Source: ADM 137/3681, in the Public Record Office. Minor 'editorial' notes are added [thusly].
H.M.S "EMPEROR OF INDIA",
30th July, 1917.
In compliance with your Memorandum dated 10th July, 1917, H.F.0021/51, we have held a full and careful investigation into the circumstances attending the loss of His Majesty's Ship "VANGUARD", which occurred at about 11.20 p.m. on Monday the 9th July, 1917, and beg to submit the following final report.
2. We find that on the morning of the 9th July the "VANGUARD" was anchored on the North Shore of Scapa Flow. During the forenoon of that day the Ship's company were exercised at "Abandon Ship." At 5 o'clock in the afternoon the "VANGUARD" left the North Shore and proceeded, at about 12 knots, to her berth in the Fleet anchorage, exercising P.V.'s [paravanes] on the way and anchoring at 6.30 p.m.
For the passage from the North Shore the following boilers were used, viz., in "A" Boiler Room Nos. 2, 3, 4, 5 and 6, and in "B" Boiler Room Nos. 1, 2, 3, 4, 5, and 6.
After anchoring, orders were given to light bank Nos. 2 and 3 boilers in "A" Boiler Room and all the boilers in "B" Boiler Room, Nos. 4, 5 and 6 in "A" boiler Room being kept for auxiliary purposes.
On this day the 'Red' and 'Sea' doors, which are customarily closed at Evening Quarters in harbour or, if the duties of the ship required it, at 8.30 p.m., were not closed at 7.50 p.m. when the Officer of the Watch was relieved, but this Officer gave orders to his relief that they were to be closed at 8.30 p.m.
3. We consider that the evidence of witnesses of the blowing up of the "VANGUARD" points to the first visible flame coming up from below just abaft the foremast, this being followed, after a short interval, by a heavy explosion accompanied by a very great increase of flame together with a very large quantity of wreckage fragments thrown up abaft the foremast in the vicinity of "P" and "Q" turrets. This explosion was followed after a short interval by a second explosion which considerably increased the volume of flame and smoke (and no doubt debris), but smoke had previously obscured the ship so that the vicinity of this explosion could not be exactly located. The evidence, however, points to it being just abaft the first one.
There are witnesses who state that they heard two or three small explosions after the second one, but there were not visible signs accompanying them.
4. We could only obtain one witness who noticed any alteration in the trim of the ship following these explosions, and this witness states that after the first explosion he could see the after part of the ship which indicated a slight trim by the head. No witness observed the ship actually to sink and this fact is explained by the enormous amount of smoke following the explosions entirely obscuring the ship.
5. We are of opinion that the evidence points to the initial explosion originating in "P" or "Q" magazine. Had it been in "A" magazine we consider that what was seen of this explosion would have appeared to extend further forward.
6. As a result of the explosion s a piece of steel plating varying between 4 and 5 feet in breadth and 6 feet in length fell on board the "BELLEROPHON", and from the various distinctive marks on it, we considered that the position in the ship from which it came might be ascertained by comparison with a sister ship. The Report of the Engineer Commander and Chief Carpenter of the "ST. VINCENT", who investigated this matter, is appended (Enclosure No. 1 [not reproduced]). We consider that the locating of the position of this plate in the "VANGUARD" strengthens our opinion that the explosion did not originate in "A" magazine, both on account of the way in which the plate was buckled and the absence of any indication of its having been subjected to great heat. Had "Q", or "P" and "Q", magazines been the first to explode, pressure would be less baffled in passing by the side of the Boiler Room and through the pipe passage into the Dynamo Room on the starboard side than it would be by passing through the air space separating "P" and "Q" magazines from "A" Boiler Room, through "A" Boiler Room and the cross bunker, into the Transmitting Station, and would cause the plate in question to be blown out from the Dynamo Room side.
7. The only survivors who were on board "VANGUARD" when the ship blew up being two men, whose evidence was of no value, it became evident that our investigations to discover causes which might either directly have brought about, or been conducive to the bringing about of, the explosion, should be carried out from the evidence of Officers of the "VANGUARD" who were not on board at the time, Officers serving on board a ship of the same class, and, in certain lines of investigation, from Officers serving in other classes of Dreadnought battleship.
8. At this point we would remark that from the evidence given us by the surviving Officers of the "VANGUARD", we have been impressed by the good organisation and thoroughness which obtained on board that ship. The general tone appears to have been excellent, the esprit de corps of a high order, and we believe that the ship's company were as contented and happy as in any ship in the Grand Fleet.
9. With regard to cordite, Commander Weston from the Admiralty, who gave evidence, informed us that all the modifications which of recent years have been introduced into the manufacture of cordite (including the period during which the country has been at war) have steadily tended towards increasing stability of the cordite and its improvement in regard to deterioration, while the tests carried out during manufacture, and before the cordite is delivered to the Naval Ordnance Store Officers, have suffered no relaxation of any material importance. He was not, however, prepared to give evidence respecting the treatment and behaviour of the cordite after it had been supplied to the Naval Ordnance Store Officers for use in the Navy, and (by our instructions) our enquiries in this direction were not further pursued. The evidence, therefore, of the Gunnery Officer of the "VANGUARD" (Commander Wilfred N. Custance, Royal Navy) relating to the landing, testing, and subsequent re-embarkation of the outfit of cordite of that ship in December, 1916, was of not particular value to our enquiry. We feel convinced however that this highly important matter will not be overlooked.
10. With regard to magazine temperatures, we find from the evidence of the Gunnery Commander of the "VANGUARD" that the temperatures of all 12-inch and 4-inch magazines in that ship were taken daily every forenoon by means of the temperature tubes and that, in addition, the thermograph charts were inspected by the Gunnery Officer when they were changed on Monday forenoons.
We find that the procedure for taking the temperatures of magazines varies greatly in different ships in the Fleet. In more ships these temperatures are taken three times a day when the cooling arrangements are not in use, and at least once in every watch when the cooling plant is running. In one ship we find that the taking of temperatures is left entirely to the Chief Stoker assisted by his four Mates. In some ships the starting of the cooling apparatus is ordered by the Gunnery Officer, whereas in others this responsibility devolves on the Engine Room Department. In no two ships did we find that the procedure is the same. We are of opinion that the procedure in regard to the cooling and taking of temperatures of magazines should be standardised throughout the Fleet and that the regular taking of temperatures should be carried out, under the direction of the Gunnery Officer, by the Gunner of the ship, who should actually enter the magazines two or three times a day, during which visits he should also inspect the magazines. In this connection we would mention a case which has come to our notice wherein acid spilt from a secondary battery leaked through the hole of a bolt, which had not been properly fitted in the crown of the magazine, and on to the cordite cases.
We also favour the taking of temperatures at more frequent intervals, by means of the temperature tubes, during such periods as the conditions are not perfectly normal, e.g., when the cooling plant is running.
11. It appears from the evidence that in some ships insufficient attention has been paid to ascertaining whether "hot pockets" exist in the magazines, the temperature as taken by the tube being, for all practical purposes, accepted as the temperature of the magazine.
As will be seen from the experience gained in the "LION" (vide Submission from Vice-Admiral Commanding, Battle Cruiser Force dated 7th July, 1917, No. BCF.1.M [not reproduced]) and the "ST VINCENT" (vide attached statement, Enclosure No. 2 [not reproduced]), the above method may not provide an accurate record of the temperature existing in all parts of the magazine, and, moreover, it has come to our knowledge that when the cooling apparatus is in use the difference between the temperatures registered by the thermometers in different parts of the magazine appears to become accentuated; this may possibly be due to the fact that the temperature tubes in certain positions in the magazines are unduly affected by the circulation of cold air in their immediate vicinity.
12. It should, we consider, be brought to the notice of officers and men who take temperatures to ascertain "hot pockets" that a "hot pocket" need not necessarily be in the vicinity of the roof of the magazine but may be in a lower corner.
We recommend that if pockets which give material variations in temperature are found, measures should, as far as is practicable, be taken to improve the circulation of air in the magazine.
13. It has been suggested that magazine temperature tubes should be abolished owing to the danger of their being utilised by evilly disposed persons. We are opposed to the abolition of these tubes for the reason that they enable temperatures to be taken without opening the magazine doors, and this, we consider, is of special importance when the coolers are running.
We are of opinion, however, that smaller tubes and suitable thermometers should be introduced and that the openings of these tubes should be fitted with a lock and key.
14. We recommend that the supply of thermographs should be increased so as to enable all ships to be provided with a thermograph for each main armament magazine.
15. With regard to the ventilation of magazines, instances have come to our knowledge in which foreign matter has passed down the ventilating trunk into the magazine; we consider that measures should be taken to prevent this.
We find that alternative openings in supply trunks below the upper deck exist in some ships; we consider these should be securely closed.
We also find that magazine ventilation trunks throughout have rarely, if ever, been examined to see if there is any accumulation of dust, waste, rags, or any other substance therein which would facilitate the passage of flame in the trunks.
We consider that the trunks should be examined periodically and, as far as possible, foreign matter removed from them; also that inspection manholes, closed with plates, made airtight with red lead and secured with screw bolts, should be fitted in the trunks were absolutely necessary for the above purpose.
16. We have observed that in some ships the openings to the magazine exhaust trunks which do not rise to the upper deck, are insufficiently protected against the introduction of objectionable matter; also that there are holes in the ventilation trunk between the cooler and the magazine for the purpose of testing the temperature of the air being delivered into the magazine, which holes are closed by moveable wooden plugs. We consider that these holes should be fitted with tubes closed at the bottom end.
17. We find that in some ships it has been the custom to oil over the floor of the magazine, whilst in others, after the floor has been carefully brushed, it is wiped over with a damp cloth, and no appreciable deterioration has occurred.
We consider that no oil whatever should be used on the floor of a magazine.
18. It has come to our notice that when turned to the "storage" position in the magazines, the lids of the cordite cases are often found to be very loose and in some instances they have fallen off altogether, due to the inclined planes, which are only lightly secured, becoming displaced or detached. We consider that steps should be taken to prevent this.
19. We find that in the "VANGUARD" coal sacks were stowed in the patent fuel spaces adjoining "P" and "Q" handing rooms. There is no ventilation to these spaces when the hatch is closed, (which was usually the case), whilst one of the bulkheads to these spaces also forms the bulkhead of a 4-inch magazine 9which was being used as a 12-inch magazine) and a 12-inch shell room. Here, in our opinion, were produced conditions favourable to spontaneous combustion, which might have taken place and the 3-inch bulkhead become heated to a dangerous degree without the fact becoming known to anyone.
About three years ago a fire occurred in "VANGUARD" in a coal bunker in which coal bags were stowed, and the bunker had to be flooded in order to put the fire out.
In a letter to the Court, dated 12th July, 1917, (Enclosure No. 3 [not reproduced]) Engineer Commander Harry Williams, Royal Navy, of H.M.S. "COLLINGWOOD", states that some time before the commencement of the war a fire occurred in "COLLINGWOOD" in the cross bunker situated between "A" Stokehold and the magazine used for blank and saluting 6-pounder and small arm ammunition, respectively, which magazines adjoin the 12-inch magazine. This fire was attributed to hot ashes being placed against the bunker bulkhead. A similar bunker fire, but in a different position, occurred in "ST. VINCENT" about two years ago.
20. The evidence shews us that, on account of the 4-inch gun deck of H.M.S. "VANGUARD" being completely closed in by protective mattresses, the supply of air to the cross bunker, and also to "A" Stokehold, was considerably restricted. it has also been brought to our knowledge that in one ship a case has occurred in which the roof of a 4-inch magazine became very hot owing to the bursting of a hydraulic pipe in one of the pipe spaces over the magazine, the escaped liquid being raised to a high temperature by the steam pipes in the vicinity.
21. Generally speaking, and particularly in the case of the "VANGUARD", we find that the compartments adjoining the magazines are closed for periods which, should spontaneous combustion take place in them, would permit of the temperature rising to a dangerous extent before the fact was discovered. A fire might be caused in such compartments through a leak in an electric lead or through a smouldering substance being left there.
We recommend, therefore, that arrangements should be made in all ships whereby a considerable rise in temperature in any compartment adjoining a magazine or shell room must be discovered within at least two hours of its taking place.
We submit for consideration the introduction of a method for drawing attention at a distance to a rise in temperature in these particular compartments, such as is used in Merchant Vessels for ascertaining the temperature of cargoes, and as suggested in the evidence of the Gunnery Officer of H.M.S. "EMPEROR OF INDIA" (page 178 of Minutes [not reproduced]).
22. We consider that when ammunition is embarked every case containing cordite should be opened, the charges inspected and the case examined to ensure that it contains no foreign matter. It is to be observed, however, that this would not reveal an incendiary apparatus inserted in a cartridge in a manner not easily detected, and for this reason the precautions taken in the Ordnance Store Depots, in Ammunition Ships, and during the transit of cordite cannot be too strict and searching.
23. We find that although Admiralty orders have been given (but have not yet been fully executed) for the supply of stronger and better locks to the hatches and doors of magazines, it happens in some cases that, if the door clips are knocked off before the door is unlocked, there is a chance of the spring of the door itself starting the lock from the door, and it would then be very easy with a small iron instrument to force open the door.
The importance of efficient locks and doors to the shell and handing rooms, and the necessity for restricting access to these places, does not appear to be fully realised. Whilst we are aware that the securing of doors by locks cannot (at least at the present time) be brought about in a manner to alone give security against their being burst open by men with evil intent, it will, in our opinion, prevent men who wish to avoid being detected in the commission of offences against good order from improperly entering compartments.
24. The fact that torpedoes fitted with warheads are stowed on magazine bulkheads in ships must not be overlooked and efficient locks and keys should also be provided for submerged flats; these flats also should not be forgotten when framing the orders for rounds.
25. We feel that our Report has already put forward many causes which, either singly or in combination, might have brought about the blowing up of the "VANGUARD", and we consider that these causes may to a large extent be overcome with the institution of a more frequent, more exhaustive and more appropriate system of rounds, built up from a combination of the best methods already employed in the Fleet. The reason and importance of every detail of these rounds should be fully understood by all concerned in the execution thereof.
26. With regard to the possible effect of wireless high frequency currents, especially in connection with the Poulsen system of Wireless Telegraphy, we called upon Commander Somerville, H.M.S. "KING GEORGE V", to study and submit to us a statement. The evidence of this Officer, together with the statement referred to, are appended hereto (Enclosure No. 4 [not reproduced]).
From this statement it will be seen that no danger need be apprehended in this respect, notwithstanding the wild rumours circulated in France, Germany and Austria before the war, and investigations in England concerning the blowing up of a magazine from a distance.
27. If, for a moment, we accept that the loss of the "VANGUARD" was not due to the act of an enemy agent, the question arises whether, possibly, the war has brought about such altered conditions as may have led to the blowing up of warships lying at their anchorages: to this question we would answer that turbines are kept practically always warm, a greater number of boilers has generally been alight, the use of hydraulic machinery is more continuous, and is nearly always warm; the average temperature in various parts of the ship has therefore probably been consistently higher. Drills are far more frequent, with the result that men enter the magazines more often and a greater amount of dust has probably thereby been created; coaling has been far more frequent and compartments in ships have, generally speaking, been more closed down, whereby rendering them less well ventilated; and lastly, cordite, certainly prior to the loss of the "NATAL", has been much more exposed outside the magazine.
28. Considering next the possibility of the loss of the "VANGUARD" being due to the act of an enemy agent; either (a) working on board the ship, or (b) working without the ship; and bearing in mind the information gathered since the outbreak of war concerning enemy agents, and the ingenuity and subtilty of such of their methods as have been disclosed; -
With regard to (a), - we examined the two Ordnance Fitters (Harston and Williams) from Chatham Dockyard who had been employed in the "VANGUARD", living on board that ship and leaving her only a few hours before she blew up.
In the case of Harston, we find that he had left the "NATAL" under similar circumstances just before that ship blew up.
From their evidence, we can ascribe no suspicious evil actions to these two men, but in regard to Harston, & taking into consideration the fact that the was a Leading Hand who had been much employed in H.M. Ships, we consider that his asserted ignorance was remarkable, and we are inclined to attribute it either to the natural anxiety of an innocent man to clear himself, or to the anxiety of a man who knows more than he wishes to disclose.
Out of the wreckage of the "VANGUARD" there were salved certain fragments of correspondence, and these, together with all available information concerning the two Ordnance Fitters mentioned above, have (with your concurrence) been placed in other hands for investigation.
We would point out that before the disaster which befell her, the "VANGUARD" had been some seven months at the Northern Base. Had enemy agents been on board for the whole of this period, it appears to us improbable that they would have taken so long before bringing into execution their nefarious action.
We think it improbable that amongst Naval drafts an enemy agent should have passed through the ship during this period, but, with regard to Dockyard and Contractors' workmen temporarily employed on board, we consider that the regulations contained in Confidential Admiralty Monthly Orders Nos. 179 and 219 of 1816, even if rigidly carried out, do not in themselves constitute a sufficient precaution against evil actions, and we presume that this has been fully impressed on those who supply such labour.
We would also remark that it does not seem to be in keeping with the action of a clever enemy to get there agents into an older class of ship, and that after a considerable sojourn with the Fleet, in order to carry out their nefarious intent, particularly when so far more powerful ships are to be found in Government and (more especially) private Yards, during their refits, where such a deed could probably so much more surely and easily be accomplished.
With regard to (b) - we feel it superfluous to dilate on the various ways in which a man-of-war could be blown up by a delay-action apparatus, of an explosive or incendiary character, placed in shell or cordite charges, either during their manufacture, storage or transit.
It has not been relegated to our enquiry to investigate precautions taken in this respect, but we presume this matter will be most thoroughly reviewed.
As to the suggestion that a magazine might be exploded by an infernal machine introduced into the ship with the Canteen, or other, Stores, we would point out that neither the Canteen Store or the Serving Room adjoined a magazine in the "VANGUARD"; nevertheless, we are of opinion that in no case should Canteen stores be stowed in close proximity to a magazine.
The flour stores in "VANGUARD", however, adjoined "A" magazine and, in the absence of full precautions in respect to the supply of flour and other provisions, we consider that the sacks or covers containing these present a suitable covering in which to conceal an infernal machine.
If, however, the loss of "VANGUARD" was brought about by laxity in the direction indicated above, it can but be remarkable that the victims should so consistently have been those ships of comparatively inferior fighting value. The fact that the three ships "BULWARK", "NATAL" and "VANGUARD" were Chatham Ships may cause it to be remarked that, Chatham being on the East Coast, ships manned from that port are possibly especially accessible to the acts of enemy agents, but, for the reasons given above, we are of opinion that the fact that the three ships blown up were Chatham ships is no more than a strange coincidence.
29. After full consideration of the evidence that has been brought before us, and bearing in mind that we have heard no evidence as to what safeguards exist against enemy agents acting without the ship, we are of opinion that the facilities for the blowing up of a ship by an enemy acting without the ship are greater than those for an enemy acting within the ship.
30. Our final conclusions are summed up as follows, viz.-
We consider that the loss of the "VANGUARD" may have been due to (i) The ignition of cordite, due to an avoidable cause; or (ii) abnormal deterioration of a charge of cordite due to hat charge having, undetected, been subjected to abnormal treatment during its life. And further, in the absence of investigation, we should not be right in omitting:-
(iii) The act of an enemy agent, probably without the ship;
and (iv) The ignition of some cordite due to its becoming unstable.
31. In conclusion, we would state that we are unable to attribute blame to any person in connection with the loss of His Majesty's Ship "VANGUARD".
We have the honour to be,
Your obedient Servants,
(signed) W. C. M. Nicholson,
1st Battle Squadron.
(signed) V. H. G. Bernard,
H. M. S. "NEPTUNE"
(signed) James C. Ley,
H. M. S. "CANADA".
The Admiral, Second in Command,
The Admiral Commanding, 4th Battle Squadron;
The Vice-Admirals Commanding,
2nd and 5th Battle Squadrons, and Battle Cruiser Force,
The Vice-Admiral, Light Cruiser Force.
For information and guidance in compiling the reports called for by H.F.243/73 of 4 August, 1917. It is considered undesirable that this report of the Court of Inquiry should be circulated generally in the Fleet.
(signed) David Beatty,
7th [?] August, 1917.
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