane captain was 

unaware of the emergency situation that had 

unfolded due to poor communication with Tower. 

After several minutes, we were finally give 

the go-ahead to shut down. As we prepared to 

begin folding the blades, we once again ran into 

another delay, as the blade fold cheater box was 

malfunctioning. Meanwhile, the Alert 30 crew 

that had rushed to our aid was stalled as it took 

nearly 25 minutes for flight deck personnel to spo 

the aircraft. As all of this was happening, fligh 

operations had come to a halt until plane guard 

could be re-established. As carrier Sierra pilots, we 

recognize that our responsibility to the Air Wing is 

to provide a ready and capable platform for search 

and rescue; as frustrating as it was for us to deal 

with these obstructions to performing our duties, 

we were safe on deck and had effectively fought 

our emergency. 

After removal and inspection of the transmission 

filte , Maintenance found several small flake 

and one larger chip, all of which were within 

limits. Our maintenance team effectively executed 

corrective actions that included a drain and flush o 

the transmission oil system, and replacement of the 

filte . After a penalty 

turn, the aircraft was 

declared up the next 

day. 

As a result of this 

experience, I took 

away several key 

lessons learned. 

Our HAC took 

charge and made 

the right decisions, 

ensuring he aviated, 

navigated, and 

communicated 

just as we had briefed. We took the appropriate 

precautions monitoring our instruments for 

secondary indications and turning on the APU. 

Even if the chips in the system were technically 

within limits, we followed NATOPS and used 

solid crew resource management to make sure our 

emergency did not evolve into anything worse. In 

so doing, we certainly made my first night plan 

guard flight an experience that I will never fo get.

I asked our aircrewmen 

if they heard any unusual 

transmission sounds in the 

cabin, at which point they 

informed us that they heard 

“zipping and grinding sounds” 

coming from the cabin... 

11 2017

VOLUME 6|No. 2
√

10years

MC2 Holly L. Herline

ACHIEVES SAFEST EPIA IN MORE THAN 

It starts from the day a new recruit gets to boot camp. They’re expected to 

carry out every action, from the way their racks are made to the precise 

positioning of the recruit manual they must carry in their right hand. Boot 

camp stresses the importance of following directions closely without 

making mistakes or missing steps. 

USS NIMITZ(CVN 68)

Image source: U.S.Navy

12 SEA COMPASS

HTTP://WWW.PUBLIC.NAVY.MIL/NAVSAFECEN
Over the course of the yard period, the Safety 

Department implemented an approach that they 

referred to as “Find it. Fix It.”. The idea was that 

if they found an issue or deviation from the safety 

standards, no matter how big or small, they would 

bring it to the attention of the Sailors in charge of 

the work being done. 

“We set incredibly high safety standards from the 

very beginning and made sure everyone knew it,” 

said Garrett. “We would go looking for the smallest 

discrepancies to put them into a spreadsheet and 

send it out the leadership daily. Those issues 

continuously got fixed.

This process proved to be effective in multiple 

ways. First, fixing the small things as soon a 

they were identified, then getting them correcte 

immediately prevented them from becoming bigger 

violations and contributed to the rectification o 

the already existing problems that were out of 

compliance. 

Second, it set a precedent of positive involvement 

from the Safety Department that sometimes doesn’t 

exist during a yard period. Being approachable 

about safety questions and always willing to help 

find the solution to any safety hits they found wa 

one of Safety’s largest goals. 

“Our approach helped to foster a lot of 

cooperation between us and the crew and people 

respected that,” said Petty Officer 1st Class Gre 

Geske, a member of Nimitz’ Safety Department. 

“We rarely got kick back.” 

Developing and maintaining a culture of safety 

at a command as large as Nimitz takes a lot of 

teamwork. Safety teamed up with Code 106, the 

shipyard’s safety team, to help keep safety in the 

forefront of everyone’s mind. 

Their collective effort is what kept Sailors 

informed and gave them the tools and motivation 

Every military evolution has a set of directions, 

if followed, is intended and proven to prevent 

injury. It is imperative that a Sailor be able to carry 

them out without mistake to ensure the safety of 

themselves and others. 

With the completion of USS Nimitz (CVN 68)’s 

recent extended planned incremental availability 

at Puget Sound Naval Shipyard (PSNS) comes the 

recognition of performing the safest aircraft carrier 

availability in the last 10 years.

This availability comes in as a complete anomaly 

with nearly half the injury rates of any maintenance 

period recently recorded at PSNS. Nimitz 

concluded the yard period with a total case incident 

rate (TCIR) of 3.02. 

The average TCIR for an aircraft carrier going 

through a maintenance period similar to the one 

Nimitz just completed is usually in the sixes, 

according to Cmdr. Jason Garrett, Nimitz’ safety 

office . 

TCIR is defined as the average number of work

related injuries incurred by 100 workers during a 

one-year period. Use of the TCIR report allows 

for the comparison of accident and injury statistics 

across industries and segments of work.

Due to the inability to accurately track a Sailor’s 

work hours, TCIR only accounts for shipyard 

worker’s work-related injuries. In most cases 

evidence suggests if required data could have been 

obtained, a similarly low mishap rate for Sailors 

would also have manifested itself.

“By the time we hit the four-month mark we 

already had people coming from all over the place 

to figure out what we were doing di ferently to get 

these results,” said Garrett.

Nimitz works hard to cultivate an atmosphere that 

promotes first time quality while always keepin 

safety in mind. At the core of one the safest carriers 

in the fleet is the Nimitz Safety Department. 

“There are many reasons that safety in general 

is important,” said Garrett. “If you work in a 

very dangerous environment where people are 

constantly getting injured, the work proficienc , 

production and morale all go down. There are a 

lot of things that come as a result of safety and 

we were dedicated to promoting job efficienc 

and effectiveness.”

13 2017

VOLUME 6|No. 2

By the time we hit the fourmonth mark we already had 

people coming from all over 

the place to figure out what we 

were doing differently to get 

these results.
to carry out daily tasks free of danger and harm. 

It also helped that Nimitz Sailors and PSNS 

contractors accepted the process. 

“The leadership setup a culture of safety that 

went from the very top to the very bottom of the 

deck plates,” said Garrett. “It came down from the 

captain and the project superintendent and trickled 

all the way down from the officers and chiefs to th 

junior Sailors and those that were doing the work 

day in and day out.”

The numbers alone prove that Nimitz had safety 

figured out in the yards. Now that Nimitz i 

underway, Safety’s newest mission is to maintain 

that standard while dealing with the new challenges 

of a fully operational aircraft carrier. 

The beginning of Nimitz’ preparation for her 

upcoming 2017 deployment brings with it added 

obstacles as the ship acquires its full capabilities. 

“We are going to have to learn how to safely 

operate side by side with the air wing and strike 

group,” said Geske. “Integration is our new goal 

and we’re excited to do it and become a safely 

operating team.”

While underway, it is Safety’s job to provide a 

constant presence and be at every major evolution 

to be the extra set of eyes and make sure the proper 

procedures are being carried out. 

Anyone in the Navy has likely heard the 

expression “written in blood” time and time again. 

This saying comes from the fact that every safety 

rule and regulation the Navy has implemented has 

come from an injury or life lost. The Sailors of 

Nimitz’ Safety Department work hard to ensure 

no more rules are written in the blood of a Nimitz 

Sailor. 

Image source: USS Nimitz PAO

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15 2017

VOLUME 6|No. 2
LT George Guagenti

Thecarrier was setting flight quarters for the first time 

in almost two years during flight deck certification 

underway. As an MH-60S squadron, HSC-8 was attached 

to the aircraft carrier to provide plane guard (PG) and 

logistics, but tonight our aircraft was scheduled for just a simple two-hour night deck 

landing qualification (DLQ) flight to certify Spot 7. Our plan included wagon-wheel 

landings with our sister squadron, HSM-75, who was flying an MH-60R aircraft and 

handling PG. Both aircraft were expecting a continuous green deck for multiple landings 

on Spot 7, while the flight deck was simultaneously landing fixed wing jets for air wing 

carrier qualifications (CQs).

ONE SPARK

TO DECLARE AN EMERGENCY OR NOT

TWO SPARK

Image source: U.S.Navy

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Shortly after takeoff, both helicopters were informed that the elevator on Spot 7 was needed to move 

aircraft and Spot 7 would be unavailable for some time. We coordinated airspace deconfliction with th 

MH-60R and decided to conduct search and rescue (SAR) training until Spot 7 was cleared. After about 

30 minutes, the helicopter aircraft commander (HAC) was about to engage an automatic approach when 

a white flash was seen under the night vision goggles (NVGs) fr m behind the co-pilot’s seat. The HAC 

called “terminate” and directed the co-pilot to climb to 250 feet, while he began to troubleshoot.

The HAC selected the diagnostics page to look for any systems degradations, but found none. The crew 

chief (CC), in the left gunner’s seat, had also noticed the flash and immediately began using is flashligh 

to look for any smoke, charring, or additional sparks or flashe . The second crewmen pulled out the 

portable fire extinguisher as an added safety precaution

We turned in toward the carrier and asked the MH-60R how much fuel it had remaining in an attempt to 

minimize the impact on flight operations. Since the flash had o y occurred one time, we asked if the MH60R needed to land first to refuel before we landed at Spot 7 a d shut down, but they had enough fuel to 

continue covering PG duties. Continuing inbound, we also used the forward-looking infrared (FLIR) to see 

if Spot 7 was clear, but we saw a jet sitting on the elevator marking Spot 7. We also decided to make small 

maneuvers to ensure that any turns, descents, or changes in pitch would not trigger another spark and we 

did not see any.

As we got closer to the carrier, we called our squadron representative (Rep) to relay our plan and help 

coordinate clearing Spot 7. Our Rep informed us that there was no specific timeline for when Spot 7 woul 

be clear. At this point the aircraft received a second spark in the same area as the first. We contacted Tower 

and requested that Spot 7 be cleared as soon as possible so that we could land and shut down. We did not 

declare an emergency and did not ask to land on Spot 9 or any other spots due to the impact that would 

have on air wing CQs. We flew along the starboard side of the carrier for an additiona 10 minutes before 

Spot 7 was cleared and we were called to land.

Upon entering translational lift on our approach, the added vibrations resulted in multiple small flashe 

seen only by the CC. This increased the crew resource management (CRM) required for the landing, as 

the HAC directed the CC to provide deck calls to back up the co-pilot executing the landing from the left 

seat. Once on deck, there were no further instances of any flas es or sparks. After shutdown, maintenance 

discovered that the sparks were due to a harness in the cabin that was not properly secured.

There were several lessons learned from this experience, but most important was the decision to not 

declare an emergency and land at another spot while Spot 7 was unavailable. 

Instead of immediately landing and 

shutting down, we stayed airborne for 

approximately 15-20 minutes after the 

first spark. We had discussed the situation 

as a crew and decided to stay airborne for 

an extended period of time because of the 

reluctance to disrupt Air Wing CQs. After 

a thorough debrief, the crew concluded 

that we should have landed sooner by 

declaring an emergency and landing on 

Spot 9. Next time, we might not be that 

lucky when we get that second spark.

After a thorough debrief, 

the crew concluded that we 

should have landed sooner 

by declaring an emergency 

and landing on Spot 9. 

Editor’s note: The title image is for illustrative purposes only and does not represent the events described in the article. 17 2017

VOLUME 6|No. 2
LT Andrea Benvenuto E-CIGARETTES EXPLODINGIN

POPULARITY 

 & POCKETS

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USSO’Kane (DDG 77) recently completed damage control 

and medical training events and the crew was ready 

to respond to a casualty at a moment’s notice. While 

the Sailor was walking through a passageway, his 

e-cigarette lithium battery exploded in his hip pocket causing the fabric of his Navy Working 

Uniform to ignite and subsequently char to his leg. Like a rocket, the white-hot e-cigarette 

battery traveled down and around his leg, eventually burning through his bloused NWU pants 

and falling to the PRC deck. The battery was so hot that it even melted a portion of the deck. 

First responders assisted the Sailor in removing his pants and used his water bottle to cool the 

still burning battery preventing any further damage. The Sailor was taken to the emergency 

room, via ambulance, where he was treated for shock and the extensive burns to his leg. He 

was placed on convalescent leave for over a month and will require extensive skin grafting 

treatments to recover from the injuries.

“MEDICAL EMERGENCY, MEDICAL 

EMERGENCY, MEDICAL EMERGENCY 

IN COMPARTMENT O2-170-1.” 

Quick and deliberate actions by witnesses in nearby spaces 

limited the extent of his injuries until help arrived. What 

could cause a fire in the pocket of a Sailor’s Navy Working 

Uniform and result in third-degree burns covering 8.0 

percent of his body? The culprit was a set of house keys 

and a lithium battery belonging to an electronic cigarette.

19 2017

VOLUME 6|No. 2
With their popularity increasing, Electronic 

Nicotine Delivery Systems (ENDS), which include 

e-cigarettes and vaping devices, provide what is 

thought to be a healthier alternative to regular 

cigarettes. According to medical professionals, the 

safety and health effects of these e-cigarettes is still 

not known. Aside from the lack of cancer-causing 

tar from tobacco-laden cigarettes, e-cigarettes — 

because of the need for battery power — pose 

additional dangers, especially in an industrial 

environment such as a warship. Many recent 

incidents, to include the mishap that occurred on 

USS O’Kane, are attributable to lithium-ion battery 

failures. 

According to the Naval Sea Systems Command 

(NAVSEA) fleet advisory regarding the usage o 

ENDS, pen-shaped e-cigarette batteries are often 

different from batteries in other consumer devices 

because of their cylindrical design. The result 

of this cylindrical design is a general weakened 

structural point at each end of the cylinder. The 

advisory notes, “When the battery seal (at the 

end of the battery) disrupts, the pressure within 

an ENDS cylinder can quickly build and rupture, 

typically at the end. As a result of battery and/

or container failure, one or both can be propelled 

across the room 

like a bullet or 

small rocket.” 

The components 

of such lithium 

ion batteries are 

highly flammabl 

and combustible 

contributing to 

their explosive 

nature. 

After the mishap on USS O’Kane, the command 

issued a warning to all users and established rules 

regarding the use of e-cigarettes onboard USS 

O’Kane. These rules include: storing your device 

separately from the battery and keeping the battery 

free from metal objects, only using e-cigarettes on 

the smoke deck, and keeping e-cigarettes out of all 

engineering or work spaces. 

The Naval Safety Center and Fleet Forces 

Command have dispersed guidance and warnings 

for these highly flammable and combustibl 

devices and their associated batteries. 

Summary of warnings:

• Protect loose batteries from damage and short 

circuit by ensuring terminals do not come into 

contact with metal objects.

• Use only batteries authorized by the e-cigarette 

manufacturer.

• Use only charging cords authorized for charging 

your specific e-cigarette battery.

• Do not use damaged batteries.

• Do not expose batteries to extreme temperatures 

or direct sunlight.

• Do not leave charging batteries unattended.

• Research the reviews of leading consumer 

advocacy testing groups before purchasing a 

particular e-cigarette device.

E-cigarette 

usage among 

Sailors is on the 

rise, and their 

popularity has not 

been deterred by 

these few isolated 

incidents such as 

the explosion that 

occurred on USS 

O’Kane. It is up 

to everyone, including e-cigarette users and their 

chains of command, to ensure that these devices are 

used as safely as possible. 

...e-cigarettes, because of the need 

for battery power, pose additional 

dangers, especially in an industrial 

environment such as a warship.

References: 

Naval Sea Systems Command Message “Fleet Advisory 

Regarding the Use of Electronic Nicotine Delivery Systems 

(ENDS) (i.e. E-cigarettes, Vaporizers, Vape Pens, Vape Twists, 

etc.) and Similar Equipment Containing Lithium-Ion Batteries 

Onboard Submarines, Ships, Vessels, and Aircraft” (dtg 

211432Z SEP 16)

Naval Surface Forces Pacific Message “Hazard Report” (dtg 

141802ZMAR16)

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Image source: U.S. Food and Drug Administration

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VOLUME 6|No. 2
Allowme to introduce Petty Officer Joe Ordinary. He’s a typical young Sailor 

aboard a typical ship in a typical shipyard. But Petty Officer Ordinary 

is about to experience an event far outside the typical life he’s been 

living to date. Today, Petty Officer Ordinary is about to enter... 

*cue eerie music*

*fade in on face of Petty Officer Joe Ordinary*

*voice-over begins*

John Mapp

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*zoom out to show our subject aboard ship*

“Hmm. Hmm hmm hmm hmm,” Petty Office 

Ordinary hummed to himself as he walked along 

the main deck passageway. “This shipyard period 

is pretty typical. We eat, sleep, and relax on 

the berthing barge across the pier. The biggest 

downside to this otherwise typical routine is the 

fact that the heads are secured. We have to use the 

smelly port-a-potties out on the flight deck.

He pauses for a moment to rub his suddenly 

unsettled stomach. “Now, isn’t that just typical,” 

he said rhetorically. “I talk about the heads being 

secured, and start having indigestion. Must have 

been the burritos I had for breakfast.”

Our subject picks up his pace and heads out to the 

flight deck. The deck is typically chaotic, since the 

ship is in a shipyard. Contractor’s work boxes are 

all over the place. Hoses and pallets of materials 

are scattered about in a typically random fashion. 

About halfway across the flight deck is Pett 

Officer Ordinary s goal: a trio of portable toilets off 

to one side, sitting in the fixture used to put them i 

place.

With practiced ease (the ship has been in the 

shipyard for several months), Petty Office 

Ordinary wends his way quickly to the portable 

toilets, only to find that the cross-bar used t 

prevent the big blue boxes from tipping out of the 

carry sling has fallen partway down across the 

doors. Snorting internally at the typically sloppy 

condition of the carry rig, our subject lowers the 

bar to the deck so he can enter the portable toilet. 

This is quickly accomplished, and he settles 

himself into what certainly seems like a typically 

uneventful mid-day experience.

*enter two shipyard riggers*

“Okay. What’s next?” asked Rigger #1.

Rigger #2 consults his clipboard. “We’ll be 

moving that load there in a few minutes,” he said, 

pointing across the Flight Deck. “Has it been 

checked out?”

Rigger #1 nodded vigorously. “Oh, yeah. I did 

that a little while ago. Should be ready to lift,” said 

the Rigger #1 as he stopped and cursed a bit. “That 

bloody cross-bar has come down again.”

“Well, you better get it back in place PDQ,” 

said Rigger #2. “The boom is already moving into 

position.”

Rigger #1 and Rigger #2 quickly secure the 

crossbar in place, incidentally blocking the doors 

of all three porta-potties. Rigger #1 then deftly 

attaches the hook to the carry fixture. “ e’re 

hooked,” he called out to Rigger #2. “Hoist away.”

Modesty and a PG-rating prevent us from looking 

inside the portable toilet, where Petty Office 

Ordinary is still sitting. Perhaps he was sleeping, 

doing a crossword or (more likely) dinkle-dorking 

around with his smartphone while taking care of 

business. In any case, between his distraction and 

the fact that he was wearing his hearing protection, 

our subject somehow completely failed to notice 

all the clamor and activity around the porta-privies; 

until it was too late.

“Isn’t that typical,” he mused for a moment. 

“Now that my stomach is feeling better, my 

inner ear is acting up. I could swear this toilet is 

moving.”

Typically, no one seems to have heard Petty 

Officer Ordinary s screams as the toilets were 

picked up and deposited on the pier. The Riggers 

certainly didn’t hear anything, but the gate guards 

50-meters away finally did

Gate Guard #1 said, “Hey, guys? I think there’s 

somebody in there.” He pointed at the toilets.

“No way!” declaimed Pier Rigger #1. “These 

things are checked before we lift ‘em. We have a 

procedure.”

“Then why is there screaming and yelling coming 

from inside the port-a-potties?” asked gate Guard 

#2.

Pier Rigger #1 and Pier Rigger #2 look at each 

other in dawning astonishment. “Oh, bloody Hell!”

*begin voice-over*

Petty Officer O dinary is duly rescued from his 

tiny blue plastic prison, only slightly wild-eyed. 

His typical day and worldview have been upturned 

during the brief crane ride. Decorum prevents us 

from commenting on the fortunate fact that our 

23 2017

VOLUME 6|No. 2
subject had been located in the one place where 

the typical response to such a fearsome experience 

would have been appropriate.

As with all such episodes, whether or not anyone 

gets physically injured, this debacle had many 

contributing causes. Petty Officer O dinary failed 

to pay attention to detail, and never considered 

that the reason the cross-bar was partly lowered 

was due to an incipient lift. Our subject certainly 

should not have been so distracted that he failed 

to notice the noise and activity of the Riggers as 

they prepared for the lift. The Riggers failed to 

follow their own standard operating procedures 

by not checking all the toilets for occupants or 

other hazards before locking everything down and 

attaching the crane hook. 

Shipboard life is already inherently dangerous. 

Adding in a major overhaul at a shipyard, and the 

Risk-o-MaticTM alarms should be going off almost 

constantly — which may be part of the problem. 

Sailors and civilians in a shipyard environment 

Complacency is one 

of the best breeding 

grounds for injuries.

become accustomed to the dangers around them. 

They become desensitized to the risks they face 

every day, because those risks have become 

familiar. Complacency is one of the best breeding 

grounds for injuries.

Overall, Petty Officer Joe O dinary was fortunate 

that his atypical experience didn’t end badly. 

He’ll have to put up with lots of jokes and snide 

comments from his entire command, and will 

probably receive many ingenious nicknames as a 

result of his experience, but he is lucky to have not 

suffered far worse.

Safety professionals don’t like luck. Luck typically 

comes in three flavors: Blind, Dumb, and Bad 

Relying on luck ignores an individual’s personal 

responsibility to look out for themselves and their 

shipmates. Petty Officer O dinary got a bit of all 

three in this episode of... The Toilet Zone.

*cue eerie music*

*fade to black*

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2017

VOLUME 6|No. 2
“THE END” IS ONLY THE BEGINNING

PREVENTING MISHAPS, SAVING LIVES & PRESERVING RESOURCES

http://www.public.navy.mil/navsafecen

NAVAL SAFETY CENTER

2011 fair winds and following seas 2017