By Oren Liebermann, CNN
(CNN) -- A fire that destroyed a US warship last year was "clearly preventable" and was the result of a series of systematic failures, according to a Navy investigation.
The cascade of errors and breakdowns involved 36 Navy personnel, the investigation found, including the commander of USS Bonhomme Richard and five admirals, who failed to maintain the ship, ensure adequate training, provide shore support, or carry out proper oversight.
The ship had been docked at Naval Base San Diego for maintenance when the fire broke out on July 12, 2020. It burned for more than four days and resulted in the Navy scrapping the amphibious assault ship.
Though one sailor from the Bonhomme Richard has been charged with starting the fire, the responsibility for its spread and the destruction of the ship is "shared across various Commanders, Commanding Offices, and subordinate personnel," the report concluded, both by "errors of omission" and "acts of commission."
The commander of US Pacific Fleet, Admiral Samuel Paparo, will decide whether anyone will be relieved of command or whether they will face any other disciplinary or administrative actions, the Navy said.
"No disciplinary or administrative options have been taken off the table," said Vice Chairman of Naval Operations Admiral Bill Lescher on a conference call with reporters after the release of the investigation findings. The process of determining disciplinary or administrative actions, called a Consolidated Disposition Authority, has already begun.
Captain Gregory Thoroman, commanding officer of the Bonhomme Richard, "created an environment of poor training, maintenance, and operational standards that led directly to the loss of the ship," the investigation found. Captain Michael Ray, the second-in-command, was also responsible, according to investigators, because he was in charge of maintaining the crew's readiness and the ship's survivability, while also being in charge of oversight for shipboard drills and exercises.
The fire spread unabated through much of the ship, fueled by combustible materials recently brought on board, and ultimately melted the aluminum structure of the vessel when temperatures climbed above 1,200 degrees.
Ship was 'significantly degraded' before fire
Even before the fire, the condition on the ship was "significantly degraded," including firefighting equipment, heat detection capability, and communications equipment, allowing the flames to spread more quickly. Meanwhile, the ship's crew had failed firefighting drills, including a repeated inability to apply firefighting chemicals during drills on 14 straight occasions leading up to the fire.
On the day of the fire, at least 10 minutes passed from the first detection of smoke to it being reported to the Officer on Duty, the report found. A duty section member who saw a "hazy, white fog" did not smell smoke and did not immediately report it up the chain of command. During the critical first few minutes, the fire began spreading in a room that also contained fueled work vehicles, space heaters, propane and other items.
Two teams tried to find the nearest usable fire hose, but the closest shipboard fire stations had cut or missing hoses that were not fixed in routine maintenance checks. Nearly an hour after the fire started, one team from Naval Base San Diego was able to start spreading fire suppressant chemicals on the flames. But the team backed away from the fire after a few minutes when one team member received a "low air" alarm on his breathing apparatus. No relief team replaced them.
As other fire crews began arriving at the pier, firefighters encountered another problem. San Diego Fire Department did not have radios compatible with the base's federal fire department. During the first three hours after the fire, the commanding officer of the Bonhomme Richard and other senior officers did not attempt to integrate civilian firefighters with the ship's crews.
The Bonhomme Richard did have "extensive" shipboard firefighting systems, including a fire main and fire suppressant foam, but the equipment was not used because it was either degraded, poorly maintained or the crews didn't know how to operate it.
Although the commanding officer, executive officer, command master chief, chief engineer, and damage control assistant were all on the scene shortly after the fire started, the investigation found that no one established command and control of the situation.
The preliminary hearing for the sailor charged with starting the fire, who has not been identified, is scheduled for November 17.