1. That concerning merchant vessels scheduled to load explosives:
a. A preliminary inspection be made as soon as a vessel arrives in port in order that any major faults may be corrected.
b. Final pre-loading inspections should be made after fueling and should be very thorough, with emphasis on the operating condition of the cargo handling equipment.
c. The inspections now made by representatives of the Captain of the Port and the Port Director be coordinated in order that they supplement and assist each other without needless duplication of work.
2. That in assigning personnel to duty in the ordnance battalions each draft should include an adequate number of men of petty officer caliber. Older and more mature men should be assigned this duty whenever possible.
3. That the feasibility of brining some of the mature, experienced, reliable negro civil service personnel from the Naval Mine Depot, Yorktown, Virginia, and the civil service negro stevedores from the Supply Depot, Naval Operating Base, Norfolk, Virginia, should be investigated.
4. That the loading of explosives at commercial piers be restricted to an absolute minimum and that when such loading must take place, the amounts of explosives present on the pier be restricted to the minimum and in no case exceed the amounts permitted in the American Table of Distances, Article 14D18, Bureau of Ordnance Manual.
5. That the methods used by commercial stevedores in loading explosives be carefully reviewed by competent persons and only those methods meeting acceptable standards of safety be permitted.
6. That a loading manual setting forth acceptable methods for loading each type of explosive item, and to include the gear to be used, be drawn up and promulgated.
a. The board or committee to draw up such a manual should have representatives from the Navy thoroughly familiar with all components in use and their structural weaknesses, representatives of the Navy and possibly from stevedoring firms, thoroughly familiar with loading, stowing, and rigging, and representatives from the Coast Guard familiar with the laws governing such subjects.
b. This manual should not be so restrictive in nature as to prevent a facility from developing and improving operating methods so long as these new means conform to safety requirements.
c. As new items or types of ammunition are brought out, the agency producing them be required to supply pertinent information, especially hazards of handling in order that acceptable methods of handling may be incorporated in the manual.
7. That the present regulations and instructions relating to the handling of explosives be carefully reviewed and those not applicable or impracticable of attainment be eliminated.
8. That facilities loading ammunition and explosives should be given priority in the assignment of experienced officers and stevedores.
9. That an experienced officer or officers of suitable rank, acting directly under the Commandant of the District, make surprise inspections from time to time at all explosive loading operations carried on in this district.
10. That a reasonable number of officers over and above those required for actual loading operations and in an "under instruction" status be maintained at the Naval Ammunition Depot, Mare Island, or Naval Magazine, Port Chicago, in order to provide adequately trained officers to meet normal attrition and expansion.
11. That the loading of explosives should never be a matter of competition.
12. That the feasibility of placing barricades between loading piers and adjacent facilities be investigated.
13. That inasmuch as the Commanding Officer of a Naval activity is in fact responsible for everything at his station, all representatives of other activities visiting the station for any duty should be required to report to the Commanding Officer for the specific duty and to submit their reports through the Commanding Officer of the station visited.
14. That the present policy of allowing the Commanding Officer of a Naval activity to accept or decline a Coast Guard loading detail be continued. That where this detail is accepted the detail should report to the Commanding Officer of the station for this duty.
15. That only such fuel oil as meets Navy specifications be delivered to ships scheduled to load ammunition.
16. That the following recommendations covering specifications for magazine facilities made by the Public Works Officer, Navy Yard, Mare Island, be favorably considered:
a. Structures that are vital for operation of the station in time of disaster should be of permanent fireproof construction. This includes the administration building, marine barracks, fire station, fire pumping station, and central power plant.
b. All important structures not of permanent, fireproof construction should be of a substantial wood frame construction, well braced.
c. Flimsy, war-time construction should not be used except for minor buildings, the loss of which will not seriously interfere with station operations.
d. Where practicable, important buildings should be laid out end on rather than broadside on to probable line of blast.
e. Unless strongly reinforced and braced, walls of buildings should have a considerable proportion of the area glazed to present a minimum obstruction to the blast.
(1) Mechanical services should be run underground wherever possible.
(2) Hangers for pipe lines should be arranged and secured to structures to allow some freedom of motion, yet definitely limit movement.
(3) BuDocks standard specification 21Yc should be modified to permit wider use of welded joint pipe and steel valves, flanges and fittings for stems, as well as other fluids in explosion hazard areas.
(4) Spring loaded pressure reducing valves should be used instead of dead weight loaded type.
17. That gas mains should not be permitted in an explosive area.
18. That the provisions for the protection of explosive ammunition components during shipment and handling, including the containers, be carefully reviewed as the present necessity of shipping large quantities of high explosives over long distances in commercial carriers, together with the lack of skilled personnel, has introduced many additional hazards.
19. The court recommends that no further proceedings be had in the matter.
Albert G. Cook, Junior,
Captain, U.S. Navy.
John S. Crenshaw,
Captain, U.S. Navy.
William B. Holden,
Captain, U.S. Navy.
The record of proceedings of the fortieth day of the inquiry was read and approved, and the court having finished the inquiry, then at 1:30 p.m., on 30 October 1944, adjourned to await the action of the convening authority.
Albert G. Cook, Junior,
Captain, U.S. Navy,
Keith R. Ferguson,
Lieutenant Commander, U.S. Naval Reserve,
March 24, 1999