6th International HRO Conference 9-11 April 2013 Ralph T. Soule, Captain, US Navy, retired Strategic Reliability [email protected] .

6th International HRO Conference9-11 April 2013

Ralph T. Soule, Captain, US Navy, retiredStrategic Reliability

[email protected]

Tragedy to High ReliabilityTragedy to High Reliability

DISTRIBUTION STATEMENT A: Approved for public release; distribution is unlimited.

Presentation Name Patient Safety and Quality8 February 20132

Outline

History - Loss of THRESHER

High Reliability Lessons: Submarine Safety (SUBSAFE) and other maintenance processes

Presentation Name Patient Safety and Quality8 February 20133

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

USS THRESHER (SSN-593)

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

She was fast, quiet, and deep diving

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Submarine Buoyancy and Ballast Tanks

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

Presentation Name Patient Safety and Quality8 February 20136

Navy Response to Loss of USS THRESHER

Immediately limited diving depth of all submarines

Court of Inquiry THRESHER Design

Appraisal Board Focus:

Design Construction Operation

Testimony Before Congress

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Investigation Conclusions

Loss ofpropulsion

power

Flooding in the engine room Unable to secure

from flooding

Spray on electricalswitchboards

Unableto blow

ballast tanks

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SUBSAFEPROGRAM

LOSS ofTHRESHER

Overhaul/Construction

MAINTENANCEPROCESSCHANGES

Inception of the SUBSAFE and Significant Culture Change

Presentation Name Patient Safety and Quality8 February 20139

Key Lessons

“The loss of the Thresher should not be viewed solely as the result of failure of a specific braze, weld, system, or component, but rather should be considered a consequence of the philosophy of design, construction, and inspection … it is important that we reevaluate our present practices where, in the desire to make advancements, we may have forsaken the fundamentals of good engineering. ” – ADM Rickover

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• Safety must be part of process design, not an afterthought• Key systems were under-designed for knowable risks• Failure to bound an unexpected problem• An attitude that specifications were merely goals, did not need

to be taken literally, and HQ permission not needed for failure to meet them

• Impact of accumulated conditions, not a single failure• The Navy had not updated its way of doing business to meet

the requirements of updated technology and high-performance ships that could operate in riskier environments

• Processes are only as good as their audit plan

Key Lessons

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Navy High Reliability Practices

It is expensive and costly to wait for mistakes to learn Use existing debriefing records to tune awareness

Safety is created in the moment, where work is done, by the people doing it “High reliability is a continuous, ongoing, dynamic

accomplishment." The blindness of hindsight bias short

circuits learning ...

Presentation Name Patient Safety and Quality8 February 2013

Getting it Wrong

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• Checklists• Work Model: training,

procedures, supervision• Critiques/Fact Sheets• Risk Management• Audits/Surveillances• Pre-operative safety briefings• Post-event/procedure debriefs

Navy Maintenance Tools for High Reliability

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• Key: capturing each person’s perspective, follow up

• Was the desired outcome achieved?• Things to do more often• Things not to do next time• Hazards caught (which ones remain open?)• Assess work process tools (effectiveness/utility

of pre-briefs, procedure, especially things not covered, but should be, training/qualifications -> management credibility rests with follow up)

• What were the surprises and how were they identified?

• Things to do differently next time

Post-action reviews (informal)

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ACCIDENT

TIME

SA

FE

TY

L

EV

EL

Minimum

Optimum

Understanding the Challenge

- Actual

- Perceived

THE BATTLETHE BATTLEWHERE YOU THINK YOU ARE

WHERE YOU REALLY ARE

Presentation Name Patient Safety and Quality8 February 2013

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“Those who cannot remember the past are

condemned to repeat it.”

- George Santayana

“A good pre-event briefing beats an accident

investigation any day.”

- ADM Kinnaird R. McKee

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Questions