(Editor's Note: This story was updated late Friday night Eastern Time and differs from the version in the May 13 Pacific editions).

YOKOSUKA NAVAL BASE, Japan — A Navy report released Friday could lead to “administrative or disciplinary action” for USS Frank Cable’s top leaders for decisions made in the Dec. 1 steam-line rupture that killed two sailors and injured six others.

The Guam-based ship’s commanding officer, Capt. Leo Goff, and the chief engineer made “errors in judgment” by running a safety valve test when one of the submarine tender’s boilers was acting strangely, according to the Judge Advocate General’s Manual investigation report released Friday.

The ship’s executive officer, Cmdr. Steve Cole, and the chief engineer’s failure to conduct evacuation training also may have led to “more serious injuries,” the report said. The chief engineer’s name was not in the report and Navy officials declined to comment Friday on the findings.

Though not considered “malicious acts” or negligence, the decisions made by the three officers may require administrative or disciplinary action, the report stated.

Whatever action is taken will be determined by Commander Submarine Group Seven, headquartered at Yokosuka Naval Base, Japan, said Cmdr. Mike Brown, a spokesman for Commander Submarine Force, U.S. Pacific Fleet.

“They have received the report,” he said. The report examined 110 pieces of evidence, cites 115 “findings of fact,” and was endorsed by Rear Adm. Joseph Walsh, Commander, Submarine Force of U.S. Pacific Fleet on May 1.

The steam line ruptured during a safety-valve check while the ship was docked at Guam’s Apra Harbor. The 29-year-old submarine tender had just returned hours before from a daylong “Friends and Family Cruise.”

According to the report, Boiler No. 1’s support tubes failed, releasing steam into the boiler’s firebox and sweeping unburned fuel vapors into the stack, where they ignited.

The stack sent hot steam into the fireroom where 14 sailors were acting as technicians, standing watch or observing the safety check, the report said.

Four of the 14 sailors had no documented emergency exit training out of the fireroom and no one could recall having a mass training on the subject since 2003, the report said.

The report vindicated the sailors hurt in the tragedy, saying that their injuries were suffered in the line of duty, not through misconduct.

Two of the sailors later died from their injuries. Seaman Jack Valentine, 20, died Dec. 7. He was posthumously promoted to petty officer third class. Chief Petty Officer Delfin Dulay, 42, died April 30.

Both had been medevaced to the burn center at Brooke Army Medical Center at Fort Sam Houston, Texas.

Petty Officer 1st Class Robert Bruce II, Petty Officer 2nd Class Michael Lammey and Petty Officer 3rd Class Matthew Bove remain hospitalized there and received Navy and Marine Corps Commendation Medals last month for their “heroic” actions during the incident.

Several sailors stayed behind to ensure the boiler was safe before they evacuated themselves, the report said.

The report also questioned the status of emergency services on Guam, calling ambulance response time “unsatisfactory.”

COMSUBPAC also is requesting that Afloat Training Group Western Pacific do a thorough assessment of the Frank Cable’s engineering department, the report said.

Report recommendations

The following are recommendations endorsed by Command Submarine Group, Pacific Fleet for the USS Frank Cable.

1. The commanding officer and the chief engineer errors in judgment allowing the ship to steam No. 1 boiler in order to perform safety valve maintenance before determining the cause of chemistry concentration and abnormal feedwater consumption of the number one boiler should be reviewed for administration or disciplinary action.

2. The executive officer and chief engineer’s failure to conduct proper mainspace (fireroom) and evacuation training may have led to more serious injuries and said failure should be reviewed for administrative or disciplinary action.

3. Several sailors should be commended and recognized for their admirable effort to secure the boiler to prevent further damage to the ship, to assist other sailors with evacuation from the fireroom and to provide first aid to wounded shipmates. A board should be convened to review personnel actions to determine if awards or recognition is warranted.

4. The No. 2 steam drum safety valve should be removed and “hot-tested” prior to reuse.

5. Naval Safety Center evaluate and promulgate best practices for EEBD’s (Emergency Escape Breathing Devices) available to watch standers.

6. That any incomplete actions listed in the preliminary statement be acted upon.

7. BUMED evaluate which stretcher is best suited for medical transport of sailors aboard ship when taking into consideration the possible accompanying on oxygen bottles, and traveling up and down steep ladderwells.

8. BUMED evaluate capability of medical facilities on Guam to respond to a mass casualty.

9. The ship should conduct recurring, meaningful and realistic evacuation drills.

10. The Frank Cable’s engineering department should be evaluated on training, watch standing, maintenance and risk management practice.

11. A training plan should be developed for submarine tenders holding to the same standards of other surface ships with steam plants, but tailored to a submarine tender’s unique parameters.

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