High Reliability from Disaster
Ralph T. Soule, Captain, US Navy, retired
Division Director
Aircraft Carrier Test, Evaluation, and Certification
Naval Sea Systems Command
ralph.soule@gmail.com
www.ralphsoule.com
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DISTRIBUTION STATEMENT A: Approved for public release; distribution is unlimited.
Risks of Submarine Operations
Risks Designers Can/Cannot Control
Case Study: THRESHER
Risks to Ships of Industrial Operations
Firefighting Aboard Ship is Complex
Case Study: MIAMI
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USS THRESHER (SSN-593)
 Laid down, 28 May 1958, at
Portsmouth Naval
Shipyard, Kittery, ME.
 Launched on 9 July 1960.
 13th nuclear powered
attack submarine.
 The first ship of its Class;
leading edge of US
submarine technology:
USS THRESHER launching ceremonies at the Portsmouth
Naval Shipyard, Kittery, Maine, 9 July 1960.
 combining nuclear power
with modern hull design
 newly-designed
equipment and
components
Ship was fast, quiet, and deep diving
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Question: What risks of normal
operations can designers control?
• Submerging and surfacing
• Navigation under the water
• Resistance to sea pressure
• Fire and flooding
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Question: What risks of normal
operations are beyond the designers'
control?
• Crew training
• Compliance with procedures
• Worker attitudes and responsibility
• Equipment maintenance performance
• What problems are worthy of attention
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Question: What risks of normal
operations are beyond leaders' control?
(or are they?)
• How people respond to problems
• How people communicate risks and problems
• Supplier conformance to specifications
• Shipyard conformance to specifications
• Material performance under operations (does it
behave the way you assumed?)
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USS THRESHER Case Study
• Background
• Piping systems cannot be made of single pieces,
connections (joints) must be leak free
• Ship is in overhaul
• Other ships in the same shipyard, all competing for
the same resources
• Much pressure to complete the overhaul on time
• 145 critical piping joints being inspected (of more
than 3000)
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USS THRESHER Case Study
• Problem – Some pipe joints do not meet standard
• Inspections show that about 14 percent of the sea
water piping joints checked require repair or
replacement.
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USS THRESHER Case Study
• What to do?
• Inspect more joints
• Disassemble joints to understand failures
• Analyze which assumptions of original design were
wrong and why
• Change/test fabrication procedures
• Report failure/unexpected results to higher
authority
• Inspect other ships to gather more data
• Document what went wrong and what you learned
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On April 10, 1963, while engaged in a deep test dive,
approximately 200 miles off the northeastern coast of the United
States, the U.S.S. THRESHER (SSN-593), was lost at sea with all
persons aboard - 112 naval personnel and 17 civilians.
PNSY
THRESHER wreckage: About 200 miles off Cape Cod in 8,400 ft of water
Investigation Conclusions
Flooding in the
engine room
Spray on electrical
switchboards
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Unable to secure
from flooding
Loss of
propulsion
power
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Unable
to blow
ballast tanks
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Navy Response: SUBSAFE and
Significant Culture Change
LOSS of
THRESHER
Overhaul/Construction
SUBSAFE
PROGRAM
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MAINTENANCE
PROCESS
CHANGES
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USS MIAMI Case
Study
Background
• USS MIAMI (SSN 755) 2012
– US Navy Nuclear-powered Attack
Submarine
– In month 2 of a 20 month overhaul
– Location: Portsmouth Naval Shipyard (PNSY), Maine
•
•
•
•
•
Ship was in dry dock
Crew had moved off the ship
All weapons removed
Many spaces empty of personnel
Reactor shut down
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Question: Risks of Submarine
Overhaul?
•
•
•
•
Fire (sources?)
Flooding, sinking
Explosion
Many personnel risks
– Electric shock
– Falls
– Dropping heavy things
– Lack of breathable air
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If a Fire Occurred, What Makes
Response Challenging?
• Normal ship systems disabled
• Firefighting equipment and crew removed
from ship
• Shipyard firefighters not familiar with ship
• Many support hoses and cables complicate
access
• Ship compartments small
• Hard to locate fire
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Fire Location
Fire Initiation Site
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Fire Event
• Major fire occurred in forward ship section
– Date: 23 May 2012, ~1730 hrs
– Duration of fire: over 10 hours
– Cause: Arson
– Initial Source: Combustible material
– Damage: > $750M US estimate to repair, but
submarine will be scrapped
instead
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Example of Damage
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MIAMI Lessons Learned
• Breathing air canister capacity insufficient
• Too much combustible material present
• Shipyard and ship’s crew had not rehearsed
response sufficiently
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MIAMI Lessons Learned
• Industrial environment complicates fire and response.
– Crew firefighting equipment removed
– Hull cut provided air to feed the fire
– Hatches and temporary services complicated access by
emergency responders
• Early detection and rapid response extremely important
– Fire set in remote location
– Heavy black smoke confused early reports of location
• Command structure inadequate for complex, extended
firefighting
– 20 mutual aid fire departments augmented shipyard
resources
– Need integrated Command structure, interoperable radios,
and coordinated fire fighting strategy
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Questions
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Getting it Wrong