EUR2013 High Reliability Conference 1 Ralph T. Soule, Captain, US Navy, retired Division Director...

EUR2013 High Reliability Conference1

Ralph T. Soule, Captain, US Navy, retiredDivision Director

Aircraft Carrier Test, Evaluation, and Certification Naval Sea Systems Command

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High Reliability from DisasterHigh Reliability from Disaster

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Presentation Name EUR2013 High Reliability Conference2

Outline

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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Presentation Name EUR2013 High Reliability Conference

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:

combining nuclear power with modern hull design

newly-designed equipment and components

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USS THRESHER (SSN-593)

USS THRESHER launching ceremonies at the Portsmouth Naval Shipyard, Kittery, Maine, 9 July 1960.

Ship was fast, quiet, and deep diving


• Submerging and surfacing

• Navigation under the water

• Resistance to sea pressure

• Fire and flooding

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Question: What risks of normal operations can 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 the designers' control?


• 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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Question: What risks of normal operations are beyond leaders' control? (or are they?)


• 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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• 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.

THRESHER wreckage: About 200 miles off Cape Cod in 8,400 ft of water

PNSY


Investigation Conclusions

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Loss ofpropulsion

power

Flooding in the engine room Unable to secure

from flooding

Spray on electricalswitchboards

Unableto blow

ballast tanks


SUBSAFEPROGRAM

LOSS ofTHRESHER

Overhaul/Construction

MAINTENANCEPROCESSCHANGES

Navy Response: SUBSAFE and Significant Culture Change

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USS MIAMI Case StudyBackground

• 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

EUR2013 High Reliability Conferencewww.ralphsoule.com

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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 EUR2013 High Reliability Conferencewww.ralphsoule.com

Questions

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EUR2013 High Reliability Conference 1 Ralph T. Soule, Captain, US Navy, retired Division Director...

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